At least 80 people have died in Britain from the human form of BSE and many more cases will follow, possibly thousands. These deaths occurred because the government wanted to avoid a health scare and a subsequent collapse in its beef trade.
Yet in the process it exchanged what started as a food scare for what the British Minister for Agriculture, Fisheries and Food, Mr Nick Brown, yesterday admitted was a "national tragedy". Its lack of decisive action, even when given compelling scientific information about possible risks, caused excessive delays in getting infected meat off the shelves. Inaction allowed BSE to transfer into humans and greatly increased numbers infected with the BSE-related disease, variant Creutzfeldt-Jacob Disease (vCJD).
Mr Brown's candour follows the release of a highly damaging report prepared by Lord Phillips.
Its 16 volumes and 4,000 pages provide a mountain of evidence testifying to the government's weak-wristed approach to the control of BSE in the early days.
The report stresses there was no deliberate intention to deceive or to protect farming interests at the expense of the consumer, but decision-makers heard only what they wanted to hear from their own experts and therefore misled consumers - a classic example of why scientific findings, particularly when they relate to food safety, must remain transparent and open to scrutiny.
"At the heart of the BSE story lie questions of how to handle hazard - a known hazard to cattle and an unknown hazard to humans," the report states. The government responded slowly to the growing BSE problem because of "the belief of many prior to early 1996 that BSE was not a potential threat to human life".
Yet long before the first reported case of vCJD in 1996, researchers at Bristol University discovered a BSE-like disease in a cat and reported their findings in May 1990. This discovery should have immediately raised concerns that BSE was transmissible and could potentially infect humans. Yet in that same year the then minister for agriculture, fisheries and food, Mr John Gummer, insisted British beef was safe and attempted to demonstrate his confidence by feeding a beef burger to his four-year-old daughter, Cordelia.
New research findings were informing government decision-making throughout the critical period between 1990 and 1996 when the first action was finally taken to protect the consumer. Yet these were not communicated to the public, and by extension to the general research community who could have contributed to the scientific effort. "The public were never told that scientists' appraisal of that risk had changed," the report states.
In normal circumstances, the pursuit of scientific knowledge is a public affair.
The benefit from this transparency is that scientists get to poke holes in the work of others. This helps to ensure the quality and accuracy of information. Closing off the UK government's BSE scientific advice from this scrutiny ensured that only one view - the least politically damaging - was being expressed in public pronouncements. The harvest of this misguided approach is now being gathered as the vCJD death toll mounts.
Are we now better off following publication of the report? Not necessarily. We think we know how BSE moved into UK and Irish cattle herds when BSE-infected animal waste meat was processed and fed back to cattle as a protein source. We still don't know for sure how the disease moves about to infect more animals four years after the introduction of controls.
There are plenty of assurances however. The acting head of the UK government's BSE advisory committee, Prof Peter Smith, spoke yesterday about the likely caseload of vCJD that would arise and about the currently understood risk. "I think the control measures they have put in place over the last decade mean that the risk of contaminated beef getting into the food chain is really very small," he said.
We have heard similar assurances before. If transparency is not maintained, should we have any more confidence in these compared to those given in 1990?