Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

The Challenge of Antibiotic Resistance, Animal Production, and Enacting Change: A Critique of U.S. Public Health Strategies – Kimber Wukitsch

Antibiotic resistance has been called one of the world's most pressing health problems. According to the Centers for Disease Control, almost every type of bacteria in the last decade has become stronger and less responsive to antibiotic treatment when it is really needed (1). The World Health Organization has raised concerns that we are entering a post-antibiotic era in which resistance is developing for virtually all currently available drugs, meaning that many life-threatening infections may be rendered untreatable (2). While healthcare practitioners and patients alike have been charged with limiting the distribution and use of antibiotics, a major contributing factor to the problem of resistance has been virtually ignored: that of antibiotic use in agricultural animal production. While leaders in public health recognize this as a global threat to human health, strategies to initiate change in the United States are proving unsuccessful because the general public have not been engaged.
Although resistance to antibiotics is a natural phenomenon to a certain extent, the CDC and the WHO cite both their overuse and incorrect use as causing the current accelerated rates of resistance. In large-scale animal agriculture, antibiotics are routinely administered to livestock for the treatment and prevention of infection, as well as to promote growth and improve feed efficiency. The latter purpose, termed “nontherapeutic” use, is designed to promote growth by administering low doses of antibiotics over prolonged periods of time, sometimes for the entire duration of production. The Union of Concerned Scientists estimates that nearly 70% of all antibiotics in the United States are used for nontherapeutic purposes in agriculture—almost 8 times the amount given to humans to treat disease (3). This routine usage is rapidly contributing to the development of resistant microbes that can be transmitted to humans via improperly cooked meat, farm workers, and even the air (2, 4). Several European countries have banned the use of nontherapeutic antibiotics in agriculture and subsequently observed dramatic reductions in resistance rates (5). Moreover, both the WHO and the Institute of Medicine have called for a rapid phase-out of antibiotic growth promotant use on a global scale. In the United States, health officials have directed their efforts at the federal legislative level by proposing bills to restrict or eliminate nontherapeutic antibiotic administration in livestock. However, the urgency of the resistance problem and its potentially severe consequences demand that U.S. public health experts step up their efforts by informing the public and gaining their support.
One way this could be achieved in order to expedite the process of addressing agricultural antibiotic use is by engaging the media. The mass media determine to a great degree what the general public find important, and the news media in particular play an increasingly large role in communicating health risks (6). According to Hierarchy of Effects models designed to explain the psychological basis of consumer habits, public awareness is a key to action; thus, informing the population of antibiotic overuse in the agricultural industry is the first step to creating change. To this end, the media can serve as the messenger. For example, McGuire's Information Processing Model suggests that people ascend through a sequence of steps prior to making a behavior change, with the first crucial step being exposure to information which eventually leads to action (7). According to the model, if people are not exposed to the risks of antibiotic resistance from antibiotic-laden meat, there is no reason to make a decision leading to behavior change, advocacy, or similar action.
Theories of agenda-setting also suggest that the media are an effective means to heighten awareness in order to initiate a change in behavior. For example, McCombs’ Agenda-Setting theory describes the role the media play in determining which issues are deemed important by the public. Studies have shown that the mass media can influence popular opinion regarding political issues, as well as their efficacy in dictating how people think about an issue (8). If the media were strategically utilized to place health risks from food-based antibiotics on public agendas, it could create an outcry and impel both U.S. legislature and agricultural workers to initiate change in the way meat is produced.
A recent New York Times article on methicillin-resistant Staphylococcus aureus (MRSA) provides an example of the role media can play in this context. The article cited a Journal of the American Medical Association study depicting MRSA as “a virulent strain of bacteria that resists many antibiotics and caused an estimated 19,000 deaths in 2005—more people annually than AIDS, emphysema or homicide [in the U.S.] (9).” In addition to providing facts about the increasing difficulty of treating infections such as MRSA, the article offered suggestions on how individuals can protect themselves and elicited nearly 400 comments from concerned readers in an online forum. While antibiotics in the food supply were not addressed (the editor admitted to a reader that she knew very little about the subject), the editor was clearly successful in heightening awareness about general antibiotic resistance and invoking a substantial response from readers. This example of agenda-setting demonstrates that the problem of antibiotic resistance and food production could be broached in context and met with similar receptivity. If public health figures applied such theories to addressing antibiotics in food, they may find that people would emulate their concern, resulting in a more timely resolution of the problem.
Another way to raise awareness among the general population and initiate change is to re-frame the problem of antibiotic resistance. Framing theory imparts that the way in which an issue is presented can profoundly influence decision outcomes (10). Despite recognition of and efforts to significantly restrict antibiotic use in the food supply, antibiotic resistance has been framed as a problem caused primarily by human medical overuse. As such, public messages about antibiotic use in agriculture are virtually nonexistent. A prime example can be found on the Antibiotic/Antimicrobial Resistance section of the CDC website, wherein the vast majority of prevention information relates to either correct antibiotic prescription usage, immunizations, or hand washing techniques (11). Downloadable brochures for hospitals further emphasize these points; the only information regarding food urges readers to “always handle, prepare, and store food correctly,” with no ensuing explanation (11). While medical overuse and improper use of antibiotic prescriptions among human populations are certainly contributing factors to resistance, they do not reflect the evidence-based extent of the problem.
To their credit, the CDC offers a page within the same section entitled “Get Smart on the Farm,” with information geared toward agricultural workers on the appropriate use of antimicrobial agents in animals. Farm worker education is an undeniably essential step in the long term reduction of resistance rates, yet a disparity exists between consumer messages and the scope of the problem. In this instance, the CDC acknowledges both medical and agricultural overuse as contributors to resistance by providing informational web pages on each, but frames them differently depending on the audience—the general public versus farmers. It is thus unlikely that the average consumer seeking information on antibiotic risks will ever visit the agricultural section of the website, where they would be exposed to the entire picture. If framing can profoundly influence decision outcomes, influential public health organizations like the CDC need to broaden the frame of antibiotic resistance so consumers can become more thoroughly informed about the issue.
Critics of the notion that increased antibiotic resistance stems in part from the food supply claim that it is difficult to quantify this occurrence, largely due to the lack of federal regulations requiring those administering antibiotics to report to a central source. While this could explain why public health officials are hesitant to caution people against consuming foods produced with antibiotics, compelling evidence of resistance associated with antibiotic growth promotants has been emerging for decades to support this message (5). For example, when researchers purchased 200 samples of ground meat in the Washington, D.C. area in 2001, they found that 20% contained Salmonella, of which 53-84% were resistant to up to three antibiotics tested (5). Several European studies have demonstrated the frequent transmission of resistant organisms from swine to pig farmers such as methicillin-resistant S. aureus (cited by 5), and a 2005 U.S. investigation found that 98% of the bacteria isolates collected from air samples on a large-scale swine farm displayed resistance to two or more of four antibiotics commonly used as growth promotants (4).
Dozens of studies have reported similar findings, and when several European countries banned nontherapeutic antibiotic use in agriculture, significant reductions in rates of resistance were observed (5). Given evidence from the research as well as the adamant encouragement from the World Health Organization, Institute of Medicine, Infectious Diseases Society of America and others to eliminate the use of antibiotics in animal production, it is clear that such an elimination has been identified as critical in curbing resistance rates. If the growing threat of resistance is to be wholly addressed, it is thus necessary to include the risk of consuming antibiotic-laden animal products in messages discouraging antibiotic use.
Another way in which public health practitioners could gain support and achieve change is by organizing people at the community level. Grassroots community groups have made advances in local policy advocacy when national policy had stalled, such as local tobacco regulation, gun control, and living wage policies (13). Since antibiotic resistance poses a threat that impacts entire populations, targeting communities is an effective means to change the current state of the agricultural industry. To date, public health officials have lobbied almost exclusively at the federal level in order to gain passage of bills amending current agricultural regulations. While these initiatives are imperative, they lack the public support necessary to realize a more immediate change that reflects the urgent nature of the resistance problem.
Past community mobilization efforts in public health encompass a wide range of activist movements such as the anti-abortion movement or anti-smoking and HIV/AIDS activism, and entail raising community member awareness to address a problem (14). One way that communities could act on antibiotic use in the food supply is by demanding wider availability of antibiotic-free meat, which is currently sold by most health food retailers but less frequently available in commercial stores. Public demand, or lack thereof for meat produced with antibiotics, would make an economic statement to farmers about what people want to consume. Advocating for policy change is another way in which community change can be effective (14). For example, the Preservation of Antibiotics for Medical Treatment Act of 2007 (PAMTA) is a proposed bill to withdraw FDA approval for all antibiotics used as feed additives in livestock in order to preserve the effectiveness of medically important antibiotics (15). The bill was introduced to the House of Representatives in February 2007 (16), yet the House sees hundreds of bills a year which may never make it past committees. By raising awareness at the community level, community members would have the opportunity to show their support for federal bills like PAMTA or apply pressure to local legislators to amend agricultural regulations more rapidly.
One caveat to adopting theories of community mobilization for public health practitioners is that it is essential to begin with a target community’s priorities in mind if the initiative is to be successful (17). Fortunately, this would not present as an obstacle in the case of antibiotic resistance. As discussed, the present culture depicts resistance as a problem of overuse among human patients and medical practitioners. However, the high reader response to the aforementioned New York Times article demonstrates that people are concerned about how to protect themselves from resistant bacteria. Moreover, the Infectious Diseases Society of America has a section of its website dedicated to the personal stories of those who have experienced a drug-resistant infection or lost someone as a result of such an infection (18). Thus, it would not be difficult to find communities to whom the issue of resistance is important, and subsequently mobilize members to support public health initiatives against the use of antibiotics in agriculture.
Public health efforts to address antibiotic resistance in the United States are headed in the right direction by targeting all the angles that impact resistance: medical overuse, patient misuse, and nontherapeutic agricultural use. However, their methods are flawed because they have neglected to involve the general population in ways that reflect the breadth of the problem. By failing to inform people about the use of antibiotics to agriculture, they are missing an important opportunity to bring about changes to the agricultural industry that could ultimately save lives. Furthermore, by neglecting to emulate other countries who have already implemented such changes—some for over a decade—the U.S. is falling behind as a prominent leader in public health advancements towards antibiotic resistance reduction. While federal legislation is important, it can also be tedious, and world public health leaders are calling for immediate action. Health officials in the U.S. need to gain support by utilizing media outlets to expose, inform, and set the public agenda, re-frame antibiotic resistance to incorporate health warnings regarding antibiotics in the food supply, and identify and mobilize communities who will make progress through their consumer and local legislative actions. Only by engaging the general public will the issue of antibiotic resistance be more immediately addressed in order to effectively mitigate the problem.
1. Department of Health and Human Services: Centers for Disease Control and Prevention. About Antibiotic Resistance. Atlanta, GA: Centers for Disease Control and Prevention.
2. World Health Organization. Antimicrobial Resistance. Geneva, Switzerland: WHO Media Centre.
3. Union of Concerned Scientists. Antibiotics and Food. Cambridge, MA: Union of Concerned Scientists.
4. Chapin, A. et al. Airborne multidrug-resistant bacteria isolated from a concentrated swine feeding operation. Environmental Health Perspectives 2005; 113:137-141.
5. Gilchrist, M. et al. The potential role of Concentrated Animal Feeding Operations in infectious disease epidemics and antibiotic resistance. Environmental Health Perspectives 2007; 115:313-316.
6. Glik, D. Risk communication for public health emergencies. Annual Review of Public Health 2007; 28:33-54.
7. McGuire, W.J. Some internal psychological factors influencing consumer choice. Journal of Consumer Research 1976; 2:302-219.
8. McCombs, M. and Shaw, D. The agenda-setting function of the mass media. The Public Opinion Quarterly 1972; 36:176-187.
9. The New York Times. Drug-Resistant Staph: What You Need to Know. New York, NY: The New York Times.
10. Iyengar, S. Framing effects of news coverage (pp. 11-16). In: Iyengar, S. Is Anyone Responsible? Chicago, IL: The University of Chicago Press, 1991.
11. Department of Health and Human Services: Centers for Disease Control and Prevention. About Antibiotic Resistance. Atlanta, GA: Centers for Disease Control and Prevention.
12. Tversky, A. and Kahneman, D. The framing of decisions and the psychology of choice. Science 1981; 211:453-458
13. Themba, M. Making Policy, Making Change. Chardon Press, Berkeley, CA: 1999.
14. Edberg, M. Social, Cultural, and Environmental Theories (pp. 65-75). In: Edberg, M. Essentials of Health Behavior. Sudbury, MA: Jones and Bartlett Publishers, 2007.
15. Union of Concerned Scientists. Food and Environment. The Preservation for Antibiotics as Medical Treatment Act of 2007. Cambridge, MA: Union of Concerned Scientists.
16. U.S. Government Printing Office: Congressional Bills. H.R. 962. Washington, D.C.: U.S. Government Printing Office.
17. U.S. Department of Health and Human Services: National Institutes of Health. Theory at a Glance: A Guide for Health Promotion Practice. Bethesda, MD: National Cancer Institute 2005; 23-27.18. Infectious Diseases Society of America. Strategies to Address Antimicrobial Resistance Act. Arlington, VA: Infectious Diseases Society of America 2007.

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