Abstract
Consuming raw milk (including all raw milk products and unpasteurized milk derived from non-human animal sources), which can be contaminated with a variety of human pathogens, is a serious health risk prevented by pasteurization. Raw milk should not be sold to consumers due to these safety concerns and, especially, concerns regarding the safety of people incapable of choosing what they consume. Among these people are children, who are at a much higher risk for developing serious health conditions associated with consuming raw milk. All federal agencies and national organizations directly involved with food safety and public health recommend against consuming raw milk because of the possibility of contamination with human pathogens. These organizations recommend the pasteurization of all milk products intended for human consumption. Many states have responded by prohibiting the sale of raw milk to consumers and the companion practice of “herd sharing” (in which consumers “own” an animal in a herd that is tended by someone else and obtain the milk, thus avoiding formal sale). However, the known health risks and uniform expert recommendations have failed to reverse, halt, or even prevent the expansion of the sale and consumption of raw milk in the United States. This policy statement addresses a global public health hazard from the specific lens of public health measures feasible in the United States, where pasteurization is a widely accessible best practice.
Relationship to Existing APHA Policy Statements
The APHA database archive has policy statements recommending pasteurizing all milk products sold to consumers. These policy statements include 6009 (Compulsory Pasteurization, which also references APHA’s position endorsing pasteurization of milk supplies for human consumption from the year 1924),[1] 6010 (Federal Milk Sanitation Legislation),[2] and 6519 (Grade A Pasteurized Milk Ordinance and Code), which was archived in 2015.[3] However, no statement specifically addresses the growing public health threat presented by the sale and consumption of raw milk in the United States.
Problem Statement
The public health hazards resulting from consumption of raw milk (defined hereafter as all raw animal milk products and unpasteurized milk derived from non-human sources) have been known for well over a century. There is overwhelming scientific evidence that raw milk can transmit human pathogens. Pathogenic organisms including Salmonella, Escherichia coli 0157/H7, Campylobacter, Listeria, Yersinia, Brucella, and Mycobacterium can contaminate raw milk.[4–6] In fact, many pathogens that can contaminate milk are shed in the feces of healthy cows. They then contaminate milk through cross contamination from the skin of the udder, the milking equipment, or the hands of the people milking the cows, and they can be sustained through processing. Furthermore, pathogenic organisms can be shed in the milk from an udder that is clinically free of signs of disease.[4,6,7]
Prior to widespread pasteurization, milk products caused 25% of all food-related disease outbreaks in the United States. Currently, they are implicated in less than 1% of food-borne outbreaks.[4,8] The Centers for Disease Control and Prevention (CDC) describes pasteurization as “one of the public health triumphs of the 20th century.”[9] In its federal regulatory role of promoting and protecting public health through supervision of food safety, the Food and Drug Administration prohibited the distribution of raw milk across state lines for direct sale to consumers in 1987.[8,9]
The evidence that raw milk transmits diseases is overwhelming.[4,10] On the basis of CDC data, the academic literature, and state and local reports, the Food and Drug Administration compiled a list of outbreaks that occurred in the United States from 1987 to 2010. During this period, there were at least 133 outbreaks due to the consumption of raw milk and raw milk products. These outbreaks resulted in 2,659 cases of illness, 269 hospitalizations, three deaths, six stillbirths, and two miscarriages. However, these totals reflect only known (i.e., identified and reported) cases of food-borne illness; the true number of cases associated with raw milk consumption is likely greater.[10] Noting that non-outbreak-related laboratory-confirmed cases are far more common than outbreak-related cases, researchers from the Minnesota Department of Health have estimated that, between 2001 and 2010, upwards of 20,500 people in the state (which allowed the sale of raw milk during that period) may have become ill after acquiring enteric pathogens from drinking raw milk.[11]
Another CDC study identified 81 outbreaks between 2007 and 2012 linked to raw milk consumption, with 73 hospitalizations.[12] In addition, the number of outbreaks rose from 30 during 2007–2009 to 51 during 2010–2012. This increase coincided with a decline in the number of states that prohibited the sale of raw milk.[12]
The CDC reports that the rate of diseases associated with raw milk is 2.2 times higher in states that allow the legal sale of raw milk than in states that do not allow this practice.[9] A study of food-borne illness reports to the CDC from 1993 to 2006 showed that, relative to outbreaks associated with pasteurized milk (primarily due to post-pasteurization contamination and storage failures), infections caused by unpasteurized dairy products were 13 times more likely to lead to hospitalization.[13] The number of outbreaks resulting from unpasteurized dairy products was also notable given the relatively low percentage (less than 1%) of the national population reporting consumption of such products.[13] Outbreaks of enteric bacterial diseases were unique to unpasteurized dairy products.[13]
Children, the elderly, and pregnant women are at the highest risk of illness, especially with respect to more severe outcomes.[5,9,12–14] The CDC reports that the largest burden falls on young children, with 59% of outbreaks involving children less than 5 years old.[9] In 2013, nine children in Tennessee became seriously ill from drinking raw milk contaminated with E. coli; three of the children developed life-threatening renal disease.[15]
Evidence-Based Strategies to Address the Problem
Food safety and public health agencies consistently recommend the pasteurization of all animal milk consumed by humans and against consuming raw milk. The CDC, the American Academy of Pediatrics, the United States Department of Agriculture, the American Veterinary Medical Association, and the National Environmental Health Association all officially recommend pasteurization of animal milk consumed by humans.[7–9,16,17]
The CDC and the American Academy of Pediatrics strongly advise people not to consume raw milk.[9,16] APHA, the National Environmental Health Association, the American Veterinary Medical Association, the American Association of Public Health Veterinarians, and the Canadian Institute of Public Health Inspectors have gone even further by recommending the passage of laws requiring pasteurization of all milk and milk products.[1–4,6–9] In addition, in a May 9, 2014, letter sent to state and territorial epidemiologists and state public health veterinarians, the CDC urged state regulators to “continue to support pasteurization and consider further restricting or prohibiting the sale and distribution of raw milk and other unpasteurized dairy products in their states.”[9]
The strong public health support for regulations has not been fully heeded, and in some cases regulations have been weakened. In 2000, “less than 20 states in the United States permitted the sale and distribution of packaged raw milk/products intrastate.”[6] However, a survey conducted in 2011 by the National Association of State Departments of Agriculture revealed that 30 states allowed the legal sale of raw milk or milk products in some form, and only 20 states prohibited such sales.[18] State regulations have changed frequently in recent years, though, in some cases resulting in new public health hazards related to raw milk. The Network for Public Health Law recently published an evaluation of milk regulations in the United States indicating that, as of June 2015, 20 states and the District of Columbia had laws prohibiting the sale of raw milk. However, of the states prohibiting the sale of raw milk, seven allowed herd-share programs to skirt regulatory bans; 30 states allowed on-farm sales of raw milk only.[19] (In so-called “herd shares,” consumers pay a fee to have a farmer board, care for, and milk their animal. The “owners” then obtain the milk from “their” cow/doe/ewe, and hence there is no sale.[4]) More recently, in January 2016, Illinois passed a law legalizing on-farm sales, and in March 2016 West Virginia legalized herd shares.[20,21] Despite the overwhelming scientific evidence of the health hazards associated with consuming raw milk and the widespread food safety and public health recommendations prohibiting the sale of raw milk, the figures above demonstrate that the number of regulations permitting such practices has not declined but, in some cases, has actually increased.
Opposing Arguments
Proponents of raw milk claim that raw milk is healthier and more nutritious, tastes better, relieves allergy symptoms, is a source of probiotics, has antibacterial properties, and may play a role in preventing autism. They also claim that drinking pasteurized milk causes more harm than good.[4,5,14] Other than the subjective claim of tasting better, either there is no supporting evidence to substantiate these claims or they have been disproven by scientific evidence.[5,10,22]
Other claims have included that “healthy cows create healthy milk” and that “modern stainless steel tanks, milking machines, refrigerated trucks, and inspections make pasteurization absolutely unnecessary for public protection.”[4] While healthier cows, refrigeration, and clean equipment can certainly help manage the health risks of raw milk, pathogens may be naturally present on the skin of cows, including apparently healthy animals, or contamination may occur during the milking process through other routes such as human handlers or insect vectors; originally low levels of bacteria may multiply in raw milk. Proper pasteurization (involving sufficiently high temperatures and sufficiently long durations) is the most reliable method for elimination of many of the harmful bacteria that may be present.[7,9,23] Although post-pasteurization contamination is possible, pasteurization is a critical component of the milk production and safety chain.
Other opposing arguments cite the saving of family farms, the burdens of government overregulation, and interference with individual freedoms.[24] One website describes laws preventing the sale of raw milk as forbidding “consumers their constitutional rights.”[25] Federal courts have upheld the ban on the interstate sale of these products as falling directly under the commerce clause of the US Constitution.[26] In addition, according to a federal judge’s ruling in one case, “should it appear the interstate sale of raw milk continues, it is within [the US Department of Health and Human Services’] authority at that time to institute an intrastate ban as well.”[27] However, there is no valid legal argument that prohibiting the sale of raw milk violates the US Constitution. State governments possess the authority to enact laws to protect the health, safety, and general welfare of the population.[28] The Supreme Court routinely upholds regulations on the sale of goods passed for these purposes.[29] Furthermore, the freedoms to purchase, sell, and consume raw milk cannot be found directly in the Constitution, nor has the Supreme Court found there to be such rights. In fact, the milk industry has been the subject of long-standing regulation in the public interest.[30] Given young people’s disproportionate burden of disease associated with unpasteurized milk, it is the obligation of public health and other officials to intervene to protect the health of populations that may not make fully informed choices.[13,14,16]
APHA’s 1960 policy statement calling for compulsory pasteurization (Policy Statement 6009) recognized the need for public health efforts to intervene in light of pressure on the part of “certain producers of raw milk and ‘health faddists’” advocating for the sale of raw milk.[1]
Action Steps
Therefore, APHA recommends that:
- States take action to implement or strengthen regulations and enforcement measures to prohibit the sale of raw milk and raw milk products as well as ban the exchange of unpasteurized milk through herd-share programs. Possible loopholes (e.g., labeling for non-human consumption) should be anticipated and proactively addressed.
- The Food and Drug Administration be given sustainable resources to continue to investigate and vigorously enforce violations of the ban on interstate sales and to target areas where interstate sales are recurring to inform public education measures on the hazards of raw milk consumption.
- All public health organizations and regulatory agencies collaborate in developing a joint task force to provide education on the dangers of raw milk. In addition to the general public, key targets for this education would be pediatricians and family practice physicians, particularly in states that allow the sale of raw milk, along with teachers of health education classes in junior high schools. Also, raw milk hazards should be highlighted during National Public Health Week and other public health outreach opportunities (including those involving public health nurses and veterinarians, pediatricians, and other communities).
- Each state public health authority and state laboratory evaluate its current response plans to disease outbreaks likely caused by consumption of raw milk and to severe illness among minors linked to raw milk consumption. The response should include rapid detection of outbreaks, rapid collection of samples and genetic identification, and referral of information to the state attorney general to pursue consumer protection measures as appropriate. State agencies should actively exercise this capability.
- A model statute be developed in concert with a nonpartisan policy organization and be distributed to those states that allow the sale of raw milk in any form to advocate for compulsory pasteurization; if states elect not to adopt this measure, constructive provisions aimed at individual risk mitigation and early warning and containment of outbreaks could be put forward (e.g., provisions on permits to sell raw milk, labeling instructions to facilitate trace-back investigations in the event of possible illnesses, warning labels highlighting the inherent hazards associated with consumption of raw milk, and warnings against providing it to the most vulnerable populations, including young children, the elderly, and immune-compromised individuals).
- States currently allowing the sale of raw milk explore declaring it an “inherently dangerous substance” similar to tobacco products and criminalizing its sale or offering to minors.
References
1. American Public Health Association. Policy No. 6009. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/23/13/54/compulsory-pasteurization. Accessed December 17, 2016.
2. American Public Health Association. Policy No. 6010. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/23/13/51/federal-milk-sanitation-legislation. Accessed December 17, 2016.
3. American Public Health Association. Policy No. 6519. Available at: https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/21/15/30/grade-a-pasteurized-milk-ordinance-and-code. Accessed December 17, 2016.
4. Canadian Institute of Public Health Inspectors. Position statement regarding the sale and distribution of raw milk. Available at: http://www.ciphi.ca/pdf/rawmilk-eng.pdf. Accessed December 17, 2016.
5. Real Raw Milk Facts Working Group. Legislative packet. Available at: http://www.realrawmilkfacts.com/legislation-packet. Accessed December 17, 2016.
6. Public Health Veterinarians Coalition Committee and American Association of Public Health Veterinarians. Public health policy statements and year 2000 action plan: position on pasteurization of milk and milk products. Available at: http://www.marlerclark.com/images/uploads/about_ecoli/PUBLIC_HEALTH_VETERINARIAN_COALITION_COMMITTEE.pdf. Accessed December 17, 2016.<
7. American Veterinary Medical Association. Position on pasteurization of milk and milk products. Available at: https://www.avma.org/Pages/home.aspx. Accessed December 17, 2016.
8. National Environmental Health Association. Position regarding sale or distribution of raw milk. Available at: dairy.nv.gov/safety/National_Environmental_Health_Association/. Accessed December 17, 2016.
9. Centers for Disease Control and Prevention. The ongoing public health hazard of consuming raw milk. Available at: https://www.cdc.gov/foodsafety/pdfs/raw-milk-letter-to-states-2014-508c.pdf. Accessed December 17, 2016.
10. Food and Drug Administration. Questions and answers: raw milk. Available at: http://www.fda.gov/Food/FoodborneIllnessContaminants/BuyStoreServeSafeFood/ucm122062.htm. Accessed December 17, 2016.
11. Robinson TJ, Scheftel JM, Smith KE. Raw milk consumption among patients with non-outbreak-related enteric infections, Minnesota, USA, 2001–2010. Emerg Infect Dis. 2014;20:38–44.
12. Mungai EA, Behravesh CB, Gould LH. Increased outbreaks associated with non-pasteurized milk, United States, 2007–2012. Emerg Infect Dis. 2015;21:119–122.
13. Langer AJ, Ayers T, Grass J, Lynch M, Angulo FJ, Mahon BE. Nonpasteurized dairy products, disease outbreaks, and state laws—United States, 1993–2006. Emerg Infect Dis. 2012;18:385–391.
14. National Public Radio. Why some states want to legalize raw milk sales. Available at: http://www.npr.org/sections/thesalt/2015/02/20/387558373/why-some-states-want-to-legalize-raw-milk-sales. Accessed December 17, 2016.
15. Tennessee Department of Health. Disease investigations linked to increased raw milk consumption. Available at: https://www.tn.gov/health/news/16338. Accessed December 17, 2016.
16. Committee on Infectious Diseases and Committee on Nutrition of the American Academy of Pediatrics. Consumption of raw or unpasteurized milk and milk products by pregnant women and children. Pediatrics. 2014;133:175–179.
17. US Food and Drug Administration. Testimony of John F. Sheehan, Division of Plant and Dairy Food Safety, Office of Food Safety, Center for Food Safety and Applied Nutrition, US Food and Drug Administration Health and Government Operations Committee. Available at: http://www.fda.gov/downloads/Food/FoodborneIllnessContaminants/UCM185696.pdf. Accessed December 17, 2016.
18. National Association of State Departments of Agriculture. NASDA releases raw milk survey. Available at: http://www.nasda.org/file.aspx?id=3916. Accessed December 17, 2016.
19. Network for Public Health Law. Raw milk resources. Available at: https://www.networkforphl.org/topics__resources/topics__resources/food_safety/raw_milk_resources/. Accessed December 17, 2016.
20. Flynn D. Illinois switch: on-the-farm raw milk sales now legal. Available at: http://www.foodsafetynews.com/2016/01/illinois-switch-on-the-farm-raw-milk-sales-now-legal/#.WFbCi00zWUk. Accessed December 17, 2016.
21. Metro News. Governor Tomblin signs raw milk bill into law. Available at: http://wvmetronews.com/2016/03/03/gov-tomblin-signs-raw-milk-bill-into-law/. Accessed December 17, 2016.
22. Lucey JA. Raw milk consumption: risks and benefits. Nutr Today. 2015;50:189–193.
23. Centers for Disease Control and Prevention. Raw milk questions and answers. Available at: https://www.cdc.gov/foodsafety/rawmilk/raw-milk-questions-and-answers.html. Accessed December 17, 2016.
24. Farm-to-Consumer Legal Defense Fund. Raw milk nation interactive map: state-by-state review of raw milk laws. Available at: http://www.farmtoconsumer.org/raw-milk-nation-interactive-map/. Accessed December 17, 2016.
5. Campaign for Real Milk. Share agreements: cowshares, goat shares, herdshares, farmshares. Available at: http://www.realmilk.com/herdshares/share-agreements/. Accessed December 17, 2016.
26. David SD. Raw milk in court: implications for public health policy and practice. Public Health Rep. 2012;127:598–601.
27. Public Citizen v. Heckler, 653 FSupp 1229 DDC (1986).
28. Schmidinger v. Chicago, 226 US 578 (1913).
29. Hutchinson Ice Cream Co. et al. v. Iowa, 242 US 153 (1916).
30. Nebbia v. New York, 291 US 502 (1934).