The BSE Inquiry was set up to: establish and review the history of the emergence and identification of BSE and variant CJD in the United Kingdom, and of the action taken in response to it up to 20 March 1996; reach conclusions on the adequacy of that response, taking into account the state of knowledge at the time; and to report on these matters to the Government. This executive summary presents the overview of the key findings and conclusions. BSE developed into an epidemic as a consequence of an intensive farming practice - the recycling of animal protein in ruminant feed. The report states that in the years up to March 1996 most of those responsible for responding to the challenge posed by BSE emerge with credit. However, there were a number of shortcomings in the way things were done. The Government took measures to address both the hazard to animal health and human health, but these were not always timely nor adequately implemented and enforced. The Inquiry found that the rigour with which policy measures were implemented for the protection of human health was affected by the belief of many prior to early 1996 that BSE was not a potential threat to human life. The Government was anxious to act in the best interests of human and animal health. To this end it sought and followed the advice of independent scientific experts - sometimes when decisions could have been reached more swiftly and satisfactorily within government. At times officials showed a lack of rigour in considering how policy should be turned into practice, to the detriment of the efficacy of the measures taken, and on occasion the bureaucratic processes resulted in unacceptable delay in giving effect to policy. The report demonstrates that the Government introduced measures to guard against the risk that BSE might be a matter of life and death not merely for cattle but also for humans, but the possibility of a risk to humans was not communicated to the public or to those whose job it was to implement and enforce the precautionary measures. The Inquiry concludes that the Government did not lie to the public about BSE. It believed that the risks posed by BSE to humans were remote. The Government was preoccupied with preventing an alarmist over-reaction to BSE because it believed that the risk was remote. It is stated that the campaign of reassurance was a mistake. When on 20 March 1996 the Government announced that BSE had probably been transmitted to humans, the public felt that they had been betrayed. Confidence in government pronouncements about risk was a further casualty of BSE. Cases of a new variant of CJD (vCJD) were identified by the CJD Surveillance Unit and the conclusion that they were probably linked to BSE was reached as early as was reasonably possible. The link between BSE and vCJD is now clearly established, though the manner of infection is not clear. This volume is accompanied by a CD ROM which contains the Inquiry's full report.
This volume describes the system of government administration within which Ministers and their civil servant operated during the period 1986 to 1996. It focuses in particular on the process of decision-making in the Ministry of Agriculture, Fisheries and Food (MAFF) and the Department of Health (DH). It also looks at some of the managerial preoccupations of officials and Ministers during the period 1986-1996, as the policy on BSE was being made. A point repeatedly made by witnesses giving to the Inquiry was that decision-making was a 'collegiate' process involving both Ministers and officials. Some witnesses went on to argue from this that no individual should be regarded as responsible for the decisions taken. This view is not shared in this report but the report does consider that judgements about individual's responses to BSE require an understanding of the normal workings of government and of the expectations and constraints that these impose.There are 3 annexes to the report: annex 1 illustrates the structures of MAFF and of DH and how they changed over the period described, focusing on the units that were dealing with BSE and new variant CJD; annex 2 outlines the development of risk assessment and annex 3 outlines the development of the Government's Deregulation initiative from 1983 to 1996.
This volume is concerned mainly with the potential pathway for BSE infection posed by the use of veterinary and human medicines using animal tissues. The arrangements covering the safety of medicines and medical devices and the response to BSE over the period 1987-96 is described. The volume goes on to review action taken on cosmetics and toiletries, which shared features with topical medicines but were not covered by the provisions of the Medicines Act. It concludes by examining the events that surround the failure to prepare a comprehensive audit of uses of bovine tissues. Charts illustrate the extent of the uses of bovine material and the complex interaction of the many industries involved, the degree of recycling and the various ultimate disposal outlets.
This volume explains the relevant legislative and executive framework which was in place when BSE was identified at the end of 1986, and the changes to this framework up to 20th March 1996 that were brought about by factors not connected to BSE. One example of this was the continuing integration with Europe, which required, amongst other things, a common standard of meat hygiene within the Single Market. This was the background against which policy makers had to consider what action to take to deal with the perceived hazards from BSE and what control measures could be introduced. The control measures taken are described in detail in volumes 3-7. The report shows how the legislation controlled processes and activities rather than complete industries or industrial sectors. At any given time, the legislation affecting a sector such as agriculture consisted of interwoven Acts, Orders and Regulations each designed to deal with specific matters. The interwoven powers affected different sectors to varying degrees with some, such as the legislative control over animal feeding stuffs, being extremely detailed. Legislation passed by Parliament did not necessarily apply throughout the UK. Legislation specific to Scotland and Northern is mentioned where appropriate and any differences are described.
This volume of the Inquiry considers the appointment of, and the advice given by, the Southwood Working Party, chaired by Sir Richard Southwood. This group's work is considered in some detail for its advice had important impacts, both in the short term and in the long term.The Working Party were asked to advise on the risks posed by BSE and the measures that should be taken to counter those risks. They addressed both matters,but sought to make it plain that they were doing their best on very limited data, that much further research was necessary,that their assessment of risk might be wrong and that, were it wrong, the consequences would be extremely serious. Unhappily, the Southwood Report was treated by many officials in the Ministry of Agriculture, Fisheries and Food (MAFF) and the Department of Health (DH) and, at times, by Ministers as if it contained definitive conclusions based on an evaluation of adequate data by expert scientists in relation to the extent both of the risk and of the precautionary measures necessary to counter that risk.
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