Portrait of a nation fed a diet of reassurances

The main findings

A catalogue of mistakes, misjudgements and criticisms are outlined in the 16-volume report of the £16m BSE inquiry. It dissects every branch of government that was involved in the tragedy of variant Creutzfeldt-Jakob disease, the human form of bovine spongiform encephalopathy which has so far killed 80 people

A catalogue of mistakes, misjudgements and criticisms are outlined in the 16-volume report of the £16m BSE inquiry. It dissects every branch of government that was involved in the tragedy of variant Creutzfeldt-Jakob disease, the human form of bovine spongiform encephalopathy which has so far killed 80 people

The report pinpoints three challenges posed by the emergence of BSE when it was first identified in 1986 by government veterinary surgeons: the need to eradicate the disease, the potential threat to other animals and, most important of all, the potential threat to humans.

In dealing with the last question, the inquiry attacks the mindset of civil servants and government advisers in the way they judged the overall risk to human health. "We have formed the view that the vast majority of those who were involved in this country's response to BSE believed, subjectively, that it was not a threat to human health," the report says.

Although the inquiry team, chaired by Lord Phillips of Worth Matravers, gave credit to many of those involved in dealing with BSE, they publicly criticise 26 ministers, civil servants and advisers for shortcomings that affected the way the BSE crisis unfolded.

Intensive farming

The report says BSE developed as an epidemic as a result of intensive farming practices, namely the recycling of animal protein in cattle feed, which was first documented in Britain in 1926. The act of rendering, when animal waste is heated to make meat and bonemeal feed, was never designed to sterilise the unusual agents responsible for sheep scrapie, BSE and other transmissable spongiform encephalopathies.

"What went wrong was that no one foresaw the possibility of the entry into the animal feed cycle of a lethal agent far more virulent than the conventional viral and bacterial pathogens, and one which would be capable of infecting cattle despite passing through the rendering process," the report says.

Many of the measures designed to protect the human food chain from BSE were not introduced soon enough. Some were inadequately implemented and not properly enforced.

'Sedated with reassurances'

Bureaucratic delays and a "lack of rigor" among officials resulted in unacceptable delays in implementing new policies on BSE. The public was also treated to an unsatisfactory diet of reassurances to sedate their fears. Although the Conservative government is cleared of lying to the public, it is heavily criticised for being preoccupied with preventing alarmist over-reaction to the crisis.

"Although most of those concerned with handling BSE believed that BSE posed no risk to humans and understood the available science as indicating that the likelihood that BSE posed a risk was remote, they did not trust the public to adopt as sanguine an attitude," the report says.

"As each additional piece of data about the disease became available, the fear was that it would cause disproportionate alarm, would be seized on by the media and by dissident scientists as demonstrating that BSE was a danger to humans, and would lead to a food scare or, even more serious, a vaccine scare."

A culture of secrecy within the Ministry of Agriculture, Fisheries and Food (Maff) and the State Veterinary Service impeded the gathering of data on the extent of the spread of BSE in the first half of 1987, in the six months following its first identification. An embargo on making the new disease public "should not have occurred", the report says.

'Scrapie not origin of BSE'

Although the report praises the efforts of John Wilesmith, the Maff scientist who first identified the link between BSE and infected meat and bonemeal (MBM), it says that the belief he promulgated of the disease being the result of cattle eating sheep scrapie was wrong.

"Great credit is due to Mr Wilesmith for his rapid identification of MBM in feed as the immediate source of infection.

"His deduction as to the probable reasons why MBM was infectious was reasonable, but wrong. It was unfortunate that his explanation - the scrapie theory - was one that provided unwarranted reassurance that BSE was likely to behave like scrapie and would thus not be transmissible to humans."

Cross-contamination ignored

Another failing emerged when officials realised that the ban on meat and bonemeal for cattle was being broached by cross-contamination in the feed mills which were still preparing feed for pigs and poultry using the same equipment.

If officials had taken into account experimental results released in 1990 showing that just half a gram of infected meat and bonemeal could cause BSE in a cow, then cross-contamination would have been recognised as a problem early on.

"A cow can become infected with BSE as a result of eating an amount of infectious tissue as small as a peppercorn. Cross-contamination in feedmills resulted in the continued infection of thousands of cattle," the report says.

Despite the years of knowing about the exceedingly small quantities of infected material that can cause BSE, nothing was done about the problem of cross contamination until 1994, when a total ban on mammalian MBM was proposed, by which time many calves with BSE had been born after the original 1989 ban on meat and bonemeal made from ruminant animals.

Maff and DoH rivalry

Repeated failures of Maff and the Department of Health (DoH) to work together effectively hindered the government's ability to deal with the disease and protect the human food chain. Maff officials recognised in 1987 that there was a risk that BSE could be transmitted in veterinary products, but failed to tell the health department of its concerns.

A compulsory slaughter scheme of affected cattle was introduced in August 1988, but it could have come sooner. "Had there been prompt and adequate collaboration between Maff and DoH, this measure could and should have been introduced months earlier," the report says.

There were also differences of opinion between Maff and DoH on the introduction of a specified bovine offal ban to protect the human food chain. The DoH was concerned about creating a public scare, but Maff decided unilaterally that the ban should be put in place.

At late as February 1996, a month before Stephen Dorrell, then Secretary of State for Health, announced the link between BSE and 10 cases of vCJD in young people, the inadequate liaison between Maff and the health department was still going on.

Lord Phillips said yesterday that public administration has in general emerged with credit following a period of intense scrutiny by the inquiry. Nevertheless, he said there were many lessons to be learnt from the BSE crisis. "Animal health and human health are closely inter-related. A sound surveillance system for animals' diseases is an essential safeguard for both," Lord Phillips said.