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Food Microbiology and Food Safety
Practical Approaches
Judy A. Harrison Editor
Food Safety for

Farmers Markets:
A Guide to
Enhancing Safety
of Local Foods
Series Editor:
Michael P. Doyle
More information about this series at http://www.springer.com/series/7131

Food Microbiology and Food Safety Series
The Food Microbiology and Food Safety series is published in conjunction with the
International Association for Food Protection, a non-profit association for food
safety professionals. Dedicated to the life-long educational needs of its Members,
IAFP provides an information network through its two scientific journals (Food
Protection Trends and Journal of Food Protection), its educational Annual Meeting,
international meetings and symposia, and interaction between food safety
professionals.
Series Editor
Michael P. Doyle, Regents Professor and Director of the Center for Food Safety,
University of Georgia, Griffith, GA, USA
Editorial Board
Francis F. Busta, Director, National Center for Food Protection and Defense,
University of Minnesota, Minneapolis, MN, USA
Patricia Desmarchelier, Food Safety Consultant, Brisbane, Australia
Jeffrey Farber, Food Science, University of Guelph, ON, Canada
Vijay Juneja, Supervisory Lead Scientist, USDA-ARS, Philadelphia, PA, USA
Manpreet Singh, Department of Poultry Science, University of Georgia, Athens,
GA, USA
Ruth Petran, Vice President of Food Safety and Pubic Health, Ecolab, Eagan,
MN, USA
Elliot Ryser, Department of Food Science and Human Nutrition, Michigan State
University, East Lansing, MI, USA
Judy A. Harrison
Editor
Food Safety for Farmers

Markets: A Guide
to Enhancing Safety
of Local Foods
Editor
Judy A. Harrison
Department of Foods and Nutrition
University of Georgia
Athens, GA, USA

ISBN 978-3-319-66687-7 ISBN 978-3-319-66689-1 (eBook)
DOI 10.1007/978-3-319-66689-1
Library of Congress Control Number: 2017953186
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Preface
Interest in buying locally produced foods is a trend seen in many countries. In the
USA, campaigns such as the US Department of Agriculture’s (USDA) Know Your
Farmer, Know Your Food and The People’s Garden and the operation of the USDA
Farmers’ Market in Washington, DC, have helped to market the “local food” move-
ment. In 1994, there were 1755 farmers’ markets listed in the USDA Agricultural
Marketing Service’s (AMS) Farmers’ Market Directory Listing. In 2016, there were
8669 markets listed. This represents an increase of almost 400% since the early
1990s. Similar trends can be seen in other countries as well with a 157% increase in
markets in Australia between 2004 and 2015 and a range from 30% to 60% across
several Canadian provinces in recent years.
In a 2011 report from the USDA Economic Research Service (ERS), small farms
selling less than $50,000 in gross annual sales accounted for 81% of all farms
reporting local food sales in 2008. The report stated that these farms were more
likely to depend exclusively on direct-to-consumer sales at farmers’ markets and
roadside stands. In 2012, 70% of farms selling foods locally sold directly to con-
sumers through farmers’ markets and community-supported agriculture organiza-
tions (CSAs).
Although there have been few documented outbreaks or cases of illness attrib-
uted to farmers’ markets, studies have identified a lack of food safety practices on
small farms and in farmers’ markets through both survey research and observational
studies. The practices in use identified in these studies could increase consumers’
risk for foodborne illnesses.
Studies from various countries examining why consumers shop at farmers’ mar-
kets and roadside stands and through CSAs indicate that consumers want to meet
and connect with the person who produced the food, to obtain higher-quality and
fresher products, to have a healthier diet, to support the local community, to enjoy
the social atmosphere of the farmers’ market, to protect the environment, and to be
safer from pesticides, added hormones, and foodborne illnesses.
The 2014 National Farmers’ Market Manager Survey conducted by the USDA
Agricultural Marketing Service (AMS) with 1400 farmers’ market managers found
that among 91% of those who managed markets in 2012 and 2013, over 60%
v
vi Preface
reported increases in the number of customers, increases in the number of repeat

customers, and higher annual sales. Eighty-five percent of the managers surveyed
were seeking to add vendors, with 62% of them seeking vendors selling different
types of products, not just fresh fruits and vegetables.
Markets have increased interest in entrepreneurship and cottage food industries.
Farmers’ markets have become venues for products requiring various types of food
safety training and licenses. Studies have found that requirements may vary from
state to state or region to region and country to country. Some studies have identified
a lack of awareness about regulations and a lack of knowledge about food safety
principles that apply to foods being made and sold through very small businesses or
under cottage food regulations, including knowledge about food allergens and
labeling requirements.
Increasing numbers of customers buying locally in their quest for what they
believe to be fresher, healthier, and safer foods create a challenge for food safety
educators and for regulatory agencies. Farmers’ markets offer unique shopping
opportunities for consumers and meaningful opportunities for the farmer. It is
important for public health and for the economic viability of farmers and farmers’
markets to provide food using the best food safety practices. The purpose of this
book is to provide an overview of potential food safety issues on farms and in mar-
kets and present best practices to enhance food safety at farms and farmers’ markets
both in the USA and internationally.
Athens, GA, USA Judy A. Harrison

Contents
1 An Introduction to Microorganisms That Can Impact

Products Sold at Farmers Markets�� 1
Faith J. Critzer
2 Food Safety Hazards Identified on Small Farms�� 13
Judy A. Harrison
3 Potential Food Safety Hazards in Farmers Markets�� 23
Judy A. Harrison
4 Food Safety Considerations for Fruit and Vegetable Vendors�� 39
Renee R. Boyer and Stephanie Pollard
5 Food Safety Considerations for Meat and Poultry Vendors�� 57
Faith J. Critzer
6 Food Safety Considerations for All Other Foods Sold
at Farmers Markets �� 67
Faith J. Critzer
7 An Overview of Farmers Markets in Canada �� 75
Heather Lim and Jeff Farber
8 An Overview of Farmers Markets in Australia�� 103
Bruce Nelan, Edward Jansson, and Lisa Szabo
9 Identifying Hazards and Food Safety Risks
in Farmers Markets �� 119
Benjamin Chapman and Allison Sain
10 Establishing a Food Safe Market: Considerations
for Vendors at the Farmers Market �� 145
Renee R. Boyer and Lily L. Yang
Index�� 167
vii
Contributors
Renee R. Boyer Department of Food Science and Technology, Virginia Tech,

Blacksburg, VA, USA
Benjamin Chapman Department of Youth, Family and Community Sciences,
North Carolina State University, Raleigh, NC, USA
Faith J. Critzer Department of Food Technology and Science, University of
Tennessee, Knoxville, TN, USA
Jeff Farber Department of Food Science, University of Guelph, Guelph, ON,
Canada
Judy A. Harrison Department of Foods and Nutrition, University of Georgia,
Athens, GA, USA
Edward Jansson NSW Food Authority, Newington, NSW, Australia
Heather Lim Bureau of Food Surveillance and Science Integration, Health
Canada/Government of Canada, Ottawa, ON, Canada
Bruce Nelan NSW Food Authority, Newington, NSW, Australia
Stephanie Pollard Department of Food Science and Technology, Virginia Tech,
Blacksburg, VA, USA
Allison Sain Department of Food, Bioprocessing and Nutritional Sciences, North
Carolina State University, Raleigh, NC, USA
Lisa Szabo NSW Food Authority, Newington, NSW, Australia
Lily L. Yang Department of Food Science and Technology, Virginia Tech,
Blacksburg, VA, USA
ix
Chapter 1
An Introduction to Microorganisms That Can
Impact Products Sold at Farmers Markets
Faith J. Critzer
Abstract With the growing demand for fresh, locally sourced foods, the popularity
of farmers markets have soared. Over the past decade, the number of farmers mar-
kets across the United States has steadily increased. With the growing popularity of
these markets, increased awareness of food safety must also be considered. The food
safety management practices used when growing and preparing foods for sale at the
farmers market are based upon scientific principles. The goal of these practices are
to decrease the likelihood food will be contaminated with harmful microorganisms
that can make us ill, referred to as foodborne pathogens, or to inhibit bacterial food-
borne pathogens from growing on the food prior to consumption. This chapter pres-
ents a broad overview of foodborne pathogens associated with products sold at
farmers markets, sources of these pathogens, and means to inhibit bacterial growth.
Keywords Foodborne pathogens • pH • Water activity • Temperature • Salmonella

• Campylobacter
The organisms that are likely to impact the safety of foods sold at farmers markets are
similar to those we would expect for foods sold in any retail setting. Many individuals
believe that since news reports of outbreaks linked to local farmers markets are rela-
tively scarce to unheard of, foodborne pathogens are not an issue with foods grown
and manufactured locally. However, pathogens do not preferentially select to con-
taminate food associated with large farms, food manufacturers, or retail operations.
Bellemare et al. have reported a positive correlation with the number of farmers
markets per capita, the number of foodborne outbreaks, cases of campylobacteriosis
(the illness caused by Campylobacter spp.) and outbreaks related to Campylobacter
[1]. Based upon data from 2004 to 2011, a 1% increase in the number of farmers
markets resulted in a 0.7% increase in foodborne outbreaks and 3.9% increase in
F.J. Critzer (*)

Department of Food Technology and Science, University of Tennessee,
103 Food Science and Technology Building, 2600 River Drive, Knoxville, TN 37996, USA
e-mail: faithc@utk.edu
© Springer International Publishing AG 2017 1

J.A. Harrison (ed.), Food Safety for Farmers Markets: A Guide to Enhancing
Safety of Local Foods, Food Microbiology and Food Safety,
DOI 10.1007/978-3-319-66689-1_1
2 F.J. Critzer
foodborne illnesses. These increases were even more substantial when only evaluating
Campylobacter jejuni, which showed a 3.9% increase for outbreaks under the same
farmers market growth parameters. If a cause and effect relationship exists, it is
important to understand what drivers may be at play resulting in the increase of food-
borne illnesses. A possibility may be that food safety best practices are not uniformly
practiced by farmers market vendors, which in many locations are self-governed or
irregularly inspected for adherence. In reality, as presented in future chapters, many
vendors do not have any mandatory regulations imposed upon them for safe growing,
harvesting, or manufacturing of the foods they sell through these venues.
In order to reduce the risk of contamination, vendors must proactively adopt
management practices that are based upon scientifically valid food safety principles.
Limitations to epidemiological traceback to a causative agent associated with food-
borne illnesses are a primary issue for local distribution systems since the popula-
tion of people consuming these goods is relatively small, the probability of having
enough people reporting illness will be even less and most likely result in what
appears to be sporadic illnesses. While outbreaks linked to farmers markets are not
as readily publicized, future chapters in this book will discuss some of the inci-
dences of outbreaks linked to foods sold through this outlet.
Farmers market vendors must accept that without adherence to best practices,
they are opening their operation up to the risk of making their patrons ill. This chap-
ter presents an introduction to the types and properties of foodborne pathogens; and
the burden of some foodborne pathogens, their characteristics, and sources where
they are commonly found.
Types of Foodborne Pathogens
Foodborne pathogens are broadly categorized as disease-causing bacteria, viruses,

or parasites associated with food. Each category has differences that should be well
understood by those tasked with managing the safety of foods sold at farmers
markets. Table 1.1 describes the overall burden from major bacterial, parasitic and
viral foodborne pathogens with relation to illnesses and hospitalizations annually
[2]. Collectively, this group is estimated to cause 9.4 million illnesses through con-
tamination or intoxication of foods [2]. Estimates of the burden of foodborne patho-
gens are used rather than actual reported cases because of drastic underreporting in
the United States. This is due to numerous factors, including the self-limiting nature
of many foodborne intoxications and infections because the ill person recovers
rather quickly before they seek medical care [3]. Even if someone does seek medi-
cal care, the physician must collect and submit a stool specimen, from which a
foodborne pathogen must be isolated, followed by reporting from the physician to
the public health officials. A breakdown at any one step will result in a lack of
reporting, making it rather easy to understand why estimates give us a more reason-
able understanding of the overall impact of foodborne pathogens.
Organisms which cause foodborne illness can be found in a number of places as
shown in Table 1.2. The gastrointestinal tract is a primary source of many foodborne
1 An Introduction to Microorganisms That Can Impact Products Sold at Farmers… 3
Table 1.1 Estimates of foodborne illness caused by 31 major foodborne pathogens annually in the
United States
Foodborne Ability Estimated annual Estimated annual
pathogen to grow illnesses in the hospitalizations in the
type in foods U.S. (% total) [2] U.S. (% total) [2] Examples
Bacteria Yes 3.6 million 35,815 (64%) Campylobacter spp.
(39%) Listeria monocytogenes
Salmonella
Shiga toxigenic
Escherichia coli
Protozoa No 200,000 (2%) 5036 (9%) Giardia intestinalis
Cryptosporidium spp.
Viruses No 5.5 million 15,109 (27%) Hepatitis A
(59%) Norovirus
pathogens. This is because most foodborne pathogens can be either symptomati-

cally or asymptomatically carried in the gastrointestinal (G.I.) tract of humans and
animals. From the G.I. tract they can be spread to many environmental sources, such
as water and soil, where they can survive extremely long periods of time. This is one
reason why fresh produce can easily become contaminated with foodborne patho-
gens via contact with the soil, animal manure, or contaminated water and is further
described in Chaps. 2 and 4. People actively shedding foodborne pathogens either
symptomatically or asymptomatically can also spread these pathogens to foods they
contact. This has been observed as a route of contamination in retail settings as well
as with vendors selling ready-to-eat foods at farmers markets. For these reasons,
future chapters will cover segregation of ill workers both on the farm and at the
market as a primary strategy to limit spread of foodborne pathogens.
Unlike viruses and parasites, bacteria have the ability to grow outside of a living
host and can therefore multiply in number on foods or in the environment if condi-
tions are favorable. Under the most favorable conditions, bacterial numbers can
double in 20 min. The primary factors which affect the growth of bacterial food-
borne pathogens include atmosphere, temperature, pH, water activity and availabil-
ity of nutrients. Understanding these factors helps to explain strategies for controlling
the growth of bacterial foodborne pathogens presented in future chapters. Viruses
and parasites, including parasitic protozoa, must have a living host to replicate, such
as when they are actively infecting humans.
rimary Factors Which Affect the Growth of Bacterial

P
Foodborne Pathogens
Atmosphere
Bacteria are categorized by their ability to grow in the presence of oxygen. If an

organism must have oxygen to grow, it is described as a strict aerobe. Given the
fact that most bacteria that cause foodborne illness do so by infecting our
4 F.J. Critzer
Table 1.2 Seven sources of pathogenic foodborne bacteria, protozoa, and viruses
Soil AIR
and AND Gastrointestinal Food Animal Animal
water DUST Plants tract handlers feeds hides
Bacteria
Bacillus ✓+a ✓+ ✓ ✓ ✓ ✓
Campylobacter ✓+ ✓
jejuni and coli
Clostridium ✓+a ✓+ ✓ ✓ ✓ ✓ ✓
botulinum and
perfringens
Escherichia coli ✓ ✓ ✓+ ✓
Listeria ✓ ✓+ ✓ ✓ ✓
monocytogenes
Salmonella ✓+ ✓+
enterica
Shigella sonnei ✓+
and flexneri
Staphylococcus ✓ ✓+ ✓
aureus
Vibrio spp. ✓+b ✓
Yersinia ✓ ✓ ✓
enterocolitica
Protozoa
Cyclospora ✓ ✓ ✓
cayetanensis
Cryptosporidium ✓+b ✓ ✓
parvum
Giardia lamblia ✓+b ✓ ✓
Toxoplasma ✓ ✓+
gondii
Viruses
Hepatitis A ✓+ ✓ ✓+ ✓+
Norovirus ✓ ✓ ✓+ ✓+
Note: + indicates a very important source
a
Primarily soil
b
Primarily water
Adapted from [4]
gastrointestinal tract, there are no foodborne pathogens which fall within this cate-
gory. Rather, foodborne pathogens are categorized as strict anaerobes, meaning they
cannot grow in the presence of oxygen or facultative anaerobes meaning they can
grow without oxygen, but can increase their metabolic processes and grow faster if
oxygen is present. Clostridium spp. are strict anaerobes and Campylobacter spp. are
microaerophilic, meaning they need reduced oxygen content (3–5%) in order to
grow. All other foodborne pathogens are considered to be facultative anaerobes.
This is especially important when considering storage conditions of foods, such as
those with vacuum packing or those which are filled hot and processed to remove
oxygen in the headspace, such as with canned goods like sauces and pickles. Vacuum
packaging and hot filling are two examples of how we have altered atmospheres of
common foods in order to inhibit spoilage organisms. While this will help achieve
a longer shelf-life, care must be taken to assure that foodborne pathogens cannot
proliferate. This can be done through processing steps that will inactivate foodborne
pathogens as well as controlling spoilage organisms.
Temperature
Microorganisms are grouped based upon the temperatures at which they grow.
Three categories play an important role in foods, psychrotrophs, mesophiles and
thermophiles. The storage temperature that certain foods require is driven by what
microorganisms are expected to be in a product and if those organisms can increase
in number based upon other characteristics such as pH and water activity. Minimum,
maximum and optimum temperatures for bacterial foodborne pathogens are shown
in Table 1.3. It should be noted that these are approximate values which allow for
comparison among foodborne pathogens and should not be taken as absolute.
Psychrotrophs grow at or below 44.6 °F (7 °C) and have optimal growth between
68 °F (20 °C) and 86 °F (30 °C) [4]. Foodborne pathogens that belong to this group
are Listeria monocytogenes, Clostridium botulinum Type E, and Yersinia enteroco-
litica. What should be noted among these microorganisms is their lower tempera-
ture limit for growth since, unlike most pathogens, they actively grow in refrigerated
conditions, although relatively slowly. Many processors will either include an anti-
microbial to restrict growth of these organisms or limit the shelf-life of the food so
these organisms cannot grow to sufficient populations to cause illness.
Mesophiles grow well between 68 °F (20 °C) and 113 °F (45 °C) with optima
between 86 °F (30 °C) and 104 °F (40 °C) [4]. Bacterial foodborne pathogens that
are not psychrotrophs are considered mesophiles. As previously mentioned, given
that most of the organisms that make people ill, do so through an infection once
consumed, they must thrive well in the range of body temperature. As shown in
Table 1.3, examples of organisms in this category include Campylobacter,
Escherichia coli, Salmonella spp., Staphylococcus aureus, and Vibrio spp. Many
times, refrigerated or frozen temperatures are selected to store foods to restrict the
growth of mesophiles. Examples would be raw beef and chicken which can readily
be contaminated with foodborne pathogens such as Salmonella. Refrigerated
storage will restrict the growth of this organism, although it will not inactivate it,
which only occurs when the food is properly cooked.
Thermophiles are the last group and include only spoilage organisms.
Thermophiles grow at or above 113 °F (45 °C) with a preferred range of 131–149 °F
(55–65 °C) [4]. With respect to foods, these organisms cause spoilage of thermally
processed canned foods held at high storage temperatures. These organisms natu-
rally survive the thermal process these products receive and can grow if stored at
temperatures in excess of 100 °F (37.7 °C), which can easily occur with outdoor
storage during the summer in certain areas.
6 F.J. Critzer
Table 1.3 Minimum, optimum and maximum temperatures which will support the growth of
foodborne pathogens [6]
Minimum Optimum °F Maximum
Organism Temperature classification °F (°C) (°C) °F (°C)
Bacillus cereus Psychrotroph/Mesophile 41 (5) 82–104 131 (55)
(28–40)
Campylobacter spp. Mesophile 90 (32) 108–113 113 (45)
(42–45)
Clostridium botulinum Mesophile 50–54 86–104 122 (50)
types A and B (10–12) (30–40)
Clostridium botulinum Psychrotroph/Mesophile 37–38 77–99 (25–37) 113 (45)
type E (3–3.3)
Escherichia coli Mesophile 45 (7) 95–104 115 (46)
(35–40)
Listeria Psychrotroph/Mesophile 32 (0) 86–99 (30–37) 113 (45)
monocytogenes
Salmonella spp. Mesophile 41 (5) 95–99 (35–37) 113–117
(45–47)
Staphylococcus aureus Mesophile 50 (10) 104–113 115 (46)
(40–45)
Shigella spp. Mesophile 45 (7) 99 (37) 113–117
(45–47)
Vibrio Psychrotroph/Mesophile 41 (5) 99 (37) 109 (43)
parahaemolyticus
Yersinia enterocolitica Psychrotroph 30 (−1) 82–86 (28–30) 108 (42)
pH
pH is the measurement of acidity or alkalinity of a food. It uses a common scale

from 0 to 14, with seven considered to be neutral. Bacteria are similar to most living
organisms, in that they prefer a pH around neutrality, with very few growing below
4.0. Minimum pH growth ranges for some foodborne pathogens are shown in
Fig. 1.1. While a more neutral pH will allow for faster growth, many foodborne
pathogens are capable of growing from 5.0 to 4.0. Spoilage organisms, especially
yeast and molds, will be able to grow at even lower pH levels, which is one factor
that plays into their ability to act in this role since they can grow in acidic conditions
when other competitive microflora cannot.
Of the foods presented in Table 1.4, it can be seen that fruits and some vegeta-
bles, such as tomatoes, have natural pH values below that which foodborne patho-
gens will grow. It should be noted that with every generality there are outliers. Such
is the case with melons, which have less acidic pH and will permit the growth of
bacteria, including foodborne pathogens. Most of the meats and seafoods have a pH
of 5.5 and greater, and as such, pH does not act as a barrier to bacterial growth in
these products.
Clostridium perfringens
Bacillus cereus
Vibrio parahaemolyticus
Shigella flexneri
Clostridum botulinum
Shigella sonnei
Escherichia coli O157:H7
Yersinia enterocolitica
Listeria monocytogenes
Salmonella spp.
Staphylococcus aureus
3 3.5 4 4.5 5 5.5 6
Fig. 1.1 Minimum pH growth ranges for some foodborne pathogens
While some foods are categorized by a natural pH, others have been produced in
a manner to achieve a lower pH to help preserve them through inhibition of spoilage
and, as an added benefit, pathogenic microorganisms. Fermented products such as
kombucha, sauerkraut, kimchi, yogurt, and pickles fall within this category. Organic
acids are produced as a by-product of fermentation resulting in a lower overall pH
upon completion of fermentation. Other foods are simply mixed with food grade
acids, such as acetic acid found in vinegar, to create a quick processed, shelf-stable
product. Examples of these foods include salsas, non-fermented pickles and
relishes.
Moisture Content
Removal of moisture is one of the oldest methods of preparing shelf-stable foods.

Examples of products sold at the farmers market that rely upon low moisture con-
tent as their primary means for preservation include breads, beef jerky, dried pep-
pers, dried herbs, and sun-dried tomatoes. Drying of foods helps preserve them
through removal of water. When available water is limited, microorganisms such as
bacteria, yeast and molds either do not grow or grow very slowly. Food scientists
use an uncommon term to the general public to describe the amount of unbound
water available for microbial growth known as water activity (aw). Water activity is
technically defined as the ratio of the water vapor pressure of food substrate to the
vapor pressure of pure water at the same temperature: aw = p/p0, where p is the vapor
pressure of the solution and p0 is the vapor pressure of the solvent (usually water).
8 F.J. Critzer
Table 1.4 Representative pH values of some foods grouped by commodity [4]

Food pH Food pH
Vegetables Fruits (cont’d)
Asparagus (buds and stalks) 5.7–6.1 Limes 1.8–2.0
Beans (string and Lima) 4.6–6.5 Honeydew 6.3–6.7
Beets (sugar) 4.2–4.4 Oranges 3.6–4.3
Broccoli 6.5 Plums 2.8–4.6
Brussels sprouts 6.3 Watermelons 5.2–5.6
Cabbage (green) 5.4–6.0 Dairy products
Carrots 4.9–5.2; 6.0 Butter 6.1–6.4
Cauliflower 5.6 Buttermilk 4.5
Celery 5.7–6.0 Milk 6.3–6.5
Corn (sweet) 7.3 Cream 6.5
Cucumbers 3.8 Cheese (American mild and cheddar) 4.9; 5.9
Eggplant 4.5
Lettuce 6.0 Meat and poultry
Onions (red) 5.3–5.8 Beef (ground) 5.1–6.2
Parsley 5.7–6.0 Ham 5.9–6.1
Parsnip 5.3 Veal 6.0
Potatoes (tubers and sweet) 5.3–5.6 Chicken 6.2–6.4
Pumpkin 4.8–5.2 Liver 6.0-6.4
Rhubarb 3.1–3.4 Fish and shellfish
Rutabaga 6.3 Fish (most species) 6.6–6.8
Spinach 5.5–6.0 Clams 6.5
Squash 5.0–5.4 Crabs 7.0
Tomatoes 4.2–4.3 Oysters 4.8–6.3
Turnips 5.2–5.5 Tuna fish 5.2–6.1
Fruits Shrimp 6.8–7.0
Apples 2.9–3.3 Salmon 6.1–6.3
Apple cider 3.6–3.8 White fish 5.5
Apple juice 3.3–4.1 Meat and poultry
Bananas 4.5–4.7 Beef (ground) 5.1–6.2
Figs 4.6 Ham 5.9–6.1
Grapefruit 3.0 Veal 6.0
Grapes 3.4–4.5 Chicken 6.2–6.4
Liver 6.0-6.4
Pure water has an aw of 1.00, and a saturated solution of table salt has an aw of
0.75. The aw of most fresh foods is above 0.99. The minimum aw values reported for
the growth of some microorganisms as well as the average aw of some foods are
shown in Table 1.5. Spoilage yeast and molds can grow at the lowest aw, followed by
bacteria, again giving them added leverage in spoilage of food preserved by this
method. Among the foodborne pathogens shown in Table 1.5, Staphylococcus
Table 1.5 Minimum water activity (aw) values that will allow for growth of microorganisms and
approximate aw values for foods [4, 6, 7]
Organisms aw Food aw
Groups Fresh fruits, vegetables 0.97–1.00
Most spoilage bacteria 0.90 Fresh meat, poultry, fish 0.99–1.00
Most spoilage yeasts 0.88 Eggs 0.97
Most spoilage molds 0.80 Bread 0.96
Cheeses 0.95–1.00
Specific organisms Cured meat 0.87–0.95
Clostridium botulinum, type E 0.97 Maple syrup 0.85
Enterohemorrhagic Escherichia coli 0.95 Jellies 0.82–0.94
Salmonella spp. 0.94 Jam 0.80–0.91
Vibrio parahaemolyticus 0.94 Honey 0.75
Clostridium botulinum, types A and B 0.93 Dried fruit 0.60–0.75
Listeria monocytogenes 0.92 Bread crust 0.30
Staphylococcus aureus toxin formation 0.88 Crackers 0.10
Staphylococcus aureus growth 0.83
aureus can grow at an aw as low as 0.83, but will only produce toxin, which causes
people to become ill if the aw is at or above 0.88. This is the lowest aw value for
growth of all pathogenic organisms, and for this reason, if dehydration will be the
only factor used to make a food shelf-stable, then regulatory guidelines have
required the foods’ aw to be at or below 0.85 [5].
It should be understood that while these higher aw values must be achieved for
the organism to grow, many foodborne pathogens have caused illness when con-
sumed in dry foods with aw values that will not allow for growth. Examples of this
include illnesses from dried herbs, nuts, and flour. While these foodborne pathogens
cannot multiply in the foods, certain pathogens can survive for long periods of time
and can make others ill if not inactivated through a processing step, such as cooking.
This is why it is very important to source these dried ingredients from reputable
suppliers and always hold dried foods and ingredients so they cannot become
contaminated.
Additionally, many foods may rely upon more than one factor to control for the
growth of microorganisms. This is referred to as “hurdle technology.” For instance,
jams and jellies rely on not only the aw of these products, but also a reduced pH and
thermal processing to establish the structure of the products and to eliminate spoil-
age organisms like molds and yeasts. Very rarely does a single parameter dictate
safety, but rather the collective profile of the food. However, understanding the rela-
tionships between individual criteria, such as aw, can greatly help with the under-
standing of why certain criteria are important to the overall safety of a product. As
an example, uncontrolled drying in a jerky product could result in too high an aw
resulting in an unsafe food that may support the growth of a foodborne pathogen.
10 F.J. Critzer
Nutrient Content
Similar to humans, microorganisms must find a source of water, energy, nitrogen,

vitamins, and minerals. Water is essential to the growth of microorganisms since
metabolic activities occur in an aqueous system inside the organism. Controlling aw
will modulate the available water for microbial growth. Energy can be derived from
simple sugars, alcohols and amino acids. A relatively small number of foodborne
microorganisms are also able to degrade complex carbohydrates by digesting
starches and structural carbohydrates such as lignin and cellulose to simple sugars.
Amino acids from proteins are the primary source of nitrogen, with some microor-
ganisms also able to use nucleic acids. Similar to carbohydrate sources, a subset of
organisms are also able to digest long and short chain peptides for a nitrogen source.
Many organisms are able to synthesize all of the vitamins needed for metabolic
function. Those that are limited tend to be deficient with respect to one or more of
the vitamin B complexes, and have evolved with mechanisms to secure them from
the foods in which they grow. Calcium, iron, magnesium, manganese, sulfur, phos-
phorus, and potassium are the primary minerals that microorganisms will source
from foods that they grow upon. Relatively small amounts of these minerals are
required, and some are only required for specific functions rather than growth in
general.
While most foods will fulfill the requirements as a substrate for microbial growth
given that humans consume them for the same nutritional reasons, it is important to
consider adequately removing the nutrient source when cleaning equipment and
utensils. Without rigorous cleaning and sanitizing practices, food particulates may
remain on equipment and support the growth of microorganisms when not in use.
These microorganisms can grow to high numbers if other conditions support growth
and act as contaminants when food is prepared subsequently using the equipment or
utensils are next used.
Summary
An understanding of the organisms that cause foodborne illness is very helpful

when trying to understand the role that food safety best practices play in the foods
sold at farmers markets. Ultimately, control strategies are used to inactivate food-
borne pathogens if present, restrict them from contaminating a food, and inhibit
their growth if they are present. Knowledge of the sources from the environment
that may contribute to foodborne pathogen contamination along with the mecha-
nisms that can inhibit bacterial foodborne pathogens from growing in foods can lead
to a very good basic understanding of the rationale behind various rules and science-
based recommendations used when growing, harvesting and further processing
foods.
References
1. Bellemare MF, King RP, Nguyen N (2015) Farmers’ markets and food-borne illness.
University of Minnesota. http://marcfbellemare.com/wordpress/wp-content/uploads/2015/07/
BellemareKingNguyenFarmersMarketsJuly2015.pdf. Accessed 4 Jan 2017
2. Scallan E, Hoekstra RM, Angulo FJ, Tauxe RV, Widdowson MA, Roy SL et al (2011)
Foodborne illness acquired in the united states-major pathogens. Emerg Infect Dis 17(1):7–15
3. Kubota K, Kasuga F, Iwasaki E, Inagaki S, Sakurai Y, Komatsu M et al (2011) Estimating the
burden of acute gastroenteritis and foodborne illness caused by Campylobacter, Salmonella,
and Vibrio parahaemolyticus by using population-based telephone survey data, Miyagi
Prefecture, Japan, 2005 to 2006. J Food Prot 74(10):1592–1598
4. Jay JM, Loessner MJ, Golden DA (2005) Modern food microbiology, 7th edn. Springer,
New York
5. Acidified Foods (1979) Final rule. Fed Regist 44:16235
6. ICMSF (1996) In: Roberts TA, Baird-Parker AC, Tompkin RB (eds) Microorganisms in foods.
Blackie Academic & Professional, London, p 513
7. IFT (2001) Evaluation and definition of potentially hazardous foods. US-FDA. [cited
2016 Dec 29]. Available from: https://www.fda.gov/Food/FoodScienceResearch/
SafePracticesforFoodProcesses/ucm094145.htm
Chapter 2
Food Safety Hazards Identified on Small Farms
Judy A. Harrison
Abstract Farmers markets have increased in number in the U.S. by almost 400%
since the early 1990s. Customers shop at these markets to get to know the farmers
who are producing their food, and to purchase products they view as more nutri-
tious, better tasting, higher quality, better for the environment and safer than foods
from larger, commercial farms being sold in supermarkets. Yet studies in the U.S.
and in other countries have identified food safety hazards on farms and in farmers
markets that may increase the risk of foodborne illnesses. Risky practices on farms
include the use of raw manure without appropriate waiting periods observed
between application and harvest, use of untested well or surface water for irrigation
and/or washing of produce, lack of sanitary facilities and handwashing facilities for
workers, lack of training for workers, food contact surfaces not properly cleaned
and sanitized and lack of temperature control both on the farm and during transport
to market. Hazards have also been identified with livestock and poultry products
such as lack of sanitation and temperature control. A lack of sanitation practices and
microbial problems associated with the use of raw milk have been identified as haz-
ards on farms making and selling artisanal cheeses.
Keywords Farm food safety • Farmers market food safety • Food safety risks
• Food safety hazards
The numbers of farmers markets have increased in the U.S. by almost 400% since
the early 1990s signifying the increasing popularity of the local food movement
(Fig. 2.1). This increase in visibility and popularity has been fueled by campaigns
such as Know Your Farmer, Know Your Food and The People’s Garden [1].
Several studies have examined the reasons why consumers shop at farmers mar-
kets. Reasons include beliefs that purchasing from the farmers market supports
J.A. Harrison (*)

Department of Foods and Nutrition, University of Georgia,
204 Hoke Smith Annex, Athens, GA 30602, USA
e-mail: judyh@uga.edu
© Springer International Publishing AG 2017 13

J.A. Harrison (ed.), Food Safety for Farmers Markets: A Guide to Enhancing
Safety of Local Foods, Food Microbiology and Food Safety,
DOI 10.1007/978-3-319-66689-1_2
14 J.A. Harrison
Fig. 2.1 National count of farmers market directory listings. Reprinted from http://www.ams.
usda.gov, by AMS-USDA, Transportation and Marketing Program, Local Food Research and
Development Division. Available from:https://www.ams.usda.gov/sites/default/files/media/
National%20Count%20of%20Operating%20Farmers%20Markets%201994-2016.jpg
local farmers and is better for the environment, the food is fresher with better quality
and flavor, the food is a better value for the money, the food is more likely to be
grown locally and is more traceable than products from the grocery store, and the
food is safer when produced locally [2–4].
In 2008, 81% of farms selling locally were small farms with less than
$50,000 in gross sales, and 14% were medium sized farms selling between
$50,000 and $250,000 in gross sales [5]. Studies have shown that often farmers
selling at farmers markets are relatively new to farming and have less experience
than those on larger, more established farms [6, 7]. According to Martinez et al.
[8], the 2007 U.S. Census of Agriculture indicated that farmers selling directly to
consumers had four years less experience than those not marketing directly to
consumers, and 40% were beginning farmers with less than 10 years of experi-
ence. The 2012 U.S. Census of Agriculture identified little change in most cate-
gories compared to the 2007 census [9]. Harrison et al found that out of 328
participants in small farm produce safety trainings in Georgia, South Carolina
and Virginia during the period from 2011 to 2013, 43% indicated farming for less
than 3 years, 20% from 4 to 9 years and 36% for 10 or more years. Of those par-
ticipants, 34% used organic methods, 29% used conventional methods and 37%
used both organic and conventional farming methods [10]. Laury-Shaw et al.
2 Food Safety Hazards Identified on Small Farms 15
noted that prior to an initial food safety training, less than 10% of participants
had food safety plans that included written policies regarding worker attire;
worker behaviors involving eating, drinking or smoking while working with
products and handling during transportation [7]. Parker et al. [11] stated that
there is little knowledge of how food safety is handled on small and medium
farms, even though a study 6 years earlier in 2006 by Simonne et al. found that
out of 47 farmers market vendors, 50% thought food safety was very important
and were very confident of their food safety practices, but only 32% had com-
pleted any type of food safety training [12]. The study by Parker et al. about food
safety concerns among growers found that regardless of the size of farm, growers
were most concerned about consumer behavior and health and hygiene of work-
ers [11]. Other lesser concerns for large growers included sanitation of facilities
and equipment, wildlife fecal contamination and quality of water for irrigating
and washing produce. Lesser concerns for medium growers were similar with
these growers including pesticide application and soil amendments as well.
Small growers in the study included the presence of wildlife feces and pesticide
drift as concerns, but only a few small growers (≤18) included concern over sani-
tation of facilities and equipment, manure use and water quality even though
these issues are of concern to food safety experts and are addressed as part of
good agricultural practices.
Although these studies indicate some level of awareness among local food pro-
ducers of potential issues and conditions that could affect the safety of produce
grown on small to medium farms and sold in farmers markets, a multi-state survey
identified growing and handling practices on small to medium sized farms that could
put consumers at risk for foodborne illnesses [6]. Out of 226 farmers responding to
a survey, 128 (57%) used manure with 18% of those using a mixture of raw and
composted manure (including one report of using humanure, human manure from a
composting toilet). Almost 15% of manure users applied manure to fields more than
twice a year, raising concerns that the recommended 90 day and 120 day waiting
periods between application of raw manure and harvest for crops that do not touch
the soil and crops that touch the soil, respectively, that are recommended in the
National Organic Program are not being met [13]. Although most growers used
tested water sources for irrigation, 30.5 % of respondents used untested well water
or rainwater and surface water from streams or ponds, for irrigation which has the
potential for microbial contamination. In terms of worker hygiene, approximately
66% of respondents reported having sanitary facilities and handwashing facilities
available near fields and packing sheds. Yet the lack of facilities at many farms makes
hand hygiene questionable and raises concern about potential contamination. Fifty
percent of the operations indicated that crops are harvested with bare hands. Only
41% of the farmers indicated they had offered sanitation training to their workers [6].
Harrison et al. also identified post-harvest handling practices that could increase
a consumer’s risk for foodborne illness [6]. Approximately 16% of the farmers who
responded used untested well water, surface water (such as ponds, streams or
springs) and rainwater for washing produce after harvest. Only 39% of respondents
sanitized surfaces that come in contact with produce at the farm, and only 33%
16 J.A. Harrison
Fig. 2.2 Model of Food Safety on the farm showing areas where best practices must be imple-
mented for production of safe produce destined for farmers markets. Reprinted from Enhancing
the Safety of Locally Grown Produce—On the Farm. Harrison JA. 2012. University of Georgia
Cooperative Extension Publication #FDNS-E-168-2
always cleaned containers used to transport produce to market between uses.

Cooling of produce on the farm or during transport was also lacking with 18.1%
reporting no cooling methods used on the farm and 35% rarely or never cooling
produce during transport to market. These findings indicate the potential for food
safety hazards associated with growing, harvesting and post-harvest handling of
produce destined for the farmers market and other direct-to-consumer outlets. Based
on these findings, a model illustrating areas where best practices must be used to
enhance produce safety has been developed and is presented in Fig. 2.2. An assess-
ment tool is presented in Fig. 2.3 for use on small farms selling direct market pro-
duce. A detailed description of best practices to control food safety hazards for
produce grower/vendors is presented in Chap. 4.
Although produce farms accounted for more than half of direct sales to con-
sumers in the 2007 U.S. Census of Agriculture, 7% of livestock producers also
sold directly to consumers with beef, poultry, dairy and eggs accounting for the
highest percentages of products sold [8]. According to Painter et al., meat and
poultry (beef, game, pork and poultry), accounted for fewer illnesses than pro-
duce in the period from 1998 to 2008 but accounted for a higher percentage of
deaths due to foodborne illness (29% versus 23%) [14]. While the debate contin-
ues over issues related to animal welfare, use of antimicrobials, etc. and the
safety of meat products from “industrial farm animal production” systems ver-
sus small-farm production, foodborne illness can be associated with either sys-
tem [15]. In 2010, the number of slaughter facilities in the U.S. had decreased
Fig. 2.3 Enhancing the safety of locally grown produce—farm self-help form. Courtesy of Judy
Harrison. University of Georgia Publication #FDNS-E-168-1
from over 1200 in the 1990s to around 800 with the consolidation of the meat
industry [16]. This closure of many facilities has made it necessary for livestock
producers wanting to sell products to seek alternative methods of slaughter and
packing, either small state inspected facilities willing to serve small businesses
or using the services of mobile abattoirs [17]. Regardless of the situation or
18 J.A. Harrison
My workers have access to toilet facilities within a short walking distance of my packing areas.
contamination for produce.
Toilet facilities are serviced and cleaned on a regular schedule.
Handwashing facilities are cleaned and stocked with clean water, soap and paper towels on a regular schedule.
Harvesting equipment (knives, pruners, machetes, etc.) is kept reasonably clean and is sanitized on a regular basis.
Harvesting containers and hauling equipment are cleaned and/or sanitized between uses.
Surfaces that come in contact with fruits and vegetables at my farm are cleaned and sanitized regularly.
Damaged containers are properly repaired or discarded.
Any cardboard boxes used are new and only used once.
Produce is handled carefully and packed securely to prevent bruising and injury.
I cool fruits and vegetables after harvest.
Produce is kept cool during transport to market.
Containers used with fruits and vegetables are cleaned and sanitized between each use.
The vehicle is NOT used to transport animals, raw manure, chemicals or any other potential contaminant.
The vehicle used to transport fruits and vegetables is cleaned frequently.
If you answered “no” to any of the questions, those questions represent areas where changes or
commitment to food safety and reduce potential risk of foodborne illness. Please read the Enhancing
the Safety of Locally Grown Produce factsheets for your risk area to learn how to minimize risk.
This project was supported all, or in part, by a grant from the National Institute of Food and Agriculture, United States Department of Agriculture (Award Number 2009-51110-20161).
Publication #FDNS-E-168-1. J.A. Harrison, J.W. Gaskin, M.A. Harrison, J. Cannon, R. Boyer and G. Zehnder. February 2012
The University of Georgia and Ft. Valley State University, the U.S. Department of Agriculture and counties of the state cooperating. Cooperative Extension, the University of Georgia Colleges of Agricultural and Environmental Sciences and Family and Consumer
Sciences, offers educational programs, assistance and materials to all people without regard to race, color, national origin, age, gender or disability. An Equal Opportunity Employer/Affirmative Action Organization, Committed to a Diverse Work Force.
Fig. 2.3 (Continued)
method used, adherence to strict sanitation practices, cooling practices and

time-temperature control would be essential to minimize foodborne illness risks.
USDA’s Food Safety and Inspection Service provides guidance documents for
mobile processing units [18].
A study of poultry products sold at farmers markets versus those conventionally
processed and sold at supermarkets in Pennsylvania identified significantly higher
levels of generic E. coli, total coliforms, Salmonella spp. and Campylobacter spp.
in whole chicken sold at farmers markets [19]. This study found increased risk of
food safety hazards associated with poultry sold in farmers markets. A detailed
description of food safety considerations for meat and poultry vendors at farmers
markets is presented in Chap. 5.
In addition to meat and poultry, dairy products are also produced on small farms
and sold at farmers markets. Although some states prohibit the sale of raw milk,
other states allow the sale which can also increase food safety risks for consumers
when sold through farm stands or farmers markets. Raw milk has a historic associa-
tion with foodborne illness due to the presence of foodborne pathogens. Painter
et al. noted a higher incidence of Campylobacter associated with raw milk [14].
From 2007 to 2012, 26 states reported 81 outbreaks to the Centers for Disease
Control and Prevention (CDC) caused by raw milk, an increase from 30 outbreaks
from 2007 to 2009 to 51 outbreaks between 2010 and 2012 [20]. The hazards asso-
ciated with raw milk outbreaks in this report were Campylobacter (81% of out-
breaks), shiga toxin-producing E. coli (17% of outbreaks) and Salmonella (3% of
outbreaks). However, outbreaks have included a multistate outbreak of listeriosis
linked to raw milk from an organic producer in Pennsylvania [21].
Many small dairy farms also make and sell artisan cheeses at farmers markets
and other venues. In addition to risks from environmental conditions and sanitation
issues on farms, some farmstead cheesemakers use raw milk as an ingredient and
rely on proper aging to eliminate pathogens [22]. Outbreaks of foodborne illnesses
linked to raw milk and raw milk cheeses have raised concerns about the safety of
these products. Regulations for the production of raw milk cheeses require that
cheeses be aged for not less than 60 days at a temperature of not less than 35 °F
(2 °C) [23]. However, studies of artisan and farmstead cheesemakers historically
have identified varying levels of risk associated with these products. In a study of 11
cheesemaking facilities, D’Amico et al. reported that 8 of the 11 facilities (73%)
had milk samples that tested positive for Staphylococcus aureus (46 of 133 samples
or 34.6 %), three milk samples (2.3%) tested positive for Listeria monocytogenes
and one for Escherichia coli O157:H7 [24]. Salmonella was not found in any of the
samples [24]. Another study by D’Amico et al. indicated that if contamination with
L. monocytogenes occurs during the post-processing period of soft, mold-ripened
cheeses, the 60-day aging period may not be adequate to ensure safety [25].
Machado et al. [22] reported that observations of five farmstead cheesemaking facil-
ities in Pennsylvania and survey responses of state inspectors indicated that improve-
ments were needed in basic sanitation, although cheesemakers had rated their
knowledge of food safety, their attitudes toward food safety and their handling prac-
tices as good to very good. Outbreaks of illness have been associated with farmstead
cheesemaking facilities. Evidence prompted a recall of 14 cheese varieties poten-
tially linked to a Salmonella outbreak that sickened 100 people in 2016 from a
farmstead creamery in North Carolina which had sold cheese through retail loca-
tions, farmers markets and restaurants throughout North Carolina, Tennessee, South
Carolina, Virginia and Georgia [26].
20 J.A. Harrison
Safety of food in farmers markets, as well as any other venues where food is sold,
requires strict attention to good agricultural practices, good manufacturing practices
and proper sanitation on farms where the food is produced. Improper handling on the
farm can lead to increased risk of foodborne illnesses from farmers markets.
Summary
Studies have identified the potential for food safety hazards to exist on small farms
selling products directly to consumers through farmers markets and other venues.
Self-reported data as well as direct observations have noted problems with hand
hygiene, sanitation and temperature control on farms. These conditions could lead
to an increased risk of contamination of products and foodborne illnesses among
consumers.
References
1. U.S. Dept. of Agriculture, Center for Nutrition Policy and Promotion. Know your farmer,
know your food – growing a healthier you [cited 2017 Apr 6]. Available from: https://www.
cnpp.usda.gov/KnowYourFarmer
2. Worsfold D, Worsfold PM, Griffith CJ (2004) An assessment of food hygiene and safety at
farmers’ markets. Int J Environ Health Res 14(2):109–119
3. Crandall PG, Friedly EC, Patton M, O’Bryan CA, Gurubaramurugeshan A, Seideman S, Ricke
SC, Rainey R (2011) Consumer awareness of and concerns about food safety at three Arkansas
farmers’ markets. Food Prot Trends 31(3):156–165
4. Wolf MM, Spittler A, Ahern J (2005) A profile of farmers’ market consumers and the per-
ceived advantages of produce sold at farmers’ markets. J Food Distrib Res 36(1):192–201
5. Low SA, Vogel S (2011) Direct and intermediated marketing of local foods in the United
States, ERR-128, U.S. Department of Agriculture, Economic Research Service. Nov [cited
2016 Sept 16]. Available from: https://www.ers.usda.gov/webdocs/publications/err128/8276_
err128_2_.pdf
6. Harrison JA, Gaskin JW, Harrison MA, Cannon JL, Boyer RR, Zehnder GW (2013) Survey
of food safety practices on small to medium-sized farms and in farmers’ markets. J Food Prot
76(11):1989–1993
7. Laury-Shaw A, Strohbehn C, Naeve L, Wilson L, Domoto P (2015) Current trends in food
safety practices for small-scale growers in the midwest. Food Prot Trends 35(6):461–469
8. Martinez S, Hand M, DaPra M, Pollack S, Ralston K, Smith T, Vogel S, Clark S, Lohr L, Low
L, Newman C (2010) Local foods systems: concepts, impacts and issues. USDA ERS Report
No. 97 [cited 2016 Aug 26]. Available from: https://ideas.repec.org/p/pra/mprapa/24313.html
9. U.S. Department of Agriculture National Agricultural Statistics Service (2012) Census of
agriculture. 2014 Aug [cited 2016 Aug 26]. Available from: https://www.agcensus.usda.gov/
Publications/2012/Full_Report/Volume_1,_Chapter_1_US/usv1.pdf
10. Harrison JA, Gaskin JW, Harrison MA, Cannon JL, Boyer RR, Zehnder GW (2013) Enhancing
the safety of locally grown produce through extension education for farmers and market man-
agers [abstract]. J Food Prot 76(Suppl A):P1–87
11. Parker JS, Wilson RS, LeJeune JT, Doohan D (2012) Including growers in the “food safety”
conversation: enhancing the design and implementation of food safety programming based
on farm and marketing needs of fresh fruit and vegetable producers. Agric Hum Values
29:303–319
12. Simonne A, Swisher M, Saunders-Ferguson K (2006) Food safety practices of vendors at
farmers’ markets in Florida. Food Prot Trends 26(6):386–392
13. Code of Federal Regulations (2017) National Organic Program, Title 7, Subtitle B, Chapter 1,
Subchapter M, Part 205, Section 205.203
14. Painter JA, Hoekstra RM, Ayers T, Tauxe RV, Braden CR, Angulo FJ, Griffin PM (2013)
Attribution of foodborne illnesses, hospitalizations, and deaths to food commodities by using
outbreak data, United States, 1998–2008. Emerg Infect Dis 19(3):407–415
15. Rossi J, Garner SA (2014) Industrial farm animal production: a comprehensive moral critique.
J Agric Environ Ethics 27:479–522
16. Johnson RJ, Marti DL, Gwin L (2012) Slaughter and processing options and issues for locally
sourced meat. USDA ERS Report No. LDP-M-216-01. June [cited 2016 Sept 16]. Available
from: https://www.ers.usda.gov/publications/pub-details/?pubid=37460
17. Thompson S (2010) Going mobile – co-ops operate traveling slaughter units to help grow local
foods movement. USDA Rural Development. Rural Cooperatives 77(6):4–7. Available from:
http://www.rd.usda.gov/files/CoopMag-nov10.pdf
18. U. S. Department of Agriculture Food Safety and Inspection Service (2010). Mobile Slaughter
Unit Compliance Guide [cited 2016 Sept 16]. Available from: https://www.fsis.usda.gov/
shared/PDF/Compliance_Guide_Mobile_Slaughter.pdf
19. Scheinberg J, Doores S, Cutter CN (2013) A microbiological comparison of poultry products
obtained from farmers’ markets and supermarkets in Pennsylvania. J Food Saf 33:259–264
20. Mungai EA, Behravesh CB, Gould LH (2015) Increased outbreaks associated with nonpas-
teurized milk, United States, 2007–2012. Emerg Infect Dis 21(1):119–122
21. Centers for Disease Control and Prevention (2016) Multistate outbreak of listeriosis linked to
raw milk produced by Miller’s Organic Farm in Pennsylvania (Final Update) [cited 2016 Dec
28]. Available from: http://www.cdc.gov/listeria/outbreaks/raw-milk-03-16/index.html
22. Machado RAM, Radhakrishna R, Cutter CN (2017) Food safety of farmstead cheese proces-
sors in Pennsylvania: an initial needs assessment. Food Prot Trends 37(2):88–98
23. Code of Federal Regulations (2017) Cheese from unpasteurized milk, Title 7, Subtitle B,
Chapter 1, Subchapter C, Part 58, Subpart B, Section 58.439
24. D’Amico D, Groves E, Donnelly CW (2008) Low incidence of foodborne pathogens of con-
cern in raw milk utilized for farmstead cheese production. J Food Prot 71(8):1580–1589
25. D’Amico D, Druart M, Donnelly CW (2008) 60-Day aging requirement does not ensure
the safety of surface-mold-ripened soft cheeses manufactured from raw or pasteurized milk
when Listeria monocytogenes is introduced as a post-processing contaminant. J Food Prot
71(8):1563–1571
26. U. S. Food and Drug Administration (2016) Chapel Hill creamery recalls cheese products
because of possible health risk [cited 2016 Dec 28]. Available from: https://www.fda.gov/
Safety/Recalls/ucm513946.htm
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of view of the statistical bureaucrat, cancer is increasing. That is to
say, an increasing number of deaths, and an increasing proportion of
deaths, are every year presented to him, both absolutely and in
relation to the population. And so many more perforated cards are in
consequence manipulated by his counting machine.
Can it be said that, for any one reader of these pages, the
chances of death from cancer are year by year increasing, as are the
chances of being run over in the London streets? Who can say?
But this is true. We must all die. We are, for the most part, anxious
to postpone the day of death, and many of us dread, more than
aught else, a death from cancer.
Effort in the path of right living—if steadily pursued—and the
intelligent utilization of what Science and Art and Experience have to
teach, will undoubtedly make for healthier and longer lived
communities, and will lessen, for each individual, the probability of
dying otherwise than in the fashion thought of by the doctor when he
ascribes death to “old age”. The problem we are considering
becomes indeed swallowed up by a still greater one; but, those who
profit by what Mr Wright has had to say about Cancer, will profit in
respect of this greater problem as well. Therein, so it seems, lies its
greatest value.
F. G. CROOKSHANK
London, 1925
THE CONQUEST OF CANCER
The cure of cancer is now ceasing to become a purely medical
problem, to be solved by biologists, pathologists and surgeons, and
is becoming a problem in psychology, and education, to be solved by
publicists, schoolmasters, and perhaps, when enough people are
alive to the facts of the situation, by legislators and statesmen.
This may sound a bold thing to say, but I hope to be able to bring
forward evidence proving that it is at present possible to cure
seventy-five per cent. of cancer cases with a mortality of under five
per cent.
Possibly the response to this essay will be that of one of the most
enlightened persons of my acquaintance who, on seeing my title,
said, “Of course this is perfectly absurd”, but it was a favourite saying
of Dr Maguire, a great American surgeon of the nineteenth century,
that the most useful thing one man can do for his fellows is to see a
thing clearly, and to say it plainly.
Here is a plain statement, susceptible of the fullest proof. Out of
every hundred people in our community, ten will in all probability die
of cancer; and, of those ten, seven or eight could be cured, or their
disease prevented with the present methods at our disposal. All that
is required is an intelligent facing of the facts concerning this
disease, and efficient medical attention.
The average annual deaths during the last eleven years in the
United Kingdom were 466,000,—nearly half a million people. Of
these, 43,000 were due to cancer; 19,000 males and 24,000
females. Moreover, although taken altogether ten per cent. of the
population die of cancer, a greater proportion of adults so die. I say
again that a large proportion of these cases is either preventable or
curable.
The Executive Committee of the British Empire Cancer Campaign
have recently published a statement based on the last census. They
say that, during the year 1921, in Great Britain, of persons over 30
years of age, one out of every seven died of cancer.
These figures make it plain that the question is not merely one of
interest to doctors and scientists; it is of concern to every one of us,
and to one person in every ten it has direct and very personal
interest.
Surgery and medicine have very little further to advance along
technical lines, so far as the type of case we see at present is
concerned. It is nearly impossible to make operations more
extensive and thorough than they are at present; and it is unlikely
that the operative mortality in the average good risk will fall much
lower than its present very small figure. Other methods of curing
cancer do not at the moment show promise of producing anything so
good as the present surgical results. We have therefore to resort to
an educational campaign for its victims before we can get much
further on.
This brings me to the first point to be brought home before any
more is said—that early cancer and late cancer are, so far as results
and cures are concerned, two entirely different diseases. A well-
known English authority, speaking of cancer of the tongue, says: “An
early superficial cancer on the free part of the tongue should be, and
is, curable in practically all cases. The general conviction of the
incurability of cancer is founded on the results of operation on the
average fairly advanced case and, until this conviction is shaken, I
fear the public will remain relatively indifferent and pessimistic as to
the advantages of early treatment. Every surgeon of any experience
is aware that, as regards its accessibility to treatment, early cancer is
a totally different disease from even moderately advanced cancer,
but I am very doubtful as to whether we shall be able to enforce the
fact by direct statement so long as the treatment of advanced cases
furnishes the public with so many terrible object lessons in the
apparent intractability of the disease.”
The problem we have before us, then, is that of changing the
whole attitude, not only of the physician, but of the patient, to cancer.
Here is an example of the present point of view:—I have frequently
heard it said that such and such a patient has a lump, or some
disquieting symptom or other, but she won’t go to the doctor as she
is afraid he will say it is cancer. What we have to do is to strip this
disease of its fear-complex and bring all the facts about it into the
open. We have to change the attitude of the patient, and often,
unfortunately, of his doctor, from one of “wait and see” to one of “look
and see.” Then, and only then, shall we be on the way to curing
cancer.
The results of the present-day and popular point of view are
appalling. Somewhere about half the cases of cancer are far too
advanced for us to think about curing them at the time the patients
appear. Of the remaining half, approximately two-thirds have about a
thirty per cent. chance of cure, and the remainder about a sixty per
cent. chance. These figures are rough estimates based on
impressions formed in hospital out-patient work, but they will not be
found far wrong. The heart-breaking part of it is that it is all the result
of fear, carelessness and crooked thinking, which could be avoided
in a large percentage of the cases.
Yet there are signs that we are entering on a new phase, and that
a realisation of the importance of early diagnosis is slowly
permeating through the medical profession. In America we see an
increasing insistence on the use of detailed and specialised
laboratory methods for exact diagnosis; and in Great Britain there is
in existence, at St. Andrew’s University, a complete medical unit,
under the supervision of Sir James Mackenzie, for the investigation
of the early symptoms of disease. The establishment of this institute
is, I think, one of the most important advances that medicine has
made in the last twenty-five years, for it is a milestone on the road to
progress, a concrete and tangible expression of a changed point of
view.
Let us for the moment leave generalities and give some few
minutes to more detailed consideration of the disease; first in outline,
and then in respect of some particular cases.
Cancer is a degeneration. It most often occurs at that period of life
when our biological work is done, and, as far as Nature is
concerned, we are of no use. From her point of view we are on this
planet to reproduce our kind and, when we are past doing that, our
tissues begin to lose their firm hold on their appointed form, and
stray from their former habit of exactly reproducing their kind when
attempting to recover from any kind of injury. Cancer is commonest
in those organs which have soonest finished their work—the
reproductive organs of women; and, after these, it appears most
often in that organ so much more abused than any other—the
stomach.
The greatest number of cases appears at or after fifty, and
therefore at that age it behoves us, not to wait and see whether we
shall get it or not, but to look and see that we have not got it, for of
people who survive till the age of fifty, a great many more than ten
per cent. die of cancer.
From the biological point of view cancer presents another
interesting feature. It used to be generally stated by biologists that
acquired characteristics cannot be transmitted. In cancer we see a
cell taking on foreign characteristics in response to some
environmental stimulus and transmitting these to its offspring until
the organism from which it sprang is destroyed.
To sum up, the tissues from which cancer grows, in their normal
process of repair tend to reproduce themselves more or less exactly,
or if the injury is too gross, they are replaced by scar tissue; but
when we reach the age at which their biological work is done, there
is a tendency to atypical reproduction, in which an atypical cell
continues to reproduce itself atypically and grows at the expense of
the organism, eating into or eroding it as it enlarges, till it finally kills
the host on which it preys.
This will serve as a general definition, but, if we wish to be a little
more concrete, we must plunge for a while into the realms of
pathology, in order to get a clearer idea of what cancer means.
Our body is made up of three layers of tissues; each of these has
its separate function, and, within small limits, its own way of reacting
to long continued injury. Early in our prenatal development, these
three layers can be distinguished, and each of these later produces
its own type of tissue, and under appropriate conditions, its own type
of malignant tumour. From the outer and inner layers develop the
cells which actually touch the outside world, that is to say, which
cover the exterior of our body and provide our inner lining, or
mucous membranes. From the inner layer is developed glands which
are, so to speak, ingrowths from this layer, and it is the tumours
arising from this latter tissue layer which mostly concern us now, and
which are the cause of so much human suffering.
These Carcinomata, as they are called, all have something in
common, alike from the point of view of their recognition, pathology
and onset. They begin in some tissue which has previously been the
seat of disease, usually some chronic inflammatory process which
has been present for years, and which may have healed up and
broken down many times. When this occurs on open surfaces, such
as the tongue, intestinal mucous membrane, or lip, we can watch the
gradual transformation of the disease from a simple chronic
inflammatory process to that of a malignant growth.
Let us take, for instance, the case of cancer of the lip. We see an
old man who for years has been smoking a clay pipe. The stem of
the pipe gets shorter as the years go by, and consequently, as he
smokes it, hotter and hotter. One day he notices that his lip is
cracked, the crack being just on that part with which he habitually
holds his pipe. If we were to look at this under the microscope we
should just see that the mucous membrane was broken at this point.
Perhaps he stops smoking for a day or two till his lip has healed, and
then continues to smoke again. Soon, from force of habit, the pipe
returns to its old comfortable spot; and again the lip cracks. This time
it is not so painful, and takes longer to heal. This cracked lip may be
present for years, and if, after some time, we were to look at it again
under the microscope, we should see a very different kind of thing.
All round the crack would be congregated thousands of white blood
cells, trying vainly to assist the sore to heal, but, as well as this, we
should notice that, in their efforts to bridge the gap of broken mucous
membrane, the delicate epithelial cells which line our lips had
increased in number and thickness. We might also see that they had
a tendency to grow down to the deeper layers of the lip.
If we were to persuade our friend to give up his clay pipe and
indulge in some other form of smoking, or even to have a few teeth
extracted so that his pipe was more comfortable in some other
position, the small ulcer would, given time and a little attention, heal
up quite satisfactorily. But, with all the perversity of human nature, he
will not; he only has a small sore: it doesn’t hurt him, or anyone else,
so why should he worry?
We pass on another few years, and our friend reappears. This
time his sore has a more permanent appearance about it. It is hard,
and somehow looks as if it goes deep, and has a tendency to bleed.
We look at it and tell him that he ought to let us cut out that small
sore, but as a rule he won’t allow this procedure; he wants medicine
to take for it, an ointment to put on it. If we were again to have a
microscopical section at our disposal we should see a very different
state of things. Those epithelial cells which before were just
thickened, and a little angry looking, have at last wakened up and
begun to grow. They have branched out and grown deeper into the
lip; there is nothing to check them since they have thrown aside all
the restraints imposed by the necessity of keeping to their original
form, and have, so to speak, got out of the control of the usual
mechanisms which the body possesses for keeping cells in their
proper place. The only thing we can do for the patient is either to find
some means to kill them—an end which has not yet been achieved,
as what will kill them will also kill the patient—or to cut away the
tissue in which they have grown, leaving a wide margin around the
farthest palpable edge of the ulcer. If this is done, the patient can be
assured of a permanent cure. But if he will not believe you, as he
often will not, possibly because you are not willing to stake your
reputation on the ulcer being malignant, or the certainty of its cure by
surgery, he will go away for another year or so. One day he appears
again because his ulcer has been showing a tendency to bleed and
has got a bit bigger lately; also he has noticed, while shaving, a
small hard lump in his neck which he feels as the razor goes over it.
He still has no pain and no discomfort whatever. We look at this and
tell him that he has to undergo an operation, both on his lip and on
his neck, and that he has got cancer. We remove the ulcer and every
gland that we can find in a large area around, but we can only
assure him that he has a one in five or three chance of a permanent
cure whereas, if he had taken our previous advice, we could have
promised him a permanent cure in between ninety and one hundred
per cent. of chances, according to the age of the disease.
If we now use our microscope, we see that the undisciplined
epithelial cells have penetrated the lymphatic capillaries which are
present in all our tissues, and have followed them until they reach
their destination, the nearest glands. What will happen next depends
on time. The growth may spread to more glands, or even outside the
glands, and the only course we have open to us is to remove the
primary growth, again with a wide margin, irrespective of what
disfigurement may result, together with its corresponding lymphatic
glands, trusting to radium or X-rays to kill any stray cells that may be
set free or missed during the operation. The chances of cure simply
depend on whether it is possible to remove the disease completely
or not.
The figures I have given are taken from a recent analysis of more
than five hundred cases of cancer of the lip carefully followed up. Of
cases in which there were no glands involved, ninety-one per cent.
were cured: of those with glands only eighteen per cent. were cured.
Now here is the point I want to emphasize. The average duration of
all these cases was two and a half years before operation. It is
impossible to devise any more radical operation, with a much lower
death-rate than we at present obtain, and there is no other method
which as yet produces better results than I have just quoted, but it is
possible to do away with that two and a half years of waiting and
medicine. There is no reason for it but ignorance, neglect, stupidity,
self-deception and fear.
The example which I have just quoted is not an unusual one, nor,
as I hope to show you later on, do the figures materially differ for
cancer arising in other parts of the body. Cancer of the lip merely
happens to be a convenient, and easily understood, peg upon which
to hang my text.
Cancer is practically always preceded by chronic irritation of some
kind or other. There may be, and in fact are, other factors which
enter into the problem, but there can be no doubt that in nearly all
cases there is what may be called a precancerous stage, which, if
adequately dealt with, will often prevent cancer appearing at all. It is
moreover a longstanding chronic condition which, as a rule, gives
rise to very little inconvenience on the part of the patient.
After this precancerous stage there appears what may be called
early cancer, often indistinguishable to the naked eye from the
original precancerous lesion, but giving rise to great suspicion in the
eyes of the initiated on account of its hardness, and tendency to be
fixed, and its resistance to treatment. Cancer in this stage can be
cured, with results which will compare favourably with the cure of
any other known disease (i.e., in about ninety per cent. of all cases)
its cure simply depending on early diagnosis. This is a fact neither
known nor appreciated by the general public, and until it is known by
everybody, and these early stages are radically dealt with, we shall
still be spending our time and money looking for new and miraculous
cures for a condition which, in its very nature, is unlikely to be
susceptible to any method of cure when its late stages are reached.
The third stage is that in which the neighbouring lymph glands are
involved. In this stage about thirty per cent. are incurable, but these
figures are not of much help or comfort to any particular sufferer as
they depend on the degree of involvement and the rapidity of growth.
There is, in the vast majority of cases, no reason why it should ever
reach this stage other than those causes which are within the control
of the patient and his doctor.
Lastly we get to a stage in which the disease is frankly inoperable,
and generally speaking, only capable of relief by one palliative
measure or other. About forty to fifty per cent. of all cases which
reach the surgeon have already arrived at this stage, and it is to this
fact that the generally hopeless attitude of everybody is to be
attributed. It is only when this stage is reached that the patient has
pain and symptoms which “wake him up,” and that he realises the
calamity which has befallen him.
The early signs of cancer may now be summed up as those of a
lesion of some kind, extending over a number of years, giving rise to
very little trouble or inconvenience, and followed by a small hard
lump or ulcer. If the latter is present, it is often characterised by
bleeding. Again, practically no symptoms. To find it we must look and
see; often an operation involving practically no suffering and a very
small mortality is necessary. But the penalties of failure to do this at
the proper time are that ten per cent. of the population die of cancer.
There are certain popular misconceptions about cancer which
require correction. The first is that cancer is necessarily painful. This
is responsible for much of the late diagnosis, operative mortality and
the bad results. Only late cancer, and it would not be far wrong to
say only incurable cancer, gives rise to pain. If only pain were an
early sign of cancer the whole aspect of the cancer problem would
be changed.
Another very widespread delusion productive of great harm is that
cancer is constantly associated with wasting, and makes rapid
progress. These two symptoms are constantly associated with the
disease in its latest stages but are not seen at all in early cases.
One frequently hears people say that cancer is contagious, and
also that it is hereditary. These two popular conceptions probably
have the same basis. As we have seen, cancer is a very common
disease, and it would be strange indeed if, putting all question of
relationship on one side, we were not to see it quite commonly
occurring in one or more members of the same family, and if
occasionally we did not find a house in which each successive
occupant for some years had cancer. I will leave it to the
mathematicians to work out the probability of cancer occurring more
than once in any given family. The necessary figures are easily
obtained from the Registrar-General’s office. As far as I know, there
is nothing truly in the nature of what may be called evidence in
support of either of these notions.
Time after time people have described parasites of some kind as
associated with cancer, but none of them has yet been made to
answer to any of the tests necessary to establish anything more than
a casual correlation. It may turn out to be that the causal agent in
cancer formation is a parasite either visible under the microscope, or,
what is more likely, belonging to the group of ultravisible, or filter-
passing, organisms; but even if this be so, there are two other
factors of immense importance, found so constantly associated with
the disease, that their significance cannot be underestimated by
anyone whose outlook is any wider than that of the mere purveyor of
prescriptions.
These two factors may be considered in a little more detail, as
they are of importance with regard to the question of prevention.
They are (1) the presence of an acid environment, and (2) what, for
want of a better term, may be called chronic irritation. Whatever the
prime cause may turn out to be, these can never be left out of
account in any consideration of aetiology, and even if some specific
cause is found, the discovery will not shake the validity of my thesis.
For two thousand years people have speculated about the origin
of cancer. Galen held a theory somewhat analogous to the present
Chinese doctrine of the yin and the yang; he taught, in essence, that
some kind of “ch’i” had got at loggerheads with its fellow gases, and
that the result was a general disturbance of bodily functions.
Paracelsus thought that the salt balance of the body was upset, and
textbooks still sometimes put this into modern medical terminology,
saying that the balance of power between different types of cells is
disturbed. This may or may not describe what happens, but it is a
long way from explaining it.
In the sixteenth and seventeenth centuries cancer was often
referred to as an “act of God” in punishment for sin. For instance,
cancer of the tongue was said to afflict those who spoke against the
Church, a view that the Church, not always strictly scientific in
interpretation of phenomena, did not discourage.
Here is a translation which Sir D’Arcy Power has made from Paul
de Sorbant, a German physician writing in 1672, in his Universa
Medicina. “We saw”; he says, “an ulcer of the tongue degenerating
into cancer in the noble baron Vertemali, which caused such a
haemorrhage from destruction of the sublingual arteries and veins
that the patient was suffocated. He recognised with great penitence
that the cause of this cancer was a divine punishment because he
had often abused the clergy.” Benetus, about the same time, in his
book called Medicinae Septentriniolanus Collatitia, describes a case
of what he calls “Tumor Linguae Miraculosa.” Here is a translation of
part of it. “There was lately a certain baron who had a very
poisonous tongue. He not only directed his jibes against all and
sundry, but he kept his most venemous shafts for the clergy and
those who devoted themselves to God’s service. He was caught at
last in the very act, by a holy brother of good repute as he was
pealing this cursed bell, who said to him: ‘Your foul tongue has
overlong deserved that punishment from an offended God which it
will shortly receive.’ The Baron went off undismayed, but a few days
afterwards a small swelling began to grow on the side of his tongue.
Little by little it increased in size until it became an inoperable
cancer, and at length the tongue having become incurved, twisted
and drawn back to his throat, miserably afflicted, but penitent and
confessed, he was summoned before the Great Judge who calls his
servants to a most strict account.”
This may all seem very far away and out of contact with our
present-day thought, but only two years ago a dear old lady sent to
the Cancer Hospital Research Department two pages of closely
written typescript, the gist of which was that she was withdrawing her
usual annual subscription, as, after giving the matter a great deal of
thought, she had come to the conclusion that cancer was caused by
the consumption of alcohol. So she proposed to forward her usual
subscription to the local Temperance Society which really was
striking at the root of the problem! The Secretary wrote and pointed
out that cancer is very common in cats who are strict prohibitionists!
The old lady did not reply!
Let us come back again from theory to fact, and consider some of
the factors which we know constantly to be associated with cancer,
and which we are justified in regarding as being, in many cases,
more than predisposing causes.
The most important of these is chronic irritation. We find that
almost every cancer is preceded for a longer or shorter period by
what may be called a precancerous condition. The more our
knowledge increases the more we are finding out that this holds
good.
The commonest sites for cancer are the womb, the breast, and the
stomach. These together account for more than sixty per cent. of all
cancers, and far below them in frequency we find the tongue, the lip,
and the bowel, and the various glands.
Cancer of the womb is constantly preceded for many years by
disease, palpable and curable, often the result of childbearing, and
the part where it occurs is one bathed in an acid medium.
Cancer of the breast also is constantly associated with preceding
chronic inflammation, this condition itself producing, as one of its by-
products, a highly acid substance, further to irritate the delicate cells
already near the end of their tether. Mechanical irritation, beyond a
doubt, is an important factor. Although in civilised countries the
disease is distressingly common, in those countries where the
breasts are habitually uncovered, cancer of this organ is extremely
rare. The habitual friction of modern clothes predisposes cell-growth,
infection from no matter what source is given a foothold, and after
years of abuse, the cells lose the impulse to normal reaction and at
last turn and slay their victim.
There is evidence that about two-thirds of all the cases of cancer
of the stomach originate in an old gastric ulcer, and the constant
eating of hot food is perhaps enough to account for the remaining
third. The delicate gastric cells, more abused than any other cells in
the body, are bathed in a highly acid medium. It is no wonder that
departure from their appointed path accounts for thirty per cent. of all
cancers in men, and in women as well, if we except the two
conditions just mentioned.
In cancer of the kidney, the bladder, and the gall bladder, stones
are nearly always present to initiate the irritation.
In cancer of the tongue, syphilitic or other preceding conditions are
nearly always there, whether it be the irritation from raw alcohol, hot
tobacco smoke, or a broken tooth. It is interesting to note that, until
syphilis appeared in Europe, cancer of the tongue was practically
unrecorded in the existing literature. We have no need to go any
further for examples of these precancerous irritative conditions. They
are all curable or removable, but, as they do not as a rule give rise to
acute painful symptoms, severely inconveniencing the patient, they
are difficult to treat, and the unfortunate patient is told to wait and
see, and is given medicine which may for a while relieve, but which
—alas!—seldom has a chance to cure, or to prevent the fate which is
slowly overtaking him.
So far the evidence which has been brought before you, that
chronic irritation has a causal connection with cancer, has been of a
circumstantial nature: it has often enough been found in what we
may call suspicious circumstances, but that does not prove that by
itself it can directly cause the disease. If a man is seen hanging
about the place where a burglary has been committed, it does not
prove that he participated in it. He may be a burglar, or he may be
what lawyers call an accessory before the fact, and before we can
feel reasonably sure that he is a guilty party we must, unless we can
actually see him committing the crime, find that whenever he is
present, and he has a chance, a burglary takes place.
Now in scientific investigation we can do what in ordinary life is not
possible; we can take our burglar, arrange a set of suitable
circumstances and see what happens and with what degree of
regularity thefts occur. In the last four or five years something like
this has been done on a large scale with cancer, and a large body of
evidence is accumulating which suggests that, given suitable
circumstances, chronic irritation will produce cancer with a fair
degree of regularity, at least in some places. If it will do so in some
places there is no reason to doubt that, under circumstances which
for the moment we do not quite understand, it will do so in all the
places where cancer is found.
That this is so has not yet been completely proved, but I think
there is a good deal of evidence along this line. It has been known
for a great number of years that certain skin cancers are constantly
found in people whose occupations necessitate their skin being in
contact with certain chemical irritants. For instance, the workers in
shale oil are often afflicted with cancer of the skin. In the spinning
industry, when reaching over to deal with the machinery, a place on
the worker’s leg is always rubbing up against an oily spindle. This
process goes on for years at the same spot, and these people are
found frequently to get cancer, beginning at the irritated place. Some
aniline dyes are excreted in the urine, and growths of the bladder are
very frequent in aniline workers. In India, some native tribes carry
little metal boxes containing charcoal next to their skin in order to
warm themselves, and the warmed spot frequently becomes the seat
of a malignant ulcer. Further, in chimney-sweeps, whose skin is
always more or less impregnated with carbon, we find that cancer
frequently develops in those places where the soot is difficult to
wash completely away and often is not cleaned off for years at a
time. Finally, we have the well-known examples of skin cancer
among X-ray workers, and mouth-cancer in those who chew betel
nut.
Now it is just this type of cancer that we have the opportunity to
imitate in the laboratory. Dr Leitch, of the Cancer Hospital, has taken
rats, guinea-pigs and rabbits; and, day after day for months, soot,
tar, oils and all the irritants he could think of were respectively
painted on some selected part of their bodies. At the Cancer Hospital
he started using tar to paint on the under surface of the bodies of
white mice. This was done every morning for several months, and, in
a large percentage of cases, small warts were produced. The fate of
these warts varied; some of them disappeared, but others
progressed to the formation of true cancer. The results of these
experiments made it extremely probable that the irritants were the
direct cause of the cancer. Of course it is not proved, for it is possible
to assume that there is some ubiquitous “other cause”, only waiting
till the tissue resistance is lowered enough by the irritants to get its
chance to act. Another interesting fact, which transpired as the result
of this work, is that some of the animals from whom the warts
disappeared developed cancer a month or so subsequent to the
disappearance, thus showing that the predisposition to cancer
formation is acquired long before the growth actually appears.
In human beings, the process of cancer formation in response to
chemical irritants takes much longer (often twenty to thirty years),
and is preceded by much the same sort of preliminary skin reaction
as in animals.
In looking for a proximal cause for cancer production, we should
not, I think, look for a common cause in all cases, but should try to
find something or anything which will produce the necessary
previous irritation.
It has not, I think, been established beyond a doubt that chronic
irritation is the sole exciting cause of cancer—this in the nature of
things would be very difficult to prove—but it has been shewn that its
presence strongly predisposes to new growth formation.
The problem which now arises is that of how we are going to put
this knowledge we have gained to practical use in the prevention of
cancer. In order to solve this we will consider in some detail the three
commonest cancers met with, namely cancer of the breast, the
womb and the stomach, and we will see how the problem applies to
them.
Now in cancer of the breast we have this outstanding fact that,
almost all the cases show for some years beforehand obvious signs
of chronic inflammation of the breast, and in nearly all of them this
precancerous stage can be seen, when they are examined
microscopically.
Obviously this is the time to deal with the disease; and the way to
do so is systematically to examine microscopically (by a procedure in
itself devoid of all risk, except the very small one due to the
administration of a general anaesthetic), every doubtfully malignant
breast, afflicted by chronic inflammation. This may seem a
revolutionary thing to say; but if we set ourselves to deal with this
plague in the logical manner that we employ when we sit down to
deal with any other pest, and, if we follow all the facts known to their
inevitable conclusion, we are driven to it, and we shall see that there
is no other course open to us but to deal in a wholesale manner with
the precancerous condition. To do this we shall have to undertake a
long campaign of education. One of the leading authorities on breast
cancer in America, did undertake such a campaign in his own
district, with the result that, from the enthusiastic propaganda of one
man, the proportion of precancerous to fully developed malignant
lesions which appeared at his clinic rose in six years by thirteen per
cent. In twenty years the proportion of fully developed cancer to pre-
malignant lesions dropped from ninety to seventy-eight per cent.
I am quite sure of the fact that the adoption of this proposal would
mean operations upon a number of breasts which would never
become cancerous, but, so far as I can see, we cannot help this, any
more than we can help vaccinating a large number of people who
will never have small-pox, or, when we isolate diphtheria contacts,
can we help disturbing also a large number of people who will never
get diphtheria. The public have been educated to regard these
precautions as natural and proper, and as a rule raise no objections
to their being carried out. Dr Bloodgood, to whose educational work I
have just referred, states that if any woman could be kept under
sufficiently close observation, she could be practically assured
against death from cancer. I think every other surgeon of experience
would agree with him.
So much for prevention and the precancerous lesions. Let us
come to the question of the cure. Here we find that the chances of
cure in any particular case simply depend on the stage at which the
case appears for treatment. We can for convenience divide cases
into two groups; those which have glands involved and those which
have not. By this I mean those which have glands so grossly
involved that they are appreciable to the touch. Again quoting Dr
Bloodgood, it is found that of those cases with gland involvement,
twenty-three per cent. only are cured after seven years but, of those
without gland involvement, sixty-five per cent.
Now, here is the fact which ought to rouse us to action: the
average duration of the disease in these cured cases was nine
months—nine precious months in which that remaining thirty, or forty,
per cent. might have been cured if they had only been treated
earlier. Or, if they had been properly examined still earlier by a
trained person, the disease could have been dealt with earlier with a
still better chance of ultimate cure, and it is Dr C. H. Mayo who has
said that there is no reason on earth why about ninety-five per cent.
of all cases of cancer of the breast cannot be permanently cured.
So far we have spoken in detail of cancer of the breast but, when
we come to deal with cancer of the uterus, we shall find that the facts
are almost exactly analogous, only that the results of indecision and
delay are even more deplorable. We find that, by the time they come
for treatment, about half the cases are quite incurable, and those
which are operable are as a rule a great deal further advanced than
those of cancer of the breast. In spite of this we find that out of two
hundred consecutive cases no less than forty per cent. were cured;
that is to say, had no recurrence within seven years. All the cases
which were operated on had had quite definite symptoms for six
months. In other words, the patient herself should have come for
examination six months before she did, and if she had been
examined in the course of a proper routine, the disease could have
been discovered far earlier than was the case.
Quite recently, a report of a series of cases has been published by
Professor Faure, a distinguished French gynæcologist, which so
exactly illustrates my views that perhaps I may be forgiven for
making use of it. Faure cut ninety-six cases of cancer of the uterus
and has divided them into good cases, mediocre cases and bad
cases. It is significant that there were only twenty-one “good” cases,
thirty-five “mediocre” cases and forty “bad” cases. The good cases
are what I have called early cases, the mediocre cases correspond
to moderately advanced cancer, and the bad cases to those which
are on the border line between operability and non-operability. His
total results approximate very nearly to most other published lists but
their analysis is very significant. Of the good cases there was one
operative death; of the remainder seventy-five per cent. were cured
and twenty-five per cent. recurred.
Of the mediocre cases there was an operative mortality of 8.57%.
Of those surviving the operation 62.5% were cured and 37.5%
recurred. In the bad cases there was a post-operative mortality of
22.5%: only six were cured and twenty-five recurred. That is to say,
respectively, 19.35% were cured and 80.65% recurred. These
figures tell their own tale.
With this hopeless condition of affairs it is no use saying that the
results of surgery are bad. They are; but it is not the fault of doctors,
or the methods at their disposal; it is the misfortune of the patient
that her lack of proper education must bear the blame.
Cancer of the uterus is in many cases preceded by precancerous
lesions, all amenable to various kinds of treatment. Again, the only
way to deal with it is not to wait and see whether a woman has got
cancer but to look and see that she has not. Until this is our attitude,
the results are not likely to be much better, whatever the means at
our disposal for its cure.
Finally, turning to another great group of cancers which make up
thirty per cent. of all in men (and in women too, if we exclude the two
previously mentioned types), we find exactly the same condition of
affairs.
In two out of every three cases of cancer of the stomach there is
evidence that it has arisen in an old ulcer, and Dr Mayo has
suggested that eating hot food may account for the remaining third. It
is moreover the experience of all surgeons who systematically
submit all gastric ulcers upon which they operate to microscopic
examination, that about twenty per cent. of them all are malignant.
We have before us the plain fact that from ten to twenty per cent.
of all chronic ulcers which have come for surgical treatment are
already malignant and can only be cured by a complete removal.
Another fact also requires taking into the most serious consideration,
and this is, that it is the considered opinion of by far the large
majority of experienced surgeons that exploration and some form of
operation is the best treatment for every case of chronic gastric ulcer
which has recurred once, or at least twice, after a thorough course of
medical treatment. (The term “chronic gastric ulcer” is here used in
its strictest scientific sense, and by it is meant an ulcer whose
diameter in any one direction is more than a centimeter, and whose
edges are hard and thickened). In spite of this, a distinguished
surgeon recently put on record that every case of gastric ulcer upon
which he operated had on an average been “cured” nine times. Why
is this? The reason is clear. In nearly every case the symptoms of
gastric ulcer (and, remember! twenty per cent. are already
cancerous) can be relieved for a time by palliative treatment, when
once again the deluded patient thinks he is cured.
There is no need for me to point the lesson from this. I have put
forward the facts, and every one can draw his own conclusions.
There is only one gleam of hope that I can see on the horizon, and
that is, in dealing with the disease in an early stage by radical
measures, and, in twenty per cent. of the cases, thus combining
prevention with cure.
Again, we must alter our attitude. We must look and see, not
merely “dope” and see! Once symptoms of this disease have
recurred after efficient treatment, there is only one good reason for
not looking and making certain, and that is when the risks of looking
exceed those of the lesion being malignant—that is to say,
somewhere between ten and twenty per cent. At present, the risks of
looking are about one in a thousand, and the risks of removal of a
cancer about three per cent., taking all cases, most of which are at
an advanced stage. The operative risks of earlier cases are less than
this, and to this must be added about a two per cent. risk of a further
operation being necessary—in all, not exceeding five per cent.
I realise that the adoption of this policy will mean a certain number
of otherwise avoidable operations. I know that it will mean operating
on a few cases that would otherwise get better by themselves, or by
other means. But until it is adopted, there is, as far as I can see, no
prospect of reducing the death-rate from cancer of the stomach. For
so long as indiscriminate medicine-taking has precedence over exact
methods of investigation and treatment, so long will cancer of the
stomach continue to make up thirty per cent. of all cancers. Again
the question is largely out of the hands of the doctors. As long as
patients come to a doctor wanting “a bottle of medicine, doctor, just
to help me carry on”, so long will they get it, as the doctor finds it
hard to refuse. For he knows the patient will go from doctor to doctor
till he gets what he wants.
I have dealt in some detail with the three commonest types of
cancer, but the same arguments apply to all. The problem is not so

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Food Safety for Farmers Markets A

Guide to Enhancing Safety of Local

Food Safety A Roadmap to Success 1st Edition Gary Ades

Practical Safety Management Systems A Practical Guide

Food Safety Management Systems: Achieving Active

Safety and Health Competence: A Guide for Cultures of

A Practical Guide to the Safety Profession The

Food lovers guide to Chicago The Best Restaurants

LEAD Safety-A Practical Handbook for Frontline

Guide to Food Safety and Quality during Transportation

Judy A. Harrison Editor

Food Safety for

More information about this series at http://www.springer.com/series/7131

Food Safety for Farmers

Food Microbiology and Food Safety

Library of Congress Control Number: 2017953186

© Springer International Publishing AG 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

reported increases in the number of customers, increases in the number of repeat

Athens, GA, USA Judy A. Harrison

1 An Introduction to Microorganisms That Can Impact

Renee R. Boyer Department of Food Science and Technology, Virginia Tech,

Keywords Foodborne pathogens • pH • Water activity • Temperature • Salmonella

F.J. Critzer (*)

© Springer International Publishing AG 2017 1

Types of Foodborne Pathogens

Foodborne pathogens are broadly categorized as disease-causing bacteria, viruses,

pathogens. This is because most foodborne pathogens can be either symptomati-

 rimary Factors Which Affect the Growth of Bacterial

Bacteria are categorized by their ability to grow in the presence of oxygen. If an

pH is the measurement of acidity or alkalinity of a food. It uses a common scale

Escherichia coli O157:H7

3 3.5 4 4.5 5 5.5 6

Fig. 1.1 Minimum pH growth ranges for some foodborne pathogens

Removal of moisture is one of the oldest methods of preparing shelf-stable foods.

Table 1.4 Representative pH values of some foods grouped by commodity [4]

Similar to humans, microorganisms must find a source of water, energy, nitrogen,

An understanding of the organisms that cause foodborne illness is very helpful

J.A. Harrison (*)

© Springer International Publishing AG 2017 13

always cleaned containers used to transport produce to market between uses.

contamination for produce.

Toilet facilities are serviced and cleaned on a regular schedule.

Damaged containers are properly repaired or discarded.

I cool fruits and vegetables after harvest.

Produce is kept cool during transport to market.

The vehicle used to transport fruits and vegetables is cleaned frequently.

Fig. 2.3 (Continued)

method used, adherence to strict sanitation practices, cooling practices and

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Athens, GA, USA Judy A. Harrison

1 An Introduction to Microorganisms That Can Impact

Types of Foodborne Pathogens

rimary Factors Which Affect the Growth of Bacterial