Volume 1: Findings and Conclusions
1. Introduction

1 In December 1986 a new animal disease was discovered by the State Veterinary Service. It quickly became known as Bovine Spongiform Encephalopathy or BSE. It caused irreversible 'spongy' changes to the brains of cattle and was invariably fatal. The public called it 'mad cow disease'.

2 For ten years the Government told the people:

• there is no evidence that BSE can be transmitted to humans;
• it is most unlikely that BSE poses any risk to humans; and
• it is safe to eat beef.

3 Then, on 20 March 1996, Mr Stephen Dorrell, the Secretary of State for Health, stood up in Parliament and announced that ten young people had contracted a new variant of the harrowing, and invariably fatal, Creutzfeldt-Jakob disease - vCJD - and that it was probable that they had caught BSE. Further cases of vCJD were to follow. By September 2000 there had been over 80 ¹ cases and the frequency with which they were being reported seemed to be growing.

4 For nearly three years we have been examining all that is known about the history of BSE and vCJD and looking at how these diseases were handled by the Government and by others in the period between December 1986 and 20 March 1996. This Report sets out what we have found.

5 In 1986 the United Kingdom had a worldwide reputation for competence and efficiency in animal health and welfare matters, and in the handling of outbreaks of serious animal diseases. Its skilled veterinarians and scientists, with the State Veterinary Service and veterinary laboratories in the forefront, operated established processes to identify, contain and eradicate animal diseases. They worked closely with farmers, veterinarians in private practice, public health professionals and the relevant industrial sectors. They raised awareness, gave advice, and recommended statutory regulation where appropriate and compensation if need be. The process required well-established communication between advisers and practitioners, effective systems of animal surveillance and information-gathering, programmes of research, and detailed shared understanding of the links between animal and human health in all its aspects, including the food chain.

6 The UK also had highly regarded public health processes of long standing to handle outbreaks of human disease. These included surveillance, preventive action, such as immunisation and advice, and treatment. The health of the nation was at the heart of the remit of the Health Ministers and the professional responsibility of the four Chief Medical Officers, one for each part of the UK, who advised the Government.

7 What went wrong after the new fatal degenerative brain disease of cattle, BSE, emerged in 1986? Why did the announcement in 1996 that humans had probably been struck down by this particular brain disease find the guardians of public health and the world at large so shocked, and apparently unprepared, and leave the public so disillusioned? Our remit does not extend to the frantic diplomatic activity and other events after that date, but the consequences are still bearing heavily on the British economy and have inflicted tragedy on some families and left blighting uncertainty and fear hanging over many more.

8 The full extent and effects of the human disease will not be discernible for many years to come. Baffling questions include the unusual nature of Transmissible Spongiform Encephalopathies (TSEs), the reasons why specific people have become prey to the human version of BSE, and the extent to which others, particularly those exposed to the agent in the 1980s, may yet develop it. These difficult and still unresolved questions have hampered and bedevilled the whole course of events. What we do know is that as of September 2000, shortly before publication of this Report, over 80 victims of vCJD, most of them young, had had their lives destroyed and their families' happiness and hopes had been irreparably damaged.

9 BSE has been a peculiarly British disaster. Almost all the victims of vCJD have been in the United Kingdom. Only four other human victims of vCJD have been diagnosed elsewhere. ² Over 170,000 cattle have been diagnosed with BSE here compared with fewer than 1,500 abroad, mostly it would appear traceable to British-sourced animals or infected feed at the beginning of the British epidemic. So far, over 4.7 million British cattle have had to be slaughtered, and their carcasses burned or buried as potentially dangerous waste. ³ A thriving high-quality cattle and meat export industry has been wiped out. The livelihood of thousands of farmers and businesses has been damaged. Even at this tail-end of the animal epidemic there were still over 2,000 cases of BSE notified in 1999 and cases continue to be reported as we write.

10 Small wonder that people want to know why it happened and whether it was handled wisely and well. In particular:

• What was the cause of BSE emerging and spreading country-wide? Was it as a result of intensive modern farming practices? Was it a result of inadequate regulation or lowered standards? Why is it so overwhelmingly the UK that has been afflicted?
• Seventy-four victims, mostly young people, have died of a new variant of CJD. Is it certain that they contracted this dreadful disease as a result of some form of connection with BSE? If so, why was it that they were struck down?
• Was the emergence of BSE and its threat to human health effectively handled by those whose responsibility it was to do so?
• Did individuals respond as they should have done, having regard to the state of knowledge at the time?
• Was the truth about the nature of BSE and the threat it posed concealed from the public? Has there been a cover-up?
• Did we make proper use of our scientists?
• Did our health and welfare services adequately cater for the special needs of those who contracted vCJD and their families?
• What lessons does the catastrophic course of events hold for public policy and the way we do things in the future?

11 These questions have been very much in our minds throughout this Inquiry, as we have explored exactly what happened day by day during the ten years that led up to the announcement of 20 March 1996 that BSE had probably generated a new and fatal human disease. Some questions, such as the numbers who are likely to succumb to the human disease, we are not in a position to answer. Our remit is to report to Ministers on the course of events and the adequacy of the responses to them in the light of knowledge at the time. We have sought to do so thoroughly and fairly. We have reviewed not only the years since BSE first emerged, but the events that led up to it. We have read a large number of scientific publications. We have sifted 3,000 files of documents, and have studied 1,200 statements and many contributions from the public, whom we have sought to keep fully up to date with every stage of our proceedings. We have listened to 138 days of public oral evidence from 333 witnesses.

12 A recurring theme in the BSE story - a point we look at in detail later in our Report - has been growing public suspicion and dissatisfaction that important information was not being shared and discussed openly so that people were denied proper choices in matters that deeply affected them and their families. One of our goals in settling the conduct of our Inquiry was to make our investigations as open as good practice and modern technology could ensure, with any significant material we received made freely available to all. Witnesses' statements and transcripts of our hearings have been made available free of charge to all with access to the Internet. Hundreds of fuller dossiers of assembled factual material have throughout been available in more conventional form for those who wish to inspect them at our offices. We have placed in the public domain a unique corpus of official documents, and we have sought to throw light on a range of normally internal public policy processes. Our aim has been to be as thorough, open and fair as we could possibly be. Annex 1 to this volume describes the procedures we adopted for this purpose.

13 We have welcomed the spirit of cooperation we have been shown by the previous and current administrations and many other organisations in opening their archives to us. As some of our witnesses pointed out, they too are consumers of animal products and they too have children and grandchildren whom they cherish. We have made heavy demands for information on many witnesses and the voluntary response has been remarkable.