* Based upon Dr. Wallinga's blog first posted at MomsRising.org
A powerful, multibillion dollar industry bets the farm on routinely using important human antibiotics where they’re not needed. Care to hazard a guess on that industry's reaction when the world’s most respected health agency calls out this practice as endangering lives? Denial? Distraction? Attack the messenger?
All of those tactics have been on display in the 2 months since the World Health Organization (WHO) called for an end to feeding medically important antibiotics to herds of chickens, pigs, cattle and other food-producing animals that aren't sick. The precious medicines are used to promote more rapid growth and to ‘prevent’ disease that hasn’t even occurred, and might not ever occur.
When they were first issued, I blogged how important the WHO’s recommendations were to public health. That importance was underscored more recently when Dr. Gro Harlem Brundtland, the former WHO Director General as well as a former Prime Minister of Norway, wrote in the British Medical Journal how the “New WHO guidelines are crucial step to fighting antimicrobial resistance.” One way to think about the guidelines is as a very common sense response to a truism that nobody credible really disputes: namely, that the use and overuse of antibiotics is a key driver of the resistance epidemic. To fight the epidemic, in other words, we should look hard wherever antibiotics are being overused, and try and stop it.
Hence, the WHO's recommendation that medically important antibiotics no longer be fed to healthy animals (except under limited, exceptional circumstances). WHO also urges that explicit targets be set for reducing overall use of these precious medicines in livestock. Neither the U.S. industry nor the FDA has been keen to set use reduction targets. In the U.S., more than 75% of the medically important antibiotics sold in 2015 were sold for use in livestock production, not for treating sick people. It’s the same in much of the rest of the world.
Let’s talk now about that industry playbook of denial, distraction and attack the messenger – virtually the same playbook Big Tobacco used for decades to head off regulation. The trigger seems to have been an official statement issued by the USDA’s Acting Chief Scientist, Dr. Chavonda Jacobs-Young, just hours after the WHO announcement. (In fact, Dr. Jacobs-Young is an actual Ph.D., with a specialty in Wood and Paper Science, which still is a tad different than the medical or public health expertise of WHO staff and advisors).
1. Denial. Dr. Jacobs-Young said the WHO’s guidelines are not based on ‘sound science’. We’ve heard that one before. As has been well-documented using industry sources from the tobacco litigation archives, Phillip Morris created The Advancement of Sound Science Coalition in 1993 to deflect regulation by the EPA based on public health science that tied cancer to exposure to second-hand smoke. This time, USDA’s ‘sound science’ critique was quickly echoed by Texas Farm Bureau, Beef Magazine, and the North American Meat Institute, to name a few.
The reality is that WHO's recommendations rest on decades worth of good science, amounting to hundreds of published, peer-reviewed studies. The WHO commissioned a systematic review of that body of evidence published in Lancet Planetary Health. at the same time the WHO guidelines were released On its website, WHO lists three additional ‘narrative’ reviews of the robust science, as well. In contrast, the poultry and livestock industries began putting medically important antibiotics into animal feed decades ago, but without ever having studied how that routine usage might affect antibiotic resistance or public health, which Maryn McKenna writes about in her superb new book, Big Chicken.
2. Distraction. A common distraction strategy is to mischaracterize an actual science-based recommendation and then to take potshots at the bastardized version, instead. In this case, the North American Meat Institute criticized the WHO for “advocating a blanket ban on using antibiotics to prevent disease”. The WHO did nothing of the kind.
WHO’s recommendation applies only to the subset of antibiotics that are important to human medicine. The industry can continue to use non-medically important drugs for a variety of purposes, including growth promotion and supposed ‘disease prevention’. But even for medically important drugs, the WHO recommendation is no ‘blanket ban’; the guidelines specifically indicate that “when a veterinary professional judges that there is a high risk of spread of a particular infectious disease, use of antimicrobials for disease prevention is justified, if such a judgement is made on the basis of recent culture and sensitivity testing results.” No blanket ban. Just common sense.
National Hog Farmer used the statement from USDA’s Chief Scientist to further mischaracterize the WHO recommendations as being based on ‘low quality’ science. For anyone who has read the systematic review published in the Lancet, this claim is a head-scratcher. Clearly, the WHO took its actions based on extensive science. The ‘low quality’ allusion derives from the very specific GRADE methodology that the WHO requires to be followed in formulating its official guidelines. Basically, the GRADE methodology means that even when there is very strong evidence that some action – like withdrawing routine antibiotic use, in this case – will benefit public health, the WHO can never characterize its final recommendation as having been based on anything stronger than ‘low level’ evidence so long as no randomized control trials, or RCTs, have been done.
RCTs are very expensive and time-consuming to do; they also can be rather impossible to imagine, in certain situations. For instance, there’s never been an RCT done to test whether it is safer to do surgery with sterilized as compared to unsterilized scalpels. Neither has an RCT ever been done to test the hypothesis that wearing a parachute will prevent death when jumping out of an airplane. Applying the GRADE criteria, a hypothetical WHO recommendation would not be able to recommend either clean scalpels or the wearing of parachutes while claiming more than a ‘low level’ of scientific support.
The WHO intentionally puts in place a very high scientific hurdle to adopt any kind of public health recommendation. The fact there is a WHO recommendation at all in this case is a testament more to the strength of the evidence in surmounting that high hurdle, than a comment on the weakness of that evidence.
In the end, good science will win out. The waning effectiveness of antibiotics will become so obvious that denying the urgent need to get smarter about their use will no longer be a winning strategy, politically or in the marketplace.
The WHO recommendations offer an alternative path for countries that are still feeding our most precious antibiotics to healthy animals. I hope that in the U.S. we take it.