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Baroness Cumberlege: My Lords, I understand that the debate has run its course. I never cease to marvel at the expertise and knowledge that are embodied in your Lordships' House, and tonight has been no exception. I thank all noble Lords for debating these difficult issues. In particular I thank the Minister for her very thoughtful and comprehensive reply. I wish her good health. In the interests of a good appetite and a hungry stomach, I conclude the debate. I beg leave to withdraw the Motion.
The noble Countess said: My Lords, it is with a heavy heart that I rise once again to question Her Majesty's Government on their policy for the diagnosis and treatment of those who suffer ill health as a result of exposure to organophosphate pesticides and veterinary medicines. On 11th July 1996 as a result of repeated requests from me and from others working in this field, the noble Baroness, Lady Cumberlege, then Under-Secretary of State, Department of Health, responded to a Starred Question from me. She announced that the Presidents of the Royal Colleges of Physicians and Psychiatrists had agreed to set up a working party to review the possible long-term adverse effects of exposure to OPs. It was not until 22nd April 1997 that the terms of reference and membership of the working party were announced. Frankly, I was appalled. The title of the working party limited the review to OP sheep dips, whereas my Question and the response of the Minister had implied no such limitation. The terms of reference were extraordinarily restrictive.
The working party comprised 11 members. One of them, Sir Colin Berry, chairman of the Advisory Committee on Pesticides responsible for licensing OP products and a member of numerous other scientific advisory committees, has publicly stated that those who attribute symptoms to exposure to toxic chemicals have a
That statement immediately aligns Sir Colin with another two members of the working party, both psychiatrists; namely, Professor Anthony David, who works with Professor Simon Wessley at King's College Hospital, the promoter of this profound assessment of sufferers of complaints such as ME, multiple chemical sensitivity, fibromyalgia and even Gulf War illnesses, and Professor Hawton.
Dr. Bateman is chairman of the Medical and Scientific Panel of the Veterinary Products Committee. His past record appears to indicate that he has an interest in preventing the admission that OP products have harmful effects on human health. Professor Thomas is also a member of the Veterinary Products Committee. To have five working party members whose credentials are perceived to include a bias that OPs are safe does not fill one with confidence. There was no representative from any of the support groups on the working party until after they met on 22nd June 1997.
Who was responsible for setting the terms of reference? The second of the terms of reference was redundant simply because the working party included members of both the Veterinary Products Committee and the Advisory Committee on Pesticides. They would be expected to report back to their respective committees as a matter of course. Additionally, as this was a clinical matter and the chief medical officer had asked the presidents of the Royal Colleges to set up the working party, should they not have reported to the Department of Health? As will be seen later, the working party made little attempt to address itself to the third of the terms of reference.
I made my concerns known to their chairman, Professor Newsom-Davis, to the Registrar of the Royal College of Physicians, Professor London, and to the Minister for Public Health. I was assured that the members would make an unbiased assessment. I now see that my initial suspicions were correct. This report is a very unpleasant sugared pill.
I am not in the least surprised that those individuals listed on page 51 of the report declined to give evidence. They have, to my knowledge, more experience than any in the UK in dealing with farmers and others exposed to OPs. They also have had many contacts with scientific advisory committees on this subject. They were right not to sully themselves with this report. My initial instinct was also to refuse to present my evidence but, as I was partially responsible for the set-up, after considerable thought, together with the assurances I had been given, I agreed to meet the working party on 22nd June 1997.
This is straight from what is becoming known as the "Wessley School". The same recommendations were made in the now notorious Royal Colleges' report on ME and chronic fatigue syndrome. Any GP reading the summary (how many read beyond the summary?) will receive the strongly implied message that the patient has a psychosomatic illness.
I now go to the body of the report. Section 2 deals with the current knowledge of the toxicology and toxic syndromes associated with OPs. Section 3 covers the written and oral evidence received from patients and patients' groups. These are factual and I find little to quarrel with, though in Section 2 there is no mention of synergistic or potentiating effects of combinations of chemicals or medication. For example, phenol, which used to be used with OP dips, is now known to potentiate the effects of OPs, and there is some evidence that cimetidine, prescribed for gastric ulcers, may have a similar effect. Nor is there any mention that children, the immunucompromised or malnourished individuals may be more susceptible to OPs.
In Section 4 the working party analyses the clinical symptoms. Contrary to early replies to my Parliamentary Questions, they acknowledge the consistent pattern of complaints they discerned from the accounts of witnesses. They note that "Dipper's Flu" has not been used as a measure of mild acute poisoning. This is a group of symptoms commonly reported in affected farmers. Why do they not appear in the following section on diagnosis and guidelines? Here we get the first indication of the direction the recommendations are to take. Sections 4.5 and 4.10 link symptoms of OP exposure with affective disorders. I acknowledge that these are present, but they are not the only symptoms. Not all those affected suffer from depression.
In Section 4.9 the group blithely reject the concept of multiple chemical sensitivity on the grounds that most authorities reject its validity for lack of evidence. In 1987, Cullen, in his book Workers with Multiple Chemical Sensitivities, wrote:
Since then the debate in the USA has widened and many US government and state agencies make provision for people who suffer from MCS. The Environmental Protection Agency has initiated its own in-house study to characterise the condition and plans to conduct chemical challenge studies in the future. I look forward to the outcome.
The working party recognises many of the problems OP sufferers have encountered when they approach the medical authorities. My quotation from Cullen applies equally to Section 5.2. I am pleased that it acknowledges the support provided by the self-help groups, though this is somewhat tempered by the remarks in Section 7.7. I have first-hand knowledge of most of the groups in this field and am aware that they are generally very careful in their handling of inquiries from sufferers and their families.
I have found environmental medicine extraordinarily helpful, as have many others who have been exposed to OPs. Rosenthal summed up the reason why there is currently no objective evidence-based justification in 1994. He said:
The working party's recommendations begin at Section 6. My filing cabinets are full of correspondence relating to the total failure of both the HSE and the National Poisons Information Service to help the victims of chemical poisoning. May I ask the Minister how Her Majesty's Government propose to rectify this situation in order to restore peoples' trust in these organisations? May I also ask her how they intend to ensure that practitioners are made aware of the range and seriousness of the symptomology associated with exposure to OPs?
Section 6.7 I find somewhat puzzling. It appears to be saying that, as the results of testing for urinary metabolites may be inconclusive, occupational groups may be forgiven for presenting late with clear histories of over-exposure to OPs. As a result of this late presentation it may have developed fixed ideas about symptoms attributable to exposure. In medicine I understand there is a teaching: "Listen to the patient, he is telling you the diagnosis". I wonder whether there is a danger of patients being mistreated as a result of the over-reliance on a psychological or psychiatric diagnosis when what we are looking at is new disease?
The first four paragraphs on management in Section 7 are very sensible. The last sentence of paragraph 7.4 is of course the basis of informed consent. The injunction that the patient should feel believed and listened to should have been stronger. It is vital that the patient not only feels believed but that he is believed.
Why should the doctor and patient accept the limitations of scientific knowledge? Who is to say that their searches are likely to be futile. They may well, between them, come up with the answer. I simply ask whether we would have been able to cure TB, eradicate smallpox, prevent the infectious diseases of childhood or establish the link between asbestos and lung disease if the medical practitioners of the time had accepted the limitations of scientific knowledge. After all the evidence the working party heard and read, where is its natural curiosity? It repeatedly mentions that there is a lack of causality, yet it makes no recommendation for causal research. Is this because it is outside its terms of reference, or does it not wish to know?
The passage on the treatment of specific symptoms deals only with the affective disorders mentioned earlier. There is the inference that the pain, weakness and incontinence described by so many sufferers are "all in the mind" and can be cured by cognitive behavioural therapy. Could it not be that there is a chemical cause to the mental symptoms? This might explain the reported findings that some people have said that they have had unpleasant side-effects from antidepressants and other drugs. Is it not equally unreasonable that patients should be experimented upon with a range of antidepressants as that they should be referred to too many specialists? This section has clearly been written by the psychiatrists as there were no clinicians practising in other specialties on the working party. It is also almost a straight lift from the Royal College's report on ME/CFS.
In paragraph 7.7 and in the last sentence of paragraph 7.8 we come to the nub of the problem. It is the far-reaching implications for the pesticide industry, for the Armed Forces, the Ministry of Agriculture, Fisheries and Food and the Department of Health, together with the financial and occupational implications which are the working party's prime cause for concern. Antidepressants and cognitive behavioural therapy will have to satisfy the patients. The status quo must not be disturbed. In the next paragraph it has the audacity to recommend an open-minded, eclectic and pragmatic approach to clinical management, yet it has all too clearly demonstrated how closed its members' minds are.
I had a little more to say. However, perhaps I may briefly ask the Minister whether she will reject the report for the time being until we have had the report of Professor Woods from the COT committee.
The Earl of Clanwilliam: My Lords, the report rightly gives recognition to the work of the noble Countess, Lady Mar, and my noble friend Lady Cumberlege in initiating this research. I was going to say that there could hardly have been a more authoritative document. However, having listened to the noble Countess and her reference to a sugared pill, I can only say that I hope the committee feels duly chastised by her severe, excoriating criticisms of its work.
Finally, those of us who have heard the noble Countess, Lady Mar, protest for so long and so often will be glad that she has been so clearly vindicated in her crusade. We sincerely hope that her efforts tonight will ensure that the crusade continues with success. We all owe her a deep debt of gratitude.
Lord Clement-Jones: My Lords, I welcome the initiation of the debate by the noble Countess, Lady Mar. I, too, wish to pay tribute from these Benches for her tireless work on behalf of those suffering from exposure to organophosphates. I hope that the debate today will range much wider than the report of the joint working party.
As the noble Countess, Lady Mar, explained in some detail, the remit of the report was extremely limited. Its conclusions were limited, not to say unhelpful. The Ministry of Agriculture has known about problems with organophosphates since 1951 when the Zuckerman Committee, under Lord Zuckerman, recommended that urgent research be carried out to replace organophosphates. Toxicologists and physicians, and the
It amounts to a complete failure of risk assessment for those chemicals. The Ministry's approach has caused a huge amount of needless distress and suffering. Blame must also be laid at the door of manufacturers such as CIBA Geigy and others who made guidance on risks available to their workforce but not to farmers.
Then there is the question: why after eight to 10 years of compulsory dipping was the plug pulled in 1992, and it was made no longer compulsory? Was it because the Ministry received new information from the Veterinary Medicines Directorate about adverse effects? Was it because MAFF could be held responsible for their use? Did the Government receive new information about dangers when the decision was taken? Without a freedom of information Act we cannot find out. If in the early days of health problems having been identified it had been possible for legal representatives to obtain this information from the Veterinary Medicines Directorate, we would now be in a very different situation.
Perhaps the Government can now answer the questions: what report did MAFF receive in 1992 which caused it to cease the compulsory use of OPs? Why did Mr. Gummer say that he was personally persuaded of the dangers of OPs back in 1992? Did he see a report? Was the Ministry frightened of judicial review or other forms of liability for personal injury? Farmers certainly never saw a report. My honourable friend Mr. Paul Tyler has campaigned for many years on their behalf as a result.
If we are to believe it, it seems that the Ministry of Defence never saw it either. As a result, our soldiers were allowed to use organophosphates extensively in the Gulf War with all the consequences that we now know about and which have been highlighted so cogently in other ways by the noble Countess, Lady Mar, and my honourable friend Mr. Menzies Campbell. These soldiers did not even receive the basic advice about use which is provided to sheep farmers. The OP group, in its report in June of this year, points out the real problems which exist with exchange of information between government departments. The safety information looked at by the Veterinary Products Committee is classified as secret--another reason for a freedom of information Act as soon as possible.
In the view of these Benches, the report of the OP group was far too cautious. We take very seriously the advice given by Dr. Goran Jamal to a briefing of MPs earlier this year. He is a consultant neurophysiologist at the Southern General Hospital in Glasgow. He said:
The view of these Benches is that in the short term much greater control on use is needed with specified contractors only being able to use OPs. In the long term, we should be giving ultimatum to manufacturers to phase out OPs. We should say that after 1st January 2000 these products will no longer have a licence for sale. The key use is for sheep scab. There are injectable pharmaceuticals that can be used. It is vital that other treatments are developed as a matter of urgency. Furthermore, it is vital that the Department of Health assumes prime control over this matter rather than MAFF. I am heartened by the fact that the noble Baroness, Lady Hayman, is replying to this debate.
Perhaps the Government, coming fresh to this issue now, recognise that this is principally a public health matter rather than a problem over which MAFF should have the power of decision. We cannot allow the bald statement by the OP group that:
In the field of further research, one of the most worrying aspects--and one on which I hope the noble Baroness can reassure us--is the omission of any official work on the effect on children. The official OP group did not address, in particular, the question of genetic damage being caused by exposure of mothers to OPs or damage caused by contact with parental clothing. There are also implications for children's headlice treatment using melathion. Are we convinced that this is safe? I hope that the noble Baroness can reassure the House that such research is now in prospect.
Earl Howe: My Lords, the noble Countess, Lady Mar, deserves our thanks, not for the first time for giving us the opportunity to consider the vexed and difficult issue of OP sheep dips and specifically for directing our attention to the recent report by the Royal Colleges.
The publication of that report is a further stage in the slow progress of what seems sometimes to be an interminable saga. I say that with some feeling. The noble Countess and I go back a long way on OP sheep dips. It was towards the end of 1992 when her campaign in Parliament began in earnest. As a Minister in MAFF at the time, I have good reason to remember what a fluttering in the dovecotes it caused. We were all made to sit up and pay attention, and quite right too.
The worst part of it all, if I may now speak personally, was coming to your Lordships' House on repeated occasions armed with a brief from the Ministry which said in unvarying terms that OP sheep dips were "safe if used in accordance with the manufacturer's instructions". Repeating that refrain was a source of some discomfort. It was not that I was being made to say something in which I disbelieved. On the contrary, I accepted the scientific advice so far as it went. It was the knowledge that the noble Countess would almost climb up the wall of this Chamber in exasperation every time I said it and the equal certainty that distinguished Members of your Lordships' House would follow her lead. No government spokesman can withstand such repeated verbal pummelling for more than a certain length of time. Therefore, I wish the Minister well this evening.
It was as a direct result of the noble Countess's efforts that MAFF set in train the epidemiological studies which were designed to elucidate some of the basic facts of the whole issue. Specifically, they were intended to shed light on the question of whether or not there exists a recognisable syndrome associated with the use of OP dips over an extended period of time and, in doing so, to give a rather more educated answer to those individuals who have attributed a considerable measure of distress and pain to that same cause.
They were intended also to point the way to further research. The year after those studies were commissioned, my noble friend Lady Cumberlege, as we have heard, as the health Minister, took forward a parallel initiative through her own department designed to assess the clinical evidence of chronic OP dip exposure as presented by sufferers and to advise on both clinical management and future studies. The result of that programme of work is the report we are now considering.
I have read this report with some care. The noble Countess has expressed her disappointment in it in no uncertain terms. She has raised a number of issues which, I confess, had passed over my head, but which should clearly be addressed by the Government with the utmost seriousness.
Despite that, I have to say to her that I do not believe that we should judge the report too harshly. As she pointed out, the members of the working party were given a fairly narrow remit and to my eyes at least, have done their best in the face of a glaring paucity of evidential data. Some of the data which does exist is contradictory. Personally, from my experience at MAFF, I cannot say that that aspect of the report is a surprise and I shall say more about that in a few moments.
What I found disappointing, indeed shocking, was the not very veiled criticism of the methodology of the epidemiological work which has so far been published. It seemed to me that paragraph 2.26 of the report is about as damning an indictment as there can be in civilised language. If we accept the criticism, as no doubt we must, it is a depressing commentary on a great deal of time and effort expended by many well-intentioned professional people over a great many years.
The most valuable parts of the report are those dealing with the clinical management of sufferers and their symptoms and the section at the end which addresses the various possibilities for future research. Those are the areas to which I hope Ministers will direct their immediate attention. One of the main messages of the document is that regardless of the array of question marks surrounding the whole subject, and regardless of there being no neat series of explanations for people's symptoms and sufferings, doctors must be in no doubt that the symptoms and sufferings are real and must treat each case seriously and with sympathy.
The inadequacy of NHS clinical care for victims of OP exposure is baldly stated and must surely be to us all a matter of acute disappointment. It is clear that sending circulars to GPs, as has been done in the past, is nowhere near sufficient to ensure that OP sufferers are treated as they should be in the doctor's surgery.
But what is the report really telling us? It has some reasonably definite things to say about acute OP poisoning, but when it comes to chronic low-level OP exposure, which we need to keep in mind is the matter at issue, it seems to me to be saying, in a sometimes somewhat round-about way but in a tone that is never less than sympathetic, that we still know almost nothing about the effects of it or how to treat it. We cannot even define the symptoms associated with it. They are non-specific.
Many who complain of some of the symptoms--depression, fatigue, loss of concentration--are apparently found to have no abnormalities at all. Those studies which have identified cognitive defects or neurological dysfunction conflict with others which have failed to find any such phenomenon. There is even a suggestion that the interpretation of the results of some of the population-based studies is open to question and that in certain quarters a bias may exist against publishing negative findings.
The difficulty, as I note from the report, is that the symptoms complained of by OP users are also precipitated by exposure to other products. When presented with a set of symptoms, how is a doctor supposed to know what really caused them? All he can do is to treat the symptoms he sees. Even someone who confidently states that re-exposure to OPs has caused a recurrence of symptoms may well be attributing the way he feels to the wrong cause. What initiated the illness in the first place may be something quite different from what perpetuates it. The report suggests that anxiety, depression and general frustration are often sufficient in themselves to trigger the symptoms which the patient associates with OPs and--apparently--may also account for reported cases of chemical hypersensitivity.
I could almost picture the face of the noble Countess reading these sections of the document. It cannot be easy for her as someone who has campaigned tirelessly to obtain recognition for a group of sufferers who have not been given the attention due to them, to be told by two Royal Colleges, albeit in a polite way, that there is no proof for what she has been saying. But I suggest to her
Government policy can only be formulated on the basis of sound and firm science. The proper way forward is to point, as the report very clearly does, to the gaps in our knowledge and look for ways in which those gaps might be filled. That is easier said than done. I am not an epidemiologist. But I well remember as a Minister appreciating how complex this particular issue is for researchers to pin down. When MAFF first advertised for research proposals in 1995, it received 13 responses from eminent scientific establishments. Not one of them met the specification. The result was great embarrassment all round. But, difficult as it was, we had to get it right. I hope in the end we did so.
Perhaps I may ask the Minister whether she will indicate the current progress of government-funded research into chronic OP exposure and what plans there are in her department or in MAFF to commission further research. It is perhaps too soon to expect a detailed response from her to the conclusions and recommendations in the report, but nevertheless can she confirm that her department will take full account of these conclusions when drawing up any further research proposals? I know that she will agree with me that while research is important, it is inevitably a long-term exercise. Meantime health and safety on farms must be paramount, and patients who complain of illness to their doctors need looking after. Can the Minister say whether Ministers have any plans to ensure that the shortcomings in clinical management revealed in the report are properly addressed and eliminated? Is this the kind of role which might be performed by the proposed National Institute for Clinical Excellence?
Baroness Hayman: My Lords, the whole House is aware of the work the noble Countess has done over many years to raise awareness about the potential health risks of organophosphates. She has vigorously pursued her concerns with my predecessors and fellow Ministers from other departments over a long period of time. Her tenacity and commitment to this cause are well known. As the noble Earl, Lord Howe, pointed out, the health risk the noble Countess presents to Ministers who come before your Lordships' House not properly briefed on the subject is well known.
From the beginning the Government have pledged to take seriously the concerns highlighted by the noble Countess and to take whatever steps are necessary to satisfy ourselves that every aspect of the subject regarding OPs is given proper consideration. It was for that reason that we set up a high level inter-departmental committee of officials to examine the issues. Its recommendations to Ministers were published earlier this year and are already being implemented.
As has been pointed out, it is a complex issue and scientific opinion is divided. While there is little dispute that acute exposure to high levels of OP compounds can cause ill health, there is no widely accepted clinical syndrome associated with prolonged exposure to low levels of OPs. It is essential that we gain a clearer picture of exactly what the health risks might be from OPs.
The noble Earl, Lord Clanwilliam, asked about certain projects that are currently being funded by the department. Details of those are set out in the report of the inter-departmental official group, copies of which have been placed in the Library. Perhaps I can say a little about one or two of them. One is being undertaken by the Institute of Occupational Medicine in Edinburgh. It is costing approximately £500,000 and will take three years to complete. A report is expected in April next year. That research is examining the potential health effects of OPs in relation to farmers but the results may help us to understand the possible effects of exposure to OP-based pesticides generally, including any possible relationship to illness experienced by Gulf War veterans.
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