"He endured explosive bouts of vomiting. His screams were followed by silence; he had tremors, delusions, and no longer knew who I was. I sat with him as monitors recorded organ failure after organ failure. A massive seizure left him on a respirator.
"I tell you Alex's story to remind you that behind every statistic is a life," Donley told a hushed crowd at "Changing Strategies, Changing Behavior: What Food Safety Communicators Need To Know," a food safety education conference attracting over 550 people to Georgetown University's Conference Center in Washington, D.C., last June 12 and 13. "Alex mattered -- I will not allow his death to be chalked up as an unfortunate statistic. To me, the 'E' in E. coli O157:H7 stands for evil."
Donley, a real estate broker who also serves as president of S.T.O.P. (Safe Tables Our Priority), frequently speaks to all types of groups about food safety issues. Her heart-wrenching story is a horrific illustration of the importance of food safety. Although the U.S. food supply is among the world's safest, as many as 9,000 Americans die each year, and millions more are sickened, as the result of a food-borne illness, according to government estimates. Those who came to Washington in June -- people responsible for food safety, consumer educators, the media, and representatives from the Food and Drug Administration, the U.S. Department of Agriculture, and the Centers for Disease Control and Prevention -- all came with the same goal in mind: to reduce the incidence of food-borne illness to the greatest extent possible.
"People ask me all the time if I cooked the hamburger [Alex ate] ... of course I did," Donley said. "But consumers need the truth: It needs to be 160 degrees as measured by a meat thermometer, or don't eat it!"
Susan Conley, director of USDA's Food Safety Education and Communications Staff, and a former director of USDA's Meat and Poultry Hotline, told the conference audience that most consumers rely on the color of meat to determine "doneness" and have little information about proper cooking techniques.
"There's a lot of conflicting information out there," Conley says. "Based on my Hotline experiences, people need to understand the characteristics of bacteria -- that it grows rapidly at room temperature and slowly while refrigerated. The issues of cross-contamination, improper cooking, and poor personal hygiene of food preparers all must be addressed."
Experts agree that prevention of pathogens in food requires an understanding of how foods become contaminated during production, processing and distribution, as well as understanding cultural changes affecting food consumption. Michael Sansolo, vice president of industry relations for the Food Marketing Institute, an organization supporting retail food stores, notes that changing eating habits of consumers and seeming lack of consumer concern about food safety all are important factors when it comes to understanding food-related illnesses.
"Competitors [for supermarkets] include restaurants as well as other markets. It was uncommon to eat out in the 1950s, but today restaurant eating is way up," Sansolo told conference participants. Eating out as often as eating at home changes the way people think and cook, he explained. "For example, 70 percent of people who eat out say [they do it because] they don't want to cook, so how do we educate them on food safety [in cooking]?" he asks.
Sansolo notes that while these days customers are demanding low-fat restaurant meals, it took a long time for the message of the importance of low-fat eating to take hold in consumers' minds. His correlation is easy to understand: Food educators also need to note that it may take time to get the issue of safe food handling and cooking practices both at home and in retail settings to become a regular part of the American psyche as well.
For example, "[When it comes to] supermarkets, consumers say they want quality produce, a clean store, etcetera, but they never mention food safety," he explains.
When it comes to safe food production, Sansolo says Institute members are focusing on HACCP ( Hazard Analysis and Critical Control Point). A science-based preventive approach to safe food production, HACCP requires a firm to identify food production, manufacturing and transportation "critical control points" where contamination could occur. Then the firm puts control measures in place at those points. HACCP varies from plant to plant and product to product.
But the most crucial issue -- educating the people who buy and prepare foods, be they consumers or restaurant workers -- remains a key challenge in the battle against food-borne illness.
"People don't see food safety problems as related to their personal food handling practices," says Alan Levy, Ph.D., a statistician and chief of the consumer studies branch in FDA's Center for Food Safety and Applied Nutrition. "[Studies have shown that] 80 percent think failures occur in the food processing system. Few see their own actions at home as having an impact.
"Consumers have major misconceptions regarding food-borne illness. Most people think food prepared at home is safer than restaurant food although food safety experts say the opposite is true. They also think food-borne illnesses are mild. If people don't see food-borne illnesses as a real problem, they will be less likely to change their behavior."
The sad fact is that food-borne illness can be very serious, as Nancy Donley's loss of her only child so clearly illustrates. Some pathogens give rise to diseases far more serious than the uncomfortable vomiting or diarrhea accompanying what most people call "food poisoning." Food-borne infections can cause spontaneous abortion, reactive arthritis, Guillain-Barré syndrome (the most common cause of acute paralysis in both children and adults), and HUS (hemolytic uremic syndrome), which can lead to kidney failure and death.
Levy says studies from the late 1980s and early 1990s have demonstrated that while people are becoming more concerned about food safety, unsafe practices are actually increasing, marking a real difference in peoples' concern vs. their actual behavior.
"There's inconsistency in food safety thinking, since normally greater knowledge is associated with better behaviors," Levy says.
One report distributed at the conference, Footnote Data Population Survey, prepared by USDA's Food Safety and Inspection Service, noted that while 87 percent of those surveyed claimed they have read the safe handling label on ground beef, only 38.5 percent have changed the way they handle or cook ground beef.
Peter M. Sandman, Ph.D., a consultant with Risk Communications in Newton, Mass., and a conference speaker, says, "The risks that do damage according to the experts are not usually the risks that upset people. Experts respond to hazards; the public responds to outrage. When hazard is high and outrage is low, the experts will be concerned and the public will be apathetic. When people are outraged, they tend to think the hazard is serious."
For example, the risks that actually can do damage to people according to experts are not usually the risks that upset most people. Sandman cited such issues as concern about genetically altered foods and pesticides on food as "low hazard, high outrage" risks, when in actuality lack of knowledge about proper cooking temperatures and times for various meats and poultry pose more of a real hazard. Personal experience, the experience of others, and the news media, Sandman notes, all make a risk memorable in the public's mind. He says that public health personnel usually are doing a good job when it comes to dealing with hazards but are not doing a good job when it comes to outrage.
"Two concepts are important -- alerting people to the risks, and assuring people," he says.
The increasing complexity of food-borne illness itself also muddies the water when it comes to understanding food-related illness. Frederick J. Angulo, Ph.D., D.V.M., a CDC medical epidemiologist, cites a 1995 Salmonella outbreak in which "seeds grown on one continent, distributed to a second continent, caused illness on a third continent."
"We truly live in a global village and this [outbreak] reflects that," Angulo says. "It illustrates the increasing complexity of food-borne disease, which is occurring in multi-state and international fashion."
Oceans and man-made boundaries are not barriers to food-borne bacteria. Click on the map at right to see how a 1995 outbreak of Salmonella infection in the United States began with tainted alfalfa seeds half a world away.
Scientists are also seeing new routes of transmission, newly identified "reservoirs" of pathogens such as Cyclospora on raspberries, and new types of pathogens, Angulo notes. Other problems include existing organisms expressing new ways to evade immune defenses and the susceptibility of certain people -- such as children, the elderly, people taking medicine for cancer treatment or organ transplants, and HIV/AIDS-infected people -- to food-borne illness.
FDA, CDC, and USDA's Food Safety and Inspection Service currently support seven FoodNet (Food-borne Disease Active Surveillance Network) early-warning sites at state health departments to track cases of food-borne infections and determine their sources. Angulo says even better surveillance is needed, not to "count cases" but to identify food-borne diseases and their sources.
Levy says that studies have shown that print and electronic news stories are the number one way people get information today when it comes to food-related issues. Second on consumers' lists: food labels, food packaging, and "the government," with cookbooks occupying third place among the ways people learn about safe food handling and preparation.
The Partnership for Food Safety Education, a public/private coalition including FDA, CDC, USDA, industry, consumer groups, and the U.S. Department of Education, is currently working to come up with effective strategies to convey food safety messages via the media and other channels.
"Until Alex's death I had no idea the food we bought and served our families could be carriers of deadly pathogens," says Donley. "I am attempting in my own small way to help others, just as Alex would have done, to be the voice for those forever silenced."