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Unpasteurized Milk
The Hazards of a Health Fetish
Morris E. Potter, DVM; Arnold F. Kaufmann, DVM; Paul A. Blake, MD; Roger A. Feldman, MD
Meaningful differences in nutritional value between pasteurized and
even increased in recent years under
unpasteurized milk have not been demonstrated, and other purported
intensive promotion by "health food"
benefits of raw milk consumption have not been substantiated. Conversely,
enthusiasts using arguments similar
the role of unpasteurized dairy products in the transmission of infectious
to those advanced in the 1890s.
diseases has been established repeatedly. To effectively counsel patients
In this review, we discuss the haz
attracted by the health claims made for raw milk, practicing physicians must
ards and purported benefits of raw
understand both the rationale used by proponents of raw milk and the
milk consumption to help the practic
magnitude of the risk involved in drinking raw milk.
ing physician and other health pro
(JAMA 1984;252:2050-2054)
fessionals more fully appreciate the
risk posed to human health by raw
milk and to enable them to under
AS THE dairy industry began to
teurization, claiming that it caused
stand and rebut arguments advanced
industrialize in the 1800s, the mass
nutritional deficiencies, allowed the
in support of consumption of raw
production and distribution of milk
marketing of sterilized filth, and
milk.
and dairy products led to widespread
destroyed the natural flavor of milk.
outbreaks of milkborne disease. The
Conversely, the pasteurized milk
Definitions
greatest perceived milkborne hazards
movement denounced certified milk
Milk, as discussed in this review, is
of the time were poor sanitation and
as unsafe despite the sanitary precau
cow milk unless otherwise specified.
handling procedures, as well as dis
tions.12 Ultimately, the best of both
Goat milk is increasingly promoted as
eased dairy cows. Repeated outbreaks
movements
became
public policy.
a
health food, but constitutes less
of typhoid, scarlet fever, diphtheria,
Pasteurization was accepted as the
than 1% of total milk consumption in
diarrheal disease, and septic sore
primary safeguard for the nation's
the United States.
throat were caused by milk that was
milk supply after several epidemics
Raw (unpasteurized) milk may be
produced, transported, and sold under
were
traced to certified raw milk,
certified or uncertified. Certified raw
unhygienic conditions.1
while the sanitary concepts of the
milk is produced in accordance with
Nationwide problems with contam
certified milk movement were incor
methods and standards established
inated milk led to two public health
porated into milk hygiene codes as
by the American Association of Medi
movements that attacked the pur
important adjunctive safeguards.
cal Milk Commissions, Inc (an indus
veyors of bad milk and each other
The apparent public health impact
try-supported
organization).
This
with equal alacrity. The certified milk
of safe milk was substantial; for
milk is produced by a few large
movement promoted sanitation in all
example, the number of infant deaths
dairies and is often sold, where state
phases of milk production and mar
due to diarrhea in Washington, DC,
laws allow, in retail food stores.
keting under the oversight of medical
dropped from 477 in 1894, the year
Uncertified raw milk is typically pro
milk commissions but denounced pas-
before sanitary requirements for milk
duced in small volumes by individual
were
strengthened, to 72 in 1909.'
dairy farmers and sold on the prem
Although there is no objective evi
ises of the producing farm or by home
From the Division of Bacterial Diseases, Center
for Infectious Diseases, Centers for Disease Control,
dence that milk pasteurization has an
delivery.
Atlanta.
adverse effect on human nutrition or
Pasteurized milk is milk heated for
Reprint requests to Division of Bacterial Diseases,
Center for Infectious
health, the sale of raw milk (certified
specified time and temperature com
Diseases, 1600 Clifton Rd NE,
Atlanta, GA 30333 (Dr Potter).
and uncertified) has persisted and
binations designed to kill all micro-
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Table 1.--Purported Health Benefits Derived From Drinking Raw Milk7
Purported Benefit
Comments
Higher nutritive value
Pasteurization causes insignificant decreases in thiamine, vitamin B12, and vitamin C contents; no effect
has ever been demonstrated on bioavailability of other milk constituents with known nutritive value; hu
man nutrition studies have shown no advantage of raw over pasteurized milk
Promotes proper development of teeth
This claim is primarily derived from a study of boys who drank raw milk and had a low incidence of caries;
'
and reduces incidence of caries
no comparisons were made with persons who drank pasteurized milk; no scientific evidence has been
subsequently produced for this contention
Enhances resistance to disease
No evidence exists in support of this claim for raw milk; on the contrary, milkborne disease was a problem
in animal studies comparing raw and pasteurized milk
Enhances fertility
This concept is based on misrepresentation of animal feeding studies that involved deficient diets
Contains beneficial enzymes,
Some enzymes are inactivated by pasteurizatfon, but these enzymes are probably inactivated by pepsin
hormones, and antibodies
and/or gastric acidity; hormone content of cow milk is uncertain, and hormones are not inactivated by
pasteurization temperatures; the small quantity of antibody in normal milk, while not inactivated by pas
teurization, is not absorbed in the human intestinal tract
Contains undefined substances such
These claims amount to little more than anecdotes
as antistiffness factor
Contains lactobacilli
Lactobacilli are contaminants rather than natural flora of milk; pasteurized dairy products containing added
lactobacilli are available
organisms that transmit disease to
Comparison of Nutritional Values
published a report about his observa
humans through milk. Currently ac
in Raw and Pasteurized Milk
tions on cats fed varying combina
cepted time-temperature combina
tions of raw and heat-treated milk
tions include 63 C for 30 minutes,
Pasteurization
causes
minor
and raw and cooked meat. In his first
71.6 C for 15 s, and 89 C or higher
changes in milk, and advocates of raw
and largest series of experiments,
for 1 s. Pasteurization does not steri
milk have at one time or another
Pottenger observed many diseases in
lize milk, but does make the milk safe
claimed that virtually every detect
cats fed raw milk and cooked meat,
to drink. Pasteurization should be
able change has profound health
but essentially no disease in those fed
distinguished from homogenization
implications. Pasteurization affects
raw milk and raw meat. Raw milk
(emulsification of milk fat) and for
six milk constituents with known
advocates have erroneously cited this
tification (addition of vitamins A
nutritional benefits: three vitamins
article as having reported that dis
and/or D). In the health food litera
for which milk is a minor source
ease occurred in cats fed pasteurized
ture, commentaries about the pur
(thiamine, B,,, and C), calcium, pro
milk (eg, Llyod F. Smith, MD's article
ported nutritional hazards of pasteur
tein, and fat.5"5 Thiamine is reduced
Why Certified Raw Milk, Let's Live
ized milk tend to blend the three
from approximately 0.45 to 0.42 mg/
Magazine). Smaller experiments re
processes into one. Like pasteurized
L; vitamin B,2 is reduced at a maxi
ported in the same article showed
milk, raw milk may be sold homoge
mum from 3 to 2.7 Mg/L; and vitamin
that a diet of one-third raw meat and
nized and with vitamins A and D
C is reduced from 2.0 to 1.8 mg/L.
two-thirds milk (pasteurized or not)
added.
None of these losses exceeds 10%, and
did not provide adequate nutrition for
The regulatory standards for pas
none
can
be considered important.
cats.
teurized milk vary by state, but these
About 6% of calcium is rendered
The major health benefits claimed
standards all meet or exceed those in
insoluble, and about 1% of milk pro
for raw milk are summarized in Table
the Grade A Pasteurized Milk Ordi
tein is coagulated. The major effect
1. These claims, except for a few
nance recommended by the Food and
on fat is a slight disaggregation of fat
recent variants, were rebutted more
Drug
Administration.
Individual
globules, resulting in a reduced cream
than 40 years ago by Wilson in his
state regulations on the sale of raw
line in whole milk. The observed
monograph The Pasteurization of
milk also vary, with some prohibiting
changes have no effect on the bio-
Milk.1 This book is required reading
such sales, others allowing sales only
availability of these three nutrients.4
for anyone interested in the topic.
on the premises of the producer, and
Raw milk has also been said to con
others setting
Infectious Disease
up standards paral
tain
undefined
and
undetectable
Hazards
leling their pasteurized milk ordi
health promoters, such
of Raw Milk
as
an
anti-
nance. All milk ordinances set mini
stiffness factor invaluable for treat
Abundant evidence has shown that
mum
standards for dairy animal
ment of arthritis, but such claims
raw
milk serves as the source of
health, personnel health, environ
have not been substantiated in the
bacteria that cause outbreaks of dis
mental hygiene, and milk quality.
medical literature.
ease in humans: in recent years, most
Quality control programs supple
Numerous studies of the relative
frequently salmonellosis and campy-
menting the official regulatory pro
nutritional merits of raw and pas
lobacteriosis. In the investigations of
grams are commonplace in the dairy
teurized milk have been conducted in
such outbreaks, the epidemiologic evi
industry. The standards for hygiene
animals and humans, and no differ
dence, combined with knowledge
of certified raw milk that are estab
ences
were
detectable. One animal
about the occurrence of specific path
lished by the American Association of
study deserves particular attention
ogens in cattle and the isolation of
Medical Milk Commissions, Inc, rep
because a misrepresentation of the
some
of these pathogens from raw
resent only one of many such pro
results has become prominent in the
milk, leaves no doubt that raw milk is
grams.
raw milk folklore. In 1946, Pottenger"
a vehicle for disease in humans.
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Modern sanitary and health stan
Salmonella dublin infections are of
during the week before onset of ill
dards observed by the dairy industry
particular concern because the associ
ness; drinking raw milk was the only
have made contamination from envi
ated illness tends to be severe. The
significant difference between cases
ronmental sources, including humans,
relative virulence of S dublin is illus
and controls (P<.05; relative risk,
an infrequent problem. In contrast,
trated by its ability to invade the
9.3).24
programs relying solely on sanitary
bloodstream18 and the rates of hospi-
In the United States, outbreaks of
and health standards have not suc
talization and mortality for infected
campyiobacteriosis associated with
ceeded in eliminating contamination
individuals.17'" Salmonella dublin is 13
drinking unpasteurized milk have
caused by symptomatic or asympto
times more likely to be isolated from
recently been reported in Arizona,
matic infection in the milk-producing
blood than are other Salmonella sero
California, Colorado, Georgia, Kan
animal. Contamination from animals
types, and more than half of the
sas, Maine, Oregon, and Pennsylva
with organisms such as Salmonella
patients with S dublin infection are
nia.2'32 In the outbreak of campyio
and Campylobacter has thus become
hospitalized. In two reports, 10% to
bacteriosis in Arizona,25 two cohort
the primary hazard for raw milk
20% of the cases of S dublin infection
studies showed that households with
consumers.
were fatal.17" Risk of S dublin infec
members who drank raw milk re
tion is significantly higher in persons
ported diarrheal disease significantly
Salmonellosis
over
the age of 40 years and in
more frequently than those in which
Many outbreaks of salmonellosis
persons with underlying chronic ill
no one drank raw milk, with relative
due to consumption of raw or improp
nesses or taking antacids.820
risks of 4.7 and 3.4. In the Georgia
erly pasteurized milk, nonfat dry
The problem of raw milk-associated
outbreak, illness due to campyiobac
milk, and cheese have been de
salmonellosis is not restricted to S
teriosis in 30 households was strongly
scribed.813 Salmonellae have been iso
dublin. From a baseline of three Sal
associated with consumption of raw
lated
from
raw
milk
repeatedly
monella typhimurium isolates in four
milk (odds ratio, 29.5), while contacts
during investigations of such out
years, the number of isolates of S
with pets, livestock, or well water
breaks.14""' Milk is an ideal growth
typhimurium from persons in a
were not associated with illness.28 As
medium for Salmonella, and some
three-county area of Oregon in
in Arizona and Georgia, only con
strains of Salmonella can even sur
creased to 27 in three months in early
sumption of raw milk was signifi
vive in cultured milk products, such
1983.2' Epidemiologie investigation in
cantly associated with enteritis in the
other
as yogurt, for as long as two weeks.14
criminated raw milk and cream from
outbreaks.
Surveillance of human salmonello
a
single dairy, and S typhimurium
Other Diseases
sis in the United States is based
with the same plasmid profile was
primarily on reports of isolates iden
isolated from milk, milk filters at the
Other bacterial diseases associated
tified at state public health laborato
dairy, the dairy cows, and the ill
with drinking unpasteurized milk
ries, and these isolates are believed to
persons.
from cows include brucellosis, coli-
represent only a small percentage of
Recently, in Vermont, eight persons
bacillosis,
listeriosis,
tuberculosis,
the cases that occur. Most isolates
(aged 10 months to 60 years) in four
corynebacteriosis,
staphylococcosis,
belong to a few common serotypes, so
families
had
diarrhea, abdominal
streptococcosis, streptobacillosis, and
epidemiologic investigations are usu
cramps, and fever.22 All had drunk
yersiniosis (Table 2). These diseases
ally not initiated unless there is an
raw milk from a single dairy. Salmo
are
now
infrequently reported as
unusual incidence of a relatively rare
nella derby was isolated from the
milkborne diseases in the United
serotype or a serotype that is a mark
patients and the milk. In 1980, a
States, but they illustrate the wide
er for a particular problem. There
multiresistant S typhimurium was
range of potential hazards.
fore, the relationship of sporadic
isolated from patients and milk dur
Milk other than cow's milk has also
cases to
been
a common source is usually
ing an outbreak of enteritis involving
associated with disease in hu
not detected when they are caused by
105 persons who had drunk raw milk
mans. Toxoplasmosis has been associ
ated with
a common serotype. Isolates of Sal
from a single source in Montana."
raw goat milk,3334 and bru
monella dublin, a relatively rare sero-
cellosis and campyiobacteriosis have
Campyiobacteriosis
type known to be host adapted to
followed consumption of raw goat's
cattle, are more likely to be investi
Since culture of diarrheal stools for
milk cheese.3538 The virus of tickborne
gated and identified as being derived
Campylobacter jejuni became com
encephalitis is shed in milk, and fresh
from raw milk than are the com
mon, many milkborne outbreaks of
cheese
made
from
unpasteurized
monly isolated serotypes. Numerous
campyiobacteriosis have been de
sheep milk has been associated with
studies in multiple locations have
tected. Fourteen (61%) of 23 Campy
this disease.3' Toxin-producing staph-
confirmed the role of raw milk in the
lobacter outbreaks reported to the
ylococci have been isolated from
transmission of S dublin to hu
Centers for Disease Control (CDC)
cheese made from raw sheep's milk.40
mans.8"7 Based on their 1982 data,
from 1980 through 1982 were traced
Comment
California health authorities calcu
to consumption of raw milk (Mark
lated that the risk of S dublin infec
Finch, MD, unpublished data, Decem
The relative merits of raw and
tion was 84 times higher in persons
ber 1983). In a detailed one-year study
pasteurized milk have been debated
who consumed
for
raw milk than in per
of sporadic campyiobacteriosis con
at least 90 years. In this period,
the
sons who did not (S. B. Werner, MD,
ducted in Iowa in 1982 and 1983, 35%
theoretic health benefits of raw
oral communication, October 1983).
of the ill persons had drunk raw milk
milk have never withstood careful
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Table 2.--Milkborne Bacterial Diseases of Less Frequent Occurrence in the United States
Agent
Comments
Bruceila sp
Worldwide, milk and other dairy products contaminated with Bruceila sp are the primary vehicles of transmission of
brucellosis to humans; in the United States, approximately 10% of the reported cases are attributed to consumption
of unpasteurized dairy products; products for one third of these cases are domestically produced35
Escherichia coli
Outbreaks of diarrhea have been reported in persons who consumed unpasteurized cream48 and Brie cheese49; plas-
mid-mediated antimicrobial-resistant E coli have also been isolated from milk50
Listeria monocytogenes
Listeria monocytogenes has been isolated from unpasteurized cow and sheep milk51,52; shedding of Listeria in milk
persists for long periods of time after the milk passes the visual examination following listeriosis53; evidence of milk
borne listeriosis in humans has been established54
Mycobacterium tuberculosis,
Sufficient tubercle bacilli are excreted by a single cow with tuberculous mastitis to make the milk of 100 clean cows
Mycobacterium bovis
infectious for infants55; in 1980, tuberculosis was diagnosed in 3 dairy herds in Arizona; 1,302 of 3,760 cattle
tested for tuberculosis were positive56
Corynebacterium pseudo-
A case of exudative tonsillitis and cervical lymphadenitis that resulted in prolonged hospitalization was described in a
tuberculosis
30-year-old man whose closest recent domestic animal exposure was drinking raw cow's and goat's milk5'
Staphylococcus aureus
Staphylococci in milk, either from mastitic milk or human contamination, cause gastroenteritis in consumers when they
ingest the heat-stable enterotoxin produced by the staphylococci58
Streptococcus sp
Streptococci cause a variety of diseases in humans and lower animals and are important saprophytes in milk and milk
products; like the staphylococci, they may be present in milk in large numbers when they cause mastitis in the milk-
producing animal; Streptococcus zooepidemicus is a common cause of mastitis in cattle, and milkborne outbreaks
of infections in humans followed by acute poststreptococcal glomerulonephritis have been reported59; a recent out
break has been associated with consumption of cheese made from raw milk60
Streptobacillus moniliformis
In the 1920s, there were some very large outbreaks of streptobacillosis traced to consumption of raw milk6'; when S
moniliformis is isolated from milk, the presumption of contamination by rats is made; it is unlikely that this disease
would present a milkborne problem in a dairy practicing currently accepted standards of dairy hygiene
Yersinia enterocolitica
Yersinia enterocolitica is frequently found in animal environments, may be present in unpasteurized milk at high con
centrations, and grows at refrigerator temperatures62,63; in a study in Ontario, Schiemann64 found Yersinia in 18% of
the raw milk samples, 9% of the cheese curd samples, none of the Cheddar cheese samples, and 1 of 265 pasteur
ized milk samples; Yersinia enterocolitica was isolated from raw milk in a suspected foodborne outbreak of yersinio-
sis in Montreal65
scientific scrutiny. Epidemic rickets
Observations
in
England
and
milk is not being singled out for
and scurvy and the other dire con
Wales, where an estimated 3.5% of
unwarranted
attention
by public
sequences
of
milk
pasteurization
the milk is consumed without pas
health authorities. Other ready-to-
prophesized by early raw milk advo
teurization, support the contention
consume
foods of domestic animal
cates have not occurred. Conversely,
that raw milk is an unsafe food
origin are subjected to processing
the fact that raw milk presents a
product. In the period 1951 through
procedures rendering them safe for
substantially greater inherent risk of
1980, these two countries reported 233
consumption and are microbiological-
infectious disease has been demon
outbreaks of communicable disease
ly monitored for adequacy of process
strated repeatedly. Surprisingly, the
attributed to milk or dairy products,
ing. Raw foods of animal origin, such
controversy continues.
with approximately 9,400 cases and
as chicken, may be contaminated with
Regulation of the sale of raw milk
four deaths.44 Seventy-five percent of
Salmonella and Campylobacter, but
often involves discussion of freedom
the outbreaks and about 40% of the
routine bacteriologie monitoring of
of choice. A major feature of the
cases were associated with raw milk;
these foods is not done because these
individual's right to free choice, how
most of the remaining cases involved
raw foods are normally cooked before
ever, is informed consent, and incor
faulty pasteurization or obvious post-
consumption. Furthermore, extensive
rect information on the purported
pasteurization contamination. Con
efforts are made to inform the public
benefits of drinking raw milk is so
tamination by Salmonella caused 74%
of the hazards and the proper cooking
widespread that truly informed con
of the outbreaks in this period. A
procedures for these products, and
sent is difficult to achieve. Also, in
detailed
cost-benefit
analysis per
practical measures to eliminate the
matters of foodstuffs, parents make
formed to determine the value of a
contamination are not available.
choices for their children. Therefore,
ban on the commercial sale of raw
In food hygiene, as in the operating
the children of advocates of raw milk
milk
in
Scotland
clearly demon
room, clean is not synonymous with
are exposed to the risks of infectious
strated a favorable ratio on the basis
safe. The raw milk industry points
diseases without a full understanding
of the costs of milkborne salmonello
to standards such as total bacterial
of the danger.4142 Children also tend to
sis alone.45 The role of raw milk as a
counts as proof of safety, but the high
drink what is given to them in school
vehicle of C jejuni infection, however,
incidence of disease associated with
without questioning its safety. There
was
not
demonstrated until 1978,
raw milk is strong evidence that these
have been numerous outbreaks of
when many laboratories began to look
standards are unreliable indexes of
enteric diseases in schoolchildren giv
for the organisms in diarrheal stools.
safety. Milk is an excellent vehicle of
en
raw milk while on field trips to
Since then, many raw milk-associ
infection because its fat content pro
dairies in the United States,32 and a
ated Campylobacter outbreaks involv
tects pathogens from gastric acid,
large outbreak of campyiobacteriosis
ing thousands of cases have been
and, being fluid, it has a relatively
traced to the consumption of free raw
reported by English investigators.*'47
short gastric transit time. Thus, low-
milk
at
school
was
reported in
When one considers the known
level contamination, which would be
England.43
health risks, it is apparent that raw
readily controlled by pasteurization,
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presents an important hazard to the
viding major health benefits beyond
cians and other health professionals
raw-milk consumer. This hazard is
those of pasteurized milk has not
must be aware of the facts concerning
magnified when the consumer has
been supported by the evidence. In
risks and benefits from raw milk to
less resistance to infection because of
contrast, the hazards of raw milk
better advise patients who have ques
age or underlying disease.
have been proved. Sale of raw milk,
tions about the safety and benefits of
The promotion of raw milk as pro-
however, is still permitted. Physi-
raw milk consumption.
References
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