Robert Cribb
STAFF REPORTER

Twenty-two dead.

Hundreds sickened.

Six months of inquiry.

Nearly $3 million in public money.

The result: 57 recommendations for improving a food safety system that allowed listeria buried inside a meat slicer in a Toronto-area Maple Leaf plant to reach nursing homes and stores, gradually claiming lives as officials miscommunicated, waited for crucial test results to travel across the country and prevaricated about the number of inspectors on the job in Canadian food plants.

Sheila Weatherill’s report on the listeriosis outbreak is not the whitewash many critics feared from an investigator appointed by the Prime Minister’s Office to conduct her work in secret without the authority to compel testimony.

But it’s no panacea either, failing to chart a clear path ahead on such mysteriously elusive questions as how many inspectors we need to ensure our food is safe.

With relentless force, the report catalogues a succession of failures that crescendo into one of the largest and most troubling public health tragedies in recent memory.

At virtually every stage of the outbreak, it seems things could have – should have – gone differently in a food safety system repeatedly hailed by government officials as “one of the safest in the world.”

“I get so annoyed when I hear them say that,” says Rick Holley, a microbiologist at the University of Manitoba and member of the Canadian Food Inspection Agency’s external advisory panel. “The food safety system in Canada is on the upper end of being mediocre.”

Changes shall come in response to the report, Agriculture Minister Gerry Ritz proclaimed yesterday.

As for accepting responsibility for the deaths, well, that’s another matter. “There are a number of things that contributed to this,” Ritz told reporters. “There is no perfect answer … no one to stand up and (say), `I did it.'”

Except, that’s exactly what Maple Leaf president and CEO Michael McCain did shortly after the outbreak – the only person to date offering Canadians an unqualified apology. Tellingly, he’s also the only major player in the sad saga who doesn’t represent a health agency or government charged with protecting public health.

In some ways, Weatherill’s report acts as arbiter in a series of bitter, public disputes between federal bureaucrats and the union representing meat inspectors in Canada over the cause and responsibility of lost lives.

Union officials have repeatedly argued chronic understaffing handcuffs their ability to ensure public safety. CFIA and government officials dismissed those allegations, claiming 200 inspectors were hired last year to bolster food safety.

Weatherill’s findings often align with union concerns. For example, lax testing regulations meant that positive listeria findings in the Maple Leaf plant months before the outbreak were never properly analyzed or communicated to inspectors, the report found.

Following a Toronto Star/CBC investigation last year citing union concerns about unreported listeria test results at the Maple Leaf plant, the government implemented mandatory testing and reporting.

Inspectors assigned to the North York Maple Leaf plant at the centre of the outbreak “appear to have been stressed due to their responsibilities at other plants,” Weatherill concluded.

The lead inspector at the plant had six other plants under his responsibility at the time – a workload union officials have said undermined his ability to complete basic food safety oversight.

Even after six months of inquiry, Weatherill remained unable to determine how many meat inspectors there are in Canada – a deceptively simple yet strangely elusive question that clouds the way forward.

Instead of detailing the number of inspectors needed to meet necessary safety standards, Weatherill simply says the CFIA should hire outside experts to conduct a “resources audit.”

Amid the voluminous array of studies and investigations already on the table, the call for further time-consuming resource analysis lands with a thud.

“The longer it takes to get these studies done, the longer they can skirt the problem,” says Bob Kingston, president of the union representing inspectors. “We’re delaying the inevitable and people don’t want to own up that some funds will be required.”

Throughout the report, the CFIA sits dead centre in Weatherill’s bull’s-eye target. The agency completed only three of the 12 quarterly audits at the plant that produced the listeria-tainted meat between 2005 and 2007, she concluded. Last year, not one was completed.

The agency also takes hits for the speed – or lack thereof – with which it informs the public of a serious health risk. Media reports have repeatedly questioned why no word of the risk reached the public until people were dying.

“Where human death or serious illnesses have occurred, the (CFIA) should promptly disclose the results of its investigation of the implicated plant … to the public,” the report says.

Public communications, in general, were a mess in part because of classic right-hand-unaware-of-left-hand puzzlement between different health agencies, she writes.

The report’s strong call for greater transparency heralds with delicious irony considering its release was delayed a day by the federal Tories for non-public review.

A reassuring harbinger of change, is it not?