The Netherlands—arguably America's agricultural twin—has drastically reduced its use of antibiotics in meat, and Dutch citizens are already reaping the health benefits. So what is the U.S. waiting for?
It's the stench, a pungent mix of ammonia and wet earth, that gives it away. This neat row of brick buildings in the Dutch village of Bergeijk is a massive chicken farm. Inside the six barns are 175,000 birds, hidden from the neighbors' view and without any access to the outdoors or even natural light. To see them, visitors must slip into sterile blue jumpsuits and plastic booties, a low-tech but effective type of biosecurity that stops people from sneaking in any dangerous bacteria—or taking anything out.
Precautions are especially important now, but not because the flock of birds looks sick or particularly unhappy. New government rules have forced farmers like Kees Koolen to cut their use of antibiotics, which for decades has served as a cheap and easy way to keep birds healthy and plump for their short, 6-week lives. Koolen, a 55-year-old with a round face, ruddy cheeks, and pale blue eyes, has been raising meat birds, or "broilers," for 30 years, and he wasn't keen on the idea of giving up his wonder drugs. But in just 3 years, Koolen has successfully cut the antibiotics used on his farm by 55% without making any substantial changes to production. Opposing the new rules would have been pointless, he says: "That's passé in the Netherlands."
Calls to curb the use of antibiotics in agriculture are growing louder the world over, with many experts concerned that we're careening toward a global public health crisis brought on by bacteria that do not respond to antibiotics. Margaret Chan, director general of the World Health Organization, has said that if we don't change course, we could soon live in a world where "things as common as strep throat or a child's scratched knee could once again kill."
Antibiotic resistance has gotten so bad here in the United States that CDC director Thomas Frieden named the issue one of his top priorities for 2014. The numbers tell the story: Every year, 2 million people in the United States get infections that are resistant to antibiotics, and at least 23,000 people die as a result. Dozens of new, virulent bacteria have emerged over the years, including methicillin-resistant Staphylococcus aureus, or MRSA, which causes more than 11,000 deaths in the United States each year, and resistant strains of E. coli that can turn a run-of-the-mill urinary tract infection into a trip to the emergency room. Last month, Consumer Reports found that 97% of the 316 chicken breasts it tested were tainted with potentially harmful bacteria, and about half harbored at least one multidrug-resistant bacteria.
Crucial to combating these so-called superbugs, the CDC says, are more thoughtful policies about when and how often to prescribe antibiotics for humans and animals. "Every time antibiotics are used in any setting, bacteria evolve by developing resistance," said Steve Solomon, director of the CDC's Office of Antimicrobial Resistance, in a press release. "The more we use antibiotics today, the less likely we are to have effective antibiotics tomorrow."
And yet in the United States, there's been shockingly little done to limit antibiotic use. In 2011, drug manufacturers sold 29.9 million pounds of antibiotics for use on industrial farms, the highest amount ever reported and four times the amount sold to treat sick people. Critics contend the FDA has turned a blind eye to the problem, but a Natural Resources Defense Council report released in January tells a more damning story: The FDA buried research revealing that 18 types of antibiotics currently in use on farms are considered high risk for increasing antibiotic-resistant bacteria outbreaks in humans. In total, 30 drugs did not meet the FDA's own safety standards.
But the Netherlands is proof that a country with an intensive farming system similar to the United States' can confront the rise of antibiotic resistance. In 2008, the Netherlands was the No. 1 user of antibiotics in livestock in the European Union. Today it is in sixth place, with antibiotic use down by 50%. "I can't believe the progress we made in just a couple of years," says Jan Kluytmans, PhD, a professor of microbiology and infection control at the Amphia Hospital in Breda, Netherlands. "And it was done without any big consequences in efficiency or financial returns."
Our reliance on antibiotics to cure our every ill has proven a tough habit to break, mainly because the drugs work so well—or used to, anyway. Penicillin was hailed as a miracle when it was developed in 1928—"the most powerful germ killer ever discovered," the New York Times proclaimed in 1940. Antibiotics proved equally extraordinary on the farm starting in the 1950s, curing livestock's infections and keeping illness at bay The drugs also had the lucrative side effect of making animals grow faster. "When someone gives you something and the results are better and you see no negative side effects, you use it," says Gerbert Oosterlaken, who raises 17,500 pigs a year in southwestern Netherlands. "You'd be crazy not to."
But the drugs came with a catch. Regular, low doses of antibiotics create the perfect conditions to breed resistant bacteria. Bacteria are constantly evolving; the organisms can produce a new generation in as little as 20 minutes. Prolonged exposure to doses of antibiotics that don't completely kill them off encourage the growth of mutant strains that are impervious to the very thing intended to annihilate them. Over weeks and years, these microscopic bugs learn to outsmart even the most powerful drugs.
The wily nature of bacteria was evident from the start. Alexander Fleming discovered penicillin in 1928, and the first recorded penicillin-resistant staph appeared in 1943. Tetracyclines, discovered in 1944 and still widely prescribed for acne and strep throat, were outwitted by 1950. And so it went. "Bacteria are like this river flooding over man," says Lance Price, PhD, a microbiologist at George Washington University and a leader in the effort to reduce the use of antibiotics in livestock. "Fleming figured out how to build a dam to control those waters, but soon they came up over the wall. So we built it up higher and higher until we ran out of bricks. Food animal production is a jackhammer knocking away at the bottom."
Put another way: By overusing the drugs, we're now fast running out of low-side-effect antibiotics that actually work. There are only a few new drugs in the pipeline; pharmaceutical companies have little incentive to make more, because resistance can emerge even before a company has earned back the estimated $1 billion it costs to produce a new drug. Among the roadblocks America faces is the livestock industry, which disputes that the use of these drugs on the farm—even the emergence of resistant bacteria there—has been proven to harm human health. Developing a truly airtight case would require unethical practices, such as injecting a human with antibiotic-resistant bacteria from a food animal and then waiting to see what happens.
But studies—not to mention the progress in the Netherlands—strongly suggest that eliminating the regular use of antibiotics on farms could have a dramatic, almost instantaneous, effect on animal and human health. In 2007, about 20% of the E. coli found in poultry in the Netherlands was resistant to the antibiotic cefotaxime. By 2012, after a few years of reduced antibiotic use on farms, resistance had dropped to only 5.8%. The downward trend is visible in almost every antibiotic in every species—pigs, veal calves, and dairy cows. And because drug-resistant bacteria in animals inevitably spread to humans (vegetarians included; see illustration below), that drop translates directly to less-dangerous drug-resistant infections for Dutch citizens. "The fact that the Dutch are already seeing an impact on human health is simply mind-blowing," says Laura Rogers, director of the Pew Charitable Trusts' campaign on human health and industrial farming. "If we followed a similar path here in the United States, we could see significant reductions in dangerous bacteria in people and in animals."
The new Dutch rules require that farmers use antibiotics only if an animal is sick; regular low doses for prevention are prohibited. (Antibiotics for growth promotion were banned in Europe in 2006.) Farmers must consult a veterinarian to prescribe the medicine. Vets, in turn, must first prescribe only drugs that do not stimulate the production of antibiotic-resistant enzymes called ESBLs. In order to use a drug that does stimulate ESBLs, a vet must substantiate the prescription and provide extensive documentation. To use antibiotics considered critical for humans, the vet must show that other microbial treatments won't work. And as of 2014, all vets will be monitored and rated by an independent regulator. A veterinarian who prescribes too many drugs will quickly raise alarms.
While the Dutch measures have worked astonishingly well—with farms reaching their target of slashing 51% before the 2013 deadline—Dutch farmers, vets, and doctors agree that the hardest work is still to come. "If it sounds ideal, remember, we have our own struggles," says Joost van Herten, a senior policy officer at the Royal Dutch Veterinary Association. "The low fruit is already picked." Further antibiotic reduction will likely compromise animal health and welfare, so eliminating the next 20% will mean making tough and sometimes controversial decisions. For example, there has been a ban on putting animal protein into livestock feed since 2001, when there was an outbreak of bovine spongiform encephalopathy, a.k.a. mad cow disease. But more nutritious food could help keep animals healthy. Over the coming years, veterinarians and farmers may have to revisit whether improved animal health is worth the risk of another bout of BSE.
The question, of course, is whether the United States can ignite its own revolution on the farm. There are some key differences that make it more of a challenge here. In the Netherlands, for instance, both the national and EU governments collect masses of data that make it easy to see what is happening on the ground. Here in the United States, the FDA is authorized to collect and report only limited information on the amount of antibiotics sold. That means that we don't know how much of which types of drugs is going to which animals or for what reason—a big problem for researchers who want to track antibiotic resistance and for regulators whose job it is to ensure that drug companies and farmers are following the rules.
In the Netherlands, the government also had buy-in from the farm industry; in the United States, both the powerful livestock and pharmaceutical industries oppose new regulations and have been successful in pleading their case. The Johns Hopkins Center for a Livable Future released a report last fall that looked at how the government has responded to modern agriculture's threats to human health. Its verdict: "an appalling lack of progress," per the center's director, Robert Lawrence. "If there were a report card for progress in the last 5 years, I would give it an F," he says.
Last December, the FDA issued new guidance that would bar farmers from using the medicines to promote growth in food animals. But while some may see that as a step in the right direction, the rules still permit preventive use, which means farmers can continue to give their animals low doses of antibiotics to keep them from getting sick. "If these products are useful and allow animals to be free of disease, there is no reason to remove them unless there is a human health concern," says Richard Carnevale, vice president of regulatory, scientific, and international affairs at the Animal Health Institute, a trade group. "I do not believe the use of therapeutic antibiotics is resulting in a human health problem."
That the industry still refuses to acknowledge the severity of the threat provokes much head-scratching in Europe. But it is why experts on antibiotic use believe that for meaningful change, consumers must put pressure on businesses to change. "In the United States, the key is McDonald's," says Dik Mevius, a senior scientist at the Central Institute for Animal Disease Control, an antibiotic research center in the Netherlands. "If McDonald's says they want antibiotic-free meat, farms will produce it no matter what it costs."
No one is specifically targeting McDonald's—not yet, anyway. But in 2012, Consumers Union, the advocacy arm of Consumer Reports, launched a grassroots campaign that asked grocery retailer Trader Joe's to sell only meat raised without antibiotics. It collected 550,000 signatures, and, for about 9 months, advocates had sporadic discussions with the company. To date, the grocer has not made a commitment, but it has introduced a line of ground turkey raised without antibiotics. Whole Foods remains the only large grocery chain that offers only meat raised without antibiotics.
Advocates haven't given up hope. The Organic Consumers Association launched an online petition last November asking Butterball to raise its turkeys without antibiotics. An online campaign at Causes.com has collected 20,000 signatures to ask Walmart to ban antibiotic-raised meat. Such campaigns can be effective, especially if consumers talk directly to retailers. "The pace with which things move in Washington is slow," says Meg Bohne, who runs Consumers Union's Trader Joe's campaign. "When you're dealing with a crisis like antibiotic resistance, we think the marketplace can move faster." Take hormones in milk as an example: In 2007, the Oregon chapter of the group Physicians for Social Responsibility launched a campaign to raise awareness about the hormone rBGH in dairy. Today, 75% of all fluid milk and yogurt sold in the United States is rBGH-free.
Experts on antibiotic resistance are crossing their fingers that she's right. "The good news is that it's not too late. That's what we are seeing in the Netherlands," says Rogers, of the Pew Charitable Trusts. "In our country, the question is: Is there enough of a wake-up call for someone to seize the reins and lead?"