Safe Food: Bacteria, Biotechnology, And Bioterrorism Part 1

Safe food: bacteria, biotechnology, and bioterrorism.

by Marion Nestle.

PREFACE TO THE 2010 EDITION.

WHEN SAFE FOOD SAFE FOOD FIRST APPEARED IN 2003, FOOD SAFETY HARDLY FIRST APPEARED IN 2003, FOOD SAFETY HARDLY appeared on the public agenda. American food safety advocates struggled to be heard but generated little public interest or congressional action. I wrote appeared on the public agenda. American food safety advocates struggled to be heard but generated little public interest or congressional action. I wrote Safe Food Safe Food to explain the political history of our fragmented and ineffective food safety system and how politics gets in the way of efforts to improve the system. Having no illusions that the book would do what Upton Sinclair's to explain the political history of our fragmented and ineffective food safety system and how politics gets in the way of efforts to improve the system. Having no illusions that the book would do what Upton Sinclair's The Jungle The Jungle accomplished in 1906, I hoped that it would at least generate some creative thinking about food safety problems and their solutions. accomplished in 1906, I hoped that it would at least generate some creative thinking about food safety problems and their solutions.

I spent the next few years dealing with invitations to speak about the health implications of food marketing discussed in my earlier book, Food Politics Food Politics. I also wrote What to Eat What to Eat, a book that uses supermarket aisles as an organizing device for thinking about food issues, safety among them. By the time that book came out in 2006, I thought I was done with food safety. I had nothing more to say about it.

Then came September 14, 2006. On that day, one that California vegetable growers still refer to as 9/14, the Food and Drug Administration (FDA) announced the recall of spinach contaminated with E. coli E. coli O157:H7, the pathogen introduced in O157:H7, the pathogen introduced in chapter 1 chapter 1 and discussed throughout this book. This incident brought the inadequacies of our food safety system to public attention as never before and renewed calls for mandatory regulation. As always, these calls were ignored. The result was an astonis.h.i.+ng series of national outbreaks and food recalls, one right after another. and discussed throughout this book. This incident brought the inadequacies of our food safety system to public attention as never before and renewed calls for mandatory regulation. As always, these calls were ignored. The result was an astonis.h.i.+ng series of national outbreaks and food recalls, one right after another.

To my surprise, I began to receive invitations to write and speak about food safety issues. These came with further invitations to visit farms, packing plants, and food manufacturing and processing operations. I was appointed to the Pew Commission on Industrial Farm Animal Production, which visited both large and small cattle, pig, and chicken farms. I also visited a free-range bison ranch. Following the pet food recalls of 2007, as part of the research for my account of those events, Pet Food Politics Pet Food Politics (2008), I visited factories that produce pet foods, raw and cooked. I had plenty of opportunity to see how food is produced under safe and unsafe conditions, and plenty to talk about. (2008), I visited factories that produce pet foods, raw and cooked. I had plenty of opportunity to see how food is produced under safe and unsafe conditions, and plenty to talk about.

In question sessions following my talks, I could hear how abstract the regulation of microbes in food feels to most people. Americans a.s.sume that the government keeps food free of contaminants and give food safety little thought. Instead, questions are about dread-and-outrage factors, topics covered in this book such as food biotechnology and irradiation, but also the right to consume raw milk, raw oysters, and other foods the government considers unsafe. Films such as The Future of Food The Future of Food and and Our Daily Bread Our Daily Bread and, later, and, later, Food, Inc Food, Inc. and Fresh Fresh, dealt with such matters and generated more questions along the same lines.

It soon became clear that Safe Food Safe Food still had plenty to say about current events and, perhaps, could be made more useful to a wider audience. In rereading it, I was relieved to find that it holds up well in establis.h.i.+ng the historical basis of our current food safety predicaments. For this new edition, I corrected typos, clarified a few fuzzy points, changed some tenses from present to past, and wrote an epilogue to bring the events up to date. Otherwise, the original text remains. But I did think one additional change was needed. The book's subt.i.tle, still had plenty to say about current events and, perhaps, could be made more useful to a wider audience. In rereading it, I was relieved to find that it holds up well in establis.h.i.+ng the historical basis of our current food safety predicaments. For this new edition, I corrected typos, clarified a few fuzzy points, changed some tenses from present to past, and wrote an epilogue to bring the events up to date. Otherwise, the original text remains. But I did think one additional change was needed. The book's subt.i.tle, Bacteria, Biotechnology, and Bioterrorism Bacteria, Biotechnology, and Bioterrorism, did not reflect its overarching theme: that food safety is political. The new subt.i.tle, The Politics of Food Safety The Politics of Food Safety, is really what this book is about.

Here, I argue that whether we view microbes or genetic modifications as the greater hazard depends on whether we look at foods through the lens of scientific or other value systems. Microbial contamination is responsible for an estimated 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths in the United States each year. Food biotechnology is responsible for no measurable human illness to date. Yet public dread and outrage about food safety problems continues to be much more about genetic modification than about the unlucky victims of severe food poisonings.

In part, the disconnect between science and values explains why it is so difficult to get Congress to act on matters of food safety. Congress also views microbes as so familiar and so much under personal control that no governmental action is needed. Food industry pressures encourage this view. I have long said that nothing short of the death of a close relative of a senior senator by food poisoning will induce Congress to fix the food safety system. Otherwise, Congress will continue to respond to pressures from food corporations willing to cut safety corners and place their customers at risk to protect profit margins.

At the time of this writing, Congress is about to pa.s.s a new food safety bill, but one designed to fix only the FDA, not the system as a whole. Absent from the current debate is public dread and outrage about microbial contaminants and the politics of food safety. Without stronger public support for coordinated mandatory regulation of the entire food safety system, we can expect outbreaks and ma.s.sive food recalls to continue, and even more people to suffer from illnesses that easily could have been prevented.

A NOTE ON THE NOTES.

Serious researcher that I am, I must mention the alarming challenge posed by updating the endnotes to this book. Seven years after publication of the first edition, I could not find more than a handful of the eighty or so Internet references at their original addresses (URLs). Using t.i.tles, I was able to find most at new locations, but some seem to have vanished into cybers.p.a.ce. I was dismayed to discover that the Internet is not the permanently tamperproof file cabinet I had imagined it to be. Fortunately, the t.i.tles are permanent. At the time of this writing they could be found at the listed URLs, but these must be considered ephemeral.

New York February 2010

PREFACE TO THE FIRST EDITION.

FOOD SAFETY IS A MATTER OF HUGE PUBLIC INTEREST. HARDLY a day goes by without a front-page account of some new and increasingly alarming hazard in our food supply. As an academic nutritionist with a long-standing interest in how food affects health, I cannot help but deal with issues of food safety, daily. Students, colleagues, and friends often ask me whether it is safe to eat one or another food or ingredient. My department at New York University offers degree programs in the new field of food studies as well as in nutrition, and many instructors and colleagues a.s.sociated with these programs work in restaurants or specialty food businesses. They also ask safety questions, as their livelihoods depend on serving safe food. a day goes by without a front-page account of some new and increasingly alarming hazard in our food supply. As an academic nutritionist with a long-standing interest in how food affects health, I cannot help but deal with issues of food safety, daily. Students, colleagues, and friends often ask me whether it is safe to eat one or another food or ingredient. My department at New York University offers degree programs in the new field of food studies as well as in nutrition, and many instructors and colleagues a.s.sociated with these programs work in restaurants or specialty food businesses. They also ask safety questions, as their livelihoods depend on serving safe food.

Nevertheless, I did not set out to write a book about food safety. My academic training is in science (molecular biology, but long lapsed) as well as in public health nutrition, and for many years my research has focused on the ways in which science and politics interact to influence government policies that affect nutrition and health. In that context, I have been speaking and writing about food biotechnology since the early 1990s. I immediately saw that genetically engineered foods raise questions about politics as much as about safety. Indeed, the safety questions seemed overshadowed by issues related to the implications of such foods for society and democratic values.

I originally intended to include several chapters on such issues in a book about the ways in which food companies use the political system to achieve commercial goals. That book, Food Politics: How the Food Industry Influences Nutrition and Health Food Politics: How the Food Industry Influences Nutrition and Health, came out in 2002 from the University of California Press. In the course of events, however, it became clear that the subject of food safety deserved a book in its own right. To begin with, during the years I worked on Food Politics Food Politics (1999 to 2001), food safety crises popped up one after another, especially in Europe. Mysteriously contaminated soft drinks, cows sick with mad cow and foot-and-mouth disease, and outbreaks of what my friend and colleague Claude Fischler calls " (1999 to 2001), food safety crises popped up one after another, especially in Europe. Mysteriously contaminated soft drinks, cows sick with mad cow and foot-and-mouth disease, and outbreaks of what my friend and colleague Claude Fischler calls "Listeria bacteria hysteria" were eliciting headlines and destroying economies as well as confidence in the food supply. On the domestic front, one food after another-hamburger and such unlikely suspects as raspberries, apple juice, and bean sprouts-appeared as sources of bacterial infections. Because some of the contaminating bacteria resisted antibiotics, the illnesses were difficult to treat. Product recalls because of microbial contamination also seemed to be growing both in size and public attention. bacteria hysteria" were eliciting headlines and destroying economies as well as confidence in the food supply. On the domestic front, one food after another-hamburger and such unlikely suspects as raspberries, apple juice, and bean sprouts-appeared as sources of bacterial infections. Because some of the contaminating bacteria resisted antibiotics, the illnesses were difficult to treat. Product recalls because of microbial contamination also seemed to be growing both in size and public attention.

Furthermore, I was receiving increasingly urgent queries from purveyors of small-scale, artisa.n.a.l cheeses who wanted to know: can cheeses in general, and raw milk cheeses in particular, transmit bacterial diseases, mad cow disease, or foot-and-mouth disease? The answers to such questions were not easy to find, and I was soon engaged in reading veterinary reports and badgering experts and federal officials for information. Eventually, I could provide a scientific answer: cheese has a low probability of transmitting these or any other diseases, but the possibility cannot be excluded. This answer is either satisfactory or not depending on whether one is an optimist or a pessimist, and it raises its own set of questions. Does a low probability of harm mean that a risk is negligible and can be ignored? Or is it unreasonable to take the chance? Would pasteurization (heating milk briefly to a temperature high enough to kill most bacteria) make cheeses safer? Should the federal government require cheese makers to pasteurize milk or to follow other special safety procedures? Is the benefit of eating prized specialty cheeses worth any risk, no matter how small? The answers to such questions involve judgments based in part on science, but also on more personal considerations-how much one values the taste of cheeses made from raw milk, for example, or the social contribution of artisa.n.a.l cheese making. Because such judgments are based on opinion and point of view, and sometimes on commercial considerations, and because they affect the regulation, marketing, and financial viability of food products, they bring food safety into the realm of politics.

I have been a minor partic.i.p.ant in making such judgments. As a member of the Food Advisory Committee to the Food and Drug Administration (FDA) in the mid-1990s, I learned about other special safety procedures, particularly a scientific method for reducing the risk of harmful bacteria in food called, obscurely, Hazard a.n.a.lysis and Critical Control Point, or by its equally obscure acronym, HACCP (p.r.o.nounced "ha.s.sip"). Despite its name, HACCP seemed to me to make a lot of sense, and I wondered why food companies-especially those that produce and process beef and chicken-seemed so reluctant to apply HACCP methods for reducing pathogens, and to test for microbial contaminants to make sure that infected meat stayed out of the food supply. Instead, food companies appeared to be using every political means at their disposal to resist having such rules imposed. Here, too, food safety issues seemed to be mired in politics.

On the morning of September 11, 2001, I was at home working on the index to Food Politics Food Politics when terrorists attacked the World Trade Center, just a mile away from my New York City apartment. Among the many consequences of that event were some otherwise insignificant ones having to do with this book. My cheese purveyor colleagues added anthrax to their list of safety questions (answer: another situation of very low probability), and I realized that a book on this subject would also have to deal with food bioterrorism-an extreme example of food safety politics in action. when terrorists attacked the World Trade Center, just a mile away from my New York City apartment. Among the many consequences of that event were some otherwise insignificant ones having to do with this book. My cheese purveyor colleagues added anthrax to their list of safety questions (answer: another situation of very low probability), and I realized that a book on this subject would also have to deal with food bioterrorism-an extreme example of food safety politics in action.

In some ways, this book extends the arguments set forth in Food Politics Food Politics. There, I discussed the ways in which the food industry (the collective term for companies that produce, process, market, sell, and serve food and beverages) influences what people eat and, therefore, health. To encourage people to eat more of their products, or to subst.i.tute their products for those of compet.i.tors, food companies spend extraordinary amounts of money on advertising and marketing. More important, they use politics to influence government officials, scientists, and food and nutrition professionals to make decisions in the interests of business-whether or not such decisions are good for public health. In doing so, food companies operate just like any other businesses devoted to increasing sales and satisfying stockholders. One difference is that the food industry is unique in its universality: everyone eats.

To pick just one example: food companies donate campaign funds where they are most likely to buy influence. According to the Center for Responsive Politics, a group that tracks campaign contributions on its Web site, www.opensecrets.org, several food companies and trade a.s.sociations discussed in this book ranked among the top 20 agribusiness donors in 2001, with contributions ranging from $100,000 to nearly $1 million. The skewed distribution of these donations to Republican rather than to Democratic members of Congress is especially noteworthy. For example, the giant cigarette company Philip Morris, which owns Kraft Foods, donated 89% of more than $900,000 to Republicans. Other companies involved in food safety disputes of one kind or another also donated heavily to Republicans: Archer Daniels Midland (70%), the National Cattleman's Beef a.s.sociation (82%), the Food Marketing Inst.i.tute (90%), the National Food Processors a.s.sociation (96%), and the United Dairy Farmers (100%). When the Republican administration of George W. Bush was in power, these groups expected to receive especially favorable attention to their views on food safety issues, and they usually did.

Underlying discussions of such matters of influence in Food Politics Food Politics and in this present volume are several recurrent themes: and in this present volume are several recurrent themes: * The increasing concentration of food producers and distributors into larger and larger units* The overproduction and overabundance of food in the United States* The compet.i.tiveness among food companies to encourage people to eat more food or to subst.i.tute their products for those of competing companies* The relentless pressures exerted by food companies on government agencies to make favorable regulatory decisions* The invocation of science by food companies as a means to achieve commercial goals* The clash in values among stakeholders in the food system: industry, government, and consumers* The ways in which such themes demonstrate that food is political Food safety, however, would seem to be the least political of food issues. Who could possibly not not want food to be safe? Consumers do not want to worry about unsafe food and do not like getting sick. Unsafe food is bad for business (recalls are expensive, and negative publicity hurts sales) as well as for government (through loss of trust). As this book explains, food safety is political for many of the same reasons discussed in want food to be safe? Consumers do not want to worry about unsafe food and do not like getting sick. Unsafe food is bad for business (recalls are expensive, and negative publicity hurts sales) as well as for government (through loss of trust). As this book explains, food safety is political for many of the same reasons discussed in Food Politics Food Politics: economic self-interest, stakeholder differences, and collision of values. At stake are issues of risk, benefit, and control. Who bears the risk of food safety problems? Who benefits from ignoring them? Who makes the policy decisions? Who controls the food supply? For the most part, these are political-not scientific-questions, and they demand political responses. Because billions of dollars are involved, food safety issues are "hot topics" demanding attention from everyone involved in the food system: producers, distributors, regulators, and the public.

I wrote this book for everyone-from general readers to scientists-who would like to know more about the issues underlying disputes about food safety issues. How concerned should we be about the safety of the food we eat? What aspects of food safety issues should concern us? What issues really are involved? The purpose of the book is to establish a basis for a better understanding of the issues, the positions of the various stakeholders, and the ways in which the political system operates in matters as fundamental as the safety of the food we eat. I hope this book will help everyone interested in food, whether trained in science or not, to develop more considered opinions about food safety issues.

In part because I want the book to reach a wide audience, I have worked hard to make it accessible, readable, and free of jargon, and have defined terms that might be unfamiliar whenever they appear. Although nontechnical discussions of science necessarily omit crucial details, I have tried to provide enough sense of the complexity to make the political arguments understandable. Because any discussion of government policy inevitably requires abbreviations, I define them in the text and in a list (page XV XV). For readers who might like a quick reminder of the science underlying genetic engineering, an appendix provides a brief summary.

Although I do not try to disguise my own views on the issues discussed in this book, I attempt to present a reasonably balanced account of them. Because any book expressing a political point of view is likely to be controversial, I extensively doc.u.ment my sources. I refer to articles in traditional academic journals and books, of course, but also to newspaper accounts, press releases, and advertis.e.m.e.nts. These days, many previously inaccessible doc.u.ments are available on the Internet, and I cite numerous Web addresses in the notes that conclude this book. The notes begin with an explanation of the citation method and the definitions of whatever abbreviations seemed most convenient to use. Because I have been a member of federal committees dealing with some of the issues considered here, and because I frequently attend conferences on these subjects, I sometimes refer to events that I witnessed personally, but I have tried to keep such undoc.u.mented observations to a minimum.

I hope that Safe Food Safe Food will interest consumer advocates, students, college and university instructors, people who work for food companies, those employed in government agencies, and everyone else who is concerned about matters of food, nutrition, health, international trade, and, in these difficult times, "homeland security." If, as I argue, food safety is as much a matter of politics as it is of science, then food safety problems require political solutions. My deepest hope for the book is that it will encourage readers to become more active in the political process. will interest consumer advocates, students, college and university instructors, people who work for food companies, those employed in government agencies, and everyone else who is concerned about matters of food, nutrition, health, international trade, and, in these difficult times, "homeland security." If, as I argue, food safety is as much a matter of politics as it is of science, then food safety problems require political solutions. My deepest hope for the book is that it will encourage readers to become more active in the political process.

ACKNOWLEDGMENTS.

THE GENESIS OF THIS BOOK LIES WITH WARREN BELASCO, JOAN Gussow, and Sheldon Margen, who read the ma.n.u.script of Gussow, and Sheldon Margen, who read the ma.n.u.script of Food Politics Food Politics and argued that the food safety material would work better as a separate ent.i.ty. My dear sponsor at the University of California Press, Stan Holwitz, agreed to take on this second project. The formidable editor John Bergez guided the ma.n.u.script reconstruction; I could not have a better writing teacher. Extraordinarily generous friends, colleagues, and relatives read and commented on specific chapters or sections of the ma.n.u.script at various stages of preparation: Philip Benfey, Jennifer Berg, Elinor Blake, Lee Compton, Laramie Dennis, Beth Dixon, Carol Tucker Foreman, Jeffrey Fox, Mark Furstenberg, Janna Howley, Kristie Lancaster, Trish Lobenfeld, Mimi Martin, Margaret Mellon, Richard Novick, Domingo Pinero, Robert Moss, and Fred Tripp. I am greatly indebted to Joanne Csete, Ellen Fried, and Rebecca Nestle, who read the and argued that the food safety material would work better as a separate ent.i.ty. My dear sponsor at the University of California Press, Stan Holwitz, agreed to take on this second project. The formidable editor John Bergez guided the ma.n.u.script reconstruction; I could not have a better writing teacher. Extraordinarily generous friends, colleagues, and relatives read and commented on specific chapters or sections of the ma.n.u.script at various stages of preparation: Philip Benfey, Jennifer Berg, Elinor Blake, Lee Compton, Laramie Dennis, Beth Dixon, Carol Tucker Foreman, Jeffrey Fox, Mark Furstenberg, Janna Howley, Kristie Lancaster, Trish Lobenfeld, Mimi Martin, Margaret Mellon, Richard Novick, Domingo Pinero, Robert Moss, and Fred Tripp. I am greatly indebted to Joanne Csete, Ellen Fried, and Rebecca Nestle, who read the entire entire draft of the book-acts of courage that extended well beyond the demands of friends.h.i.+p, collegiality, and filial affection. draft of the book-acts of courage that extended well beyond the demands of friends.h.i.+p, collegiality, and filial affection.

Many people provided information or doc.u.ments to which I might not otherwise have had access: James Behnke, Jennifer Cohen, Dennis Dalton, Caroline Smith DeWaal, Carol Tucker Foreman, Rebecca Gold-burg, Karen Heisler, Michael Jacobson, James Liebman, Charles Margulies, Robert Marshak, George Pillsbury, Sarah Pillsbury, Krishnendu Ray, Michael Taylor, Catherine Woteki, Annette Yonke, and Lisa Young. For several years, Christine McCullum has been forwarding information on biotechnology gleaned from the Internet, carefully filtered to include just what I most needed to know. Kristie Lancaster, Domingo Pinero, and Sheldon Watts graciously dropped whatever they were doing to help me deal with computer emergencies. Rob Kaufelt (Murray's Cheese) and Peter Kindel (Artisa.n.a.l) asked questions about cheese, and Sara Firebaugh helped answer them. I also thank all the other contributors of information and materials who preferred to remain anonymous. Finally, I "borrowed" the t.i.tle of this book from Safe Food: Eating Wisely in a Risky World Safe Food: Eating Wisely in a Risky World (Living Planet Press, 1991, but now sadly out of print), for which I thank Michael Jacobson and his colleagues at the Center for Science in the Public Interest. (Living Planet Press, 1991, but now sadly out of print), for which I thank Michael Jacobson and his colleagues at the Center for Science in the Public Interest.

At a particularly difficult moment during the ma.n.u.script revision, Margaret Mellon provided inspiration. For encouragement throughout I am grateful to my agent, Lydia Wills; to Wendel Brunner, Loma Flowers, Ruth Rosen, JoAnn Silverstein, and Sam Silverstein; to my Moss cousins, and to my children and their partners: Rebecca Nestle and Michael Suenkel, and Charles Nestle and Lidia l.u.s.tig. I owe special thanks to my extraordinary colleagues in the Department of Nutrition and Food Studies at NYU for their forbearance and a.s.sistance and review of the ma.n.u.script at every stage of preparation, particularly to Alyce Conrad for designing several of the more complicated ill.u.s.trations, Fred Tripp for his daily clipping service to the Wall Street Journal Wall Street Journal, Ellen Fried for expert research a.s.sistance and review of the ma.n.u.script at every stage of preparation, and Jessica Fischetti and Kelli Ranieri for office life support. Dean Ann Marcus granted sabbatical leave, and Deans LaRue Allen, Gabriel Carras, and Thomas James granted much else in the way of encouragement. I recognize and very much appreciate the unusual level of care and attention given to Safe Food Safe Food by the production and design teams at the University of California Press and BookMatters. Preparation of this book was supported in part by research development grants from New York University and its Steinhardt School. by the production and design teams at the University of California Press and BookMatters. Preparation of this book was supported in part by research development grants from New York University and its Steinhardt School.

ABOUT THIS BOOK.

This book traces the interweaving of science, values, and politics through an examination of three broad areas of food safety: bacteria, biotechnology, and bioterrorism. The first part of the book examines the politics of foodborne microbial illness. These chapters describe government attempts to force food producers, particularly those that slaughter and process meat, to take steps to prevent bacterial contamination of their products, and they explain how those industries consistently resist such safety measures. From a science-based approach to risk a.s.sessment, food-borne illness is the single most important food safety problem; it is responsible for millions of cases of stomach upset and thousands of deaths each year. Bacteria rank low on the dread-and-outrage scale, however, because meat is familiar, eating it is voluntary, food "poisonings" are common, and most people survive them. Politics enters this picture at the level of responsibility for preventing foodborne illness. We will see how the meat industry exploits the relatively low level of organized public outrage about microbial safety to oppose federal regulations and, instead, to argue that consumers consumers bear the princ.i.p.al burden of ensuring safe food. bear the princ.i.p.al burden of ensuring safe food. Part 1 Part 1 also describes the fragmentation of government oversight as a basis for developing a more coherent approach to dealing with problems of food safety. also describes the fragmentation of government oversight as a basis for developing a more coherent approach to dealing with problems of food safety.

Part 2 s.h.i.+fts the discussion to a different issue: genetically modified foods. By the standards of scientific risk a.s.sessment-counting cases of illness and death-such foods appear no less safe than foods developed through traditional plant genetics, but, as the StarLink affair indicates, they present many reasons for distrust and alarm. These chapters describe how the food biotechnology industry, in dismissing dread-and-outrage factors as emotional and unscientific, lobbied for-and won-a largely science-based approach to regulation of its products. The chapters explain how the dismissal of consumer concerns about value issues related to food biotechnology forced advocacy groups to use safety as the only "legitimate" basis of discussion. In the StarLink affair, for example, advocates could not use concerns about corporate control of the food supply as an argument against approval of genetically modified foods. They could, however, use the remote risk of allergenicity as a basis for opposition because of the double negative: it is not not possible to prove that the StarLink protein is possible to prove that the StarLink protein is not not allergenic. These chapters describe the origin of disputes about genetically modified foods that arise from conflicting interests and values. allergenic. These chapters describe the origin of disputes about genetically modified foods that arise from conflicting interests and values.

The concluding chapter takes up a third area: food bioterrorism-the deliberate poisoning or contamination of the food supply to achieve some political goal. Questions about food bioterrorism take us into the realm of emerging food safety hazards that might be used as biological weapons: mad cow disease, foot-and-mouth disease, and anthrax. From a science-based perspective, these problems are of uncertain or low overall risk to human health, but they rank high as causes of dread and outrage. The terrorist attacks of September 2001 increased the level of anxiety, particularly about the country's vulnerability to bioterrorism in general, and to food bioterrorism in particular. In concluding this discussion, I offer suggestions for ways in which the government, the food industry, and consumers might engage in political action to deal with this and the other food safety issues raised in this book. Finally, a short appendix briefly summarizes some of the basic scientific concepts that underlie the debates about food safety issues.

With this introduction, we can now begin our discussion by examining the historical and modern reasons why government attempts to keep harmful bacteria out of food have proved so controversial and why they raise issues of politics as well as of science.

PART ONE

RESISTING FOOD SAFETYFRIENDS AND COLLEAGUES, KNOWING THAT I WAS WRITING about harmful bacteria in food, wondered why anyone would care about things so invisible, tasteless, unp.r.o.nounceable, and, for the most part, innocuous. Like most people, they view occasional episodes of food "poisoning" as uncomfortable (sometimes about harmful bacteria in food, wondered why anyone would care about things so invisible, tasteless, unp.r.o.nounceable, and, for the most part, innocuous. Like most people, they view occasional episodes of food "poisoning" as uncomfortable (sometimes very very uncomfortable), but certainly more a matter of random bad luck than of decades of industry and government indifference, dithering, and outright obstructionism. They accept at face value the endlessly intoned mantra of industry and government: the United States has the safest food supply in the world. uncomfortable), but certainly more a matter of random bad luck than of decades of industry and government indifference, dithering, and outright obstructionism. They accept at face value the endlessly intoned mantra of industry and government: the United States has the safest food supply in the world.Whether this a.s.sertion is true is a matter of some debate. Safety is relative. The most authoritative estimate of the yearly number of cases of foodborne disease in the United States defies belief: 76 million illnesses, 325,000 hospitalizations, 5,000 deaths. As the chapters in part 1 part 1 explain, such numbers undoubtedly explain, such numbers undoubtedly underestimate underestimate the extent of the problem. Although the most frequent causes of these illnesses are viruses and species of bacteria- the extent of the problem. Although the most frequent causes of these illnesses are viruses and species of bacteria-Campylobacter, Salmonella, s.h.i.+gella, and Escherichia coli Escherichia coli ( (E. coli)-most episodes are never reported to health authorities and their cause is unknown.1 From a science-based perspective, the risks and costs of foodborne illness are extremely high. From a science-based perspective, the risks and costs of foodborne illness are extremely high.Furthermore, although outbreaks of foodborne illness have become more dangerous over the years, food producers resist the attempts of government agencies to inst.i.tute control measures, and major food industries oppose pathogen control measures by every means at their disposal. They lobby Congress and federal agencies, challenge regulations in court, and encourage local obstruction of safety enforcement. We will see, for example, that the culture of opposition to food safety measures so permeates the beef industry that it led, in one shocking instance, to the a.s.sa.s.sination of federal and state meat inspectors.To explain this culture of resistance, we need to understand that current problems of food safety are not new but are different different. A century ago, the main sources of foodborne illness were milk from infected cows and spoiled meat from sick animals. Public health measures that we now take for granted-water chlorination and milk pasteurization, for example-eliminated typhoid fever, cholera, and most lethal diarrheal diseases. The food supply depended on local production and was largely decentralized. Fish, for example, were caught wild from the sea. Even though cattle were transported to common areas for slaughter and kept in close quarters-conditions ripe for spreading infections-federal inspection and veterinary care kept most sick animals from entering the food supply.Today, centralized food production has created even more favorable conditions for dissemination of bacteria, protozoa, and viruses. We call these organisms by collective terms: microbes, microorganisms, or "bugs." If harmful, they are pathogens. Many pathogens infect the animals we use for food without causing any visible signs of illness. Infected animals excrete pathogenic microbes in feces, however, and pa.s.s them along to other food animals, to food plants, and to us. If the pathogens survive cooking, stomach acid, and digestive enzymes, they can multiply, produce toxins, upset digestive systems, and do worse. Their effects are especially harmful to people with immature or weakened immune systems-infants, young children, the elderly, and those ill from other causes. Even from this brief description, it should be evident that people involved with every stage of food production, from farm to fork, must take responsibility for food safety to prevent animal infections (producers), avoid fecal contamination (processors), and destroy pathogens (food handlers and consumers).Sharing of responsibility, however, also permits sharing of blame. As these chapters explain, producers blame processors for foodborne illness, and processors blame producers; government regulators blame both, and everyone blames consumers. The role of government in food safety demands particular notice. Current laws grant regulatory agencies only limited authority to prevent microbial contamination before food gets to consumers. Federal oversight of food safety remains unshakably rooted in policies established almost a century ago, in 1906. Congress designed those policies to ensure the health of animals animals, in an era long before most of the current microbial causes of foodborne illness were even suspected, let alone recognized. Although food safety experts have complained for years about the gap between hazards and oversight practices, attempts to give federal agencies the right to enforce food safety regulations have been blocked repeatedly by food producers and their supporters in Congress, sometimes joined by the agencies themselves, and more recently by the courts. Some progress has occurred, driven by the appearance in common foods of new and more deadly pathogens such as E. coli E. coli O157:H7, an exceptionally virulent strain of an otherwise normal and relatively harmless bacterial inhabitant of the human digestive tract. The multimillion-dollar costs of product recalls, legal counsel, and liability payments, and the a.s.sociated costs of damaged reputation and loss of sales, have made the need for more forceful government oversight of food safety apparent to all but the staunchest protectors of food industry self-interest. O157:H7, an exceptionally virulent strain of an otherwise normal and relatively harmless bacterial inhabitant of the human digestive tract. The multimillion-dollar costs of product recalls, legal counsel, and liability payments, and the a.s.sociated costs of damaged reputation and loss of sales, have made the need for more forceful government oversight of food safety apparent to all but the staunchest protectors of food industry self-interest.For the most part, the events described in this part of the book are political political and outside the daily experience of most people in our society. Most of us do not worry much about the possibility that foods in our supermarkets might be contaminated and dangerous, and we act on the basis of what Nicols Fox calls the "unspoken contract" among food producers, government regulators, and the public to ensure that food is safe. and outside the daily experience of most people in our society. Most of us do not worry much about the possibility that foods in our supermarkets might be contaminated and dangerous, and we act on the basis of what Nicols Fox calls the "unspoken contract" among food producers, government regulators, and the public to ensure that food is safe.2 On a daily basis, most of us think the risks are so small, so familiar, and so voluntary that we can ignore them. Microbial risks generate little dread and virtually no outrage. On a daily basis, most of us think the risks are so small, so familiar, and so voluntary that we can ignore them. Microbial risks generate little dread and virtually no outrage.I most clearly recognized the extent of our collective denial about the hazards of food pathogens in the summer of 1999 when I served as a member of an American Cancer Society committee developing dietary guidelines for cancer survivors-people diagnosed with cancer and treated for it. Because surgery, radiation, and chemotherapy can cause a temporary decline in immune function, our committee wanted to stress the importance of preventing microbial infections during periods of treatment and recovery. This advice, we realized, firmly precludes even a taste of raw cookie dough, not to mention avoidance of a host of other foods: Caesar salads, homemade ice cream, and anything else made with raw or partially cooked eggs; rare or medium-cooked hamburger and beef tartare; sus.h.i.+ and other raw seafood; raw milk and cheeses made from it; freshly squeezed juices; unpeeled vegetables and unwashed salad greens and berries; and raw sprouts. For people with weakened immune systems, eating uncooked and unpasteurized foods means taking a risk, and not just of minor discomfort but perhaps of hospitalization, long-term disability, or death.3But what about those of us with healthy immune systems? As these chapters explain, everyone everyone takes a risk when eating uncooked foods, but the extent of that risk is uncertain. In the absence of better oversight of safety at the production end, federal agencies now advise us to follow safety guidelines that used to be reserved for travelers to developing countries. Such advice converts the act of eating to a matter of risk management rather than of nourishment or pleasure, and must be understood as a political act in itself. Because federal policies cannot ensure that food is safe before people bring it home, government agencies s.h.i.+ft the burden of responsibility to consumers. takes a risk when eating uncooked foods, but the extent of that risk is uncertain. In the absence of better oversight of safety at the production end, federal agencies now advise us to follow safety guidelines that used to be reserved for travelers to developing countries. Such advice converts the act of eating to a matter of risk management rather than of nourishment or pleasure, and must be understood as a political act in itself. Because federal policies cannot ensure that food is safe before people bring it home, government agencies s.h.i.+ft the burden of responsibility to consumers. Of course Of course all of us should learn to prepare foods properly, but the industry can and should do its share as well. all of us should learn to prepare foods properly, but the industry can and should do its share as well.As these chapters explain, for reasons of history, inertia, turf disputes, and just plain greed, government oversight of food safety has long tended to provide far more protection to food producers than to the public. Only in recent years, when foodborne illness began to raise serious issues of liability, have food companies and federal agencies been forced to consider measures-albeit grudgingly-to prevent microbial pathogens in food.Like the events related to the StarLink affair, those recounted in these chapters reflect certain recurrent themes. With respect to government, one theme is the fragmented, overlapping, and ultimately obstructive distribution of authority between two federal agencies: the Food and Drug Administration (FDA) and the Department of Agriculture (USDA). Another is the historic closeness of working relations.h.i.+ps among congressional agriculture committees, federal regulatory agencies, and food producers. We will see how food producers repeatedly deny responsibility for foodborne illness, invoke science to promote self-interest and divert public attention from harm caused by their products, and express outright hostility to federal oversight. From the standpoint of consumer advocacy, an additional theme bears on the ways in which food safety relates to much broader societal concerns. As Eric Schlosser discussed so compellingly in Fast Food Nation Fast Food Nation (Houghton Mifflin, 2001), much of the actual work in the food industry-in agriculture, slaughterhouses, processing plants, and places where food is served-is carried out by immigrants, teenagers, and other groups paid the minimum wage. People can only produce safe food if they know how to do so, if they follow the rules, and if they are themselves in good health. Thus, the production of safe food also depends on the adequacy of fundamental social support systems such as public education and health care. (Houghton Mifflin, 2001), much of the actual work in the food industry-in agriculture, slaughterhouses, processing plants, and places where food is served-is carried out by immigrants, teenagers, and other groups paid the minimum wage. People can only produce safe food if they know how to do so, if they follow the rules, and if they are themselves in good health. Thus, the production of safe food also depends on the adequacy of fundamental social support systems such as public education and health care.In this part of the book, chapter 1 chapter 1 sets the stage by reviewing the origins of the present system of governmental oversight of food safety. sets the stage by reviewing the origins of the present system of governmental oversight of food safety. Chapters 2 Chapters 2 and and 3 3 review some of the landmark incidents leading to the current "crisis" over bacterial pathogens. They also explain how government agencies attempted to deal with such crises in the face of resistance by food producers and processors. In review some of the landmark incidents leading to the current "crisis" over bacterial pathogens. They also explain how government agencies attempted to deal with such crises in the face of resistance by food producers and processors. In chapter 4 chapter 4, I discuss some political alternatives for improving oversight of our food safety system.For the most part, these chapters focus on the actions of producers and processors of meat-in this case, beef. Unlike the producers of most other foods, the beef industry makes little attempt to hide its self-interested political activities. Beef industry pressures on Congress and federal regulators are more transparent than those of other food industries, and are better doc.u.mented. Nevertheless, many of the food safety issues raised by beef production are similar to matters that affect poultry, eggs, seafood (especially the farmed variety), and pork, as well as to those that affect fruits and vegetables inadvertently contaminated as they move from farm to table, sometimes from one country to another.

CHAPTER 1.

THE POLITICS.

OF FOODBORNE ILLNESS.

ISSUES AND ORIGINS.

IN THE EARLY 1970S, A TIME WHEN FOOD SAFETY WAS BECOMING a matter of public debate, my young family went to a dinner hosted by a colleague. I don't remember much about the party, but its aftermath remains vivid. Within hours, all but one of us became violently ill. I will spare the details, as nearly everyone has had a similar experience. A flurry of telephone calls the next day made it clear that we were not the only ones who suffered after that dinner. In retrospect, what seems most remarkable about that event was how a matter of public debate, my young family went to a dinner hosted by a colleague. I don't remember much about the party, but its aftermath remains vivid. Within hours, all but one of us became violently ill. I will spare the details, as nearly everyone has had a similar experience. A flurry of telephone calls the next day made it clear that we were not the only ones who suffered after that dinner. In retrospect, what seems most remarkable about that event was how ordinary ordinary it was. We survived. We felt better in a day or two. We did not report our illness to health authorities, and neither did anyone else. We did not try to trace the source of the outbreak (although our one son who did not become ill, and who ate nothing green in those days, insisted that the salad must have been at fault). it was. We survived. We felt better in a day or two. We did not report our illness to health authorities, and neither did anyone else. We did not try to trace the source of the outbreak (although our one son who did not become ill, and who ate nothing green in those days, insisted that the salad must have been at fault).

We a.s.sumed that minor food poisonings were a normal part of daily living; they were low on our dread-and-outrage scale. It did not occur to us that microbial illness transmitted by food might be anything more serious than a minor inconvenience and a mess to clean up. If we gave any thought to cholera, typhoid, or botulism (let alone anthrax), we viewed them as diseases of the past, eliminated by basic public health measures such as water chlorination, milk pasteurization, or canning at appropriate temperatures. We were quite unaware of the emerging bacterial pathogens that I discuss in these chapters. At the time, if we worried at all about food safety, it was about agricultural pesticides or food additives-the chemical colors, flavors, and preservatives then increasingly used to make processed foods look and taste better. We were not alone in worrying about food additives: a 1979 report recommended a complete revision of the food safety laws to strengthen our ability to control the use of food chemicals such as saccharin, the artificial sweetener that had just been linked to cancer risk.1 Additives and pesticides remained primary public safety concerns through the mid-1980s. Dr. David Kessler, who later became commissioner of the Food and Drug Administration (FDA), said that food safety laws needed an overhaul to control food additives-without even mentioning microbial hazards. Surveys of public att.i.tudes toward food safety often asked about additives and pesticides but rarely probed knowledge or opinions about bacterial pathogens. When the surveys did include such questions, most people continued to rank additives and pesticides first among food safety concerns. At the time, less than 1% of food samples contained chemical additives and pesticides at "unacceptable" levels. Even if such levels were still too high-and any level of pesticides in food continues to raise safety questions-harm from food chemicals paled in comparison to that caused by pathogens. In the late 1980s, health officials found Salmonella Salmonella in one-third of all poultry and estimated that 33 million Americans experienced at least one episode of foodborne microbial illness each year. in one-third of all poultry and estimated that 33 million Americans experienced at least one episode of foodborne microbial illness each year.2 A few farsighted advocacy groups such as the Community Nutrition Inst.i.tute in Was.h.i.+ngton, DC, pressed for more action to prevent pathogens from entering the food supply. They were aware of the emergence in the early 1980s of an especially nasty variant of Escherichia coli Escherichia coli ( (E. coli), usually a relatively harmless inhabitant of the human digestive tract. As reports of toxic pathogens in food became more frequent, food safety priorities began to s.h.i.+ft. By 1989, both Time Time and and Newsweek Newsweek had published cover stories on microbial food hazards. In 1991, the Center for Science in the Public Interest (CSPI), which had led public debate about food additives, published a consumer guide to food safety with exceptionally clear instructions about what needed to be done to prevent foodborne infections. had published cover stories on microbial food hazards. In 1991, the Center for Science in the Public Interest (CSPI), which had led public debate about food additives, published a consumer guide to food safety with exceptionally clear instructions about what needed to be done to prevent foodborne infections.3 In the early 1990s, such publicity encouraged Congress to introduce more than 30 bills-a record number-related to food safety, and at least eight states were trying to develop their own rules. Ellen Haas, then president of the consumer advocacy group Public Voice, called food safety "not just a kitchen issue anymore."4 At the time, federal officials ranked microbial hazards first among food safety issues, residues of animal drugs second, and new technologies (such as genetically modified foods) third. By 1994, more than 60% of consumers said they worried most about consuming rare beef, raw sh.e.l.lfish, and residues of animal drugs. In 1997, consumers and food editors said they were more concerned about food safety than they had been just one year earlier, and nearly all of them blamed meat and poultry producers-and government agencies-for not doing enough to prevent microbial pathogens in the food supply. At the time, federal officials ranked microbial hazards first among food safety issues, residues of animal drugs second, and new technologies (such as genetically modified foods) third. By 1994, more than 60% of consumers said they worried most about consuming rare beef, raw sh.e.l.lfish, and residues of animal drugs. In 1997, consumers and food editors said they were more concerned about food safety than they had been just one year earlier, and nearly all of them blamed meat and poultry producers-and government agencies-for not doing enough to prevent microbial pathogens in the food supply.5 To establish a basis for understanding the significance of such a profound s.h.i.+ft in att.i.tudes, this chapter begins with an introduction to the current status of microbial pathogens in the food supply. We will see that foodborne illness is more than a biological problem; it is strongly affected by the interests of stakeholders in the food system-the food industry, government (agencies, Congress, and the White House), and consumers. The present system of food safety oversight and its political implications are best understood in historical context. Thus, this chapter describes the origins of the century-old policies that govern federal actions to this day. In the case of meat safety, Congress designed those policies to prevent sick animals-not microscopic pathogens-from entering the food supply. As this chapter explains, efforts to modernize such policies do not come easily.

MICROBES IN FOOD: FRIENDS AND FOES.

Thinking too much about the life we share with microbes can lead to paranoia. Microbes are everywhere: around us, on us, and in us. They inhabit soil and water, skin and digestive tract, and any place that provides favorable conditions for growth (and hardly any place does not). They are incredibly small, and incredibly numerous. All kinds-viruses, bacteria, protozoa, and yeasts-are ubiquitous in raw foods. Most are harmless. Some are even "friendly," helping to make bread, wine, vinegar, soy sauce, yogurt, and cheese, and keeping our digestive tracts healthy. Others are less helpful; left to their own devices, they rot apples, mold bread, and spoil meat. Some are decidedly unfriendly, and cause more than 200 known foodborne diseases.

To avoid getting food poisoning, we take precautions: we preserve foods and we cook them. Preservation methods-some ancient, some modern (among them salt, sugar, alcohol, acid, and freeze-drying)-all inhibit microbial growth. Refrigeration slows down growth, and freezing does so even more. Cooking, a brilliant invention, not only makes foods taste better but also kills microbial pathogens. Cooked foods, however, do not remain sterile. Microbes in air, water, and other foods can recontaminate them, as can microbes on packages, plates, utensils, cutting boards, and hands. With common measures such as hand was.h.i.+ng, dish was.h.i.+ng, and other such basic precautions, we live with most food microbes in relative peace. Our digestive and immune systems take care of those that survive cooking. Mostly, we do not worry much about them.

TABLE 3. The most frequent microbial causes of foodborne disease in the United States: estimated numbers of illnesses, hospitalizations, and deaths, 1999 [image]

SOURCE: Mead PS, s.l.u.tsker L, Dietz V, et al. Emerging Infectious Diseases Emerging Infectious Diseases 1999;5:607625. 1999;5:607625.NOTE: Illnesses generally include some form of gastrointestinal distress-diarrhea, vomiting, cramps-as well as the problems indicated. These figures continue to const.i.tute the basis of prevalence estimates.

Whether we should should worry more about them is a matter of how we perceive risk. For most of us as individuals, an occasional episode of stomach upset-if not too severe-is tolerable. From a public health standpoint, however, the cost to society of such episodes is staggeringly high. worry more about them is a matter of how we perceive risk. For most of us as individuals, an occasional episode of stomach upset-if not too severe-is tolerable. From a public health standpoint, however, the cost to society of such episodes is staggeringly high. Table 3 Table 3 lists, for example, the most frequent causes of foodborne disease, along with estimates of their cost in illness, hospitalization, and death. Viruses cause most foodborne illnesses, but some bacteria and protozoa are also to blame. Nearly all induce highly unpleasant symptoms, usually mild but sometimes very severe. lists, for example, the most frequent causes of foodborne disease, along with estimates of their cost in illness, hospitalization, and death. Viruses cause most foodborne illnesses, but some bacteria and protozoa are also to blame. Nearly all induce highly unpleasant symptoms, usually mild but sometimes very severe. Table 3 Table 3, however, lists only the best-known pathogens. The causes of the vast majority of episodes of foodborne illness remain obscure.6 Furthermore, pathogenic microbes pervade the food supply. A Furthermore, pathogenic microbes pervade the food supply. A Consumer Reports Consumer Reports investigation in 1998, for example, identified investigation in 1998, for example, identified Campylobacter Campylobacter in 63% of market chickens, in 63% of market chickens, Salmonella Salmonella in 16%, and both in 8%. Pathogenic in 16%, and both in 8%. Pathogenic Salmonella Salmonella can pa.s.s from chickens to their eggs. Because egg production is so enormous, a low rate of infection-one out of every 10,000 eggs, for example-means 4.5 million infected eggs each year. can pa.s.s from chickens to their eggs. Because egg production is so enormous, a low rate of infection-one out of every 10,000 eggs, for example-means 4.5 million infected eggs each year.7 Counting Cases and Estimating Costs If harmful microbes are widespread in food and if they make so many people sick, why isn't everyone-the food industry, health officials, and the public-doing something to prevent them from getting into food? One reason is that most episodes of food poisoning are not very serious. Another is that it is difficult to collect accurate information about the number of cases and their severity. Attributing a bout of diarrhea to food rather than to other causes is no simple matter. Most of us eat several foods at a time, several times a day, in several different places. How could we possibly know which food might be responsible for our getting sick, especially if there is a delay in the onset of symptoms? I cannot imagine bothering to call a doctor about a brief stomach upset. Even if I did, the doctor might not suspect food as the source of my problem. Busy doctors rarely report such suspicions to health authorities. It usually takes an "outbreak"-the severe illness or death of more than one person eating the same food-before health officials learn about a foodborne illness and attempt to trace its origin.

For these reasons, counting cases is a formidable undertaking, and to this day there is no national system for doing so. The current surveillance system, such as it is, evolved piecemeal. In the 1920s, the Public Health Service started tracking diseases carried in milk. In 1961, the Centers for Disease Control (CDC), an agency of what is now the Department of Health and Human Services (DHHS), took over that task and began to issue annual counts of illnesses transmitted by food and drinking water. Five years later, the CDC initiated a voluntary voluntary program of state surveillance of outbreaks, meaning that states could choose whether or not to partic.i.p.ate. program of state surveillance of outbreaks, meaning that states could choose whether or not to partic.i.p.ate.

As early as 1970 the CDC realized that its counts were way too low. Nearly half the partic.i.p.ating states were reporting no outbreaks or very few, suggesting considerable underreporting. In 1985, several federal and private agencies began to make more serious attempts to estimate annual cases of foodborne disease, based on two a.s.sumptions: (1) an episode of diarrhea counts as a foodborne illness, and (2) the proportion of reported cases to those that are not reported ranges from 1 out of 25 to 1 out of 100 or more. The agencies understood perfectly well that diarrheal diseases could be due to causes other than foodborne illness, and that foodborne illness also causes symptoms other than diarrhea. Nevertheless, they multiplied the number of cases of diarrhea by 25 to 100 to estimate the "real" number of cases. During the next few years, these confusing a.s.sumptions led to widely varying guesses about the number of annual cases (6.3 to 81 million) and deaths (500 to 9,000), depending on how the a.s.sumptions were interpreted.8 In 1996, the CDC initiated a new surveillance program, FoodNet-the Foodborne Diseases Active Surveillance Network-in just a few states and for just seven microbial pathogens. In its first year, FoodNet identified 8,576 laboratory-confirmed cases of foodborne illness, of which 15% resulted in hospitalization. In 1999, the CDC used this and other information from its surveillance networks to suggest that known known pathogens caused 14 million illnesses, 60,000 hospitalizations, and 1,800 annual deaths. When they added these estimates to those for cases caused by unknown pathogens, they arrived at the annual totals mentioned earlier: 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths. pathogens caused 14 million illnesses, 60,000 hospitalizations, and 1,800 annual deaths. When they added these estimates to those for cases caused by unknown pathogens, they arrived at the annual totals mentioned earlier: 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths.9 Because these estimates rely so heavily on diarrheal symptoms, and the reporting system is voluntary, these figures almost certainly underestimate the extent of foodborne illness. A 1998 report on food safety from the Inst.i.tute of Medicine (IOM) in Was.h.i.+ngton, DC, for example, gave a higher estimate. It a.s.sumed that adults in the United States average about 1.4 episodes of diarrhea every year, and that food is implicated in about one-quarter of those episodes; these a.s.sumptions yielded an estimate of 91 million cases per year. Because these estimates rely so heavily on diarrheal symptoms, and the reporting system is voluntary, these figures almost certainly underestimate the extent of foodborne illness. A 1998 report on food safety from the Inst.i.tute of Medicine (IOM) in Was.h.i.+ngton, DC, for example, gave a higher estimate. It a.s.sumed that adults in the United States average about 1.4 episodes of diarrhea every year, and that food is implicated in about one-quarter of those episodes; these a.s.sumptions yielded an estimate of 91 million cases per year.10 Some experts suspect that even this number may be too low. Such uncertainty means that reported trends in foodborne illness must be interpreted with caution. In 2002, FoodNet data suggested that cases of infection from four key pathogens had declined markedly since 1996, but cases caused by some strains of Some experts suspect that even this number may be too low. Such uncertainty means that reported trends in foodborne illness must be interpreted with caution. In 2002, FoodNet data suggested that cases of infection from four key pathogens had dec