Killer Food

You stand transfixed in the candy aisle, salivary glands pumping furiously and your head swimming with words: Snickers. Milky Way. Almond Joy. But your reverie ends when other words intrude: Saturated fats. Empty calories. Rotting teeth. "Stop the insanity!" you think to yourself. Swiftly, decisively, you bolt off to the produce section and fill your cart with natural, healthy snack foods. That night, you pluck a melon from the fridge. But what if the farmer who grew it was careless and failed to thoroughly cleanse the melon before shipping it off the farm? Traces of pathogenic bacteria might linger on the rind, which you don't bother to wash. You slice up the melon and savor its cool, bracing fruit, ingesting bacteria as you lick your fingers. The nasty little microbes -- it takes as few as a dozen, depending on your health and the type of bacteria -- lodge in your small intestine and begin spewing toxins. A day later you're a wobbly, feverish mess, camped in the bathroom due to your severe diarrhea and vomiting. The steady passing of bodily fluids is accompanied by a case of the chills and abdominal cramps. It's three or four days, maybe a week, before the horrid symptoms pass. If your immune system is weak -- as in small children and older adults, as well as AIDS sufferers and recent transplant or chemotherapy patients -- you could even die. All because you tried to eat a nutritious snack. Sound far-fetched? The authors of an influential article titled "The Changing Epidemiology of Food-Borne Disease," which appeared last year in the journal Clinical Infectious Diseases, would disagree. Three epidemiologists from the Minnesota Department of Health report that a healthy trend in the American diet has come at a cost. "Given national trends toward consumption of fresh fruits and vegetables," they write, "[food-poisoning] outbreaks are likely to occur more frequently in the future." And you thought eating safely just meant skipping medium-rare hamburgers and scrubbing your cutting board after chopping chicken. Two years ago, Washington state's E. coli nightmare called national attention to the problem of unsafe food. Three small children died and more than 600 other people became ill eating undercooked hamburgers tainted with the bacterium E. coli 157:H7 served by Jack-in-the-Box restaurants. (One of those who became sick, 4-year-old Shanika Baldwin of Federal Way, suffered brain, kidney, and colon damage, as well as hearing loss; in October, she received an estimated $7 million settlement from Jack-in-the-Box.) The deadly outbreak triggered a new awareness of the dangers of infectious diseases carried by food. But the danger of getting sick simply by eating hasn't diminished in its wake. In fact, epidemiologists and microbiologists say that the problem of food-borne illness caused by bacterial and viral agents is actually getting worse. What's more, as the technology for detecting lethal microbes improves and our system for gathering data about eating-related disease expands, the true breadth of America's food-borne illness problem will emerge. The Centers for Disease Control and Prevention estimates that about 9,000 Americans die each year as a result of eating tainted foods, and that between 6 million and 33 million experience the gastrointestinal anguish of food poisoning. But some experts say the figure could be much, much higher -- as high as 80 million per year. Most cases of diarrhea and nausea, which we simply write off as "stomach flu," could, in fact, be mild cases of food poisoning. Whatever the annual total of dyspeptic diners, a complex stew of cultural, economic, biological, and political influences is conspiring to send it higher still. The age when food was viewed solely for its nutritional value (or lack thereof) and gustatory pleasure is ending. Add to those an increasingly common dimension: food as threat. For a public numbed by a growing list of Things that Can Kill You, the news that fruits and vegetables can be toxic might be the final insult. Although widespread public concern about pesticide abuse has faded in recent years, now comes a warning that dangerous bacteria associated with beef and poultry are creeping into earth-grown foods, too. Nutritionists and doctors have been encouraging Americans for years to swap meats and other high-fat foods for more produce and grains. While this is undoubtedly a healthy move, since 1990 our nation's growing appetite for fresh fruits and vegetables has led to at least four large outbreaks of food poisoning (involving up to 400 people each) in the United States. Craig W. Hedberg, Kristine L. MacDonald, and Michael T. Osterholm, the authors of the "Changing Epidemiology" article, point out that in two of the outbreaks, the illness was traced back to contaminated cantaloupes; in the others, the culprit was tomatoes. All involved strains of Salmonella. Although salmonellosis is the most common form of food-borne illness in the United States, the rod-shaped bacterium has largely been associated with raw eggs, milk, and poultry. Investigators were left to speculate as to what influences produced these toxic tomatoes and corrupted cantaloupes. "These are things we didn't have to think about in the past," says Dr. I. Kay Wachsmuth, the US Food and Drug Administration's deputy director for programs. One thing is known. America's food suppliers must struggle to match demand for fresh produce. Frozen and canned fruit and vegetables are gradually falling out of favor; compared to fresh, they tend to be bland and mushy, not to mention lower in nutrients. To satisfy the craving, food distributors have been importing an increasing amount of produce. According to United States Department of Agriculture data, between 1991 and 1994 the amount of fruits and vegetables the United States imported increased by 12 percent. The dependence is felt most acutely in the winter. Between the months of January and March, for instance, as much as three-quarters of all cucumbers and two-thirds of all tomatoes sold in the United States are imported from Mexico. Our economic relationship with Mexico, and Canada, in the age of the North American Free Trade Agreement troubles Hedberg and his colleagues. With the elimination of trade restrictions, increased competition between agribusinesses in all three countries could lead to cost-cutting measures. Skimping on worker training and oversight, for example, could allow unsanitary or sick employees who handle food to pass along infectious bacteria. Trucks with poorly maintained refrigeration systems might allow for temperature fluctuations, creating a breeding ground for pathogens. That's speculation about the future. But how much do we know today about those Mexican tomatoes? Or beef from Brazil? Or olives from Greece? What do we know about the standards adhered to by the farmers and food distributors in other countries? It turns out, not much. "As our food supply becomes more complex, we're getting food from further and further away. And we know less and less about what's going on with that food," says Bert Bartleson, a technical expert with the Washington State Department of Health's food program. Many of the companies selling food to the United States have modern plants and adhere to hygiene and sanitation standards that meet or exceed ours. But there are also cottage industries in developing countries that operate out of shacks with dirt floors and no running water. The big problem is, American importers know very little about who's shipping the pure, safe food and who's sending us outbreaks-waiting-to-happen. "We are clueless," says Bartleson. "If you want to deregulate the world, you pay the price by having fewer standards and less control." Mind you, it's not as though all of the 30 billion tons of food we import each year flows across our borders unchecked. But you might be surprised to know how little of it is scrutinized. Take the Food and Drug Administration, which regulates about a quarter of all food that enters the United States. FDA inspectors perform random spot checks on cargo in search of rotten or bacteria-laced foods. They also employ a system of automatic inspections on shipments from selected companies or countries with bad track records. But the FDA only samples 3 percent of the food it is charged with monitoring. "We can't check everything," says Wachsmuth. When you consider that 40 percent of the food the FDA does sample is rejected for being a potential health hazard (or for other reasons, such as mislabeling), it's hard not to wish Wachsmuth's agency could check everything. The obvious problem is personnel. Consider: The FDA's Northwest district, headquartered in Bothell, oversees 71 ports of entry, covering five states -- with just 10 inspectors. The FDA has recently computerized its tracking system, making the targeting system more efficient (the Northwest district was the pilot site for the program). But because there are so few inspectors for so many ports of entry nationwide, the agency is often forced into a reactive role, banning an import after an outbreak has occurred. A notorious example of this too-little-too-late approach occurred in 1989, when diners at a college cafeteria in Mississippi, two restaurants in Pennsylvania, and a hospital in New York were infected with Staphylococcus bacterium. More than 100 people developed nausea, cramps, and vomiting; 16 were hospitalized. There is a category of imported food-borne illness caused by products the FDA and other regulatory agencies never get a crack at: "suitcase diarrhea." Although anyone entering or re-entering the United States is prohibited from carrying fruits or meats, it's easy enough to lie on your US Customs form and stow away a few tins of some exotic delicacy in your valise. Unfortunately, food smuggling, especially among US immigrants returning from visits to their homelands, has led to outbreaks of disease rarely found in the United States. Take cholera, a disease we don't think much about here. It's caused by a bacterial infection of the small intestine and is spread through ingestion of water or food contaminated by the feces or vomit of infected humans. Cholera induces diarrhea so severe that the body can lose up to a liter of fluid per hour. A cholera epidemic has plagued Latin America, including Mexico, since 1991, afflicting 1 million people and killing 9,000. The epidemic south of the border has led to a succession of cholera outbreaks in the United States since the early 1990s. Small and contained, but outbreaks, nonetheless. In New Jersey, the disease was spread by undercooked crabs smuggled into the country from Ecuador. In Indiana, a couple developed cholera after eating palm fruit brought into the United States by a relative from El Salvador. The most notorious outbreak, though, involved cold seafood salad prepared by a caterer in Peru and served aboard a Buenos Aires-to-Los Angeles flight after a stopover in Lima; 100 passengers were infected with the Vibrio cholerae toxin; 10 were hospitalized and one man died. Compared with other food-borne illness in the United States, cholera is still an obscure menace, but the message is clear: Questionable cuisine easily crosses our borders. Physicians need to be open-minded when examining patients with gastrointestinal problems. Some unfamiliar ailments have already begun turning up on our shores. As the trend toward importing food continues (total agricultural imports have increased 26 percent in the last four years), increasing outbreaks of food-borne illness could stir calls for tighter regulations, perhaps even fomenting anti- foreign-food sentiment to rival the current anti-immigrant fever in some parts of the nation. But let's not forget that we currently do a perfectly good job of making ourselves sick without outside help. The Jack-in-the-Box hamburger fiasco is the most notorious instance of food contamination on US soil in modern times. Ground beef produced from cattle carrying E. coli 157:H7 was used to make hundreds of thousands of hamburger patties; burgers that weren't cooked well done, which kills the bug, passed the bacteria onto diners. Although it was more deadly, the Jack-in-the-Box scare was dwarfed in scope by a more recent outbreak that demonstrated the way an apparent improvement in our ability to deliver food can also be a more efficient way to spread illness. Last fall, ice cream lovers around the nation developed salmonella poisoning after eating products sold by Schwan's Sales Enterprises, of Marshall, Minnesota. The company is still processing damage claims from a class-action suit; customers in at least 32 states will receive between $80 and $75,000 each from Schwan's. Food-borne contamination on such a scale is a modern phenomenon, and largely an American one. "There has been a change in the way we process and distribute food," says pathobiologist Marilyn Roberts of the University of Washington School of Public Health. "Until 20 years ago, you couldn't contaminate a huge area because we didn't have the kind of infrastructure to move food long distances that we do now." In the past, a food processor that turned out a batch of tainted food was likely to infect only consumers in the surrounding community. Today, with refrigerated trucks and interstate highways, even a small player can reach, and infect, regional and national consumers. Beyond infrastructure, changing lifestyles are playing a role in the increase of food-borne illness, too. Americans, especially two-career couples with kids, rely more on restaurant food today. According to the USDA, 44 cents out of every dollar Americans spend on food is for a meal prepared outside the home. That's up 18 percent since 1980. If the trend continues, it could lead to a lot more unhappy meals. The restaurant industry has a notoriously high turnover rate. In 1990, according to Hedberg, et al., one out of every three restaurant employees hadn't graduated from high school, and 42 percent had worked for their current employer for less than one year. These inexperienced, and often very young, employees have been know to show a blatant ignorance and disregard of basic sanitation concepts, which has been captured by TV news shows in lurid "hidden-camera exposes," notably a recent gross-out segment on ABC's Prime Time. In a memorable moment, a young female food handler was surreptitiously taped while she reached into her pants, scratched energetically about her crotch, then immediately resumed work. Unfortunately, as food-safety expert Bert Bartleson points out, these exposes usually miss the real story. "It's illegal and stupid to stick meat that's fallen on the floor back on the grill. But if you cook it adequately, it's probably not going to make anyone sick," he says. As a public health official, Bartleson is more interested in knowing that food is being cooked to the proper temperatures and that employees wash their hands thoroughly. "By and large, you can't catch a lot of temperature violations with a hidden camera," he concedes. Changing tastes are leaving Americans more susceptible to gastrointestinal turmoil. Sushi was introduced in this country through Japanese restaurants. It caught on, and now it's sold in supermarkets. Microbiologists interviewed for this article expressed little concern over the safety of commercial sushi. But the growing popularity in preparing sushi at home could be a perfect recipe for anisakiasis, the painful stomach disturbance caused by a marine larvae often found in uncooked and unfrozen fish. Sushi chefs are trained to spot and remove the worms; anyone else is taking a gamble. Some efforts to head off the burgeoning food plague are under way. A growing number of academics say the solution is simple: expose foods to irradiation, which kills off harmful bacteria. But the use of X-rays to pasteurize remains controversial; food distributors, unconvinced the public will buy pre-zapped zucchini, have not yet committed to the technology. In July, the CDC, FDA, and United States Department of Agriculture announced the formation of a joint project to improve the nation's system for gathering and compiling data about the transmission of food-borne disease. "We don't have a wonderful surveillance system right now," says the FDA's Wachsmuth. (Other public health officials are less charitable: "The national reporting system is horrible," says one food safety expert.) Knowing how many people get sick from the food we eat will demonstrate how well the safety programs in place are working. Consumers whose families have been hit by food-borne illness have organized to educate others and lobby Congress to enact tougher food-safety laws. The best known is probably the San Diego D based group STOP (Safe Tables Our Priority), which tracks cases of E. coli 157:H7 infection. Earlier this year, STOP leader Donna Rosenbaum led a delegation of food-borne-illness victims and their families to Washington, DC, to brief legislators and hand over 100,000 postcards signed by Americans demanding meat-inspection reform. But political obstacles may impede efforts to safeguard the food supply. Rosenbaum accused food processor ConAgra of sabotaging her lobbying efforts by flying key congressional aides to Colorado for a plant tour while STOP was visiting Capitol Hill. And there is the USDA struggle to overhaul the federal government's 88-year-old meat-and-poultry inspection guidelines. Food inspectors rely on sight, smell, and touch to determine if a carcass is rotten or tainted with microbial bacteria. The USDA's proposal would require scientific testing of meat samples and require processors to do a better job of cleaning animals before they're slaughtered. But the meat industry is mightily fighting the new regulations, and, with congressional support from Republicans Newt Gingrich and Bob Dole, has so far prevented the new provisions from being enacted. In the words of consumer advocate Ralph Nader, if the Clinton administration doesn't stop the reform-minded GOP from stalling the new meat regulations, "there will be more jobs created for the hospital and funeral industries." Calls to end the agricultural practice of feeding antibiotics to livestock have gone unheeded, too. In the human population, antibiotics are used to kill off infectious bacteria. Marilyn Roberts, the UW pathobiologist, points out that big poultry farms in the US have been treating chicks with low doses of antibiotics since the 1950s to make them grow bigger and faster (the theory: fewer germs in the gut allows a bird to turn more feed into meat). But the chicken bacteria eventually becomes immune to antibiotics through adaptation, making the drugs useless. Roberts says it's not inconceivable to think that poultry resistant to an antibiotic could pass on to humans the same traits for resistance, making a valued bacteria-killing drug worthless. (There's evidence that antibiotics are rapidly losing their potency as therapy for food-borne bacterial infection. The Journal of Infectious Diseases reported last year that the percentage of patients with antibiotic-resistant Salmonella infection in the US almost doubled in the 1980s.) And yet, in spite of the darkening clouds over our growing and grazing fields, Americans remain blase about contaminated cuisine. Surveys show that our food-safety practices are uneven at best and that most of us are convinced that the majority of problems occur in food-service or -manufacturing establishments, anyway. But according to Barbara Rasco, of the UW department of food science, that's only about half-true. She says 95 percent of all food-borne illness in the United States can be traced to mishandling in one of two places: food-service establishments and the home. The reasons for our reluctance to adopt wiser food-handling habits aren't hard to understand. There is little appreciation today for the realities of food processing. Most Americans are generations removed from farm life. Few of us have ever seen an animal brought to slaughter, for instance, much less killed and carved up a beast ourselves. Our children are even less likely to perceive a relationship between the funny moo-cow in their picture books and the shrink-wrapped ground beef in the meat case. If we could picture carcasses stacked on a gut-strewn floor, maybe we'd be inclined to listen when told to cook meat at temperatures high enough to kill dangerous bacteria. What's more, most of us who do the cooking don't belong to the groups who are most vulnerable, that is, anyone whose immune system is less likely to rise up and wipe out an invasion of malicious microbes. In the end, no matter how grim the food plague becomes, there will always be those who insist on eating medium-rare hamburgers or steak tartare, with its double whammy of raw ground beef and uncooked egg. Or who devour unpasteurized imported cheeses, which can be fouled by any number of pathogens with strange, Latinate names. Why take the gamble? The answer can be found in a chapter titled "Eating Yuppie Cuisine" in an academic text titled Infections of Leisure (Springer-Verlag, 1994), which ends on this cheery note: "You can get an unbelievable number of gross and unpleasant diseases by eating raw and contaminated foods, most of which are delicious and delightful. Enjoy!"

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