Raw Milk: A Research Anthology of Legal and Public Health Resources

Raw milk, or milk that has not been pasteurized, is a public health concern.1 Studies have shown that the legal sale of unpasteurized dairy products is associated with a higher incidence of related disease outbreaks.2 With the recent increase in the availability of raw milk to consumers, public health experts are researching the health risks and increased disease outbreaks resulting from raw milk sales. The consumption of raw milk is linked to a significant number of foodborne illnesses, some of which can result in serious complications and death.3 These illnesses are attributed to a variety of pathogens, including Escherichia coli, Campylobacter jejuni, Salmonella, Listeria monocytogenes, and Brucella abortus.4 Of recent concern are exposures of persons consuming raw milk to Brucella strain RB51, a pathogen that is both difficult to diagnose and resistant to the first-line antibiotic used to treat brucellosis.5

The advent of milk pasteurization, a heating process that destroys pathogens,6 provided legislators and regulatory agencies with a critical tool to protect public health. In 1947, Michigan instituted the first statewide milk pasteurization requirement.7 Since then, both the federal government and the states have played important roles in governing milk safety. Under authority granted by the Commerce Clause of the US Constitution,8 the federal government regulates the interstate sale of raw milk. In 1987, the Food and Drug Administration (FDA) issued its final regulation on the mandatory pasteurization of all milk or milk products (with the exception of some cheeses) for sale or distribution in interstate commerce.9 The FDA also regulates milk through its branding requirement, which states that anything labeled as “milk” sold in interstate commerce must be pasteurized.10

While the federal government has authority to regulate the interstate sale of milk, the individual states retain control over the intrastate sale of dairy products. Many states have adopted a model law proposed by the US Department of Health and Human Services, the Grade “A” Pasteurized Milk Ordinance, which prohibits the retail sale of unpasteurized milk,11 but state law on the sale of raw milk is far from uniform. States allow the distribution or sale of raw milk in several ways; some states allow its retail sale, while others prohibit sale in retail stores but allow sales on the farm, at farmers’ markets, or through cow or herd shares (an arrangement under which an individual owns part of a cow or herd and is entitled to the milk produced).12

In recent years, consumer demand has resulted in expanded legal access to raw milk in several states. Increased legalization of the intrastate sale of raw milk is expected to increase the disease burden associated with consumption of raw milk.13 The following resources describe and discuss some of the legal and public health issues associated with the sale of raw milk. Research for this anthology was restricted to the consumption of fluid, unpasteurized cow’s milk primarily in the United States, and was conducted in Westlaw and PubMed databases between February and May 2019.

Legal Resources

Federal Laws on Raw Milk

  • 21 C.F.R. § 131.110 (2019)external icon
    Federal regulation for the standardization of milk and cream in interstate commerce, defining “milk” as “the lacteal secretion” from cows and requiring that it be pasteurized and contain certain percentages of milk solids and milkfat.

Surveys of State Laws on Raw Milk

The following websites summarize state laws on the intrastate sale and distribution of raw milk. Contents, however, may be outdated.

  • State Milk Lawsexternal icon
    National Conference of State Legislatures (2016)
    Categorizes state raw milk laws based on legality of sale or distribution for different sites or modes (e.g., retail stores, on the farm, through cow-share programs). Links to an undated state-by-state summary of raw milk laws.

Legal Policy Articles on Raw Milk

The following articles give historical background and policy analyses of raw milk laws, including legal challenges to and theories of recovery under those laws.

  • The dangerous right to food choiceexternal icon
    Wiseman SR. Seattle University Law Review 2015;38:1299–315.
    Discusses the argument that the right to choose the food one eats, even if the government deems a food unsafe, is a fundamental right under the Constitution.
  • The legal anatomy of product bans to protect the public’s healthexternal icon
    Subscription required; link to abstract provided.
    Hodge JG & Scanlon M. Annals of Health Law 2014;23:20–41.
    Analyzes government product bans to protect consumer safety and devises a framework of essential elements to support passage (and prevent reversal) of product bans intended to protect the public’s health. Mentions raw milk among examples of bans on consumable products.
  • Raw milk in court: implications for public health policy and practiceexternal icon
    David SD. Public Health Reports 2012;127(6):598–601.
    Explains federal laws governing the sale of raw milk and reviews two federal cases involving raw milk, Farm-to-Consumer Legal Defense Fund v. Sebelius (action challenging constitutionality of federal interstate ban) and US v. Allger (action by FDA against Pennsylvania farmer engaged in interstate sale and cow-share program).

Public Health Resources

Disease Outbreaks Associated with Raw Milk

CDC defines a foodborne disease outbreak as “an incident in which two or more persons experience a similar illness after ingestion of a common food, and epidemiologic analysis implicates the food as the source of the illness.”14 The resources below describe some of the outbreaks associated with raw milk reported from 2010 to present.

  • Campylobacter jejuni infections associated with raw milk consumption—Utah, 2014
    Davis KR, Dunn AC, Burnett C, et al. MMWR Morbidity and Mortality Weekly Report 2016;65(12):301–5.
    Reviews a 2014 outbreak of campylobacteriosis in three patients who had consumed raw milk from a dairy in Utah, where raw milk sales from the farm are legal. Notes that raw milk from the dairy had passed state testing requirements prior to outbreak.
  • Outbreak of Escherichia coli O157 associated with raw milk, Connecticut, 2008external icon
    Guh A, Phan Q, Nelson R, et al. Clinical Infectious Diseases 2010;51(12):1411–7.
    Presents results of a study of an E. coli outbreak associated with raw milk sold from one Connecticut dairy farm store. Of 14 cases, 5 required hospitalization and 3 experienced hemolytic uremic syndrome. The dairy had met all state regulatory standards. Estimates put the combined cost of outbreak investigation and hospitalization expenses of case patients at more than $400,000.

Health Risks Associated with Raw Milk

The resources below discuss both emerging concerns and well-established risks associated with drinking raw milk, focusing primarily on risks posed by raw dairy in the United States. Articles assessing comparative risks and benefits are also included under this heading.

  • Raw milk intake: beware of emerging brucellosisexternal icon
    Sfeir MM. Journal of Medical Microbiology 2018;67:681–2.
    Highlights the importance of proper diagnosis and treatment of persons infected with Brucella abortus RB51, a potentially life-threatening emerging infection associated with consuming raw milk.
  • A 100-year review: microbiology and safety of milk handlingexternal icon
    Boor KJ, Wiedmann M, Murphy S, et al. Journal of Dairy Science 2017;100:9933–51.
    Presents a historical analysis of the improvement of milk safety through pasteurization and other microbial controls. Assesses future challenges and underscores need for the dairy industry to implement updated science-based food safety practices to protect public health.
  • Unpasteurized milk: a continued public health threatexternal icon
    Lejeune JT, Rajala-Schultz PJ. Clinical Infectious Diseases. 2009;48(1):93–100.
    Discusses pathways and sources of raw milk contamination, methods used to control contamination, and trends in raw milk consumption and associated disease outbreaks in the United States. Counters purported disadvantages of pasteurization and emphasizes that avoiding consumption of raw milk is critical to disease prevention.
  • Food safety hazards associated with consumption of raw milkpdf iconexternal icon
    Oliver SP, Boor KJ, Murphy SC, et al. Foodborne Pathogens and Disease 2009;6:793–806.
    Reviews literature on the prevalence of pathogens in raw milk in the United States (2000–2009), summarizes outbreak data (2000–2008), and describes state laws allowing sale of raw milk. Argues there is scant data to support contentions of raw milk proponents, while hazards are well established.

Potential Benefits of Raw Milk

Advocates for raw milk emphasize benefits of drinking raw milk related to nutrition, allergies, and lactose intolerance.15 While there is some evidence connecting raw milk to the “farm effect”—an association between children growing up on farms and reduced allergies—evidence of other benefits is lacking.16 Furthermore, the scientific literature in this area routinely acknowledges that even if raw milk plays a role in, for example, preventing allergies, the risk of serious infection far outweighs possible benefits.17 Following is a sampling of resources that address potential benefits of raw milk consumption.

Raw Milk Consumers (characteristics/motivation)

Raw milk consumers themselves occasionally have been the subject of studies to determine their characteristics and motivations. The following articles present the results of some of these studies.

  • Survey to determine why people drink raw milkexternal icon
    Mullin GE, Belkoff SM. Global Advances in Health & Medicine 2014;3(6):19–24.
    Examines the health-related motivations of individuals for consuming raw milk, testing a hypothesis that preference for raw milk would be related to lactose maldigestion.

Selected Websites

  • Raw Milk
    Information from CDC for consumers and researchers, with links to outbreak studies, resources and publications, questions and answers, infographics, and videos of individuals who describe their experiences with foodborne illness from raw milk.
  • Food Safety and Raw Milkexternal icon
    Explains the role of the FDA in regulating raw milk and provides information for consumers and links to internal and external sites about raw milk.

Position Statements by National Organizations

In addition to US government agencies, such as the FDA and CDC, the following national organizations have issued formal statements about the hazards of drinking raw milk and the need for pasteurization:

References

  1. See, e.g., Centers for Disease Control and Prevention. Raw Milk [website]. Last updated June 8, 2017. Available at www.cdc.gov/foodsafety/rawmilk/raw-milk-index.html.
  2. Langer AJ, Ayers T, Grass J, et al. Nonpasteurized dairy products, disease outbreaks, and state laws—United States, 1993–2006. Emerging Infectious Diseases 2012;18(3):385–90.
  3. Oliver SP, Boor KJ, Murphy SC, et al. Food safety hazards associated with consumption of raw milk. Foodborne Pathogens and Disease 2009;6:793–806.
  4. Langer, supra note 2.
  5. Centers for Disease Control and Prevention. Exposures to Drug-Resistant Brucellosis Linked to Raw Milk (Food Safety Alert) [website]. February 8, 2019. Available at www.cdc.gov/brucellosis/exposure/drug-resistant-brucellosis-linked-raw-milk.html.
  6. Lejeune JT, Rajala-Schultz PJ. Unpasteurized milk: a continued public health threat. Clinical Infectious Diseases 2009;48(1):93–100.
  7. Boor KJ, Wiedmann M, Murphy S, et al. A 100-year review: microbiology and safety of milk handling. Journal of Dairy Science 2017;100:9933–51.
  8. US Const. art. I, § 8, cl. 3.
  9. Requirements Affecting Raw Milk for Human Consumption in Interstate Commerce, 52 Fed. Reg. 29509-02 (August 10, 1987) (codified at 21 C.F.R. § 1240.61).
  10. 21 C.F.R. § 131.110 (2019). See also 21 USC § 331(a) (2019) (prohibiting introduction into interstate commerce of any adulterated or misbranded food).
  11. US Department of Health and Human Services, Public Health Service, Food and Drug Administration. Grade “A” Pasteurized Milk Ordinance (2017 Revision). Available at www.fda.gov/media/114169/downloadexternal icon.
  12. See, e.g., Mungai EA, Behravesh CB, Gould L. Increased outbreaks associated with nonpasteurized milk, United States, 2007–2012. Emerging Infectious Diseases 2015;21(1):119–22; Adams DC, Olexa MT, Owens TL, et al. Deja moo: is the return to public sale of raw milk udder nonsense? Drake Journal of Agricultural Law 2008;13:305–46.
  13. Costard S, Espejo L, Groenendaal H, et al. Outbreak-related disease burden associated with consumption of unpasteurized cow’s milk and cheese, United States, 2009–2014. Emerging Infectious Diseases 2017;23(6):957–64.
  14. Centers for Disease Control and Prevention. Foodborne Disease Outbreak 2011 Case Definition [website]. Accessed March 21, 2019. Available at https://wwwn.cdc.gov/nndss/conditions/foodborne-disease-outbreak/case-definition/2011/.
  15. Lucey, JA. Raw milk consumption: risks and benefits. Nutrition and Food Science 2015;50(4):189–93.
  16. MacDonald LE, Brett J, Kelton D, et al. A systematic review and meta-analysis of the effects of pasteurization on milk vitamins, and evidence for raw milk consumption and other health-related outcomes. Journal of Food Protection 2011;74(11):1814–32.
  17. Davis JK, Li CX, Nachman KE. A literature review of the risks and benefits of consuming raw and pasteurized cow’s milk. Johns Hopkins Bloomberg School of Public Health, Center for a Livable Future, 2014 report. Available at www.jhsph.edu/research/centers-and-institutes/johns-hopkins-center-for-a-livable-future/research/clf_publications/pub_rep_desc/Literature-Review-Risks-Benefits-Consuming-Raw-Pasteurized-Cow-Milk.htmlexternal icon.

This anthology was developed by Lisa Landsman, JD, MPH, Cherokee Nation Assurance (CNA) contractor and program analyst for the Public Health Law Program (PHLP) within the Center for State, Tribal, Local, and Territorial Support at the Centers for Disease Control and Prevention. The author thanks Dawn Pepin, JD, MPH, and Rachel Hulkower, JD, MSPH, CNA contractors with PHLP, for their editorial assistance.

For technical assistance with this anthology, please contact phlawprogram@cdc.gov. PHLP provides technical assistance and public health law resources to advance the use of law as a public health tool. PHLP cannot provide legal advice on any issue and cannot represent any individual or entity in any matter. PHLP recommends seeking the advice of an attorney or other qualified professional with questions regarding the application of law to a specific circumstance. The findings and conclusions of this summary are those of the author and do not necessarily represent the official position of the Centers for Disease Control and Prevention.