By Jonathan E. Hostottle<\/p>\n\n\n\n
Download pdf\u00a0here<\/a><\/p>\n\n\n\n The World Health Organization considers antimicrobial-resistant (AMR) infections one of the most significant health threats today.<\/a>[1]<\/a> AMR infections are a major cause of sickness and death worldwide.<\/a>[2]<\/a> By 2050, AMR\u2019s global annual death rate is estimated to grow from 1.2 million to as many as 10 million.<\/a>[3]<\/a> Although there is a dearth of scholarship on racial and economic disparities in infection rates and deaths in the United States,<\/a>[4]<\/a> available data suggest that these infections disproportionately impact people of color and those experiencing poverty.<\/a>[5]<\/a> AMR\u2019s disparate impacts demonstrate that this is not just a public health crisis, but an environmental justice concern as well.<\/p>\n\n\n\n The United States agricultural system is a major contributor to AMR through its rampant use of antibiotics in animal production.<\/a>[6]<\/a> Although industry and regulators have taken steps to address AMR\u2019s causes in recent years,<\/a>[7]<\/a> the changes have not gone far enough to ameliorate the roots of the problem: the continued overuse of antibiotics in human medicine and animal agriculture, as well as insufficient data collection systems.<\/a>[8]<\/a> Furthermore, those committed to addressing AMR have failed to even acknowledge the significant racial and socioeconomic disparities when crafting regulations on antibiotic use.<\/a>[9]<\/a> If we are to curb this issue, regulators and consumers in the United States must take account of these disparate impacts and use them to frame solutions to AMR as this threat continues to grow through the 21st century.<\/p>\n\n\n\n This article argues that AMR is a significant environmental justice concern, a framing historically ignored by those in power, and that should be addressed by policymakers, regulators, and researchers through an environmental justice lens. This article will examine the issue of AMR from historical and legal lenses, looking at the industry practices and regulatory failures that have contributed to the seriousness of the problem. Part I examines what AMR is, how it develops, and the history of antibiotic use in animal agriculture; discusses the history of agricultural antibiotic regulation in the United States; and explores the disparate impacts of AMR and dive into some of the factors scholars have suggested may contribute to this persistent but understudied problem. In Part II, this article proposes legal and social reforms to curb AMR and promote environmental justice. Although AMR is a significant global threat, this article will primarily explore AMR and the related environmental justice implications as they manifest in the United States.<\/p>\n\n\n\n Antimicrobial resistance occurs when bacteria evolve to the point at which they no longer respond to antibiotic treatment through the evolutionary selection of resistant strains.[10]<\/a> Antimicrobial agents accelerate this process.<\/a>[11]<\/a> Certain bacteria in populations resist and survive the deadly effects of antimicrobial medication. These survivors proliferate, spreading the characteristics that made them resistant to the antibiotics to their genetic successors.[12]<\/a> As a result, the efficacy of antibiotic treatments drops drastically among the newly resistant bacterial population. This occurs quickly and often, leading some researchers to aver that \u201c[t]oday, antibiotics are regarded as \u2018endangered species\u2019 as they are experiencing fast extinction because of the global occurrence of [antimicrobial resistance].\u201d[13]<\/a><\/p>\n\n\n\n In 2019, AMR infections were the attributable cause of 1.2 million deaths globally,[14]<\/a> two percent of that year\u2019s total deaths worldwide.[15]<\/a> The burden of AMR infection disproportionately impacts those who are elderly,[16]<\/a> those who are low-income,[17]<\/a> and those in sub-Saharan Africa and South Asia.[18]<\/a> These disparate global impacts have many contributors, but one of particular significance is the lack of access to the newer and stronger antibiotics in low and middle income countries.<\/a>[19]<\/a> Although the global data for AMR shows some positive trends,[20]<\/a> the global strategy to combat AMR is still insufficient to address its projected harm. Given its current trajectory, some researchers estimate that AMR infections could cause over 90 million deaths worldwide between 2025 and 2050.[21]<\/a><\/p>\n\n\n\n In the United States, AMR infections pose major health and economic threats. Nearly two million Americans develop infections due to AMR pathogens each year.[22]<\/a> Between 35,000 and 162,000 adults<\/a>[23]<\/a> die each year from these infections.[24]<\/a> The burden of AMR goes far beyond its death toll. These infections are costly for individuals who get sick and are hospitalized, the medical industry, and the economy writ large.[25]<\/a> The exact economic impact of AMR is difficult to calculate, but the Centers for Disease Control and Prevention (the CDC) cited a 2009 study estimating that the annual direct costs of AMR infections are as much as $20 billion and result in $35 billion in lost economic productivity.[26]<\/a> Further studies estimate that the costs of infection to individuals or insurers of certain strains of AMR bacteria ranged from $13,701 and $18,206 per infection, bringing the cost of AMR infection higher than the annual price of chronic diseases such as high blood pressure, asthma, and diabetes.[27]<\/a><\/p>\n\n\n\n Due to difficulties in reporting and the studies\u2019 susceptibility to methodological error, we don\u2019t know the exact human and economic costs of AMR.[28]<\/a> Measuring this burden is no easy feat, and many of the discrepancies in the data are due to the inadequacy of our current data collection methods as well as AMR\u2019s wild variability by country.[29]<\/a> Even in the United States and other high-income countries, the laboratory infrastructures needed to reliably measure the burden of AMR are difficult to coordinate.[30]<\/a> To understand and combat this pressing threat effectively, scientists and researchers must conduct more research, especially among those who disproportionately bear the cost of AMR: under-resourced and underserved communities domestically and abroad.[31]<\/a><\/p>\n\n\n\n Although AMR has a complex network of causes, antibiotic use in both human and veterinary medicine contributes to the selective evolutionary pressures that lead to resistant pathogens.[32]<\/a> The widespread use of antibiotics in animal agriculture has led researchers to declare that this source of AMR by itself constitutes a universal health crisis.[33]<\/a> Sales of medically important antibiotics in the United States for use in animal agriculture are far greater than those for use in human medicine.[34]<\/a> Antimicrobial agents, antibiotic resistant genes, and the antibiotic resistant bacteria themselves share a complex network of transmission from agricultural sources to humans.[35]<\/a><\/p>\n\n\n\n Manure from livestock farming is a major source of antibiotic resistance: from the manure, the AMR agents spread to irrigation water, crops, and the soil itself, thereby increasing the exposure risk of humans to these agents.[36]<\/a> In fact, most of the antibiotics used in animal agriculture are not metabolized, but are instead discharged into the environment as waste.[37]<\/a> However, the exact amount of antibiotic agents discharged into the environment from agricultural sources is unknown and understudied.[38]<\/a> Introducing these antibiotic agents into the environment speeds up the natural evolutionary development of AMR of the bacteria, resulting in pools of AMR agents that eventually spread animal agriculture\u2019s AMR burden to human populations.[39]<\/a> These pools create environmental hazards that create inequitable exposure vectors for already underserved communities.[40]<\/a><\/p>\n\n\n\n AMR poses significant domestic and international costs and challenges, but its causes are hard to pinpoint and its costs difficult to fully ascertain. However, antibiotic use in animal agriculture contributes significantly to the problem. The CDC estimates that 75% of dangerous new infections spill over from animal to human populations.[41]<\/a> If there is to be any hope of curbing the looming threat of AMR and its disproportionate burden, antibiotic use in animal agriculture must be revolutionized.<\/p>\n\n\n\n Scientists discovered and isolated penicillin in 1929, ushering into the world what seemed an impossible biomedical future: one in which we could effectively fight bacterial infection.[42]<\/a> Bayer synthesized the first effective human-made antimicrobials, sulphonamides, in 1935,[43]<\/a> and began marketing them for antibiotic use in animal agriculture as early as 1938.[44]<\/a> Their use spread rapidly. The Second World War galvanized antibiotics\u2019 importance in animal agriculture as the high demand for milk allowed for their efficacy to be battle-tested.[45]<\/a><\/p>\n\n\n\n In 1949, researchers discovered that administering antibiotics non-therapeutically could lead to additional weight gains for animals.[46]<\/a> Catalyzed by the United States\u2019 postwar demand for meat, sales of antibiotics for nontherapeutic agricultural use skyrocketed after the announcement of the research findings.[47]<\/a> All uses of antibiotics in agriculture spread throughout the world as the 20th century dragged on.[48]<\/a> Concerns about overpopulation and communism led American policymakers and researchers to consider the yield-increasing magic of technologies like antibiotics as a way of defending Western industrial values.[49]<\/a> The use of antibiotics in the United States grew immensely in the second half of the 20th century. From 1951 to 1970, the country experienced an 11-fold increase in the use of medically important antibiotics and a 30-fold increase of non-medicinal antibiotics.[50]<\/a> The growth of disease-promoting dense animal agricultural practices, such as concentrated animal feeding operations (CAFOs), in the United States drove a significant part of this expansion. By 1970, calves raised in dense feedlots represented as much as two-thirds of the national calf crop.[51]<\/a> American demand for meat soared, increasing the need for dense farming practice. Agricultural antibiotics usage in the United States continued to skyrocket along with this need, almost doubling from 1970 to 1978.[52]<\/a><\/p>\n\n\n\n Researchers became aware of AMR as early as 1940 when they noticed resistance to antibiotic treatment in certain bacteria cultures.[53]<\/a> British scientists began warning about the dangers of antibiotic overuse in animal agriculture in the 1950s. These scientists lambasted the unfettered use of antibiotics without veterinary supervision that was common in the United States.<\/a>[54]<\/a> Some American commentators joined the British scientists warning about the problem of antibiotic resistance around the same time.[55]<\/a> As these alarm bells rang louder and the discursive divide deepened in the 1960s and 1970s, actions toward combating AMR remained infrequent and ineffective.[56]<\/a> Agricultural antibiotic use continued to spread relatively unbounded.[57]<\/a><\/p>\n\n\n\n Antibiotic use in American animal agriculture continued to rise until 2015, after which there was a decline in use followed by a subsequent increase.<\/a>[58]<\/a> It is unclear whether these trends are due to voluntary limitations on antibiotic use in the poultry industry[59]<\/a> or were pushed by Food and Drug Administration (FDA) policies.[60]<\/a> Simultaneously, as death rates from cancer and heart disease rose to replace deaths from infectious disease, pharmaceutical companies lost their economic incentive to go through the resource-intensive process of developing new and stronger antibiotics that target specific resistant bacteria.[61]<\/a> Due to its entrenchment in our agricultural practices and economy, the persistent use of antibiotics in animal agriculture continues to exacerbate the threat of AMR.[62]<\/a><\/p>\n\n\n\n Historically, attempts in the United States to regulate agricultural antibiotic use have been viewed as a failure.[63]<\/a> The FDA, responding to concerns about antibiotic residue in milk, introduced a national residue monitoring program in 1960, with one for meat following six years later.[64]<\/a> In 1972, an FDA task force report was released, finding that continuous and subtherapeutic use of antimicrobial drugs in animal agriculture contributed to AMR.[65]<\/a> The report also suggested that the FDA needed to begin categorizing between antibiotics important for human health and medicine and those that are not.[66]<\/a> As a result, in 1977, the FDA began to take steps to move away from the residue-focused regulations to those focused on addressing AMR. Donald Kennedy, the FDA Commissioner and former microbiologist, moved to limit the nontherapeutic agricultural use of antibiotics.[67]<\/a> However, the industry successfully parried these efforts by funding numerous counter-studies to dispute the report\u2019s findings and sow public doubt.[68]<\/a> The beginning of the anti-regulatory Reagan administration served as the death knell for Commissioner Kennedy\u2019s efforts.[69]<\/a> The public discourse about AMR and the FDA\u2019s regulations remained quiet until the late 1980s when public concerns about residue surfaced again.[70]<\/a><\/p>\n\n\n\n The current FDA agricultural antibiotic regulatory scheme is structured on the findings of the 1972 report.[71]<\/a> The current regulatory scheme categorizes antibiotic drugs as \u201cmedically important antibiotics\u201d (MIA) and \u201ccurrently not medically important antibiotics\u201d (NMIA).[72]<\/a> In 2003, the agency began issuing guidance for industry (GFI) documents pertaining to antibiotic use in animal agriculture.[73]<\/a> These guidance documents have shown increasing levels of alarm and attempts by the FDA to curb antibiotic use in animal agriculture: GFI 152 issued in 2003 provided a list of MIA ranked in order of importance to human health and medicine; GFI 209 issued in 2012 urged for \u201cjudicious use\u201d standards for farmers in the hopes that MIA would not be used for growth promotion and NMIA would only be used in accordance with their labeling requirements; GFI 213 issued in 2013 provided guidance for manufacturers in accordance with GFI 209; and GFI 263, issued in 2021, admonished manufacturers to update their recommended conditions for prescription of MIA.[74]<\/a><\/p>\n\n\n\n These guidance documents are exactly that: just guidance. The Code of Federal Regulations explicitly states that the GFIs are not legally binding on the public or the FDA.[75]<\/a> The FDA has publicly defended its approach, calling their push for industry voluntarism \u201cthe quickest, most efficient way to reach our collective goal\u2014considerably faster than a mandatory ban.\u201d[76]<\/a> However, the voluntary use approach ignores the fact that industry actors may continue to profit and shift the burden to communities who are disproportionately at risk of bearing the costs of AMR infection.[77]<\/a> The industry response to the GFI documents has been mixed. On one hand, the \u201cjudicious use\u201d guidance from the FDA has coincided with a reduction in antibiotic use in American agriculture,[78]<\/a> specifically in poultry farming.[79]<\/a> However, the FDA has no legal enforcement mechanism to urge compliance with the GFI document recommendations, leaving pharmaceutical manufacturers and agribusiness producers free to continue antibiotic overuse.[80]<\/a><\/p>\n\n\n\n The GFI documents were not the only actions taken by the FDA. In 2017, the FDA fully implemented their Veterinary Feed Directive (VFD) from a final rule issued in 2015.[81]<\/a> This rule creates responsibilities for veterinarians, distributors, and clients using antibiotics in animal feed.[82]<\/a> This regulation requires a VFD from a licensed veterinarian for the distribution of animal feed with MIA, creating legal responsibilities for some of the guidance in GFI 209.[83]<\/a> Importantly, the VFD regulation contains an attempt to close the information gap present in agricultural antimicrobial use, requiring \u201c[a]ll involved parties (the veterinarian, the distributor, and the client) [to] retain a copy of the VFD for 2 years\u201d[84]<\/a> and maintaining that these parties \u201cmust make the VFD and any other records specified in this section available for inspection and copying by FDA upon request.\u201d[85]<\/a> However, in the early years of this regulation, the FDA has rarely exercised its authority to request documents. They only did so once between 2017 and 2018.[86]<\/a><\/p>\n\n\n\n Beyond the FDA, the Executive Branch has shown persistent interest in combating AMR. In 2014, the White House released a report, \u201cNational Strategy for Combating Antibiotic Resistant Bacteria\u201d (CARB Strategy).[87]<\/a> The CARB Strategy set out five goals[88]<\/a> and created national targets to reach by 2020.[89]<\/a> The document called for the creation of \u201can interagency task force co-chaired by the Secretaries of Health and Human Services, Agriculture, and Defense [which] will develop a National Action Plan for Combating Antibiotic-Resistant Bacteria.\u201d[90]<\/a> This task force, the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB), was officially created by President Barack Obama\u2019s Executive Order 13676.[91]<\/a> The National Action Plan was released in 2015 and was originally set to expire in 2020.[92]<\/a> President Donald Trump re-established PACCARB after its expiration in 2020,<\/a>[93]<\/a> and the task force is now authorized to operate until August 29, 2026.[94]<\/a> As a result, in 2020, the task force released a new National Action Plan serving the years 2020\u20132025.[95]<\/a><\/p>\n\n\n\n Some data point to the efficacy of executive measures to combat AMR. From 2013 to 2019, the CDC reported an 18% drop in deaths from AMR, citing strategies that worked in healthcare and the \u201ccommunity\u201d at large.<\/a>[96]<\/a> Even though death rates declined, annual infection rates in the United States increased from 2.6 million to 2.8 million during the same period.[97]<\/a><\/p>\n\n\n\n The future of AMR in the United States in 2026 appears grim. The FDA recently approved the first new antibiotic for UTI treatment since 1996,[98]<\/a> potentially contributing to the arms race between antibiotics and AMR bacteria.[99]<\/a> The first Trump administration seemed to take the threat of AMR seriously by acknowledging the threat of AMR and reestablishing PACCARB.[100]<\/a> However, some commentators asserted that the budget cuts from the administration\u2019s first term put people in the United States at a heightened risk of AMR infections, potentially signaling that this is not a priority for the administration.[101]<\/a> Furthermore, the Second Trump Administration canceled PACCARB\u2019s meeting scheduled for January 2025 in which the committee was to make their recommendations for 2025\u20132030.[102]<\/a><\/p>\n\n\n\n After pressure from the medical community, the federal government announced that PACCARB would reconvene in June 2026.[103]<\/a> During the meeting, the Committee planned to \u201cprovide input and information to the federal, Inter-Agency Combating Antibiotic-Resistant Bacteria Task Force (Task Force) as they develop the next five-year iteration of the CARB National Action Plan 2026\u20132031.\u201d[104]<\/a> The Committee will convene again on September 9th and 10th to discuss \u201chow microbiome science can support AMR prevention, drive novel interventions, and build public awareness and understanding of microbiome-focused health promotion measures.\u201d[105]<\/a><\/p>\n\n\n\n Despite PACCARB\u2019s revival, the Second Trump Administration has demonstrated hostility to conversations about structural racism in educational institutions.[106]<\/a> Given this hostility, it seems unlikely that an environmental justice-framed solution to AMR will prevail during this presidency. Such a framework necessarily involves examining the systemic inadequacies that contribute to this racially disproportionate problem.<\/p>\n\n\n\n Although there has been nominal improvement to the threat of AMR, federal regulators\u2019 primarily voluntaristic approach constitutes a failure to sufficiently combat AMR. Notably, none of the regulatory efforts in the United States have ever taken the disparate racial and economic impacts of AMR into account,[107]<\/a> exacerbating the persistent environmental injustices of AMR.<\/p>\n\n\n\n \u201cFar from being a global leveller, the biological and social effects of AMR have been felt unevenly.\u201d[108]<\/a> AMR exposure and risk mirror other environmental justice issues: the globally powerful have profited from the rampant and unexamined use of antibiotics and have, thus far, been wealthy enough to buy \u201cquick fixes\u201d such that they do not feel the impacts of AMR as strongly as underserved communities.[109]<\/a> As discussed above, available data betray the disparate impact that AMR has along economic lines.[110]<\/a> These effects may be due to lack of access to sufficient healthcare and disproportionate terrestrial, aquatic, and airborne exposure to AMR residues and bacteria.[111]<\/a> We must approach remediation with \u201cacknowledgement of the significant differences with which [AMR\u2019s] fallouts have been distributed.\u201d[112]<\/a> In doing so, we may be able to effectively address the globally-urgent AMR problem without leaving vulnerable communities behind.<\/p>\n\n\n\n Although the disparate racial impacts of AMR are understudied,[113]<\/a> data point to disproportionate deaths among Black and Hispanic populations in the United States from AMR.[114]<\/a> Emerging studies show that the disparate racial impact of AMR infections is far from tenuous. However, due to methodological limitations, more research is needed to fully understand the scope of the problem.[115]<\/a> Nicole Gualandi et al. assert that their 2018 survey study \u201crepresents the first description of trends for racial disparities in healthcare-associated infections using data from an entire population area.\u201d[116]<\/a> Their study found that there are persistent racial differences in the rates of Methicillin-resistant Staphylococcus aureus infections (MRSA) between Black and white populations despite rates of MRSA declining overall.[117]<\/a> Given that we have known about the potential seriousness of AMR for decades, it is alarming that we have only recently begun to examine the racial disparities in AMR exposure and infection.<\/p>\n\n\n\n These nascent studies along with the racially imbalanced impact of the COVID-19 pandemic have led researchers to call for more inquiry into the disparate impacts of AMR infections.[118]<\/a> The exact reasons why these differentiated outcomes persist are unclear, but researchers have identified three main reasons to explain these inequities: (1) Black and Hispanic patients receive fewer antibiotic prescriptions but are more likely to consume unprescribed antibiotics than white patients;[119]<\/a> (2) Black and Hispanic populations have more frequent underlying medical comorbidities;[120]<\/a> and (3) workers in food processing are typically the first affected by animal production-related illness,[121]<\/a> and about 60% of US meat processing plant workers are Black or Hispanic.[122]<\/a> Several of these issues are exacerbated by our structurally racist healthcare system through segregated care, lack of access, and healthcare policy.[123]<\/a><\/p>\n\n\n\n The solutions to AMR infection require addressing the complex network of systemic causes of the disparate racial impacts.[124]<\/a> AMR will not be solved by agricultural policy alone. However, despite the emerging research on this topic, no federal AMR risk reduction plan, including those pertaining to animal agriculture, has taken into account the racial disparities in AMR outcomes.[125]<\/a> To effectively curb the threat of AMR, regulators must consider the disparate impacts on these populations and meet these challenges where they arise. These challenges are explored below.<\/p>\n\n\n\n \u201cWe must acknowledge that inequities in social determinants of health, as well as provider implicit and explicit biases, heavily influence antimicrobial prescribing patterns and the propagation of AMR.\u201d[126]<\/a> There are large racial disparities in antimicrobial prescription fills, with white persons reporting as many as double the antimicrobial drug prescriptions filled as those who are nonwhite.[127]<\/a> Some studies suggest that the prescribing practices of individual clinicians are influenced by racial bias.[128]<\/a><\/p>\n\n\n\n Unequal prescribing practices stem partially from ouroboric treatment cycles: patients of color often perceive interactions with clinicians more negatively, leading them to change how they may otherwise describe their symptoms.[129]<\/a> As a result, minoritized patients receive lower quality treatment for infection than their white counterparts.[130]<\/a> Antibiotic undertreatment accords with research done in other areas of medicine.[131]<\/a> Under-utilization of antibiotics increases the risk of repeated infection which necessitates more treatment with stronger antibiotics and promotes further AMR.[132]<\/a> These disparate practices, although not a primary driver of AMR, put Black and Hispanic individuals at a higher risk of AMR infection.<\/p>\n\n\n\n The disparate medical treatment of Black and Hispanic patients, although not the only cause of disproportionate levels of comorbidities, contributes to a negative health feedback loop. After a study examining racial differences in multi-morbidities across large groups of data, Pankush Kalgotra et al. opined that racial \u201cdisparities [in comorbidity rate] are not ONLY due to the sickness differences among races, it is also about diagnoses and treatment of specific groups of people.\u201d[133]<\/a> The COVID-19 pandemic illuminated the significant threat of AMR as a co-infection in hospital settings and helped elucidate, in limited ways, the disparate risks of AMR for patients with comorbidities.[134]<\/a> Antibiotic treatments too early and too late increase a patient\u2019s risk of exposure to AMR. One study found that several patients admitted into intensive care for COVID-19 were given antimicrobial drugs prior to their infection screens coming back, and this early treatment contributed their risk of AMR infection on top of a serious COVID-19 infection.[135]<\/a> Intensive care units have historically been a hotbed for the spread of AMR, and in them, minoritized patients are significantly less likely to receive timely treatment for their infections and other emergency medical issues.[136]<\/a> Treatment differences are not the only drivers of this inequity: lack of access to quality healthcare facilities is a major contributor to the disproportionality of AMR as well.[137]<\/a> The entrenchment of these societal inequities in medical access and treatment exacerbates the threats of AMR and distributes its burdens unequally.<\/p>\n\n\n\n AMR infections also present an occupational hazard for farm and food processing workers.[138]<\/a> Farm and food production workers are exposed directly to AMR bacteria through their work with animals and animal products.[139]<\/a> Many health departments don\u2019t regulate or consider health conditions for workers in CAFOs.[140]<\/a> Meatpacking workers are particularly susceptible to the spread of infectious disease, as evidenced by the plants in which they work becoming \u201chot spots\u201d for COVID-19 infection.[141]<\/a> Black and Hispanic workers are disproportionately represented in CAFOs and food processing plants,[142]<\/a> making these populations more susceptible to the frontline risk of infection and the subsequent transmission of AMR bacteria.[143]<\/a><\/p>\n\n\n\n Working conditions that increase the risk of negative health outcomes are so bad in some circumstances that they have led researchers to assert \u201c[t]he agencies responsible for regulating CAFOs\u2014their mission is not to protect human health.\u201d[144]<\/a> These exposures put the families and communities of the agribusiness workers at a disproportionately high risk of AMR infection.[145]<\/a> These risks do not cease when workers\u2019 exposure to the bacteria in their work environment ceases, and some research points to the possibility that farm workers may carry these resistant bacteria for as long as 14 days since they were last exposed.[146]<\/a> However, despite workers\u2019 disproportionate exposure, the research in this area is thin and the exact impact needs further study. Moreover, agribusiness workers are less likely to be able to use legal and political processes to protect their interests,[147]<\/a> and thus can become stuck working in unsafe and dangerous conditions in which they are more likely to be exposed to risks like AMR infection.[148]<\/a><\/p>\n\n\n\n Even though some studies are beginning to explore the socioeconomic causes of disparate impacts of AMR, the data is inadequate.[149]<\/a> This problem remains understudied partially because \u201c[m]edical treatment studies remain dominated by white males.\u201d[150]<\/a> Fully understanding the drivers of the disparate impact of AMR will be a first step to meaningful change.[151]<\/a> To address AMR effectively, we need to examine the disparate racial and socioeconomic outcomes of the problem and take them into account as we act. As we learn more about the causes of these inequities, we will gain the knowledge to create effective solutions which don\u2019t distribute the burdens of AMR and the benefits of continued agricultural antibiotic use unequally.<\/p>\n\n\n\n Before even reaching the data collection point, we must first acknowledge the existence of disparate impacts in AMR infection rates. Only then may we begin to design effective research to help us understand the racial disparities of AMR.[152]<\/a> This will likely include better data gathering in both the medical and agricultural fields. For example, the FDA\u2019s surveillance program for antibiotic use, although expanding, has historically under-collected data to the point where it is not terribly helpful.[153]<\/a> The lack of available data permeates and exacerbates the problem of AMR so severely that data collection should be one of the first major goals for addressing the threat posed. If we do so with care as we examine the future of antibiotic use in animal agriculture, we may prevent the next \u201cepidemic of inequality.\u201d[154]<\/a><\/p>\n\n\n\n AMR is an incredibly complex issue that will likely only be solved by global industrial and regulatory cooperation.[155]<\/a> This paper will only focus on potential legal and social solutions the United States may employ to combat AMR.<\/p>\n\n\n\n California and Maryland have recently attempted to address agricultural antibiotics use through localized regulatory schemes.[156]<\/a> In 2015, California codified in a statute some of the principles laid out in the FDA\u2019s GFI A Review of the Effectiveness<\/em> 152 and 209.[157]<\/a> The law was set to go into effect in 2018 and required that a MIA drug may not be given to livestock without a veterinary prescription.[158]<\/a> Furthermore, the statute placed restrictions on the circumstances in which prescription of MIA drugs is allowed.[159]<\/a> The statute requires that MIA be prescribed only when necessary to treat disease or infection, to control the spread of disease or infection, and for surgical operations.[160]<\/a> However, a crucial loophole remains that may allow for the potential overuse of MIA in animal agriculture: use is allowed when, \u201cin the professional judgment of a licensed veterinarian, it is needed for prophylaxis to address an elevated risk of contraction of a particular disease or infection.\u201d[161]<\/a> Importantly, the California regulations ban use of MIA for growth promotion or for consistent and regular use as a practice.[162]<\/a> However, MIA usage in dense farming practices may be relatively unchanged by this scheme because a veterinarian could easily deem prophylactic MIA as a necessity in a CAFO because of their density and disease-promotion. The statute also includes a significant surveillance scheme that accords with the 2015 National Action Plan for Combating Antibiotic Resistant Bacteria[163]<\/a> and a penalty for use and reporting violations.[164]<\/a><\/p>\n\n\n\n This law represented an important step forward in addressing AMR and gave meaningful and legally-binding requirements to agribusiness in California, a major agricultural producer.[165]<\/a> However, the law was not quite as effective as the legislature had hoped. The surveillance and data collection lagged behind the 2018 implementation goal.[166]<\/a> Additionally, California\u2019s Department of Food and Agriculture (CDFA) initially suggested that producers may still be able to use MIA in a regular pattern. This led some commentators to believe that many producers will continue to use the drugs in violation of the statute.[167]<\/a> Notably, California\u2019s law also fails to account for the inequitable burdens of AMR stemming from agricultural antimicrobial use. The law is similarly silent regarding the occupational hazards posed by continued overuse in agriculture, including that which is labeled \u201cjudicious.\u201d[168]<\/a><\/p>\n\n\n\n In 2017, Maryland passed a law, the Keep Antibiotics Effective Act of 2017, which also banned the regular use of MIA (as defined in GFI 152) starting in 2018.[169]<\/a> This law is similar to California\u2019s, but it has some stringencies that give it greater efficacy. First, the law exempts small farm operations from its requirements, tailoring the law to large agricultural actors.[170]<\/a> The Maryland law also has a reporting standard. Each year, licensed veterinarians must submit data to the Maryland Department of Agriculture, including:<\/p>\n\n\n\n (1) A copy of the record prescribing the medically important antimicrobial drug or a copy of the veterinary feed directive for each medically important antimicrobial drug . . . administered in feed or water to cattle, swine, or poultry during the previous calendar year; and (2) An accounting, as provided by the owner, of the total number of animals raised during the previous calendar year\u2026[171]<\/a><\/p>\n\n\n\n The Maryland law provides a great model for other states with its stringent reporting requirements. Other states have introduced bills for regulating antibiotic use in animal agriculture that mirror those passed in California and Maryland.[172]<\/a><\/p>\n\n\n\n Although state laws have begun to address some of the major failures of U.S. federal agricultural antibiotic regulation, there is some equivocality surrounding their efficacy in reducing the usage of agricultural antibiotics. Scarlet Bliss et al. released a study in 2023 suggesting that these laws lacked teeth for four main reasons:<\/p>\n\n\n\n 1) vague language on antimicrobial use within policies reduces policy effectiveness; 2) the lack of reporting by producers challenges the ability to evaluate the impact of the policies on actual use; 3) diverse stakeholders need to be involved in order to develop a more effective policy; and 4) funding should be linked to the policy to provide for reporting and data analysis.[173]<\/a><\/p>\n\n\n\n State and local regulatory policy may be an effective way to curb antibiotic use in the absence of meaningful federal action, and current laws in Maryland and California may serve as models for other states. However, these laws still have room for improvement. First, they fail to consider the disparate racial impacts of AMR. As a result, they still omit disproportionately affected communities from the AMR decision-making process.<\/p>\n\n\n\n Legislators could curb the risks of AMR by implementing overuse penalties or a tax on antibiotic manufacturing that fund medical monitoring or treatment of AMR infections.[174]<\/a> Such a law could very easily mirror the liability structure in the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA).[175]<\/a> CERCLA imposes a tax on petrochemical industries which creates a fund for cleaning up hazardous waste sites.[176]<\/a> Here, lawmakers could impose a tax on antibiotics manufacturers, agribusiness above a certain size which uses antimicrobial drugs in their feed, or both to create a fund. This fund could then be put to use for research into AMR, its disparate impacts, and effective treatment. CERCLA\u2019s owes its success to shifting the payment of risky activity to those responsible, and this \u201cantimicrobial CERCLA\u201d could do the same.[177]<\/a> If lawmakers were to pass such a law, we may begin to ameliorate both the distributive and procedural injustices of AMR.<\/p>\n\n\n\n Federal regulation of antibiotics use in animal agriculture has been largely unsuccessful.[178]<\/a> Even though state legislative action may be mobilized to address the threat of AMR, Bliss et al. mention in their study that there is consensus among experts that \u201cfederal policy is the most important path forward.\u201d[179]<\/a> In fact, they view state action \u201cmainly as a means to urge stricter antimicrobial use regulation at the federal level.\u201d[180]<\/a> Other researchers agree with the need for a much stronger federal leadership in the fight against AMR.[181]<\/a> To provide effective guidance, the federal government should, at the very least, adopt regulations and monitoring requirements like those in place in Maryland and California.<\/p>\n\n\n\n The FDA could also look to standards adopted in European countries for reducing antibiotic use in animal agriculture.[182]<\/a> In Denmark, the regulatory scheme includes well-implemented data collection programs and targets users who exceed the thresholds mandated by these regulations.[183]<\/a> The Netherlands provides a stricter regulatory approach in which use of growth-promoting antibiotics is simply banned.[184]<\/a> However, some experts suggest that this outright proscription may be slightly less effective at functionally reducing antibiotic use rates than the comprehensive regulatory framework adopted by Denmark.[185]<\/a> Although these regulatory measures have proven effective at curbing the issue overall, international efforts for curbing AMR still have not effectively addressed the disparate burden that AMR poses on historically underserved populations,[186]<\/a> and regulators adopting them would likely be insufficient alone for ameliorating the environmental justice concerns of AMR in the United States.<\/p>\n\n\n\n Many effective solutions for combating AMR center around data collection and monitoring of antibiotic usage on factory farms. The closest that the United States has to a reporting requirement is the National Antimicrobial Resistance Monitoring System (NARMS).<\/a>[187]<\/a> NARMS is an interagency effort to collect data about the causes of AMR, and the system collects data from CDC, FDA, and the United States Department of Agriculture.[188]<\/a> NARMS has been active for over two decades, and has undergone significant improvement since its conception.[189]<\/a> Its efficacy in collecting on-farm antibiotic use data is still critically limited and must be improved if federal agencies hope to effectively combat AMR.[190]<\/a> While NARMS collects data about the bacteria themselves, their focus is not centered around the question of who gets infected.[191]<\/a> Data collection and regulatory frameworks must include an acknowledgement of AMR\u2019s disparate impacts if they are to effectively promote environmental justice. AMR, as the CDC 2019 report says, is a risk that we all face,[192]<\/a> but it disproportionately impacts specific groups. Federal regulators must take these inequities into account as they continue to develop an effective schema for combating AMR.<\/p>\n\n\n\n The major gaps in research about the exact costs of continued agricultural overuse of antibiotics and the disparate impacts of AMR may necessitate creative solutions from legislatures and regulators. One avenue that could prove fruitful in closing the data gaps is medical monitoring. Medical monitoring grew out of tort law as a common law solution to \u201ccompensate plaintiffs who have been exposed to various toxic substances\u201d about which there may be limited medical data.[193]<\/a> Beginning in 1984, medical monitoring developed as a tort law cause of action and remedy, and was shortly thereafter applied toxic substance exposure claims.<\/a>[194]<\/a> Medical monitoring is intended to help plaintiffs pay for diagnostic tests after the defendant has exposed them to a substance known to increase their health risk.[195]<\/a> These claims have been used somewhat successfully in PFAS class actions, including in litigation against DuPont\u2019s Washington Works plant in Parkersburg, West Virginia.[196]<\/a> There, DuPont settled with the class members to provide, among other things, $235 million toward medical monitoring funding an independent panel to study the connection between PFOA and negative effects on human health.[197]<\/a> As a result, the 70,000 West Virginians in the class forewent a direct settlement payout in order to fund this gap-closing research.[198]<\/a> Seven years later, the study\u2019s scientists began to deem conclusively that there were probable links between exposure to PFOA and the negative health effects in the community.[199]<\/a> Moving away from reliance on the common law, some states have enshrined medical monitoring as a cause of action in various statutes.[200]<\/a><\/p>\n\n\n\n The medical monitoring approach could help address AMR and the research gaps about its disparate impacts as well. One plausible way to do this is to compel pharmaceutical manufacturers of agricultural MIA to fund medical monitoring studies. These funds could be distributed evenly to different research causes but may be more equitably and effectively used if they are earmarked for studying AMR resulting from occupational exposures such as work in slaughterhouses, meatpacking, or CAFOs. Although direct causal links between the manufacture of antibiotics for use in animal agriculture and any given infection may not be enough for a tort law claim, it may be enough to convince a legislature or agency to impose this sort of burden on manufacturers.[201]<\/a> An effective implementation of medical monitoring would represent a step forward in resolving the distributive injustices of AMR: those at risk would be those for whom the testing would provide the greatest potential for relief.<\/p>\n\n\n\n Some experts assert that the best solution is education for farmers.[202]<\/a> In the United States, farmers are, on average, more knowledgeable about antibiotics and AMR than farmers globally.[203]<\/a> However, researchers report that American farmers still have major knowledge gaps about the consequences of insufficient antimicrobial stewardship.[204]<\/a> Some studies suggest that greater knowledge among farmers increases the chance of positive outcomes regarding AMR, but other studies support the notion that knowledge alone is not sufficient.[205]<\/a> Some studies have also suggested that more sophisticated and larger farming operations are more likely to showcase knowledge about AMR.[206]<\/a> This research suggests further that lack of access to adequate educational resources in low-income farming communities have hampered the efficacy of these resources\u2019 distributive benefits, and that this inequity itself must be addressed in order to effectively educate farmers.[207]<\/a> As with most issues that have been addressed in this paper, there remains a paucity of research on this topic, and more studies are needed to examine efficacy of educational programs for farmers in combating AMR.[208]<\/a><\/p>\n\n\n\n Beyond statutes and regulations, consumers need to rethink the availability of cheap sources of animal protein and could potentially effect change through widespread behavioral shifts.[209]<\/a> Likely one of the best methods to curb the threat from AMR is to diminish our reliance on inexpensive products of industrial agriculture.[210]<\/a> The global wealthy rely on cheap sources of animal products at the cost, among other things, of underserved communities disproportionately bearing the burden of AMR.[211]<\/a> Even if meat consumption continues at its current high rates, some researchers suggest that American consumers choosing to buy meat raised without the nontherapeutic use of antibiotics could have a significant ameliorating effect on AMR.[212]<\/a><\/p>\n\n\n\n Another food-system-focused solution to AMR is to reduce the large amounts of food waste in the United States. Annually, 26% of the meat, poultry, and fish and 30% of the dairy products produced in the United States are wasted.[213]<\/a> In 2010, the estimated total loss of food products was 132.9 billion pounds, and consumers wasted over double the amount of food wasted at the retail level.[214]<\/a> Although there may be limits on how much the United States may effectively address the massive problem of food waste,[215]<\/a> the relatively high percentages of wasted animal products signifies a nontrivial amount of antibiotic usage in animal agriculture providing only detriment without any benefit. Addressing food waste in the United States will have significant environmental justice implications beyond AMR, as there are deeply rooted racial disparities in food access, quality, and security.[216]<\/a><\/p>\n\n\n\n However, these market-level consumer solutions seem unlikely to be implemented in the United States given our rising meat consumption and ostensible lack of willingness to regulate in this space.[217]<\/a> Increasingly, American animal agricultural products are being exported as global demand for meat products rises.[218]<\/a> However, trends in animal production in the United States may portend the possibility of meeting this demand without increasing the threat of AMR: even as antibiotic use fell in the late 2010s, meat production did not have a similar decline.[219]<\/a><\/p>\n\n\n\n Antimicrobial resistance is situated to be one of the most significant health crises of the 21st century. In addition to presenting a pressing medical threat, AMR is an environmental justice issue. Although we have reliable data that AMR infections disproportionately impact those who are low-income globally, there is a paucity of data on the disparate impacts of AMR in the United States. What data are available point to the probability that the burden of AMR is disproportionately borne by low-income people of color in the United States as well. Although there have been several attempts at combating AMR in the United States, none of the regulatory solutions proposed have considered this problem through the lens of environmental justice. If we are going to address AMR effectively in the 21st century, the United States must take into account the inequitable burdens imposed by AMR resulting from the use of antibiotics in animal agriculture. In doing so, the United States may begin to address the threat posed by AMR more effectively than it has yet. The challenges posed by AMR will not be easily solved, but any long-term strategy must take account of those who disproportionately bear the brunt of the costs.<\/p>\n\n\n\n [1]<\/a> Nathalie Prescott, Antibiotics: It\u2019s What\u2019s for Dinner<\/em>, 28 Geo. Env\u2019t L.J. 307, 311 (2016).<\/p>\n\n\n\n [2]<\/a> See<\/em> David Wallinga et al., U.S. Livestock Antibiotic Use Is Rising, Medical Use Falls<\/em>, Nat\u2019l Res. Def. Council (Nov. 18, 2021), https:\/\/perma.cc\/8H3P-E7PT.<\/p>\n\n\n\n [3]<\/a> GBD 2021 Antimicrobial Resistance Collaborators, Global burden of bacterial antimicrobial resistance 1990\u20132021: a systematic analysis with forecasts to 2050<\/em>, 404 Lancet 1199, 1200, 1209 (2024) [hereinafter GBD 2021]. A major issue that permeates this paper is the dearth of reliable data on which to base the true human and economic costs of AMR infection. To effectively address the threat of AMR, we must solve our reporting and methodological issues so that we truly understand AMR\u2019s costs, its causes, and its disparate impacts. See Strengthening Surveillance,<\/em> in<\/em> Combating Antimicrobial Resistance and Protecting the Miracle of Modern Medicine 117, 117 (Gillian J. Buckley & Guy H. Palmer eds., 2022); see also <\/em>Chidozie D. Iwu et al., The incidence of antibiotic resistance within and beyond the agricultural ecosystem: A concern for public health<\/em>, 9 MicrobiologyOpen 1, 17 (2020), https:\/\/perma.cc\/QL96-TKR3.<\/p>\n\n\n\n [4]<\/a> Margaret B. Planta, The role of poverty in antimicrobial resistance<\/em>, 20 J. Am. Bd. Fam. Med. 533, 537 (2007).<\/p>\n\n\n\n [5]<\/a> Nicole Gualandi et al., Racial Disparities in Invasive Methicillin-resistant Staphylococcus aureus Infections, 2005-2014<\/em>, 67 Clinical Infectious Diseases 1175, 1180 (2018); Gillian Smith et al., Impact of Social Determinants on Racial Differences in Carbapenem-Resistant Enterobacteriaceae Incidence, Atlanta, 2012-2018<\/em>, 7 Open For. Infectious Diseases S718, S719 (2020); Isaac See et al., Socioeconomic Factors Explain Racial Disparities in Invasive Community-Associated Methicillin-Resistant Staphylococcus aureus Disease Rates<\/em>, 64 Clinical Infectious Diseases 597, 603 (2017); Jacinda C. Abdul-Mutakabbir & Brenda Simiyu, Exploring the intersection of racism, antimicrobial resistance, and vaccine equity<\/em>, 2 Antimicrobial Stewardship Healthcare Epidemiology 1, 1\u20133 (2022), https:\/\/perma.cc\/5BLW-4B9W; Planta, supra <\/em>note 4, at 537.<\/p>\n\n\n\n [6]<\/a> Christy Manyi-Loh et al., Antibiotic Use in Agriculture and Its Consequential Resistance in Environmental Sources: Potential Public Health Implications<\/em>, 23 Molecules 1, 17 (2018), https:\/\/perma.cc\/W5WE-2T3U.<\/p>\n\n\n\n [7]<\/a> Claas Kirchhelle, Pharming animals: a global history of antibiotics in food production (1935\u20132017)<\/em>, 4 Palgrave Commc\u2019n 1, 9 (2018), https:\/\/perma.cc\/AUQ9-7VDF.<\/p>\n\n\n\n [8]<\/a> See <\/em>Stacy Sneeringer et al., U.S. Dep\u2019t of Agric., Econ. Info. Bull. No. 264, The U.S. and EU Animal Pharmaceutical Industries in the Age of Antibiotic Resistance 19 (2019) [hereinafter Age of Antibiotic Resistance].<\/p>\n\n\n\n [9]<\/a> Maya L. Nadimpalli et al., Antibiotic resistance: a call to action to prevent the next epidemic of inequality<\/em>, 27 Nat. Med. 187, 187 (2021).<\/p>\n\n\n\n [10]<\/a> Age of Antibiotic Resistance, supra <\/em>note 8, at 5.<\/p>\n\n\n\n [11]<\/a> Julian Davies & Dorothy Davies, Origins and Evolution of Antibiotic Resistance<\/em>, 74 Microbiology Molecular Biology Rev. 417, 418 (2010).<\/p>\n\n\n\n [12]<\/a> Age of Antibiotic Resistance, supra <\/em>note 8, at 5.<\/p>\n\n\n\n [13]<\/a> Iwu et al., supra <\/em>note 3, at 2.<\/p>\n\n\n\n [14]<\/a> GBD 2021, supra<\/em> note 3, at 1209.<\/p>\n\n\n\n [15]<\/a> See Deaths per Year<\/em>, Our World in Data, https:\/\/perma.cc\/LFK8-DMBT.<\/p>\n\n\n\n [16]<\/a> GBD 2021, supra<\/em> note 3, at 1216.<\/p>\n\n\n\n [17]<\/a> Id.<\/em> at 1207.<\/p>\n\n\n\n [18]<\/a> Id. <\/em>at 1200.<\/p>\n\n\n\n [19]<\/a> Devin Hunt & Olivia S. Kates, A Brief History of Antimicrobial Resistance<\/em>, 26 AMA J. Ethics 408, 412 (2024). Antibiotics researcher, Claas Kirchhelle, refers to access to \u201cquick fixes\u201d like stronger antibiotics as the root of the global environmental justice problem: it is \u201crisk mitigation . . . available at a price\u201d that only those with resources may access. This quick fix contributes to the antimicrobial \u201carms race\u201d and only serves to deepen the persistent environmental injustice of AMR as the globally wealthy escape consequences for their overuse of antibiotic medication, but those without resources find no such quarter. Claas Kirchhelle, The Antibiocene \u2013 towards an eco-social analysis of humanity\u2019s antimicrobial footprint<\/em>, Human. Soc. Sci. Commc\u2019n 1, 6 (2023), https:\/\/perma.cc\/3HPD-VUZ7 [Hereinafter Antibiocene<\/em>].<\/p>\n\n\n\n [20]<\/a> This includes rapidly declining death rates for children under the age of five. GBD 2021, supra <\/em>note 3, at 1199.<\/p>\n\n\n\nIntroduction<\/strong><\/a><\/strong><\/h1>\n\n\n\n
I. The What, Why, How, and Who of AMR<\/strong><\/a><\/strong><\/h1>\n\n\n\n
A. Antimicrobial resistance\u2014The What<\/strong><\/a><\/strong><\/h2>\n\n\n\n
B. A History of Antibiotics in Animal Agriculture\u2014The Why<\/strong><\/a><\/strong><\/h2>\n\n\n\n
C. A History of Federal Regulation of Antibiotics in Animal Agriculture\u2014The How<\/strong><\/a><\/strong><\/h2>\n\n\n\n
D. Disparate Impacts on Health of Traditionally Underserved Communities \u2013 The Who<\/strong><\/a><\/strong><\/h2>\n\n\n\n
i. Disparate prescribing practice and comorbidities<\/strong><\/a><\/strong><\/h3>\n\n\n\n
ii. Occupational Hazards<\/strong><\/a><\/strong><\/h3>\n\n\n\n
E. The Lack of Data Illustrates the Problem<\/strong><\/a><\/strong><\/h2>\n\n\n\n
II. Proposed Action<\/strong><\/a><\/strong><\/h1>\n\n\n\n
A. Legal Solutions<\/strong><\/a><\/strong><\/h2>\n\n\n\n
i. State and Local Action in the United States<\/strong><\/a><\/strong><\/h3>\n\n\n\n
ii. Federal agency action<\/strong><\/a><\/strong><\/h3>\n\n\n\n
<\/a>iii. Medical monitoring requirements<\/strong><\/a><\/strong><\/h3>\n\n\n\n
B. Social Solutions<\/strong><\/a><\/strong><\/h2>\n\n\n\n
i. Education for farmers<\/strong><\/a><\/strong><\/h3>\n\n\n\n
ii. Rethinking our relationship with food<\/strong><\/a><\/strong><\/h3>\n\n\n\n
Conclusion<\/strong><\/a><\/strong><\/h1>\n\n\n\n
\n\n\n\n