The Organic Trend

Consumers all over the world are becoming increasingly health conscious and are more than ever concerned about the quality of their food supply. Food is also crucial economically: Forbes magazine estimates that food is the world’s biggest industry, citing 2006 World Bank statistics that indicated that food represented about 10% of global gross domestic product, roughly $4.8 trillion dollars.¹

One of the major food choices facing consumers today is whether to buy organic or conventional food. While consumers wishing to buy organic food once had to seek out a specialized health food store or a farmers’ market, organic food is now a standard offering at major supermarket chains. Today, organic food is the fastest growing segment of the American food industry. Between 1997 and 2010, US sales of organic food increased from $3.6 billion to $26.7 billion, an extraordinary rate of growth.² By 2011, organic foods earned over $31 billion in the United States and accounted for about $450 million in exports in 2012. There are now over 17,750 USDA certified organic food producers and processors in the United States, and over 25,000 worldwide that meet USDA standards.

The growth in organic food sales has been so rapid over the past two decades that the phenomenon begs for explanation. Is it just a massive social fad, or does it reflect a profound change in our modern marketplace and in our personal consumption habits? Given the importance of food in the global economy, the trend toward organic foods is destined to have a major impact on a wide range of business sectors, including agriculture, food processing, supermarkets and groceries, fast food chains, restaurants, hotels, school and workplace cafeterias, caterers, and so on. Businesses in each of these sectors will have to make strategic decisions regarding the extent to which they will feature organic food products or related services.

In order to make responsible decisions, companies will need to understand the pros and cons of organic food, and especially why consumers are gravitating toward organic options. In fact, consumers who choose organic foods are driven by a number of different motivations and factors. The most common reasons for choosing organic foods are health concerns, including fear of pesticides and bacterial-borne illnesses; higher nutritional value; better taste; and environmental sustainability. However, as we will see, there is no clear consensus on the benefits to be derived from organic foods in any of these areas.

Regardless of the discussion over the benefits claimed for organic foods, there is no question but that they are more expensive. Organic foods are more costly to produce and as a result the prices to consumers are higher, with some organic options costing twice as much as their conventional counterparts. As a general rule, consumers will not pay significantly higher prices unless they are driven by some clear motivation. As with so many other areas in our society, the access to organic food—and the ability to afford it—comes most easily to those with deeper pockets. This creates a dilemma for many businesses faced with a choice between organic and conventional alternatives. If they offer organic food options, they will incur greater costs and have to charge a higher price. Whether or not this is a smart, strategic decision is an issue that every company (and every consumer) will have to decide on a case–by-case basis.

In this chapter’s debate section, we will consider the case of a private hospital deciding whether or not to institute an all-organic food service. Many hospitals are already beginning to provide some organic and locally produced food. As consumer demand increases for organic food, should hospitals follow this trend? The disturbingly high cost of health care is already one of the most contentious issues in American politics today. Should hospitals nonetheless accept the higher costs (and hospital charges) associated with organic offerings, so as to model and promote a public health policy related to nutrition? Should a hospital devote a greater percentage of its operating budget to providing organic food? The more a hospital spends on food, the less it will have available for other important health-related services. Will the health outcomes associated with eating organic food (even for the short time of the average hospital stay) outweigh the potentially higher costs entailed, or are the benefits too uncertain, taking money away from more pressing medical needs?

In order to answer these questions, we need to have a better understanding of the pros and cons of organic foods, especially relative to health outcomes. Organic farming practices attempt to promote a healthy and sustainable relationship between animals, humans, and the environment. Organic food production is a booming industry, but is it actually providing healthier, more nutritious food, or is it a successful packaging and marketing strategy with no real value to consumers?

What Is “Organic”?

In general, organic means that food was grown or produced without the use of synthetic pesticides or fertilizers, without GMO ingredients, without chemical food additives or artificial food-ripening substances, and without irradiation. Meats labeled as organic must come from animals raised without hormones or antibiotics. Processed foods may be allowed to contain a small percentage of non-organic ingredients and still be labeled organic (in the United States, no more than 5% non-organic). Note, however, that organic fruits and vegetables may be grown with a certain usage of natural (non-synthetic) pesticides and natural fertilizers. Animals raised for meat on organic farms may be treated briefly with antibiotics to manage disease.

In the United States, the 1990 Organic Foods Production Act (OFPA) set the national standards for the meaning, regulation, and certification of organic food. Only farms and facilities that have been inspected and certified by the USDA can claim to be organic and use organic on their labeling and packaging. Other countries around the world have different standards for what it means to be certified organic, which makes the import and export of organic foods difficult. In response to these constraints, the European Union and the United States created a new partnership in organic trade equivalence in 2013 with the objective of allowing organic products to flow more easily internationally.

For most of human history, agriculture was, by default, what we now call organic. Chemical pesticides only came into regular use about 60 years ago, allowing for expanded farming and greater output. Early on, most pesticides used were insecticides, but as potency increased, the amount of insecticides needed began to drop. Now about 70% of pesticides used are herbicides, and most of those are used in the cultivation of corn. Although pesticides are used widely across the United States, there is some fluctuation depending on the current pest infestations and types of crops. As public awareness grew about the potential dangers of chemical pesticides, certain pesticides were banned during the 1960s and 1970s. Consumers and public health advocates began demanding a return to natural and organic food production. The increased scrutiny led to new restrictions on the toxicity of allowable pesticide use. Today, chemical pesticides must adhere to health and environmental standards, and chemical companies continue developing new pesticides that may be less harmful to humans and the environment.

In addition to organic pesticides, organic farmers battle insect and pest infestation with crop rotation and cover crops.

Organic Food Evaluated: Pros and Cons

A poll conducted in 2011 by NPR–Thomson Reuters found that 58% of American consumers preferred organic foods.³ The reasons cited by those that preferred organic were support for farmers’ markets (36%), avoiding toxins (34%), environmental impact (17%), and taste (13%).

Let us now briefly examine some of the claimed benefits and alleged disadvantages of organic food and organic farming.

Environmental Impact

Pro

• Because organic farming is done without the use of pesticides and chemicals, toxic residues do not poison the land, water, and air. Organic farming is a sustainable use of land and resources. Crop rotation promotes fertile, healthy soil.
• Pesticide use in conventional farming contaminates runoff, water flowing over land, which is a natural part of the water cycle. Pesticide residues are found in ground water, surface water, and rainfall. This means that contamination may not be isolated in food produced with pesticides, but affects the environment as well.
• Healthy soil is a key component of organic farming.
• Organic farming seeks to protect and promote biodiversity.
• Conventional food production often involves thousands of miles of transportation from point of production to the grocery store, using oil and gas that contribute to global warming.

Con

• While one of the arguments for organic farming is the absence of chemical pesticides, natural pesticides may be used on organic farms, and these may also have potentially harmful effects. Organic plants grown without chemical or natural pesticides or fertilizers may produce naturally occurring pesticides, called phenols, to protect themselves against insect infestation. The effects of phenols on humans is an ongoing area of research and debate, as those in favor of organics tout their benefits while those skeptical of organics purport their potential health risks.⁴
• Pesticides allow farmers to obtain larger harvests and are therefore an economic asset to food production. Every dollar invested in pesticides results in about four dollars’ worth of crops produced. Pesticide use makes more economic sense, and provides more food to more people.
• Organic farming is too costly in terms of its greater use of land and resources. Organic farms are less productive (80% in one study) than conventional farms,⁵ and therefore require greater land use. In organic farming, weeds are removed without the use of chemicals. However, mechanical cultivation—including turning soil between crops to reintegrate plant parts and physically removing unwanted plants—can actually damage soil structure, remove needed moisture, release carbon into the atmosphere, and lead to increased soil erosion.
• As organic food carves out a greater share of the market and international markets expand, the carbon footprint of organic food distribution may exceed that of conventional food.

Health Impact

As often happens when opposing groups look at the same data, they come to different conclusions. In the view of proponents, organic food is much better for your health than conventionally grown alternatives. However, a number of studies, including a controversial metastudy published by researchers at Stanford University Medical School in 2012, find no evidence of significant benefits from organic food consumption in terms of health outcomes. There have been no long-term studies following children and adults who consume only organic food, and such studies would actually be rather cost-prohibitive to conduct. Nonetheless, let us review the arguments put forward by both sides.

Pro

• Organic produce has much lower—as much as 81% lower—levels of pesticide residue than conventional food. It also almost never contains high-risk pesticides. And while conventional produce can harbor multiple pesticide residues, that is rarely the case with organic produce.
• Evidence suggests that fetuses exposed to pesticides have higher rates of neurodevelopmental problems and disorders, birth defects, autism, ADHD, asthma, and lower IQ. In one study, school-aged children who began a primarily organic diet showed no pesticide exposure after only five days. Switching to an organic diet can thus have immediate and very beneficial advantages. Like fetuses and young children, other segments of the population, especially the elderly and people with degenerative diseases, are particularly vulnerable to the damaging effects of pesticide exposure. Another area of pesticide use that cannot be overlooked is its impact on the health and safety of farmworkers who have higher levels of exposure with conventional farming practices than organic.
• Proponents of organic farming maintain that organic food is more nutritious than conventional food. Organic apples, strawberries, grapes, carrots, milk, and grains have been found to have higher levels of vitamin C, antioxidants, and phenolic acids as compared to conventional food. On average, organic produce has nutrient levels 12% higher than conventional fruits and vegetables.
• Organic dairy products and meats contain an optimal balance of omega-6 and omega-3 fatty acids. Fats, consumed in the right amount, are crucial to human health. They provide energy, are the building blocks of cell membranes, and can be converted into other essential substances, like hormones, which are necessary for healthy bodily functioning. Diets higher in omega-6 and lower in omega-3 fatty acids can lead to a higher incidence of myocardial infarction and heart disease. On the other hand, eating diets with the optimal ratio of omega-6 and omega-3, found in organic food, can decrease the risk of heart disease.
• Organic farming virtually eliminates the consistent use of antibiotics in meat and dairy production, limiting the spread of antibiotic-resistant bacteria into the human population. Conventional meats are 300% more likely than organic to test positive for bacteria resistant to three or more antibiotics.⁶ About 70% of antibiotics given in the United States are used for animals in meat production, not in treating sickness, but to enhance growth and to mitigate the ill effects of overcrowding.⁷ Antibiotic resistance makes the treatment of infectious diseases much more difficult to control. The Centers for Disease Control (CDC) lists antibiotic resistance as one of its top concerns. The production of organic meat therefore has an immense public health benefit.

Cons

• The now well-known and often referenced Stanford study, a meta-analysis and comprehensive review of academic research on organic food and production, found virtually no health benefits associated with consumption of organic food. The Stanford research reported that organic food had only a 30% lower risk of pesticide residue than conventional food, compared to the 81% lower risk claimed by those in favor of organics.
• The Stanford study also found no significant differences in the nutritional value of organic versus conventional produce. The researchers noted that the risk for the presence of E. coli (a common bacteria) was about the same in organic and conventional produce. Although they also acknowledged that only five studies have been done, they found that four out of the five studies actually found a slightly higher risk for E. coli in their organic samples.
• Other studies have found that manure, a natural fertilizer, often transfers E. coli to soil, plants, and water used in irrigation and cleaning. Even though organic farming requires manure to be composted before usage and may only be applied to soil not used for growing food for human consumption, E. coli may still survive and can live in soil for over 200 days. This means that even if crops are rotated, E. coli can remain a threat to a new crop and to human consumers.
• Actual practices in organic farming differ widely. Although the USDA has attempted to define “organic” for certification purposes, these regulations nonetheless permit a great deal of variation of production methods in organic farming, just as in conventional food production. Simply having an organic label may not be a guarantee of best practices or of safe and nutritious food.
• In October 2012, the American Academy of Pediatrics (AAP) issued their first statement about organic food consumption, stating that there simply is not enough evidence to support claims of clear health benefits from an organic diet. While the AAP confirmed research that higher levels of pesticide residues and antibiotic-resistant bacteria are found in conventional rather than organic food, they advocated for parents to provide their children with a well-rounded diet, including a variety of fruits and vegetables, whether organic or not.

Hospitals, Health Care, and Organic Food

Just as ordinary consumers are showing a steadily increasing market preference for organic food, medical patients are following suit, expecting and demanding fresher, healthier, organic, and local foods. Many hospitals are beginning to respond to this demand, offering more organic food, hosting farmers’ markets in their facilities, and providing more information about nutrition to patients and medical workers. In addition to patient demand, organizations like the international coalition Health Care without Harm (HCWH) have pushed for changes to provide healthier and more sustainable food options in the health-care industry as well as education about nutrition. HCWH has issued a blueprint for change, including a variety of ways that hospitals can incorporate healthier food in their facilities, ranging from forming food “teams” and holding conferences to purchasing local and/or organic food.⁸

Traditionally, economic costs and organizational issues have made buying and providing organic food in hospitals a challenge. Hospitals have their own regulations and standards concerning food and food delivery. For example, some hospitals require potatoes to be delivered already peeled and cut, which lies beyond the production and distribution capabilities of most small organic farms.

Hospitals in the United States have predominantly relied on large-scale, nationwide food distributors. However, in 2005, MedAssets, a major purchasing agent for the health care industry, teamed up with United Natural Food, the leading distributor of natural and organic food, to supply healthier food options to hospitals around the country. In the first quarter of 2013, United Natural Food earned revenues of about $1.64 billion, up 22% from the previous year. There are almost 6,000 registered hospitals in the United States today.⁹ More than 2,000 hospitals in the United States offer some permutation of organic and local foods to patients and staff.

Many hospitals already do community outreach, running educational programs targeting nutrition and healthy eating. Some examples of local/organic food initiatives supported by hospitals today include the following:

• Catholic Healthcare West, a health system with 42 acute care facilities in three states, has developed an educational program about the relationship between food production and ecology, and no longer purchases dairy products containing the hormone rBGH.
• Kaiser Permanente hosts farmers’ markets in 25 of its medical buildings around the country and serves local and organic produce according to seasonal availability. To balance cost concerns, Kaiser has made changes in some of its traditional food service, including eliminating dessert from patient meals and replacing it with fruit.
• Dominican Hospital in Santa Cruz, California, buys organic food from a local farm and has created its own vegetable garden.
• Good Shepherd Medical Center in Hermiston, Oregon, no longer serves deep fried food and is switching to more organic food.
• St. Luke’s hospital in Duluth, Minnesota, now provides fair trade coffee, rBGH-free milk, wild salmon, and local organic salad.
• Alice Peck Day Memorial Hospital in Lebanon, New Hampshire, purchases vegetables from a local organic farm and provides an informational card with food served to patients. Food waste is returned to the farm for composting.
• Fletcher Allen Health Care in Burlington, Vermont, buys organic eggs and grows vegetables on its rooftop garden.

Although food does not make up a large part of a hospital’s operating budget, food prices continue to rise between 3% and 5% yearly, and with the cost of health care also increasing, every dollar spent must be justified by hospital management.

While patient demand may be spurring change, physicians and hospital workers also have a personal stake in the food served in hospital cafeterias and commissaries. Doctors, nurses, and other hospital workers account for most of the food consumed in hospitals. As more research shows links between diet and health outcomes, hospitals have the opportunity to model best practices. But that begs the question, what are best practices, and do they imply 100% organic offerings? Health care costs are often exorbitant and keeping costs down is a major issue for hospitals operating on a tight budget. Some people argue that food eaten during a brief hospital stay will have negligible effects on patient health outcomes and may simply not be worth the cost. Others, however, suggest that hospitals have a unique and powerful role to play in public health.

Case Study: Organic Hospital

In late January 2014, the (fictional) Lincoln Memorial Hospital of Yonkers is holding its annual strategic retreat for top executives. The retreat is held on a Friday and Saturday at the Taconic Hotel, a small hotel on the Hudson River. Item 1 on the agenda is a proposal by the hospital’s vice president of marketing, Jonah Strong, who has suggested that the hospital move to a 100% organic food policy for patients as a means of distinguishing itself from competitors.

Lincoln Memorial is a for-profit hospital owned by a large health-care provider, OmniHealth, which owns 11 other hospitals in 3 states. OmniHealth management is concerned that profits have been stagnant for the past 3 years at Lincoln Memorial and has informed Lincoln’s CEO, Dr. Sandra Maxwell that the company would like to see a return to 2% to 3% growth per year. Dr. Maxwell is prodding her executive staff to come up with new ideas to control costs and increase revenues.

Lincoln Memorial is an above-average sized hospital of 575 beds that offers a diverse range of medical services, from emergency care to maternity, pediatrics, cancer treatment, and so forth. Although it is not facing competition from other large hospitals in the area, a new trend toward small local clinics seems to be taking business away from Lincoln.

Lincoln is trying to control costs to stay attractive because the average cost of a stay at Lincoln is currently $1,925/day, which puts Lincoln slightly above several other competitors. As a result, Lincoln’s marketing approach is to vaunt its superior services. This is becoming increasingly hard to do as the main hospital building dates from 1968 and is beginning to need a renovation, which could cost over $10 million.

When the idea of the all-organic option was put on the table, Dr. Maxwell was approached by the vice president of human resources, Martin Torres, who informed her that the doctors and nurses would insist that food in the hospital’s cafeterias would also be organic, so that costs could escalate. The Food Services Director, Jennifer Wang, is extremely opposed to the idea. Ms. Wang tells Maxwell:

Do you have any idea how hard it is to source organic food for 1,000 people per day? Our patients and staff are used to eating food like tomatoes and spinach out of season, and that’s when organic prices go sky-high, sometimes even three times higher than conventional. Right now, the average food cost per patient is running at $55 a day and we’re billing them $125 just for food. If we have to go to 100% organic, my costs are going to go up at least 20% and we’ll have to pass that on, it could add $30–$50 per day to the cost of a hospital stay. Patients are already disturbed by the current cost per day, if this is what pushes us over the $2,000-a-day threshold, I’m afraid you’ll get sticker shock.

On the other side, Jonah Strong, the marketing vice president, has argued that it would be worth it:

Have you been to the Whole Foods recently? It’s packed every day, with very long lines, and those people are our customers. They’re already voting for organic with their pocketbooks. Organic food consumption is going up 20% per year and now we’re getting patients who get very upset if we can’t tell them if their food has GMOs. There’s no way we can keep bringing patients in, with all these new clinics, unless we can distinguish ourselves. If we don’t jump ahead of the other hospitals and distinguish ourselves first, one of the other hospitals will beat us to the punch.

Dr. Maxwell asks you to prepare the strongest arguments you can think of, on one side or the other, for presentation at the executive retreat.

Topic for Debate: Go Organic, or Stay Conventional?

Affirmative

Memorial should go to a 100% organic option.

Possible Arguments

• It will allow us to improve the health outcomes of our patients.
• It will allow us to do public service by performing a leadership role in health education.
• It will distinguish us from competitors.
• It will motivate our employees and show them that we care about them.

Negative

Memorial should not move to a 100% organic option.

Possible Arguments

• There is no evidence that organic food consumption has a significant impact on health.
• It would simply increase our costs, which will render us less competitive.
• Our average patient stay is only 5 days and, in that time, the benefit of organic food, if any, would be negligible.
• We should care more about cost and health outcomes than about marketing.

Readings

7.1 “Lots of Chatter, Anger over Stanford Organic Food Study”

Mestel, Rosie. “Lots of Chatter, Anger over Stanford Organic Food Study.” Los Angeles Times. September 12. 2012. http://articles.latimes.com/print/2012/sep/12/news/la-heb-stanford-organic-food-study-controversy-20120911

7.2 “Michael Pollan Responds to Study Finding “No Significant Health Benefit” to Organic Food”

Brooks, Jon. “Michael Pollan Responds to Study Finding ‘No Significant Health Benefit’ to Organic Food.” News Fix (blog). NPR: KQED News. September 4, 2012. http://blogs.kqed.org/newsfix/2012/09/04/michael-pollan-organic-study/.

You may have heard the NPR story this morning about the meta-study from Stanford University, published in the Annals of Internal Medicine, which found “no significant health benefit” to organic food. As physician R. Dena Bravata, the study’s co-author, told KQED Science’s Amy Standen today, when it comes to healthfulness, “there is, in general, not a robust evidence base for the difference between organic and conventional foods.”

Huh.

A 2010 Nielsen study found 76 percent of respondents bought organic because they thought it was healthier. So this seemed to merit a call to the person who convinced me in the first place that it was okay to pay $4.00 for a head of cauliflower: local journalist, professor, and food advocate Michael Pollan, whose book The Omnivore’s Dilemma was a major influence in popularizing organic and locally produced food.

JON BROOKS: So is this meta-study a big deal?

MICHAEL POLLAN: I’m not sure it’s a big deal. The media’s playing it as if there were something new here, but this is not new research, it’s a meta-study [a review of previously conducted research], and I’ve seen the exact same data analyzed in a very different direction. A lot of it depends on how you manage your assumptions and statistical method.

I think we’re kind of erecting a straw man and then knocking it down, the straw man being that the whole point of organic food is that it’s more nutritious. The whole point of organic food is that it’s more environmentally sustainable …which has a lot more to do with how the soil is managed and the exposure to pesticides, not just in the eater’s diet but to the farmworker…

JON BROOKS: Let’s say you’re a consumer standing there at your grocery store and you have a choice between an organically grown piece of produce grown far away and a conventionally grown piece grown locally. All things considered, which is the best choice?

MICHAEL POLLAN: It depends on your values. If you’re concerned about nutritional value and taste, you might find that the local food, which is more likely to have been picked when it was ripe, is better. Because any food that’s traveled a few days to get to you or been refrigerated for a long time is going to have diminished nutritional value. That argues for fresh being more important than organic.

But if you’re concerned about pesticides—let’s say you’re pregnant or have young kids you’re feeding—then you might choose organic, because it will have on balance fewer pesticide residues. You may also be concerned with the welfare of the people picking and the farmers growing your produce, or you may be concerned about soil health—that would argue for organic too…

I tend to favor local food, whether it’s certified organic or not. Most of the local food available to us in the Bay Area, though, tends to be grown organically, even if it’s not certified. So it is possible to have it both ways. If you’re shopping at your farmers’ market, you’re getting food that’s very fresh, probably very nutritious, and probably grown without synthetic pesticides.

7.3 “Mythbusting 101: Organic Farming > Conventional Agriculture”

Wilcox, Christie. “Mythbusting 101: Organic Farming > Conventional Farming.” Science Sushi (blog). Scientific American. July 18, 2011. http://blogs.scientificamerican.com/science-sushi/2011/07/18/mythbusting-101-organic-farming-conventional-agriculture/.

7.4 “The Benefits of Organic Food—For Less”

Villacorta, Manuel. “The Benefits of Organic Food—For Less.” Healthy Living (blog). Huffington Post. July 12, 2011. http://www.huffingtonpost.com/manuel-villacorta/natural-produce-pesticides_b_894031.html

…You have people who swear by organics and others who feel the whole movement is overblown—and often I hear that the organic movement is just a scheme to charge more at the markets. This whole “organic” concept has complicated our already difficult relationship with food.

I don’t write this article to fan the flames of the argument. Certainly, I understand that emotions on both sides run high… What I have learned that’s valuable to everyone, I think, is that there exists a middle ground between pesticide crops and certified organics: that is, fruits and vegetables that are seasonal, pesticide-free, and locally grown by farmers. There is such a thing as “clean” crop that is 100 percent natural in terms of no pesticides, but still absent an organic label. This comes as a surprise to many as we seem to think now that everything not marked organic is chemically tainted.

Finding pesticide-free non-organics is a great way to spend less money and enjoy natural produce. The only downside—if you consider it one—is that you have to eat seasonally, meaning you have to stop expecting ripe tomatoes and avocados in February in many parts of the country

Farmers’ markets provide a great opportunity to learn exactly how and where your food is produced and to sample items prior to purchasing. This option will also reduce cost, as well as be pesticide-free. Regardless of the kind of produce you buy, please buy it. I believe the benefits that come from consuming fruits and vegetables will outweigh the hazards of conventional farming…

Endnotes

1. Sarah Murray, “The World’s Biggest Industry,” Forbes Magazine, November 15, 2007, http://www.forbes.com/2007/11/11/growth-agriculture-business-forbeslife-food07-cx_sm_1113bigfood.html.

2. Smith-Spangler, Crystal, et al., “Are Organic Foods Safer or Healthier than Conventional Alternatives?” Annals of Internal Medicine, 157 (2012): 348–366.

3. Scott Hensley, “Organic Foods Have Broad Appeal, But Costs Temper Demand,” NPR.org, July 20, 2011, http://www.npr.org/blogs/health/2011/07/20/138534183/organic-foods-have-broad-appeal-but-costs-temper-demand.

4. Burke, Maria. “Don’t Worry, It’s Organic.” Chemistry World 1.6 (2004): n.p. Royal Society of Chemistry. http://www.rsc.org/chemistryworld/Issues/2004/June/organic.asp

5. Maeder, Paul, et al., “Soil Fertility and Biodiversity in Organic Farming.” Science 296.5573 (2002): 1694-697. http://www.sciencemag.org/content/296/5573/1694

6. Benbrook Charles. “Initial Reflections on the Annals of Internal Medicine Paper “Are Organic Foods Safer and Healthier than Conventional Alternatives? A Systematic Review.”” 4 Sept. 2012. http://caff.org/wp-content/uploads/2010/07/Annals_Response_Final.pdf

7. “Pew Recommendations to FDA Regarding Use of Antibiotics in Food Animal Production.” The Pew Charitable Trusts, 22 Feb. 2012. http://www.pewtrusts.org/~/media/legacy/uploadedfiles/phg/content_level_pages/issue_briefs/HHIFIBRecommendationsforFDAFactSheetpdf.pdf

8. Larry Cohen et al., “Cultivating Common Ground: Linking Health and Sustainable Agriculture” (Oakland, CA: Prevention Institute, September, 2004), , 14–15, http://www.noharm.org/lib/downloads/food/Cultivating_Common_Ground.pdf.

9. “Fast Facts on US Hospitals.” Fast Facts on US Hospitals. American Hospital Association, 2 Jan. 2014. http://www.aha.org/research/rc/stat-studies/fast-facts.shtml

The author wishes to acknowledge the invaluable research assistance of Vanessa Hemenway in the preparation of this chapter.