Posted: March 18, 2004
This page is categorized as:    link to Outrage Management index
Hover here for
Article SummaryMad cow disease has never been a serious threat to human health in the United States. When it tries to convince people of this truth, the U.S. Department of Agriculture often says things that aren’t quite true. In this long column, Jody Lanard and I painstakingly dissect nine instances of misleading USDA mad cow risk communication in the wake of the December 2003 discovery of the first known mad cow in the U.S. Not that the USDA was unusually dishonest. This sort of dishonesty is routine in risk communication, especially when its perpetrators know they are in the right. This column introduces the phrase “misleading toward the truth” to describe the well-intentioned – but ultimately ineffective – dishonesty of information sources who are convinced the unvarnished facts might themselves be misleading.

Misleading toward the Truth:
The U.S. Department of Agriculture
Mishandles Mad Cow Risk Communication

This column will analyze the misleading, over-reassuring, “absolutely” typical PR campaign launched by the U.S. Department of Agriculture (USDA) on December 23, 2003 after the first U.S. mad cow was found – and why it constitutes bad risk communication.

In early summer of 2004, the USDA seemed to be doing a much better job of risk communication. For an update, see “Sharing and Bearing Dilemmas: The USDA’s Transparent Mad Cow Risk Communication.”

But before we say anything else, we must say this: The evidence is extremely persuasive (to us) that mad cow disease is not a significant public health problem in the U.S. It’s not our field, but everything we read from genuine experts on mad cow disease points to three key truths:

It is apparently hard for humans to catch mad cow disease. The disease is called Bovine Spongiform Encephalopathy (BSE) when it strikes cows, and variant Creutzfeldt-Jakob Disease (vCJD) when it strikes people. By 1993, the United Kingdom was finding about a thousand cows a week with BSE. Overall, the U.K. has confirmed almost 200,000 cows with BSE since 1986. Disease modeling suggests that 1-2 million additional BSE-infected cattle may have entered the U.K.’s human food supply. Even so, only about 150 cases of human vCJD have been diagnosed in the U.K. so far. Allow for the fact that some may have been missed and some may still appear; allow for the possibility that people everywhere may not react the same way as people in the U.K. The conclusion is nonetheless inescapable. A lot of people can eat a lot of beef and beef products from BSE-infected cows and, unless they’re unlucky, not get vCJD.
The U.S. hasn’t had and isn’t going to have a large BSE epidemic like the one the U.K. had. The regulations imposed after the U.K.’s experience pretty much assure that this is so. Cows get BSE mostly from eating feed that includes BSE-contaminated neurological tissue from other cows. Since 1997, the U.S. has outlawed putting cow tissue into cattle feed. Granted, there were exceptions like plate waste and blood, compliance wasn’t necessarily 100% and enforcement was a long way from 100%. Still, cows born in the last few years are a whole lot less likely to end up with BSE than their parents and lder siblings. (Both the cow found in the U.S. in December and the one found in Canada in May were born before the new regs.) An occasional cow with BSE is still out there, undoubtedly, but not many and fewer every year. And when a BSE-infected cow dies, other cows are no longer as likely to end up eating its neurological tissue. Fewer cows with BSE and fewer chances to pass it on add up to no epidemic.
If the U.S. were to have a large BSE epidemic, we wouldn’t miss it. Since 1990, the U.S. government has tested a total of roughly 60,000 cows for BSE; it found one BSE+ cow, in December 2003. Prior to that one, they were zero for 60,000. There is room for debate over whether the U.S. has tested enough cows to be confident that fewer than one in a million adult U.S. cows has BSE, as the USDA has sometimes asserted. (Or, a different question, whether it was testing enough cows to be confident of that before December’s one hit.) The answer depends largely on what sorts of cows were tested; testing “downer” cows (cows too sick or injured to walk) increases the likelihood of finding BSE if it’s there to find, but the statistics lose some of their meaning if the USDA was testing non-downers and calling them downers. Still, downer or non-downer, one BSE+ cow in 60,000 was enough information to tell us we didn’t have any sort of large-scale epidemic. And the USDA’s various testing plans for the future – first 20,000 a year, then 40,000 a year, now (thanks to December’s surprise) 200,000+ during the next 12 to 18 months – are all enough information to tell us if we start to have a large-scale epidemic … which is extremely unlikely.

So far, one U.S. resident has been diagnosed with vCJD, and she lived in England during its BSE epidemic. Another U.S. vCJD case would be a personal tragedy and a big news story, but it wouldn’t be a statistical shock or a public health disaster. The same can be said for several more. Hundreds more won’t happen. Before the U.S. found its first mad cow in December, the BSE/vCJD public health risk in the U.S. was greater than zero, but very small. Now that we have found one, it is greater than it was – but still very small.

When you think about the risk of eating beef, think about cholesterol. Think about E. coli. If you’re really worry-prone, think about choking on a piece of gristle. As a public health threat, mad cow disease ranks below even that.

Of course there are psychologically sound reasons for taking mad cow disease seriously despite the very low statistical probability of catching it. It is, after all, a new, poorly understood, incurable, and terrifying way to die. Anyone who doesn’t shudder at images of rotting brains … images of eating meat from cows with rotting brains … even images of eating meat from cows that ate other cows’ rotting brain tissue … isn’t quite human. But a public health threat it’s not.

Officials at the USDA knew all this well before they found their first mad cow. They knew it as they tried to figure out how to cope with their first mad cow. They knew, in short, that public health was not at stake. Domestic beef sales and other countries’ regulation of U.S. beef exports were at stake. Public confidence in the safety of U.S. beef, and the safety of U.S. food generally, was at stake. Public confidence in “sound science” was at stake. The reputation of the USDA itself was at stake – its reputation for regulating food risks wisely and its reputation for being candid with the public. Future USDA autonomy in deciding how cautiously to regulate food risks without much interference from Congress and the public was at stake. How much Americans would need to spend in tax money or food money to pay for whatever new regulations got passed was at stake. Whether we eat our beef placidly or worriedly, with or without visions of cows that are forced to drink other cows’ blood and machines that strip meat off the bones and sometimes include hunks of spinal column – all that was at stake. Public health was not at stake.

And so the USDA felt entitled to mislead us.

Well-Intentioned, Common, and Dangerous

That’s why we call this column “Misleading toward the Truth.” We are not talking about true evil, as when corporations or government agencies intentionally mislead the public about information of real health significance, doing something even they must know is wrong. We’re not talking about brinkmanship, as when the evidence is mixed or uncertain and a corporation or a government agency takes a gamble and tells us it’s sure everything is fine, knowing it isn’t sure and hoping it turns out right.

That’s not what happened here. The USDA knew, confidently and justifiably, that mad cow disease in the U.S. was not a widespread threat to human health. It didn’t just guess this was true and get lucky. It knew it was true. But it feared that the unvarnished facts (about its December surprise, about its BSE surveillance program, about how cows are turned into meat) might lead people to mistakenly conclude that the risk was sizable. To keep us from making this mistake, it carefully shaped the information it provided. It misled us about a number of relevant facts. Usually if not always, it managed to do so without quite lying.

Misleading toward the truth is exceedingly common. It is well-intentioned – or at least it is grounded in a normal mix of self-serving and altruistic intentions.

So what’s the problem? Misleading people, even toward the truth, is a very dangerous behavior. If and when people learn they have been misled, they have great trouble thereafter believing the truth they were misled toward. If and when they discover that the company or agency they have been listening to cannot be trusted, they jump to the conclusion that the facts it withheld or papered over must be damning. In our field, risk communication, this is predictable – as sound as Sound Science gets.

If you hide information from people because you are afraid they will misinterpret it, and then they find the information you hid, they are bound to leap to the very misinterpretations you feared. And so once you start to mislead people, even toward the truth, you are started down a path from which retreat is extremely difficult – a slippery slope more than a path. The “soft cover-up” of hyperbole and de-emphasis morphs into more aggressive strategies of distortion and deception, and not infrequently ends in outright lies. This isn’t a new or hotly debated insight: “Oh what a tangled web we weave….”

Of course you don’t always get caught. Sometimes you start with hyperbole and de-emphasis and that does the job. People stay calm, the media lose interest, and nobody quite notices that your assurances went beyond your facts. While the USDA’s efforts to mislead us toward the truth about mad cow disease were still in the early stages, officials at state agriculture departments in Texas and Delaware faced local outbreaks of avian flu. Both issued Day One statements that were prematurely over-reassuring. The Texas statement turned out wrong on whether the local bird flu outbreak was a virulent strain or not – but officials managed to contain the outbreak anyhow and nobody complained about the earlier misstatement. The Delaware statement also said the local strain was comparatively mild, and turned out right, though officials didn’t finish identifying the strain until three days later. Arguably, the Texas and Delaware ag departments were doing something much more serious than what the USDA was doing. They were misleading without actually knowing the truth. But neither department faced public challenges to its credibility. So they presumably think they did a typical good communication job. What they did is get away with a typical bad communication job. Because they got away with it, they probably don’t even know they did it.

We are willing to bet that few if any USDA officials thought they were misleading the public about mad cow disease. Especially at the beginning, they were leading the public, helping us understand the capital-T Truth by carefully massaging a few lower-case-f facts. Toward the end, as their prior misleading over-reassurances began to unravel, they may (or may not) have resorted to cover-up efforts that are harder to be self-deceptive about. Among the charges now being leveled at the USDA are things like doctoring official documents to support prior claims. Even if these charges are true, USDA officials are likelier to feel like victims than like perpetrators. After all, they were only trying to keep people from over-reacting.

When you start out misleading toward the truth, you feel like you’re doing nothing wrong. If you get away with it, you feel like you didn’t do it. And if things go south and your dishonesty escalates, you feel like you had no choice – while the rest of us, who didn’t get caught, feel like we would never do what you did!

We don’t know yet how far down the slippery slope the USDA actually slid. But we will. It is now under increasing attack not just by the usual activist groups but also by committees of Congress and even by criminal investigators at the USDA Office of Inspector General. And nearly all its critics believe or claim to believe that the USDA miscommunications they are examining are evidence that mad cow disease threatens the health of American consumers.

Mad cow disease is not likely to threaten the health of many American consumers. And so far, American consumers are paying relatively little attention to mad cow disease. Domestic beef consumption declined only briefly in December, if that. By the time the USDA miscommunications started really unraveling in February and March, Americans’ attention was elsewhere. A number of newspapers ran editorials criticizing the USDA’s lack of candor, but our usual “meters” of public attention, Google News and CNN, showed barely a ripple. Perhaps the Martha Stewart trial was filling the niche in media coverage and public consciousness reserved for malfeasance in high places.

Now is a good time to document the USDA’s early steps in the wrong direction – while the public still isn’t paying much attention and there is still time for the Department to change course and deal candidly with its critics.

We are going to look at nine instances of misleading USDA communications about mad cow disease. Here they are:

Please notice that phrase: “encouraged us to think….” In an earlier draft we wrote “claimed or implied” instead, but we decided that this was a little unfair to the USDA. Sometimes the Department did make one or another of these nine claims explicitly. But it did a lot more implying than claiming; occasionally, on some of the nine points, it even explicitly acknowledged the less reassuring side of the truth. Usually what it did is encourage these nine misimpressions. It implied them when it could; when journalists got them wrong it usually left the record uncorrected; when journalists asked about them explicitly it usually changed the subject.

Much of what happened after December 23 reflects the important distinction between traditional public relations and not-so-traditional risk communication. (See “Four Kinds of Risk Communication.”) PR, or at least the classic stereotype of PR, sells your side of the story hard and pretty much ignores the other side. That works just fine when your audience isn’t paying much attention and isn’t frightened, angry, or suspicious. Newer approaches to risk communication tell a much more balanced story, bending over backwards to concede your critics’ best points and to acknowledge an attentive public’s worries. This is the strategy of choice when talking to attentive, emotional, or skeptical audiences – or to audiences that are likely to become attentive, emotional, or skeptical. The USDA rightly does lots of PR on lots of routine topics. It was a mistake to do PR on mad cow disease.

But even traditional PR tells you that misleading people is likely to backfire big-time. We’re not going to focus on the many things a risk communication advisor would have urged the USDA to do: aggressively acknowledge the “yuck” factor of slaughterhouses in general and BSE in particular; give credit to critics and worried publics when taking new precautions; legitimize the public’s emotional reactions and other countries’ commercial reactions; share dilemmas and solicit input from a wide range of viewpoints; establish accountable ways to prove claims instead on leaning so heavily on trust; etc. We will focus instead on something even a PR advisor should stress: Don’t mislead people, not even toward the truth.

We are also confining our analysis almost entirely to the communication efforts of the U.S. Department of Agriculture. We will save for another day any extended discussion of the other major communicators in the campaign of reassurance launched on December 23, including the Food and Drug Administration and the various industry sources. And we will not dwell on what seems to have been a conscious decision to have minimal involvement from human health experts (such as the Centers for Disease Control and Prevention) or from state authorities in Washington where the index cow was found.

We understand that it is tempting to pronounce the whole mad cow experience of winter 2003–2004 a communication success. After all, people haven’t panicked, beef prices haven’t plummeted, and at least so far heads at the USDA haven’t rolled. But the U.S. Department of Agriculture, and by extension the U.S. government, has lost stature as a credible, reliable source of information in a crisis – stature it could ill-afford to lose, stature it will need if and when a more serious crisis arises.

Nine Instances of Misleading Mad-Cow Communications

What follows is not a damning story; it is for the most part a “darning” story, regrettable but typical. As you read, remember: We’re not writing about a major health threat or a major government cover-up. This is a case study of pretty ordinary misleading communication about a risk that is statistically pretty minor. In other words, this is a case study of something any of us might end up doing … and why we shouldn’t.

1. The USDA encouraged us to think that December’s mad cow changed nothing.

link up to indexWe start with the softest aspect of the USDA’s initial “soft cover-up” – the use of hyperbole and de-emphasis, overstatement and understatement, to give the impression that nothing has changed.

It started on Day One, with the USDA’s media briefing and Agriculture Secretary Ann Veneman’s comment: “I, personally, do not hesitate to recommend to anyone that beef is absolutely safe to eat.” Comments like this were rife throughout USDA communications about BSE, but this Day One quotation from the USDA’s top official is especially revealing. Bear in mind, this was mere hours after the confirmation that the U.S. had found its first mad cow. Many questions were unanswered. At the very least, a statistical reanalysis was called for; the USDA’s best estimate of how many mad cows there are in the herd had to go up, now that the testing total was 1-in-60,000 rather than 0-in-60,000. Granted, the “index cow” (the one they found) was a lot older than most of the cattle slaughtered for food – old enough to have incubated BSE, even old enough to have eaten contaminated food before the cattle feed regulations changed. Most of the 60,000 cows tested were older cows; younger ones are a lot less likely to be BSE+. Even so, the purpose of the USDA surveillance program was to see if the U.S. had any mad cows; specifically, to see if more than one in a million adult cows in the U.S. herd had the disease. Well, they saw. As of December 23, the answer was yes. But Secretary Veneman said pretty much exactly what she would have said a week earlier: U.S. beef is “absolutely safe.”

So what does it mean to Ann Veneman that we found a BSE+ cow? It means the system is working. (In prior years we didn’t find a BSE+ cow. That also meant the system was working.) As Veneman put it at that first media briefing:

The presumptive positive today is a result of our aggressive surveillance program. This is a clear indication that our surveillance and detection program is working.

What else could Secretary Veneman have said? “Obviously, this is bad news.” “We understand how upsetting this news must be, and we can hardly blame people who want to avoid eating beef for a while, at least until we learn more.” “Even though we always knew our surveillance program might possibly find a BSE+ cow one day, we were hoping it would never happen.” “Now that we have found our first mad cow, we will be rethinking our regulations and deciding what additional precautions might be appropriate.” Of course she should also say reassuring things, explaining why she thinks the number of mad cows in the U.S. herd is low (but probably not as low as she thought before we found one) and why she thinks the human health risk is also low (but, again, not as low as she’d have said yesterday).

What did Veneman mean when she said the system was working? Conceivably she could have meant that the system was designed to deliver a warning if the U.S. had a mad cow problem, and the warning had been delivered. But nobody thinks that was her message. Rather, “the system is working” was clearly meant to translate to “the risk is negligible.” How was this alchemy accomplished? How was discovering a mad cow reframed as good news? One key was to convey the misimpression that the surveillance system was supposed to keep BSE out of the food supply by detecting the first case if it happened. December’s mad cow was the first case the U.S. actually found through its limited BSE testing program. Without ever claiming it was the first case we had, the USDA managed to give that impression, reinforced by the oft-repeated phrase, “the single case.” First case found = first case period = only mad cow in the herd. So the meat supply is absolutely safe. This implication warred with the USDA’s endless insistence that its surveillance program was never meant to be a food safety program, prompting the obvious follow-up from reporters: “If you don’t have a food safety program for BSE, how can you assure us so confidently that the food supply is safe?”

Should Veneman and the USDA have given people some reassurance? Sure – but only in the context of acknowledging the new reality: The United States is now officially not BSE-free, and everyone, from our trading partners to our meat consumers to our regulatory policy-makers, will need to decide how to respond.

Instead, the USDA sounded weirdly happy. People were feeling anxious – not panicky, and not for long, but for a while there people were anxious. And instead of affirming our anxiety, joining in our anxiety, and helping us cope with our anxiety, the USDA told us there was nothing whatever to be anxious about. Officials sounded pleased, even proud – enthusiastic that finding the index cow was “proof” the USDA’s “aggressive surveillance system” is “working”. The food supply was “absolutely safe.” There was “virtually no risk” to health. The U.S. had found its first mad cow, that cow had made its way into the food supply, nobody knew for sure how many more there might be, and as far as the USDA was concerned nothing had changed.

2.  The USDA encouraged us to think that cows don’t eat cow tissue any more.

link up to indexIn 1997, the U.S. passed new feed regulations aimed at preventing tissue from cows and other ruminants from ending up in cattle feed. Similar regulations had been passed by the United Kingdom in 1988. This wasn’t about “restoring nature” (left to themselves, cows are herbivores); it was explicitly about stopping the spread of BSE. As regulations usually do, the new U.S. regs had some exceptions. For example, it remained legal to use cow blood as a protein source in feed for calves not fed their mothers’ milk – a particularly disgusting factoid that stuck in many minds after the U.S.’s first known mad cow made such things newsworthy.

The question of how often cows somehow end up consuming cow tissue despite the 1997 regulations is an empirical question with health implications, since that’s the main way BSE is transmitted. The “yuck factor” is a different but overlapping issue. Critics of USDA policies and alarmists about BSE naturally make use of the yuck factor, capitalizing on the vivid imagery of cannibal cows tearing into the flesh of their neighbors, or of vampire calves weaned prematurely from their mothers’ milk and forced to drink cow blood instead. It isn’t like that. Processed protein product derived from cow tissues looks for all the world like granulated brown sugar; there are no hamburgers in the feed trough. And the plasma derivative added to calf diets has had the red blood cells removed; it’s been heated and treated and isn’t recognizable as blood. (The critics and alarmists know all that, of course. They, too, feel entitled to mislead their audience toward what they consider to be the truth.)

So why do we risk losing credibility with those who know better by referring to “cows eating cows”? Because the only way to address the yuck factor is head-on. You can’t correct a disgusting but misleading image by ignoring it, or by trying to substitute less dramatic imagery. You have to concede that people are repelled by the idea of cannibal cows and vampire calves, explain that the reality is disgusting enough though not as bad as these images imply, and go on from there. Other risk controversies provide plenty of precedents: “explosion” versus “rapid oxidation”; “sewage sludge” versus “biosolids”; vaccination “horrific side effects” versus “adverse events.” The side with the euphemisms is rarely the side that wins.

Besides the exceptions in the 1997 regulations, there were at least three other ways cow tissue could end up eaten by cows: (1) Feed manufacturers could accidentally or intentionally add cow tissue to cattle feed. (2) Farmers could give their cattle other food sources that contained cow tissue – chicken feed, for example, or restaurant plate-scrapings. (3) Cattle could eat something they weren’t intended to eat – pig feed, hay contaminated with stockyard offal, whatever was lying around.

Then of course there’s the matter of enforcement. The USDA referred often to the regulatory “firewall” that keeps cow carcasses out of cattle feed. Unless pushed, it didn’t talk much about the enforcement record, preferring the unstated assumption that regulations are invariably followed. It was left to activist sources like Public Citizen and Friends of the Earth to direct reporters to the FDA web page where violators of the feed regulations are listed. A government agency that seems to assume all regulations are always obeyed can hardly be convincingly reassuring!

Pushed to talk about enforcement, the USDA offered assurances of “over 99% compliance” with the feed ban regulations. It didn’t tell us what a one percent failure rate might add up to, how many cows might have eaten cow tissue from time to time. More importantly, it didn’t acknowledge that 99% was a recent accomplishment. The Food and Drug Administration, which actually enforces feed regulations, was more candid. At the Day Two USDA media briefing, the FDA’s Stephen Sundlof said:

I’ll just tell you, though, that the compliance rate is extremely high, it has been increasing since the ban went into place in 1997…. At that time we had about 75 percent of the firms were in compliance with that, with our feed ban. Since then, we’ve achieved a level of 99 percent compliance with the beef ban. So the compliance has improved dramatically during that time.

So there are plenty of cows still around who have eaten feed dating back to the days of less-than-99% compliance – a reality nobody at the FDA or the USDA cared to emphasize.

And there are grounds for questioning the FDA’s confidence about compliance. In January 2001, The New York Times had reported: “The widespread failure of companies to follow the regulations, adopted in August 1997, does not mean that the American food supply is unsafe, Dr. Stephen Sundlof, director of the Center for Veterinary Medicine at the F.D.A., said in an interview. But much more needs to be done to ensure that mad cow disease does not arise in this country, Dr. Sundlof said.” The Times said Sundlof’s report stated that 16 percent of 180 large rendering companies were not properly labeling their products and did not have a system in place to prevent commingling of ruminant and nonruminant materials; among small feed mills, 40 percent were using improper labels and 25 percent had no system to prevent commingling.

In 2002, the U.S. General Accounting Office had strongly criticized the FDA for poor enforcement of the feed ban. It noted poor reinspection follow-ups of previous violators, and said: “FDA’s data on inspections are severely flawed and, as a result, FDA does not know the full extent of industry compliance.”

Five days after December’s mad cow was found, UPI wrote: “In July [2003], the FDA took legal action against X-Cel Feeds Inc., of Tacoma, Wash., a feed manufacturer, because the firm had violated the feed ban and had incorporated cattle tissue into cattle feed. However, X-Cel’s violations go back some 14 years to 1989 and FDA never moved to shut down operations or warn ranchers the feed contained improper material.”

In early March 2004, after the criminal investigation of the USDA was announced, the Associated Press reported:

The GAO, a watchdog agency for Congress, is checking the FDA’s claims of near-total compliance with a ban aimed at keeping the protein that causes mad cow from being transmitted through animal feed, said Larry Dyckman, who is heading the congressional investigation.

We are not asserting that enough cow tissue gets eaten by cows to represent a substantial risk of a BSE epidemic in the U.S., and thus a substantial risk of vCJD among U.S. beef-eaters. Most regulations are porous. They are designed to work “well enough,” not perfectly. We can be easily convinced that the U.S. feed regulations do in fact work well enough – but not by a government agency that encourages us to think they work perfectly.

Banning cow tissue in cattle feed hasn’t always worked well enough. The U.K. imposed a ruminant feed ban in 1988. By 2000, approximately 40,000 U.K. cows born after the feed ban had nonetheless been confirmed BSE+. The U.K. Government’s Report on the BSE Inquiry stated:

When the ruminant feed ban was introduced on 18 July 1988, hopes were high that the BSE epidemic would subside relatively quickly. Hence the dismay and alarm when confirmed cases of the disease in cattle born after the ban, having started as a trickle in 1991, then rapidly increased to a peak in 1994. Cross-contamination of feedstuffs was blamed as the most likely cause.

We trust that the USDA and the Harvard University Center for Risk Analysis are right when they stress that the U.S. initiated its feed ban with a lot less BSE already in the herd than was the case in the U.K., so we are not remotely headed for a U.K.-like epidemic. Nonetheless, the U.K.’s experience clearly demonstrates that cross-contamination between different kinds of animal feed is not uncommon. The USDA’s firewall is not perfect, and the USDA should say so. People are more likely to buy a documented argument that the firewall works really, really well if the USDA starts by conceding that it isn’t perfect, that it hasn’t always worked all that well, and that we aren’t fools to wonder if it is adequate this time.

3.  The USDA encouraged us to think that no nerve tissue gets into beef.

link up to indexJust as the BSE risk to cows usually comes from consuming infected cows’ nerve tissue, so does the vCJD risk to humans. People who routinely eat cow brains and the like are taking a higher risk than those who confine themselves to muscle meat.

It isn’t as clear as the USDA would like us to think that muscle meat cannot carry BSE, though it is certainly clear that central nervous system (CNS) tissue is far riskier. The big question is how much nerve tissue gets into the muscle meat – and especially into ground beef. The USDA immediately and consistently promoted the strong misimpression that there was virtually no chance that cow central nervous system (CNS) tissue could contaminate processed beef. Chief veterinarian Ron DeHaven put it with typical absence of nuance on December 29: “There is also no reason to question the safety of the U.S. beef supply. Muscle tissue or cuts of meats are safe.”

Of our nine areas of misleading reassurance, this is the one the USDA emphasized most frequently and most explicitly, ignoring readily available contrary information from mainstream sources.

It’s easy to understand why the USDA felt pressure to encourage the misimpression that muscle meat never contains CNS tissue. By the second or third day of the story, it became clear that the mad cow’s muscle meat had entered the human food supply before the BSE test was even done. Until after December 2003, this was Standard Operating Procedure for U.S. slaughterhouses. But the USDA assured us that at least the most dangerous parts of that mad cow hadn’t been made into human food. On Day Four, the recall widened to include four more states, in addition to the four previously announced. USDA food safety official Dr. Kenneth Petersen said, “The recalled meat represents essentially zero risk to consumers,” emphasizing that the infectious parts of the diseased cow – brain, spinal cord, and lower intestine – had been removed.

The USDA was as certain of this as it was that the cow was a downer, but perhaps with even less evidence. We haven’t been able to tell from published reports if the vet on site actually observed the removal, or if it is simply assumed to have taken place because that was the required procedure. USDA food safety rules in effect on December 23, 2003 allowed brains, spinal cords, and most other potentially infectious parts of slaughtered cows – including downers not tested for BSE – into the human food supply, as long as the cow “passed” inspection, as the index cow did. The only “passed” cows required to have their central nervous system parts removed from the human food supply were the cows actually chosen for BSE testing. The index cow was certainly tested for BSE. But given the debate that has emerged over whether the cow was really a downer, it is fair to ask who actually saw what happened to the rest of its CNS tissue. And the USDA has published nothing whatever that we can find about any contamination tests it might have done on the meat recovered in the recall.

Many journalists and consumers were aghast to learn that sick cows were allowed into the food supply at all, let alone that they were allowed in before they were tested. The misimpression that downers were kept out of the food chain isn’t on our list of nine. But it could be. As with many of the other misimpressions, USDA officials didn’t claim it was true; they just let people assume it was true. Others sometimes claimed it was true. Shortly after Canada found a mad cow in May 2003 (preceding the U.S. by seven months), New York Representative Gary Ackerman told the House of Representative that downer animals carried the highest risk for mad cow disease, and showed a picture of a crippled cow. Texas Representative Charles Stenholm, who is also a rancher, insisted that current USDA BSE screening was sufficient: “The picture the gentleman is showing, that sick animal, will never find its way into the food chain. Period.” This anecdote was reported by The New York Times on December 28, 2003, five days after the U.S. found its own mad cow – and about the same time the USDA was outlining its new BSE rules. Downers must now go straight to rendering, and may not be processed into meat at all.

Given the bad news that downer meat was legal, and that meat from the nation’s first known mad cow was already in the food supply, the USDA understandably went to great lengths to reassure people that mad cow meat wasn’t dangerous because it contained no nerve tissue.

Here’s Dr. Elsa Murano, undersecretary for food safety, at the Day One media briefing:

You should know that the tissues that are the infectious tissues from an animal that has BSE, that is the central nervous system tissues, the brains, spinal cord and so forth, of this animal did not enter the food supply. Those tissues [went] to rendering. So they did not enter the food supply. That’s very important to know…. Again, the muscle cuts are where there is virtually no risk of BSE. The material, the brain, spinal cord, distal ileum, which is where the BSE agent resides, those materials did not enter the food supply.

And Secretary Veneman at the same briefing:

But again, one thing that is important to remember is that muscle cuts of meats have almost no risk…. So the fact that it’s gone to further processing is not significant in terms of human health…. [A]s Dr. Murano just indicated, there is virtually no chance that the meat has been contaminated … so we really don’t believe that there is, we believe that the risk of any kind of human health effect is extremely low.

And Veneman the next morning on the Today show:

[Because it was a downer scheduled for testing] as a matter of course the brain and spinal column were removed from this cow. And that would be the material that would cause concern in terms of human health. And, therefore, we are confident in the safety of the food supply.

And the USDA’s Ron DeHaven at the Day Two media briefing:

Any infectious tissues would have gone to rendering and would not have gone to the human food chain and any of the tissues that would have gone for human consumption would be safe tissues even if they came from an infected animal.

There are really three issues here. (1) Does the USDA really know that the nerve tissue from the BSE+ cow was sent for rendering, or does it know only that that’s the prescribed procedure? (2) Even if the procedure was followed, what about the risk from secondary meat byproducts like lard, beef tallow, and gelatin, used in foods of all sorts? (3) And even if the procedure was followed, why is the USDA so confident that no nerve tissue remnants contaminated the muscle meat that went into the food supply? The third issue is the one that got the most attention.

We can find only one time when USDA spokespeople came close to acknowledging that muscle meat from a BSE+ cow might not be entirely risk-free. In the Day Two media briefing, Veneman announced that the slaughterhouse was voluntarily recalling (or trying to recall) “approximately 10,410 pounds of raw beef that may have been exposed to tissues containing the infectious agent that causes BSE.”

With this exception, USDA sources kept telling us that muscle meat is perfectly safe. We “know” that neurological tissue from the December 23 mad cow didn’t get into the food supply because slaughterhouses aren’t supposed to use neurological tissue from downers picked for BSE testing. And even though neurological tissue from cows not tested for BSE does go into the food supply, we “know” that ordinary cuts of beef are just muscle meat and are therefore safe. (Let’s not talk about hotdogs or sausages, lard or beef tallow or gelatin.)

It was left to insider whistleblowers to point out that slaughterhouses cut as close to the bone as they can get, and sometimes a little neurological tissue goes into the mix. Facts about retractable bolt stunning, carcass-splitting, and automatic meat recovery (AMR) systems emerged gradually from activists, journalists, and other unofficial sources. These are all meat processing technologies that increase the probability of nervous tissue winding up in muscle meat.

We learned from activists – who got the information from the National Cattlemen’s website – that a 2001 Colorado State University study showed that more than 50% of AMR neck bone beef samples were contaminated with CNS tissue, and that hamburger patties from six out of seven major suppliers to large fast food chains had detectable CNS tissue as well. The USDA never mentioned the study. It preferred us to imagine that beef-eaters aren’t also eating small amounts of brain and spinal column.

Similarly, it was left to Friends of the Earth to cite studies by the USDA itself showing that 35% of AMR meat is contaminated with neural tissue. The USDA didn’t get to put this information into perspective because the USDA wasn’t talking about it. This is typical of one-sided, over-reassuring rhetoric (“knee-jerk under-reaction”): It hands outside experts and critics the role of putting safety data into perspective.

The USDA’s insistence that muscle meat is free of nerve tissue didn’t stop it from taking further steps. A week after telling us that it had already taken all imaginable precautions against BSE-contaminated meat, the USDA announced a new rule that prohibited AMR-produced products “labeled as meat” from including “dorsal root ganglia, clusters of nerve cells connected to the spinal cord along the vertebrae column, in addition to [previously prohibited] spinal cord tissue.” This is in keeping with a long tradition, common to government and industry alike, of solving a problem while denying that there is any problem. The new policies could be aimed at closing a loophole that might pose a genuine risk. Or they could be aimed at reassuring an understandably distressed public. Attributing them to “an abundance of caution” and letting it go at that contributes to a general mistrust of the USDA’s “sound science.”

One way of nailing the issue would have been to test the meat from the recall that followed the December 23 discovery. Much of this meat was never recovered and some undoubtedly got eaten. But the USDA recovered what it could – not just meat from the index cow, which couldn’t be identified separately, but meat from all cows slaughtered at that time and place. Patiently, over and over, USDA sources explained that even meat from the index cow, the one with BSE, was safe to eat, since it was muscle meat. The USDA was attempting a recall anyway in “an abundance of caution.” Interestingly, nothing was ever said publicly about whether the recalled meat was tested for CNS tissue … including, conceivably, CNS tissue infected with BSE prions. We don’t know if the USDA did such tests or not. If it did, we don’t know what it found. That is, we don’t know whether the USDA didn’t want to know, or just didn’t want us to know. Our guess (but it’s just a guess):  They figured they’d probably find some CNS tissue, so they didn’t test.

This whole discussion of how much nerve tissue gets into muscle meat ignores the larger reality that people consume cow tissue in lots of ways other than eating meat. As vegetarians know and the rest of us tend to forget, cows are made into all sorts of beef byproducts such as gelatin, which turn up in foods from marshmallows to mayonnaise, from beer to yogurt. In the Federal Register for January 12, 2004, the USDA describes the current rules for cow brains:

Cattle brains are also permitted to be used as a source material in edible rendering. Edible rendering involves the processing of materials inspected and passed for human food into products, such as edible oils, meals, beef extracts, beef protein, beef broths, beef stocks, and beef flavorings.

In more public places than the Federal Register, the USDA tried to avoid discussing how much nerve tissue gets into beef byproducts. Activists and critics, of course, did not.

4.  The USDA encouraged us to think that non-downer, non-symptomatic cows can’t have BSE.

link up to indexThe USDA never actually said that only downers are infected with BSE. They couldn’t possibly say it. Japan, the U.K., and perhaps other countries have actually found healthy, walking-around cows that tested BSE+. And a moment’s thought reveals that obviously a cow has to get BSE before it can get sick from BSE … which means it’s infected before it’s sick. The day before a BSE+ cow is no longer able to walk, it is a BSE+ cow that can walk.

More importantly, a BSE+ cow can be infective (capable of passing the disease along) before it is symptomatic. The USDA was well aware of BSE experiments in the U.K., in which oral doses of infected cow brain were given to cattle, which were then sacrificed at specified intervals to see how long it took for various organs to become infective, and to correlate this with actual symptoms. In the January 12, 2004 Federal Register, the USDA commented on these UK studies:

In some cattle in the studies, BSE infectivity was demonstrated in the brain, spinal cord, and DRG as early as 32 months post oral exposure to the BSE agent. In addition, infectivity was demonstrated in these tissues three months before animals began to develop clinical signs of the disease.

On December 24, Day Two of the story, CNN’s Soledad O’Brian asked Ann Veneman exactly the right question about getting BSE from healthy cows:

I know this time you test all of those downed cows or the ones that are so sick they can’t walk to the slaughter. But my understanding is that Mad Cow Disease can incubate for up to six years. So theoretically couldn’t a perfectly healthy cow have Mad Cow Disease and be off to the slaughter and the parts that you are concerned about, the brain and the spinal cord could make their way into human consumption?

Leave aside O’Brian’s mistaken belief that all downers were tested; we’ll get to that next. What she wants to know is why non-downers can’t have BSE. This is Veneman’s chance to say they can. Instead, she replied that “in this country we take every precaution” and “we’ve taken every imaginable step that we can to prevent BSE….”

Without ever making the claim, the USDA did everything it could to perpetuate the misimpression that walking-around animals are guaranteed to be BSE-free, and are thus absolutely safe to eat. Ironically, the best evidence that this effort succeeded is the furor that arose over questions about whether the December 23 index cow was actually a downer. That’s the issue that provoked the House Government Reform Committee to initiate an investigation. A February 16 letter from the committee chairmen to Ann Veneman pointed to information apparently showing that the USDA had long known some tested cows weren’t downers, possibly including the one that tested positive.

The committee’s letter says this information “challenges a key principle guiding USDA’s surveillance program for BSE, which is that all infected cattle in the United States will either be downer cows or show symptoms of central nervous system disease….” Committee spokesman David Marin made the same point to the media after news of the letter broke: “If indeed it is true that the [only known] infected cow in the nation was walking around, then clearly it’s not safe to assume that all infected cattle will be downers…. That in turn has serious implications for the Agriculture Department’s surveillance program and serious ramifications for the information that has been shared with the public.”

These statements accurately reflect how successfully the USDA misled us. Now USDA officials will claim that they never actually said that only downers were infected or infective – and they didn’t. They will start parsing their own previous words, to prove that they were only pointing out that downers were the highest-risk animals and therefore especially useful to test, not implying that healthy-looking walkers couldn’t ever be BSE+.

But millions of reasonably intelligent people, including Republican and Democratic Congressmen paying more than the usual amount of attention, absorbed the reassuring but inaccurate message that non-downer cows are “absolutely safe.” Yes, USDA officials never denied the truth: that every single infected downer cow, every single infected symptomatic cow, was walking around normally the day before it started acting sick – and would have tested BSE+ the day before too. But USDA officials never stated that truth either. And they misled us into believing it wasn’t so, no matter how deniable their parsed words sound to themselves.

The fact that BSE+ non-downers exist wasn’t exactly covered up. It just wasn’t one of the USDA’s talking points. Plenty of outside commentators pointed to the Japanese and U.K. findings, and to the logical necessity that BSE+ non-downers must exist. If you read those outside commentators, you were left with the impression that the USDA had its head in the sand. If you didn’t read them – if you followed the story via TV news sound bites of USDA media briefings – you were left with the impression that healthy cows can’t have BSE. Worst of all, if you followed the story via TV news at first and then after a while started reading the outside commentators, you were left with the impression that the United States Department of Agriculture was trying to mislead you.

5. The USDA encouraged us to think that every downer cow was tested.

link up to indexOn Day One of the crisis, Agriculture Secretary Ann Veneman told the press that “it is our standard operating procedure that what they call downer animals will be tested if they come to the slaughter facility as a downer animal.”

It took a few of days for reporters and the public to realize that not all downer cows – in fact, very few downers – are “tested” in the sense we all assumed Veneman meant. All downer cows are supposed to be looked over by an inspector on site, which gives Veneman a way to weasel out of claims she lied. But testing for BSE requires a laboratory analysis of a brain sample. This is surely what normal people interpreted Veneman to mean, and what she had to know they would interpret her to mean.

It is certainly what reporters on Day Two of the story thought she meant. The quotations that follow are taken from a transcript (release no. 0439.03) on the USDA’s own website. It is December 24, 2003 (Day Two), and Veneman is on CNN’s “American Morning ”show. Reporter Soledad O’Brian repeatedly expresses surprise that meat from downer cows can get to supermarket freezers. Then she asks the Secretary a question. We quoted O’Brian’s question before in our discussion of whether healthy cows could have BSE. Now we’re focusing on the question’s embedded assumption that all downers are tested:

I know this time you test all of those downed cows or the ones that are so sick they can’t walk to the slaughter. But my understanding is that Mad Cow Disease can incubate for up to six years. So theoretically couldn’t a perfectly healthy cow have Mad Cow Disease and be off to the slaughter and the parts that you are concerned about, the brain and the spinal cord could make their way into human consumption?

Veneman ignores O’Brian’s embedded error that every downer is tested, replying that “in this country we take every precaution” and “we’ve taken every imaginable step that we can to prevent BSE….”

A little later in the interview, O’Brian again asks a question with the embedded assumption that all downers are tested for BSE:

Why don’t we do what they do in Great Britain and across Europe which is test every single animal that’s slaughtered as opposed to just the ones that are downed or the ones that are clearly showing evidence of sickness?

Veneman’s answer includes even more categorical over-reassurance:

[We] are confident the steps we have taken in the past have done everything we can to lower to the greatest degree possible our risk of BSE and in particular for BSE in the food supply….

At no point does Veneman correct O’Brian’s incorrect assumption that all downed or sick cows are tested. After Veneman has left the studio, CNN medical correspondent Sanjay Gupta shows that he has absorbed the misleading information:

What’s sort of interesting though, and I think you [O’Brian] pointed this out, was that they have mandatory testing of all cows that are acting funny or downed cows as they call them. But they don’t automatically quarantine that meat.

It is extremely unlikely that Veneman thought of herself as lying. She didn’t even actively mislead. All she did is let an inaccurate assumption go uncorrected when the truth was less reassuring. The truth is that only a small percentage of downers were tested for BSE as part of the USDA’s BSE prevalence surveillance program. This kind of early over-reassurance made the story sound that much scarier over the next few days, as the public learned more about the BSE surveillance program that wasn’t a food safety testing program after all.

When journalists report information that officials consider overly alarming, the officials typically correct the reporters. But when Veneman did not correct Soledad O’Brian’s overly reassured and overly reassuring assumption that all downer cows were “tested,” this was also typical.

6.  The USDA encouraged us to think that every cow tested – including December’s mad cow – was a downer.

link up to indexWe come now, finally, to what actually got the USDA into hot water: the claim that the BSE+ cow discovered on December 23 was by all accounts a downer, too sick to walk.

At the Day One media briefing, Secretary Veneman put it this way: “The animal tested was a downer cow or nonambulatory at the time of slaughter and was identified as part of USDA’s targeted surveillance program.”

The next day, December 24, slaughterhouse owner Tom Ellestad told his local paper, the Columbia Basin Herald, that the index cow wasn’t a downer. He made strenuous efforts to make sure that USDA officials knew that he thought the cow wasn’t a downer. It was right there on Google News for everyone to see: “Ellestad, whose father Vern started the business in 1961, said the cow which was found to have mad cow, or bovine spongiform encephalopathy disease was not a ‘downer,’ or a cow that cannot walk, as it initially had been reported by the media.”

For weeks, national reporters did not pick this up as an issue. Despite repeated correspondence from Ellestad, the USDA didn’t acknowledge the issue publicly until February 2004, when it was dragged kicking and screaming into the story by a letter from the House Government Reform Committee, which had already been investigating the downer-or-not question for a month. In their February 16 letter to Ann Veneman, committee chairman Tom Davis and ranking Democrat Henry Waxman noted that the USDA had not released to the public a January 6 fax from Ellestad, asserting the cow was not a downer; it also noted that Ellestad had a policy of not accepting downers, a policy known to the USDA when it signed a contract with him to provide up to 1,000 cow brains for testing at $10 a sample.

As often happens, concern about credibility went hand in glove with concern about hazard. The February 16 letter said the downer controversy, and the fact that the public wasn’t told about it, “could have serious implications for both the adequacy of the national [mad cow] surveillance system and the credibility of the USDA.” Angry newspaper editorials made similar demands for stricter BSE prevention standards. This illustrates the “Risk = Hazard + Outrage” phenomenon that underlies our approach to risk communication. If the source is less than honest, people reason, the hazard must be less than safe.

Two days later, on February 18, USDA spokeswoman Julie Quick acknowledged that the USDA’s own inspector general had been investigating the issue of whether the cow was a downer for several weeks. But the USDA did not tell the public this until after news of the House committee’s letter broke. USDA spokesman Ed Loyd said, “Our records clearly indicate that this animal was not able to walk.” And USDA Food Safety and Inspection Service spokesman Steven Cohen insisted the cow was “absolutely” a downer.

But the evidence from slaughterhouse personnel that maybe it wasn’t a downer kept mounting. Defensive, knee-jerk over-reassurance wasn’t working as well as it had. And so the USDA began to hedge. Chief USDA veterinarian Ron DeHaven said on February 23:

Well, we’re basing our statement that the animal was [a] downer on the fact that there are records from the Food Safety Inspection Service veterinarian who examined this animal before slaughter. He examined her in a recumbent position on the trailer that brought her to the livestock market. Having said that, there is nothing saying that an animal that is down cannot get up. So in fact both accounts could potentially be true.

So maybe when the vet saw the cow it happened to be lying down. Sometimes a downer cow gets up again. Well sure, we think to ourselves. We’ve all seen cows lying down in a field; there used to be a folksy belief that meant rain was on its way. We can accept that healthy cows lie down sometimes, so it must be true that they get up sometimes too. But is that what the USDA meant by “downer” all this time?

The USDA never said anything like this in December or January. Late February was the first we heard that a “downer” could get up. So we checked out the definition of a downer on the USDA website, and read: “Downer Cattle: Cattle that can not rise from a recumbent position.” Well, it doesn’t say “…can never rise….” USDA apologists may manage to make “it was a downer” just barely consistent with “sometimes it walked.” What they cannot do is convince us that when they said they were certain the animal was a downer and didn’t tell us Tom Ellestad had a different opinion, they meant to help us understand the situation, rather than give us a false impression so we would be less worried.

On Day One the USDA taught us that a downer was a cow too sick to stay on its feet. Now that it looks like the index cow may have spent some time on its feet, the USDA tries to teach us that a downer is a cow that happens not to be on its feet at the moment. But at least it was down when the vet saw it, right? Well, maybe. In early March, the media reported that the internal body temperature record for the mad cow was missing from the vet’s report – and other vets, including former USDA vets, said this meant one of two things: Either the inspector had not followed the established protocol or the cow’s temperature couldn’t be taken because it was up and about. Also in early March, a criminal investigation was announced, focusing on whether any records had been falsified bearing on whether the index cow was a downer or not.

There it lurked between late December and mid-February, like a liability on the USDA balance sheet of trust: Tom Ellestad’s December 24 published statement that the index cow wasn’t a downer. Early on, it would have been easy for the USDA to tell us the downer-or-not issue was unclear or disputed. Instead, it ignored Ellestad and told us, endlessly, that the cow was a downer, period. It was nearly two months before the rest of the story began leaking beyond the Columbia Basin Herald. When it did, it came in the form of angry complaints of USDA cover-up, lodged by slaughterhouse personnel and taken up by activists and government investigators.

The controversy isn’t just about the index cow. The USDA has often implied that it tests only downers for BSE. But not always. USDA spokesman Nolan Lemon acknowledged to the Seattle Times that “downers weren’t the only source of samples, but they were a high source of it….” Out of 20,277 tests in the fiscal year ending in September 2003, Lemon said, 16,560 were downers and 3,090 were cows that died before arriving at the slaughterhouse. It’s not clear what the other 627 were – some may have been ambulatory but symptomatic; some were presumably healthy.

These numbers, too, are subject to debate. Ellestad has provided documents showing that his slaughterhouse does not accept downer cows, and that the USDA knew this. On February 24, 2004, the Seattle Times reported:

Ellestad said USDA officials repeatedly offered him up to $10,000 a year to participate in the testing program because they weren’t meeting their quotas in the Northwest region. He finally signed a contract to provide up to 1,000 brain samples for $10 each.

It isn’t clear yet how many of the cows tested under the USDA BSE surveillance program were downers, and how many were not. (Presumably most or all of the 250-odd cows already tested from Ellestad’s slaughterhouse were not.) But despite the USDA’s best efforts, it’s likely to get a lot clearer in the months ahead. The main technical reason this matters: Since healthy animals are less likely to have BSE, testing healthy animals is less likely to find BSE. The main nontechnical reason it matters: If the USDA said it was testing downers and other high-risk cows, it should have been testing downers and other high-risk cows.

The question of whether or not the index cow was truly a downer has become the smoking gun in a criminal investigation of the USDA announced on March 3, 2004. The fact that the downer issue is the smoking gun is itself proof that the USDA successfully misled us on another issue, convincing us that only downers can have BSE. Otherwise, why care if the index cow was a downer or not? There are some statistical reasons for caring that we’ll get to a little later. But for the critics, the issue was obvious. If a non-downer cow turned out to have BSE, then non-downer cows can have BSE. And if non-downer cows can have BSE, wouldn’t that undermine the whole basis for the USDA testing program?

It wouldn’t – but there is poetic justice to the fact that so many people think it would. Actually, as we have seen, walking-around animals can be BSE+; animals with BSE walk around until BSE or something else makes them sick. The reason for testing downers rather than non-downers isn’t because you’re sure that non-downers can’t have BSE. The reason for testing downers is because it’s efficient. Downers (that is, animals too sick to walk) are likelier to have BSE than non-downers. So a surveillance program that tests downers has a better chance of finding BSE than a program that tests the same number of non-downers. If (and it’s a big if) you can accurately estimate how much likelier a downer is to have BSE than a non-downer, you can use arithmetic to calculate from your downer data what you would have found if you’d tested non-downers. Thus you can test a lot fewer animals and get the same information. As the USDA asserted over and over, it was running a BSE prevalence surveillance program, not a BSE food safety testing program – its simultaneous assertions about the absolute safety of U.S. beef notwithstanding.

The USDA gave us the reassuring misimpression that non-downers can’t have BSE, that walking-around cows are absolutely safe, and that that was why it was testing downers instead of non-downers. Then the USDA learned that the index cow might not have been a downer after all, that it might have found a non-downer with BSE. That information promised to be much scarier to the public than it would have been if the USDA hadn’t misled us in the first place. And so the incentive for the USDA to keep it secret was all the greater. If the USDA had prepared us for the reality that walking-around cows can have BSE, then questions about whether the index cow was really a downer would have been far less inflammatory.

Let’s tease apart the different possible reasons for being unhappy that the index cow may not have been a downer after all. There are at least four:

1. It would prove a non-downer can get BSE, and that could mean the food supply isn’t “absolutely” safe. We’ve covered this one. Yes, a non-downer can get BSE; we’ve known that all along. It isn’t new knowledge casting doubt on the safety of the food supply. But by letting us think non-downers can’t get BSE, the USDA set us up for being shocked that the index cow might not have been a downer. This is the issue critics are focusing on, and it’s a bogus issue.

2. It would suggest a higher level of prevalence than if the index cow were known to be a downer. Nobody but techies thinks this way, but the techies are right. We know that, cow for cow, downers are likelier to have BSE than non-downers – which is why the USDA decided to test downers in the first place. If the index cow was a downer and so were all the other cows tested, then we’ve tested some 60,000 downers so far and found one BSE+ cow. But suppose the index cow wasn’t a downer; suppose (this is just a guess to illustrate the point) that 2,000 of the 60,000 cows tested weren’t downers (or symptomatic) either. That would mean we tested 58,000 downers and found no BSE+ cows. And now the bad news: It would also mean we tested a mere 2,000 healthy animals and found one BSE+ cow. Try extrapolating that fraction, one-in-2,000, to the whole U.S. herd, or to the number of cows that have entered the U.S. food supply, or even to the number of adult cows that have entered the food supply. You end up with some potentially scary arithmetic. If a small number of healthy cows were tested and one of them turned up BSE+, you’ve got to figure you could have way more than one mad cow in a million.

3. It might show that the USDA hasn’t been following its own surveillance protocol. It isn’t entirely clear what the USDA protocol was for its BSE surveillance program. The advantage of testing downers is they’re likelier to have BSE, so you can test fewer animals to get the same level of confidence about BSE prevalence. On the other hand, to draw conclusions about healthy animals from data about downers, you need to estimate their comparative likelihood of having BSE; a random sample of healthy animals would be statistically sounder (if it were large enough). However many downers and neurologically symptomatic non-downers the protocol said the USDA was supposed to test, if it turns out that’s not what got tested then the USDA is in trouble for violating its protocol.

4. It would prove the USDA has been less than candid, and that casts doubt on everything it says and does. Yes.

The Columbia Basin Herald, the local paper that first reported the downer controversy on December 24, 2003, got it exactly right in a February 21 editorial headlined “USDA Credibility Hurt”:

[W]hy should we worry about a matter of simple semantics? The answer cuts to the very heart of what we should expect from our government, especially in a crisis: the truth….

[W]hy emphasize the downer status from the beginning as evidence that beef is safe to eat?… [I]t was more politically convenient to place the outbreak at the fringe of the food chain, only inflicting animals that are easily identified…. Then we Americans can go back to our hamburgers and rib steaks, knowing full well the animal we are eating could walk and is therefore a far cry different from the dangerous mad cow….

To reiterate, we at the Herald do not feel the public should expend too much energy worrying about catching mad cow disease from infected beef…. But we do feel the public should worry about the quality of information coming from the USDA.

7.  The USDA encouraged us to think that every cow tested – including December’s mad cow – had BSE symptoms.

link up to indexHere’s the truth the USDA couldn’t possibly have denied but didn’t want us thinking about: Any cow might have been exposed to BSE, and any cow old enough to have had time to incubate the disease might be able to pass it on. A cow born before the 1997 feed regulations is likelier to have BSE than a younger one; a cow that can’t stand up is likelier to have BSE than a cow that’s walking around; a cow showing symptoms of central nervous system damage is likeliest of all to have BSE. But no cow is “absolutely safe.”

Back in late December and January, when we took it for granted along with nearly everyone else that the index cow was a downer (after all, that’s what the USDA had said), we pointed out in news interviews and a brief website Guestbook comment that this wasn’t a terribly significant fact, since it was a downer for reasons irrelevant to BSE. According to the USDA, the cow had recently given birth in what turned out to be a difficult delivery that left the animal unable to walk. We praised the USDA for being “steadfastly honest about revealing information it would rather not have revealed (even if it then ignores the implications of what it has revealed) – starting with the early revelation that the BSE-afflicted cow was discovered by a fluke.”

Of course USDA officials never used the word “fluke.” They noted the difficult delivery and then changed the subject, allowing most casual viewers, listeners, and readers to imagine that “downer” and “shows symptoms of BSE” meant roughly the same thing. Combine that with the other misimpressions we have documented – especially the misimpression that all downers were being tested and the misimpression that cows without symptoms can’t have BSE – and you begin to understand why the claim that our beef is “absolutely safe” sounded reasonable.

Consider this Day Two quotation from Secretary Veneman, appearing on the Today show:

My understanding from the early investigation is that this cow had given birth, and that it had not been able to get up since then. And that does happen in cows, so would not have created a lot of suspicion, although our standard procedure is to test downer cows and to remove any brain and spinal column….

The passage starts well, conceding that the index cow was tested because of post-partum problems, not because of BSE suspicions. Then it goes south, implying that all downers (not just a small percentage) were tested for BSE and that all downers (not just those that are tested) had their CNS tissue kept out of the food supply.

Even if the index cow was a downer, it was a downer with no visible signs of BSE. It was tested for BSE, the USDA admitted without emphasis or explanation, because of that bad delivery. Take away the bad delivery and it would have gone untested into the food supply, with no one ever the wiser. (That, of course, the USDA never said, though it gave us the information we needed to deduce it, and critics pointed it out frequently.) That the index cow got tested at all was pure good luck … or bad luck, as it must have seemed to some beleaguered USDA officials.

The best proof that people didn’t understand this is their strong reaction to the discovery that the index cow may not have been a downer after all. If the USDA had been candid from the outset about the relative unimportance of that cow’s being a downer, the revelation that maybe it wasn’t would have been a minor wrinkle. Imagine an early USDA media briefing that said things the USDA never said – that aggressively pointed out that it was just dumb luck we found the index cow at all; that acknowledged that any cow past the incubation period, including a healthy cow, could have BSE; that stressed that testing mostly downers is only an efficiency mechanism to reduce the total amount of testing needed; that stressed that the surveillance program pretty much guarantees that there’s not a lot of BSE in the food supply but “absolutely” does not guarantee that there’s no BSE at all. Now add the surprising discovery that the index cow might have been on its feet after all. No biggie.

Even more importantly, if the USDA had been candid from the outset about the relative unimportance of that cow’s being a downer, it would have found it a lot easier to be candid later about the dispute over whether it was actually a downer or not. The progress here from “soft cover-up” to what looks like it may have been a real cover-up – from obscuring the significance of some facts to hiding the facts themselves – is a cautionary tale for the rest of us.

There is another way the USDA implied that it was testing only symptomatic animals: It compared its surveillance numbers to an international standard that required testing a minimum number of symptomatic animals.

USDA officials repeatedly bragged that testing 20,000 cows (roughly the number the U.S. tested in 2003) was far in excess of the World Organization for Animal Health’s (OIE) recommended minimum number of test samples for a herd the size and age of the U.S. herd: 433 samples. But that “433” figure comes from OIE article, entitled “Examination of cattle displaying clinical signs consistent with BSE.” It specifies 433 as the minimum number of test samples from cows showing neurological signs – including “progressive behavioural changes such as excitability, persistent kicking when milked, changes in herd hierarchical status, hesitation at doors, gates and barriers, as well as those displaying progressive neurological signs….”

Testing 433 symptomatic cows, in other words, should do the job. Testing 433 miscellaneous downers – not to mention 433 cows some of which turn out to be both asymptomatic and walking around – wouldn’t cut it. (The OIE does say that if you can’t find 433 symptomatic cows, downers are the next best choice.) Testing 20,000 miscellaneous cows, most of them downers, might very well pass muster. We haven’t a clue; go ask a mad cow testing expert. Our point here is only about communication. By comparing the number of cows it was testing to the 433 symptomatic cows the OIE said should be tested, the USDA invited the inference that the animals it tested showed symptoms “consistent with BSE.”

This particular misleading communication wasn’t invented after the December mad cow discovery. A January, 2003 USDA press release states that 5,272 cows were tested in fiscal year 2001, and 19,990 cows in fiscal year 2002. The release explains that the animals tested were the “highest risk animals, including downer animals, animals that die on the farm, older animals, and animals exhibiting signs of neurological distress.” Then comes the misleading claim:

Both [years’] figures are significantly higher than the standards set by the Office International des Epizooties (OIE), the standard setting organization for animal health for 162 member nations. Under the international standard, a BSE-free country like the United States would be required to test only 433 head of cattle per year. The USDA is now testing 41 times that amount.

The USDA seems to have been testing apples and trumpeting oranges.

8.  The USDA encouraged us to think that nobody was taking (or could imagine) precautions beyond those it was taking.

link up to indexOn December 24, Day Two of the mad cow story, CNN’s Soledad O’Brian asked Agriculture Secretary Ann Veneman whether it wasn’t possible for a healthy, ambulatory cow to have BSE. As we have seen, this was a good question. Rather than answer it, Veneman replied that “in this country we take every precaution” and “we’ve taken every imaginable step that we can to prevent BSE….”

This sort of empty claim is so common we don’t usually notice how dishonest it is. At the time Veneman spoke, other countries were taking precautions the U.S. had decided not to take. The U.K., which first banned ruminant-to-ruminant feed in 1988, had later decided that wasn’t enough and banned cow tissue from all animal feed. It had also banned all cows older than 30 months from the human food supply. Canada had required slaughterhouses to hold onto the carcasses of tested cows until after the test results were known. Other countries had banned human consumption of the most high-risk organs, even from healthy animals, or required BSE testing of all older cows since they were likelier to have eaten contaminated feed. And Japan had insisted on testing every cow for BSE before allowing it into the food supply – not every symptomatic cow, not every downer, not every older cow, but every cow. Within days the U.S. would itself announce a new set of mad cow precautions (though nothing as precautionary as the U.K. and Japanese regulations), talking as if none of us would remember or care that it had previously assured us that every imaginable step had already been taken.

And on December 31, after the new precautions were announced, there was Ann Veneman on CNN with Soledad O’Brian again:

[W]e announced the measures yesterday to further protect an already strong food safety system in this country…. [T]he additional measures that we announced yesterday will be even more protective of our food supply in this country…. We are doing everything we can to protect the food supply. And I can tell you that we’re making decisions based upon sound science and good public policy, given the circumstances that we are now in.

So it turns out we weren’t actually taking every possible precaution on December 24, right? But now we are.

Veneman makes no reference to the discrepancy between her claim a week ago that everything imaginable was already being done and her claim today that several new things are going to be done. She doesn’t tell us about all the additional things that still aren’t going to be done … at least not yet. And she doesn’t begin to explain how the same “sound science” that justified the previous policy could also justify the new policy. Her last phrase, “given the circumstances that we are now in,” suggests a possible basis for the change: “My God we found a Mad Cow! Of course we’re going to ratchet up our precautions. We only wish we’d done so earlier.” The USDA doesn’t want to go there. Or: “It’s foolish and unnecessary technically, but we need to do something to placate our trading partners and reassure American consumers.” The USDA doesn’t want to go there either.

But Veneman wasn’t just saying something misleading about U.S. BSE precautions. She was saying something fundamentally misleading about the very concept of precaution-taking. Deciding what precautions to take is intrinsically a matter of weighing the benefits of the precaution against its costs – financial costs, of course, but sometimes also cost in convenience, in freedom, in lost opportunities, even in increased risk somewhere else in the system. There are always – always – additional precautions you might take. Even Japan, which already tests every cow for BSE, could theoretically decide to test every cow twice to protect against a possible testing error. Risk managers distinguish the precautions that are clearly worth taking from the ones that are clearly not worth taking. Then they worry over the precautions that aren’t clear, that might or might not be worth taking. A good risk manager can always tell you what the tough calls were, which precautions he or she almost decided to take, and which precautions he or she almost decided not to take. A risk manager who tells you that there were no tough calls, that he or she is taking “every imaginable step,” is either a very poor risk manager or a liar.

Prior to December 2003, the USDA had in place a surveillance system that was designed to find a mad cow if the U.S. had a bunch of them, but not necessarily if it had only a few (fewer than one adult cow in a million). And it had in place regulations that were designed to keep most cow tissue (but not necessarily all) out of cattle feed, and most nerve tissue (but not necessarily all) out of muscle meat (though not out of the human food supply). Some countries had less stringent testing and regulatory precautions than we did. Other countries had more stringent ones – especially countries that had suffered a serious BSE outbreak (like the U.K.) and countries that were particularly fastidious about meat (like Japan). Periodic calls for more stringent U.S. precautions by activists or individual members of Congress were routinely and vigorously opposed by the meat industry and successfully beaten back.

The U.S. government was protecting public health from vCJD as much as it wanted – not as much as possible, but as much as it thought appropriate. And its judgment about how much protection was appropriate was influenced, sensibly enough, by the fact that so far the U.S. hadn’t found any mad cows at all.

All the USDA had to do before December 2003 was tell us so. It didn’t. It could have encouraged a lively debate over whether the U.S. wanted tougher BSE protections, or laxer ones, or exactly the ones it had. It could have stressed that the current regs were enough to prevent and detect a BSE epidemic, but not necessarily an isolated case. It could have explained that that’s good enough from a public health perspective, but that “zero tolerance” for BSE would require more. It could have pointed out that it had other, more serious and less adequately regulated food risks on its plate already, but that vCJD is an especially horrifying disease and people might therefore want to jump it to the front of the line and pay the price for zero tolerance. And it could have added that everything it had to say about BSE and vCJD was less than completely confident, because they are diseases about which much is still unknown or uncertain.

And all the USDA had to do after December 2003 was reassess, and tell us it was reassessing. “This is obviously a time to revisit whether our regulations and procedures are tough enough,” it should have said … but didn’t. “Precautions aimed at a risk not known to be present in the country obviously don’t need to be as strong as precautions aimed at a risk we know we face. The incidence of BSE is still low, and still a very small risk to human health. A Harvard University study suggests that even if we do nothing further, it is likely to remain low and become ever lower as residual cattle from before the feed ban are eliminated from the herd – mostly by way of the food supply, of course. But the risk is not zero. We have seen our first mad cow, and we must presume that there are probably others. In hindsight, now that a case has emerged, many people inside and outside the USDA wish we had taken some of the precautionary steps we decided not to take. The question is whether we should take them now.” USDA officials could have said all that, and more.

The irony of mad cow risk communication (mad cow public relations, really) is that the USDA has done a far better job of protecting public health than of protecting beef sales. That is, it has to have been clear all along that finding one mad cow would represent a very small health risk, but would almost certainly injure U.S. beef exports and might well hurt domestic consumption as well. A low prevalence of BSE was always a bigger threat to the industry than to the public. Two strategies were available to protect the industry. The first would have been to do virtually no testing, so as to be fairly sure not to find any mad cows. Some critics claim that is essentially what the USDA did. The USDA rebuts that it did, after all, find a mad cow, and credibly claims it tested enough cows to protect public health from a possible BSE epidemic, though not from an occasional instance. The second possible strategy to protect the industry would have been to take additional precautions to further reduce the incidence of BSE in the U.S., precautions modeled on Japan’s and the U.K.’s. But the U.S. beef industry preferred to gamble, saving money in the short term and hoping that a BSE+ cow wouldn’t turn up. Since the risk to public health was so low, the USDA had no particular objections.

And neither do we. Our only objection to any of this is to the misleading communications. On a scale of BSE precaution-taking, the USDA before December 2003 chose a defensible middle – and pretended it was taking every conceivable precaution. After December 2003 it ratcheted its regulations and procedures a few notches in a more protective direction – and pretended it was still taking every conceivable precaution. It is the pretense, not the precautions, that we find objectionable.

9.  The USDA encouraged us to think that the adequacy of its precautions were deducible from “sound science.”

link up to indexThe USDA repeats over and over its mantra that its policies are based on Sound Science. This is true, apparently, even when its policies change without any noticeable change in the science. A week after the mad cow was found, Ann Veneman announced a USDA ban on downer cows in the food supply (a policy officials had long vehemently opposed), and the speeded-up development of an animal tracking system (which officials had been pondering, debating, and resisting for ages). A CBS/AP article has this exquisite sentence:

“Sound science continues to be our guide,” Veneman said, adding that the food supply was safe even before she announced tougher regulations.

Veneman could of course have said that the December 23 discovery had changed the scientific situation, justifying additional regulations. She could have said that the USDA had always intended to ratchet up the precautions if it ever found a mad cow. But that would have suggested that finding a mad cow was a surprise and that the food supply hadn’t been quite safe enough before. What Veneman preferred to say, in essence, was that the new U.S. regulations are simultaneously unnecessary and grounded in sound science.

Other countries’ unnecessary regulations, on the other hand, are not grounded in sound science. In late January 2004, Veneman spoke to reporters about efforts to get Japan to start importing U.S. beef again. She said: “They do in Japan require testing of every animal. That is something that we don’t think is based on sound science and so we are addressing whether or not there are equivalent ways that Washington can provide the consumer satisfaction that they are requiring.”

Whenever “sound science” is invoked, it helps to ask exactly what scientific question is being addressed, and why that question rather than a different one. The scientific question that controlled USDA policy before December 23 was this one: How many mad cows can a country tolerate and still be confident it’s not going to have a vCJD epidemic? Japan was interested in a different scientific question: What does it take to be confident that you’re not tolerating any mad cows at all? What underlay both questions was yet a third (social) scientific question: How much precaution does my citizenry want (and want to pay for) in protecting its beef supply from BSE? Japan’s answer to this social science question was different from the U.S. answer, which is why Japan asked and answered a different set of technical questions and ended up with different regulatory policies. And the U.S. answer to the social science question changed after December 23, which is why the USDA changed the rules.

There are three problems with the way the USDA wraps itself in the mantle of Sound Science.

(a) Sound science isn’t certain science.

Like all science, the science of BSE is incomplete and tentative. There is a great deal the scientists admit they don’t know, and a great deal they think they know but disagree about. And inevitably some of what they agree about will turn out wrong in the end. This isn’t a criticism of the scientists; that’s how science works. It is a criticism of USDA officials and spokespeople who sound like they think the scientists know everything worth knowing about BSE.

Probably the single biggest technical question about BSE is how many BSE+ cows are in the current U.S. beef cattle herd. On the safe assumption that the vCJD risk is proportional to the BSE prevalence in the cows we will end up eating, that’s the number you most want to know.

The USDA declines to guess. Ideally it would like us to imagine the number is zero. That’s what this misleading toward the truth is all about, fundamentally: Get us to think (mistakenly) that there are almost certainly no mad cows in the U.S. food supply, and then we will think (correctly) that the mad cow risk to U.S. consumers is almost certainly negligible. So that’s one piece of Sound Science the USDA doesn’t want to go near. In February 2004, the USDA’s Jim Rodgers told the Sacramento Bee: “We cannot give you a specific count because that’s not what our surveillance program is designed to do.” What Rodgers means is that the USDA surveillance program is sufficient only to make sure there aren’t a lot of mad cows around, not to estimate how many there are – not something the USDA wanted to be clear about before or after the December discovery.

Even so, the USDA has sometimes claimed its surveillance program is sufficient to be fairly confident of finding at least one mad cow if the prevalence among adult cows were one-in-a-million or greater. The U.S. herd of 95 million cattle currently has about 42 million adults. So we’re talking about a theoretical maximum of 42 mad cows in the U.S. herd so long as none were found in U.S. testing. Some outside experts have said the USDA should have tested more cows than it did to reach the one-in-a-million mark, or it should have made sure all the animals tested were symptomatic or at least downers. Anyway, the USDA did find a mad cow in December 2003. So even if its surveillance program met the criteria for one-in-a-million, we can no longer say that means fewer than 42 BSE+ cows in the herd.

Two studies done for the USDA by Harvard University’s Center for Risk Analysis don’t shed much light on the answer to this question. (It is the Harvard studies that USDA sources are usually talking about when they start intoning the phrase “sound science.”) The main thrust of the Harvard studies is to show that the 1997 U.S. feed regulations would successfully choke off any BSE epidemic over a twenty-year period. Harvard made various assumptions about so many BSE+ cows crossing the border from Canada or so many healthy American cows getting BSE from contaminated feed. Then computer modeling was used to figure out how many secondary infections were likely – how many more cows would get BSE from eating contaminated tissue from the original sick cows. Because of the feed regulations, Harvard concluded, any such outbreak would be self-limiting and wouldn’t turn into a major epidemic. If five BSE+ cows had entered the U.S. in 1990, for example, Harvard calculated that up to 500-600 U.S. animals might have become infected before the outbreak peaked and started to decline – not enough to constitute a major human health threat. What Harvard did was build a computer model to estimate how much BSE would be likely given various sets of assumptions. It didn’t try to figure out which of its assumptions correctly mirrored reality or how much BSE there actually was.

Other experts, including a science advisory group convened by the USDA itself, have quarreled with some aspects of Harvard’s model, and therefore with its conclusions. And one of the Harvard study authors, Joshua Cohen, told the Sacramento Bee in February 2004 that the nationwide number could range between zero and a few thousand. He added: “I believe we’re in the lower end of that range.” Nobody knows for sure, of course. To know for sure we’d have to test a lot more cows. Note that this isn’t a criticism of the Harvard study. That’s how science at its best works – expert disagreement, constant reassessment, acknowledged uncertainty.

Despite its oft-stated “absolute” confidence in the safety of U.S. beef, the USDA has steadfastly prohibited any private use of its gold standard BSE test. In the U.S., only the USDA itself is permitted to test cow brains for BSE. It won’t run private tests for individual meat producers, and it has not yet authorized U.S. use of the rapid BSE test kits used in Japan, the U.K., and other countries. In a March 9, 2004 front-page story, Wall Street Journal reporter Scott Kilman offered several different USDA rationales for the test ban – which small “organic” meat producers have protested unsuccessfully. The USDA’s Ron DeHaven went on the record with the official reason, that widespread testing might lead to too much confidence that meat is BSE-free:

USDA officials say they worry meat companies might mislead consumers into thinking that cattle that test negative are free of the infection, of which there is no way to be sure…. “These tests aren’t really designed to be food safety tests” but rather surveillance tests, says Ron DeHaven, the USDA’s chief veterinarian….

It is heartening, if not credible, that a government that assures us U.S. beef is “absolutely safe” is worried that negative test results for BSE might over-reassure consumers.

Other USDA officials offered Kilman more credible explanations – anonymously. (1) Officials worry that “if some beef is labeled as coming from cattle tested for mad cow, it may imply that untested beef isn’t necessarily safe.” (2) Officials “fear that private laboratories would report false positives, upsetting overseas customers and causing cattle prices to crash.” (3) The USDA “is respecting the wishes of most big meatpackers, which want a tight lid on mad-cow testing.” (4) And if private testing found any more mad cows, that “could challenge the Bush administration’s position that mad cow isn’t a problem in the U.S.”

Science isn’t “unsound” just because it’s debated or uncertain. We’re not claiming that the USDA’s science is unsound, only that there is plenty of expert disagreement and the science is a moving target. In the first half of the 20th century, animal husbandry experts relied on Sound Science as they ramped up the use of bone meal and other ruminant byproducts as an effective and inexpensive protein source in feed for ruminants. In 1986, then-British Agricultural Minister John Gummer relied on Sound Science when he assured the public that mad cow disease could not be transmitted to humans. Scientists later learned that cattle that eat tissue from BSE-infected (or scrapie-infected) ruminants can get BSE, and that people who eat tissue from BSE-infected cattle can get vCJD. Sound Science changed. Has Sound Science now come to a full stop? Of course not. We will learn things about mad cow disease in the coming years that will surprise us.

But the USDA never says so. USDA officials know that uncertainty surrounds most scientific findings, especially in new fields. But when trying to reassure the public, they make Sound Science sound like gospel truth.

(b) Sound science doesn’t apply to values.

The second problem with the USDA’s invocation of Sound Science is its application to judgments that aren’t scientific at all. The USDA consistently confuses and conflates science (however sound) with values.

As we have stressed before, precaution-taking is almost never perfect. The risk management question isn’t whether U.S. beef is “safe” or “not safe.” The empirical question is how safe U.S. beef is. And the values question is how safe we want it to be, how safe is safe enough. Only science can answer the first question, how safe is U.S. beef – and at least so far science can answer it only approximately. As for the second question, how safe is safe enough, science has nothing to contribute. There is no scientific answer here, only a political debate. The USDA invokes Sound Science in an effort to squelch this debate.

The people and government of Japan, for example, have decided that they want to come as close as possible to zero BSE. So they test every cow before it goes into the food supply, and they ban meat from the U.S. because we had a BSE case in December and still refuse to test every cow. There is nothing scientific – or unscientific – about this choice. It is a policy decision based on public preference. Japan relies on the same BSE science the U.S. relies on. It interprets that science more cautiously because it has decided to be more cautious about BSE risks. The USDA consistently implies that other countries should not mind a low but non-zero risk of importing an occasional mad cow into their food supplies. There is nothing scientific – or unscientific – about this opinion either. We are in the realm of values … and in democratic countries, that is the realm of politics.

(c) Whatever happened to sound social science?

One of the most predictable impacts of the December 2003 discovery of a U.S. mad cow was the decision of many other countries to ban U.S. beef. As empirical relationships go, this one is well established. The U.S. itself has consistently banned beef from any country that found BSE in its cattle herd. (To his credit, the USDA’s Ron DeHaven conceded this when he urged other countries not to do likewise.) To predict this cause-and-effect relationship, further research, for a change, was not needed. What was needed was an economic analysis of the cost of tolerating low levels of BSE in the U.S. herd (and eventually finding one) versus the cost of aiming for zero. Such an analysis might have justified precautions that considerations of public health alone did not require.

But we are not economists. Let the U.S. beef industry chew on the economic case for more BSE precautions. Let the industry ponder the irony that the USDA pandered to its wishes instead of looking after its interests.

We are social psychologist types – one of us is trained in communication effects and the other in psychiatry. So what really makes us grind our teeth is the USDA’s steadfast disinclination to pay the slightest attention to “sound science” in our field. Some well-established risk communication truths:

  • People react to attributes of risks other than how serious they are technically – to “outrage factors” like trust, voluntariness, control, dread, knowability, responsiveness, and familiarity. BSE and vCJD are intrinsically high in many of these outrage factors. Therefore, BSE and vCJD are potentially major sources of public concern, regardless of whether or not they are also major threats to health.
  • Officials who ignore people’s concerns are likely to exacerbate those concerns. So are officials who patronizingly acknowledge that people are concerned but insist that they shouldn’t be. These are common errors. Officials (especially officials who see themselves as scientists) typically discount outrage when planning how to address potentially controversial risks.
  • The outrage factor officials are likeliest to discount is the one that points the finger right back at them: trust. Misleading official statements about risk are likely to backfire when the public begins to sense the dishonesty. This is true even when the dishonesty is well-intentioned, when it aims at misleading people toward the truth. The soundest of sound social science predicts that the public will convert feelings of being misled into feelings of being at risk.
  • Even when it isn’t deceptive, over-reassurance tends to backfire. Instead of telling people there is nothing to worry about, officials need to help them cope with their worries. This means both validating that it is normal to be worried, and conceding that some aspects of what is known justify worry. Acknowledging the normality and validity of people’s concern is a prerequisite to putting that concern into perspective. “Everything is under control” rings false when said too quickly, too early. So do phrases like “perfectly safe” and “absolutely no risk.” We may want to hear this, but we won’t believe it if we do. As an antidote to fears that the risk may be huge, claims that it is real but small work better than claims that it doesn’t exist.
  • Over-confidence is nearly as harmful as over-reassurance. People prefer certainty to uncertainty, but they greatly prefer uncertainty that is acknowledged to uncertainty that is papered-over.
  • It is normal for people to respond to new risks by pausing and temporarily over-reacting. This “knee-jerk over-reaction” – like the body’s other reflexes – is useful. It gives people time to assess the situation , and helps them rehearse the responses they may need to use if things get worse. If things don’t get worse, most people recover quickly. They recover more quickly if their caution is legitimized rather than criticized or patronized. Being contemptuous of people’s concerns, even when the contempt is subtle, is not an effective way to allay those concerns, nor does it build trust and rapport.
  • The worst risk communication is simultaneously (1) misleading, (2) over-reassuring, (3) over-confident, and (4) contemptuous of people’s concerns. The USDA wasn’t often openly contemptuous of the public’s concerns, though it wasn’t as visibly sympathetic as we’d have recommended. (It did voice considerable contempt for our trading partners’ “knee-jerk reaction” when they banned U.S. beef in response to the December discovery, as if the U.S. hadn’t done exactly the same thing whenever any other country found a mad cow.) As we have documented, it pretty consistently messed up the other three.
  • Even if you do everything wrong, you may get away with it, at least for a while. Sadly, getting away with it helps prevent you from noticing you did everything wrong. Eventually it catches up with you. And then you blame your critics or the public itself. If people are going to over-react like that, you tell yourself, you certainly can’t afford to be candid – never quite noticing that your lack of candor (and your other risk communication errors) contributed massively to our over-reaction.

Here is our one-sentence assessment of the USDA’s performance. In its response to BSE so far, the U.S. Department of Agriculture has done a good job of protecting public health, but has ignored public concerns; it has done a good job of deferring to beef industry concerns, but has failed to protect the industry’s health.

But here is the more important take-home lesson for most readers: Misleading toward the truth is incredibly tempting, but it usually backfires in the end. To stop doing it, first you have to notice that you’re doing it.

Virtue, Redemption, and Balance

Did the USDA do anything right? Absolutely. Here are three examples:

One of the things Ann Veneman said in that Day One media briefing stands out as a piece of good risk communication. “It is too early at this point to say whether or not this will be an isolated case,” she told reporters, preparing them for the possibility of finding a second or third mad cow. This is a nice example of acknowledging uncertainty, of avoiding over-reassurance, of telling people what to expect – a risk communication trifecta in one short sentence.
We were also impressed, especially early on, with the USDA’s willingness to share preliminary information and even conflicting information, without waiting until all the facts were nailed down. Was the U.S. mad cow imported from Canada or not? Which report on its birthdate was the correct one (not an unimportant question, since older animals are likelier to have eaten contaminated feed before the rules changed)? Some critics argued that the USDA should have kept silent on matters like these until it was sure. But good risk communication means being willing to speculate, while carefully underlining that the speculations are tentative. The USDA did this well. If it had been similarly tentative about whether the index cow was a downer, things might have gone much better.
The USDA website is in many ways a delight. It includes a huge amount of information, including the transcripts not just of all the USDA media briefings but also of key interview appearances by Secretary Veneman. We relied on it heavily in producing this assessment. We hope that doesn’t lead someone at the USDA to decide to purge the website of all that good documentation! What we’d like to see instead is an effort to annotate what’s there in terms of what’s been learned since. A series of addenda and footnotes – “we turned out wrong on this”; “here’s a more responsive answer to that question”; “other sources have a different interpretation” – could turn what is already an invaluable, uncensored historical record into a living representation of the USDA’s ever-changing response to BSE.

These virtues are overshadowed by the USDA’s gargantuan error of misleading toward the truth. What would a more candid approach have looked like? On December 27, just four days after the U.S. found its first mad cow, Antonio Regalado of the Wall Street Journal asked us what the USDA should be telling people. Here’s the script we wrote for an imaginary USDA client. (We’re resisting the temptation to revise based on what we have learned since.)

What happened last week we never wanted to let happen. We hoped never to see a positive BSE result for an animal in the U.S. If there was going to be a positive test, we hoped that animal wouldn’t get into the food supply. If it got into the food supply, we hoped we’d be able to trace it and recall it before it got eaten. If it got eaten, we hoped we’d be able to say for sure that muscle meat carries no risk, and that the meat in question carried no trace of brain or spinal cord tissue. We failed on all these counts.

When we gather together our best scientists and ask if there is any risk from the meat from this one cow, they tell us they don’t think so. When we ask if they’re absolutely certain, they tell us … not quite. That’s why we tried to recall the meat; we believed it was safe, but we weren’t absolutely certain. Now that we know the recall was too late, we are left as the people who bought and ate this meat are left: hoping and believing that the risk is very, very small, but not absolutely certain. This is not the Christmas present we wanted to give to any American.

But the bigger question is, of course, whether there might be more BSE-afflicted cows in our food supply. A week ago we would have said this was vanishingly unlikely. Now we need to be more humble. The chances of a widespread BSE epidemic like the one England endured a decade ago are still extremely small, almost zero. But since we have one cow, we may well have others. And since that one cow was found by accident without showing any symptoms of the disease, the others may be apparently healthy too. It’s going to take some work for us to figure out the size of this newly discovered problem and what additional steps, if any, are needed to contain it.

Is it too late for the USDA to reverse course on its BSE communication? Probably not. There have been some allegations of falsification of records that need to be looked into, but most of what the USDA did wrong is garden-variety misleading risk communication. The American public tends to be pretty forgiving of people and organizations that acknowledge how they have mishandled a situation and start handling it differently. But notice that there are two tech specs here for forgiveness. Changing course is a necessary but not a sufficient condition. Apologizing for the prior course is also necessary.

We are hopeful, but not confident, that the USDA will do this. We are somewhat more hopeful, but still not confident, that it will learn the right lesson from its BSE experience – not the lesson that critics and Congressmen are prone to exaggerate tiny risks but the lesson that misleading toward the truth is a strategy that boomerangs. We are most hopeful – though still not all that confident – that others can learn from the USDA’s mistakes.

We end with a final note to anyone wishing to use this column as ammunition in an attack on the USDA. As we have said again and again, there is very little reason to believe BSE is a major threat to public health in the U.S. And what we have called “misleading toward the truth” is extremely common. What would we say about an argument that implied that the U.S. BSE risk is exceedingly high (false) or that the USDA’s communications were egregiously dishonest (false) in order to build a stronger case that government agencies should hold themselves to a higher standard of candor (true)? Such an argument would itself be misleading toward the truth.

Copyright © 2004 by Peter M. Sandman and Jody Lanard

For more on outrage management:    link to Outrage Management index
      Comment or Ask      Read the comments
Contact information page:    Peter M. Sandman

Website design and management provided by SnowTao Editing Services.