Will Historic White House Actions On Resistance Scant The Role of Farms?

A public meeting that takes place tomorrow in Washington will launch the Obama White House’s ambitious attempt to be the administration that finally does something about antibiotic resistance. But as much as that appears to be good news, some advocates are concerned that the attempt comes with omissions that could mute the effort’s effectiveness down the line.

The event tomorrow will be the first public meeting of the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (CARB), a body of academic and private-sector experts that were appointed earlier this month. Their task is to guide the government’s new push to blunt resistance before it fatally undermines the effectiveness of antibiotics. The complaint is that in some areas, representation on the council is unbalanced in ways that could tilt any policies that emerge.

If all this is new to you, here’s some backstory.

Almost exactly a year ago, three things happened at once. The White House published a National Strategy that laid out multiple steps for combating the rise of resistance. At the same time, President Obama signed an Executive Order that directed the enactment of the strategy. And, backing up both those actions, the President’s Council of Advisors on Science and Technology (PCAST) released a long-awaited report, almost a year in the writing, that provides the intellectual and scientific support for the actions the National Strategy calls for.

All of those actions were spurred by the alarm bells rung by the Centers for Disease Control and Prevention in September 2013, when it released a “threat report” that revealed antibiotic resistance kills 23,000 Americans, sickens another 2 million, and costs $35 billion in extra health care spending, every year.

The White House moves, and the actions and spending specified in the strategy, were welcomed by people in medicine, public health and patient safety who had been calling for a while for something big to be done. (For more detail, here’s the analysis I wrote at the time.) But in one area, the PCAST report and the strategy were viewed as a disappointment. Though they set out detailed initiatives regarding antibiotic resistance in medicine, they were much less specific about what should be done regarding resistance flowing from agricultural misuse of antibiotics.

This is a sensitive issue in the US. In the European Union, it is accepted that using antibiotics in animals that are not sick—to increase their weight or protect them from farm conditions—contributes to resistance, and the practice has been prohibited since 2006 (and was strictly controlled before that). But in the United States, the effect of antibiotic use on farms is still being argued over. The US Food and Drug Administration attempted to control antibiotic use by regulation as far back as 1977, was forestalled by Congressional interference, and only caught up—by creating non-binding voluntary guidelines for companies that make veterinary antibiotics—in 2013.

When the strategy and PCAST report were released last year, their contents demonstrated how sensitive this issue continues to be. The report called only for “education” and “monitoring” around farm antibiotic use; the strategy called for more aggressive actions, but was not as tough on farm antibiotic use as on medical use.  In one  of many reactions, attorney Mae Wu of the Natural Resources Defense Council told the journal Nature: ““It’s a little too passive… How long do we have to wait for them to take more aggressive action to reduce the amount of antibiotic use on farms?” Similarly, the nonprofit Trust for America’s Health said, “We are concerned that the PCAST report does not make powerful enough recommendations around the routine agricultural use of medically-important antibiotics in food animal production.”

Which brings us up to this week. The council that meets tomorrow comprises 15 voting members and five non-voting representatives of organizations. Among the voting members, there are five who are expected to represent the medical aspects of antibiotic misuse, five who come from the agriculture side, and five representing other concerns. But here’s where it gets tricky. In medicine, there really isn’t any disagreement that antibiotic misuse drives antibiotic resistance. But in agriculture, there is disagreement. And several of the experts representing that side have expressed skepticism in the past about whether farm antibiotic use is a source of antibiotic resistance—a link that in Europe is taken for granted. Of greater concern, there doesn’t seem to be anyone on the council who would disagree with them.

Several prominent public health scientists and advocates last week expressed concern over the council’s makeup.

Steve Roach, food safety program director for the Food Animal Concerns Trust (FACT), said in a letter to the council: “FACT is concerned that most of the members with expertise in animal agriculture have expressed repeatedly, both publically and in writings, very similar views on the link between animal agriculture and antibiotic resistance and on how it can best be addressed. To be clear, FACT believes that it is entirely appropriate for these experts to be members, but what is lacking are Council members representing consumer perspectives on the problem or any of the equally talented researchers that hold diverse views.”

Laura Rogers, deputy director of the Antibiotic Resistance Action Center at George Washington University’s Milken Institute School of Public Health, told me: “There are some excellent people on the committee… My concerns are with the folks who are the experts in antibiotic use in animal agriculture. Many seem to support the status quo. That’s disappointing.”

And Dr. Tara Smith, an associate professor at Kent State University who demonstrated that antibiotic-resistant “pig MRSA” exists in US pig herds and has spread to people here, asked on Twitter:

Q: Where are the public health scientists looking @ animal antibiotic use on the @POTUS advisory board? A: absent http://t.co/hoAk89yeKG

— Tara C. Smith (@aetiology) September 18, 2015

It’s possible of course that the members’ views could be more nuanced than they appear. It’s also possible that the moral force of the White House push for change could create an urgency for re-examining both medical and agricultural use. There too, unfortunately, advocates are skeptical. In preparation for the meeting, the multi-organization coalition Keep Antibiotics Working released a “report card” that scores the administration pretty low on its efforts so far:

The White House efforts on antibiotic resistance are the biggest thing to happen on this issue in a very long time—and the Council could oversee policy even after Obama leaves the White House. It’s good news that an administration has at last championed the issue, but for the effort to make a lasting difference, it’s crucial that all aspects of the problem get a fair hearing.