Handling of the listeriosis outbreak is a disgrace

People started dying in June, and it took until mid-August to trace the problem to the plant. On Aug. 13, when the Canadian Food Inspection Agency was in the plant looking for the source of listeria monocytogenes, Maple Leaf started warning distributors to stop shipping some meats. But nobody told the public to stop eating them. By Aug. 17, there were positive lab tests and it was abundantly clear a number of deaths were due to the contamination. Yet it wasn't until Aug. 20 that the public was really warned of the extent of the problem. And products were still being recalled, in piecemeal fashion, into September.

The Globe and Mail
September 11, 2008

Handling of the listeriosis outbreak is a disgrace
Andre Picard

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One of the last orders of business for Prime Minister Stephen Harper before calling an election was to announce an independent inquiry into the recent outbreak of listeriosis that has killed at least 14 people across Canada.

He said investigators will:

• Examine the events, circumstances and factors that contributed to the outbreak;

• Review the efficiency and effectiveness of the response of the federal organizations;

• Make recommendations on what could be done to prevent and respond to similar outbreaks in the future.

The results of the investigation are expected next March.

That sounds like a pretty good outline for the master's thesis, replete with a leisurely academic deadline.

But is this any way to run a government?

In Canada, we have developed a perverse fondness for commissions of inquiry and their retrospective self-flagellation and contrition.

Inquiries are explicitly forbidden from laying blame, criminal or civil. They invariably make wonderful recommendations - most of them glaringly obvious - and many of which will never be implemented.

What ever happened to people actually doing their jobs? What happened to taking responsibility? And what about the quaint notion that governments should govern?

Before we spend $10-million or $20-million or $50-million on an inquiry into luncheon meats, let's step back for a minute and examine what we know about what happened, what went wrong and how we can do better.

The outbreak of food poisoning stems from one plant, the Maple Leaf Foods Inc. plant on Bartor Road in Toronto. Specifically, the listeria bacterium seems to have proliferated in two meat-slicing machines even though they had been cleaned regularly.

Obviously, machines of this kind - and maybe all meat-slicing machines - have to be cleaned differently and inspections have to be more thorough. You don't need a six-month inquiry to figure that out.

Nor do you need an esteemed judge and hours of cross-examination by top-notch legal counsel to know that the response to suspected contamination of mass-produced meat products was far too slow and secretive.

People started dying in June, and it took until mid-August to trace the problem to the plant. On Aug. 13, when the Canadian Food Inspection Agency was in the plant looking for the source of listeria monocytogenes, Maple Leaf started warning distributors to stop shipping some meats. But nobody told the public to stop eating them.

By Aug. 17, there were positive lab tests and it was abundantly clear a number of deaths were due to the contamination. Yet it wasn't until Aug. 20 that the public was really warned of the extent of the problem. And products were still being recalled, in piecemeal fashion, into September.

The issue here is not a couple of dirty meat slicers, or raw-milk cheeses (the source of an ongoing outbreak in Quebec).

The reality is that some contamination of food is inevitable. There are upward of 10 million cases of food poisoning in Canada each year, and at least 500 deaths, due in large part to poor food handling by consumers. But when you mass-produce food, you also risk massive outbreaks of disease.

Prevention and good inspection are important, but education of consumers, along with good tracking, active disease surveillance and recall procedures are also essential.

The way the CFIA warns the public of food-borne threats and manages recalls is a disgrace. Transparency and good communication are essential in responding to any public health threat but, at the CFIA, information is released in dribs and drabs, without coherence or context, and almost always on a voluntary basis by manufacturers.

In this case, thankfully, Maple Leaf was, after some initial foot-dragging, quite open. CEO Michael McCain gave the public more information and explanation than all government agencies combined. He also had the backbone and decency to apologize.

Federal cabinet ministers contented themselves with uttering a few platitudes.

Gerry Ritz, the Minister of Agriculture and Agri-Foods, had this to say more than three weeks after the outbreak was discovered: "Our professionals are working to resolve this situation as quickly as possible." Instead of an apologia for second-rate work, he should have been kicking CFIA butts around the block.

Health Minister Tony Clement, for his part, was gushing with pride about the actions of the Public Health Agency of Canada even before the final body count was in.

"This is an example of where our surveillance system worked," he said. There's truth in that statement: The outbreak of listeriosis was caught relatively quickly, thanks to changes in the tracking of illnesses in the wake of SARS.

But, again, the response to that surveillance information was not good enough, and ultimately the minister must hold his department to account for that failure. (In fairness, though, it must be said that this government shackles and muzzles its public health officials to the point where they can hardly do their jobs.)

Instead, we have the classic Canadian non-response: an inquiry.

We don't need more reports to gather dust on shelves. We need our politicians and senior civil servants to read and absorb the analyses of past tragedies - the 540-page Walkerton report of Mr. Justice Dennis O'Connor; the 1,004-page report on the provincial response to SARS by Mr. Justice Archie Campbell; and the 234-page report by Dr. David Naylor on the federal response to SARS.

It's all in there in painful detail.

Whether it's water, food or infectious diseases, the principles are the same: You need to invest in public health infrastructure, particularly in good people; you need to value prevention, not just pay lip service; when threats to public health occur, you need to act forcefully and communicate well.

And above all, you need to take responsibility for your actions (and inaction).

That is something government agencies like CFIA and PHAC, and in particular their political masters, seem unable to grasp.

That willful blindness and aversion to leadership is a bigger threat to the health of Canadians than bacteria in luncheon meats.

Report on Business Company Snapshot is available for: MAPLE LEAF FOODS INC.

http://www.theglobeandmail.com/life/health/article51735.ece


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