Volume 1: Findings and Conclusions
1. Introduction
The structure of the Report

34 Almost every aspect of the BSE story takes us into territory that may well be unfamiliar to the average reader of this Report. Anyone who wishes to follow the story fully will need to understand:

• the involvement of government in UK agriculture during and after the Second World War;
• the influence of the Common Agricultural Policy on agricultural production;
• the digestive system of the cow;
• intensive feeding methods designed to boost milk production;
• feed compounding;
• rendering;
• slaughterhouse techniques;
• the administrative structure of the Government Departments and local authorities involved;
• the powers available to government to regulate and enforce;
• the use made by government of advisory committees;
• basic human and animal biology;
• genetics; and
• current scientific knowledge in relation to the nature of Transmissible Spongiform Encephalopathies (TSEs).

35 These topics form the background to ten years of activity in response to the emergence of BSE. We must review that activity in context. A key consideration in an exercise as far-ranging and complex as this Inquiry is how best to present and make widely available the significant material and findings we have assembled.

36 We are conscious that while some will wish to follow, in detail, our examination of the BSE story, or some specific parts of it, most will not have the time or the energy for such an exercise. The majority will wish to read, in simple language, a summary account of the emergence of BSE and how it was handled, with particular reference to its implications for human health. More particularly, the majority will be looking to us to answer, as best we can, a number of questions about BSE, vCJD and the conduct of government in relation to them over the period with which we are concerned. This volume aims to meet those wishes of the majority.

37 The emergence of BSE called for responses of different kinds and in relation to different areas of activity. In this volume we propose to follow a topic-based approach. At the outset we shall explain the nature of Transmissible Spongiform Encephalopathies and examine the assumption which lies at the root of this Inquiry: that the variant of the human disease CJD is a consequence of the emergence of BSE. We conclude this chapter by setting out the BSE story in a nutshell. In the next chapter we have included sections about the industries which feature in the BSE story; how government was set up to handle an issue like BSE; and handling risk. We aim in that chapter to give much of the background that will enable the reader to follow the story in the rest of this volume.

38 Chapters 3 to 6 contain a narrative of a part of the BSE story which, for the most part, has been in the public eye:

• the emergence of BSE;
• the theories as to its cause;
• the measures taken to try to eradicate it;
• the concerns that humans might be able to catch BSE and worries about the safety of beef;
• the official reassurances about the risk to humans and the safety of beef; and
• the dreadful discovery that BSE had probably been transmitted to humans after all.

39 In Chapters 7 to 9 we turn to parts of the story of which the public was generally not aware at the time. As a result of recent media coverage, the subject matter of Chapter 7 - steps taken to address the possibility that BSE might have infected medicines, vaccines and cosmetics that used bovine products as ingredients or in the manufacturing process - has now become public. But Chapters 8, 9 and 10 deal with the less familiar topics of guidance given to occupational groups which may have been at risk from handling potentially infected tissues at work; the consideration given to tracing all the uses of bovine tissue and thus all possible pathways along which infection may have been transmitted; and the impact of BSE on pollution and waste control. In Chapter 11, we summarise our main findings about the part played by the Territorial Departments, as they then were, in Wales, Scotland and Northern Ireland.

40 In Chapter 12 we set out the conclusions we have been able to draw about the scientific response to BSE, dealing with some important questions, such as the origin of the BSE agent.

41 We conclude with two chapters which fulfil what we believe to be the essence of our remit, that is, to understand why things happened in the way they did and to suggest how lessons may be learned from the BSE story for the benefit of those facing similarly difficult situations in future.

42 In summarising our findings and conclusions in a manner and at a length which we hope will make them accessible to all, we have had to paint with a broad brush and to leave untouched some parts of the gigantic canvas. The picture is painted in greater detail in the remaining 15 volumes, starting with Volume 2, which contains an analysis of the scientific evidence. Volumes 3 to 9 contain a detailed description and analysis of the events which are summarised in this volume.

43 Volume 10, which is a background volume, describes the impact of BSE on the economy and looks at how international trade was affected. Before BSE emerged, the majority of exports from the UK, of both live cattle and beef, went to the European Union (EU). ¹ After BSE emerged, these exports were subjected to restrictions that were imposed under European law. They did, however, benefit from the protection of the Single European Market, which made it unlawful for individual members of the EU to impose more stringent requirements on UK exports. Our Terms of Reference require us to consider the response to the emergence of BSE in the UK. We have not traced the deliberations that took place in Europe - in which representations of the UK played a key role - which determined the extent of the restrictions consequent upon BSE that were placed on our trade with the EU.

44 So far as the export of live cattle was concerned, the EU response was to restrict this to cattle of a BSE-free provenance which, after 1990, were aged less than six months. So far as beef was concerned, exports were restricted to beef on the bone of a BSE-free provenance, or beef off the bone from which all obvious nervous and lymphatic tissue had been trimmed. From December 1994 there were exemptions in respect of beef from younger cattle.

45 Statistics of exports of cattle and beef during the period with which our Inquiry is concerned are set out in Chapter 5 of Volume 10. They make interesting reading. Despite the EU restrictions, our exports of live cattle to the EU climbed steadily between 1988 and 1994, dropping only slightly in 1995. Outside the EU, sales of live cattle slumped to negligible proportions after 1989. The value of exports of beef on and off the bone to the EU climbed by 1995 to well over double their value in 1987. Outside the EU, sales of beef off the bone slumped between 1986 and 1993, before recovering to close to previous levels. Sales of beef on the bone reduced to negligible proportions after 1987.

46 Volume 11 looks at the important role in the BSE story played by scientific committees and independent scientists. It forms the basis for a large number of lessons to be learned about the use of expert scientific committees which are set out in the final chapter of this volume.

47 The factual parts of these volumes have been based in large measure on 'draft factual accounts', which were collated from the evidence, were published as the Inquiry progressed, and have been revised on the basis of comments received and additional evidence. To these we have added, in Volumes 2 to 9 and 11, sections of comment and discussion in which we have considered conflicts of evidence and explained the conclusions that we have drawn from the facts. Readers who want detailed explanations for the findings and conclusions set out in this volume will find them in those volumes. They will also find an abundance of references to source material, which will remain accessible to the public. In this volume we have sought to keep references to a minimum.

48 Volumes 10 and 12 to 15 contain background material which provides a detailed context in which the BSE story is set. Volume 16 contains relevant reference material. It should be noted that Volumes 10 and 12 to 16 are background volumes which have been prepared by researchers on the Inquiry team under our supervision and guidance. Conclusions of the Committee are not to be found in these volumes.

49 It has been clear that speedy access to Inquiry material through the Internet has been widely appreciated, and we have therefore cast and referenced our Report and its supporting material in a form immediately transmissible through this medium. We hope that it will thus prove another example of open practice on matters of legitimate public concern.