In this tale of two labs, the state-of-the-art facility is one that provides HIV/AIDS testing; it was paid for by wealthy foreign donors. The other facility is the Mbarara regional hospital’s antiquated general diagnostic laboratory, which operates on a shoestring budget provided partly by Kabakyenga’s university department. The disparity between the two labs means that, while many HIV/AIDS patients can get reasonable care, vastly larger numbers of patients — in an area long stricken with numerous other killer diseases besides AIDS — cannot. In a hospital where up to 20 percent of patients have HIV, investment in an HIV/AIDS lab is critically important. But the lack of resources for testing and treating diseases other than HIV/AIDS is disastrous: “We can do rapid and comprehensive viral load analyses for HIV patients,” Kabakyenga says, using the careful cadences of a scholarly man who risks straying into a political minefield. “But we can’t always manage a timely malaria test.”

Few places have enjoyed peace amid continuous political bloodbaths as long as Mbarara, which is the largest city in mostly rural western Uganda. In the 1970s, when much of Uganda descended into political butchery under the notorious dictator Idi Amin, Mbarara’s small population was largely spared. In the 1980s, when civil war ravaged the country, Mbarara’s handful of paved streets again served as sanctuary. In the 1990s, when a million people died during a genocide in Rwanda, just 60 miles away, Mbarara remained placid. Today, the lucky streak continues: With millions dying in the war-torn Democratic Republic of the Congo, just 80 miles to the west, Mbarara is largely untouched. But peaceful as it is, Mbarara and the region around it have frighteningly high death rates, especially among mothers and children. Meager medical services and high levels of malaria, tuberculosis, HIV/AIDS and numerous other killers mean that young children in western Uganda are about 25 times more likely to die before the age of 5 than in the U.S.

And even while attention to AIDS grew rapidly in Uganda and across Africa in recent years, many diseases that kill far more people — especially women and children — remain neglected. “For years, maternal and child health have been side issues, while concern for HIV was at the forefront,” Kabakyenga explains. “Now, some of us think it’s time these other issues get attention as well.”

It is the rainy season in Buhihi, a village of about 100 families located about a two-hour drive north of Mbarara. This is an area of banana plantations and deep rural poverty. Alice Tumisine is a subsistence farmer who depends on 2 acres of land to raise her family. Today, two of her three children are sick. The youngest, who is 3 years old, has a cough and seems sluggish. The middle child, who is 6, has a painful skin rash around her neck. Both children sit on a straw mat that divides the dirt floor in their home, a two-room mud-and-wattle house surrounded by banana trees.

A thin sheet of tattered cloth is all that shields Tumisine’s doorway from the rain, and although the weather is mild, the children seem cold in a home without heat. “I’m not sure why they are ill,” she says. “They have both been to the local government-run health clinic to receive medication for malaria and diarrhea many times.”

A neighbor, Richard Nuwagira, is trying to help. As part of a program organized by Kabakyenga at Mbarara University of Science and Technology, Nuwagira has been instructed in a set of basic concepts in managing child illnesses, including malaria, tuberculosis, diarrhea, pneumonia and HIV/AIDS. He has helped Tumisine take the children to the local government clinic in the past, and he’s now pushing her to go back to the clinic tomorrow. “I also worry about Alice,” he says discreetly. “I think she needs some tests as well.”

Nuwagira’s decision to volunteer as a village health coordinator stemmed in part from the little perks — a new pair of boots, an occasional tank of gas for his tiny motorcycle — that came with the role, he acknowledges. But mostly, he says, he volunteered because, at 47, he’s now one of the oldest remaining men in the community. Over his life span, he’s seen a tsunami of death and disease. Malaria, pneumonia, tuberculosis and all manner of tropical diseases and parasites have always plagued Buhihi, he explains. But in the mid-1980s, he recalls, AIDS struck the village as well. “Many people died here from AIDS,” he murmurs while staring down at the puddles growing around his boots in the rain. “Too, too many.”

The arc of Uganda’s AIDS epidemic almost exactly matches the time span of Nuwagira’s adult life. Uganda was an early hot spot in Africa’s horrific AIDS disaster, and by the late 1980s, the country was a byword for the disease’s ravaging progress across the rest of the continent. That notoriety spurred action: In the early 1990s, the Ugandan government adopted a mix of successful AIDS prevention strategies based on massive public information campaigns emphasizing safe sex. By the end of the decade, the epidemic’s spread had been largely staunched — making Uganda something of a poster child among international AIDS campaigners. Partly as a result, in recent years, Ugandan AIDS programs have benefited from international assistance on a huge scale. And thanks to that, health workers and activists living in even remote quarters of the country, such as Nuwagira, have now begun to think that other health problems — especially the handful of easily preventable diseases responsible for killing roughly four times as many Ugandans as AIDS — also require urgent attention from wealthy international donors.

Much of the money flowing into Ugandan AIDS programs comes from Washington. In 2003, then-President George W. Bush won distinction as the biggest spender in the history of international AIDS efforts by launching The U.S. President’s Emergency Plan for AIDS Relief. Through PEPFAR, in just five years, U.S. appropriations for international HIV/AIDS prevention and treatment more than tripled, from about $5 billion to more than $18 billion. But some countries have been luckier than others: For the war-ravaged Democratic Republic of the Congo, with a population of 68 million and an HIV prevalence of 3.2 percent, about $47 million was earmarked between 2003 and 2008. For neighboring Uganda, with a smaller population of 27 million but a higher HIV prevalence of 5.4 percent, $880 million was made available.

PEPFAR’s worldwide achievements have been substantial. In the five years after President Bush launched the program, it extended care to more than 10 million people affected by HIV/AIDS. About 57 million people received HIV counseling and testing, and 2.2 billion condoms were distributed. Support was given for the prevention of mother-to-child transmission of HIV during nearly 16 million pregnancies, and antiretroviral prophylaxis was supported for nearly 1.2 million pregnant women found to be HIV-positive, allowing nearly 240,000 infants to be born HIV-free. Some 2.1 million HIV-infected patients received antiviral drug treatment, saving an estimated 3.28 million adult years of life through the end of September 2009.

Such success stories are extremely rare in the history of disease-control in poor regions like sub-Saharan Africa. But in a report released last November praising PEPFAR and another massive effort, The Global Fund to Fight AIDS, Tuberculosis and Malaria, a team of researchers from Médecins Sans Frontières, a medical aid group that offers health care in war zones but has also provided AIDS care to 140,000 patients in 30 countries, described the global response to AIDS in recent years as exactly that — an overall success. “As a result of widespread public pressure and an eventual worldwide mobilization of resources,” MSF noted, “HIV/AIDS care, treatment and prevention programmes have expanded massively. There are now four million people alive as a result.”

But far from suggesting that anything like a celebration was in order, MSF offered a stark warning: “Rather than looking for ways to leverage and replicate the success of the AIDS public health revolution to improve global health, there are increasing calls for a diversion of foreign aid away from HIV/AIDS and towards other health priorities. While there is clearly a need to give urgent and additional resources to an array of global health priorities, not least maternal and child health, cutting HIV/AIDS funding is not the answer.”

In the war on preventable international diseases, relatively well-financed AIDS fighters have begun to attract resentment from fighters of less bankable diseases. With 3 million new people infected with HIV every year, huge resources are required to combat the epidemic, those involved primarily with fighting other diseases agree. But many experts, including Kabakyenga, say the time has come to find matching resources for the 530,000 women who die annually from largely preventable complications related to pregnancy and the 8.8 million children who die every year, many from easily treatable or vaccine-preventable conditions and malnutrition.

Propelled by this logic, efforts to rebalance international health care assistance to include formerly neglected killers alongside HIV/AIDS are gathering momentum. The Obama administration, for example, has decided not to increase funding for PEPFAR as it promotes a new six-year, $63 billion Global Health Initiative focusing on overall family health rather than any one specific disease. Similarly, the British government, which led the charge for support for HIV/AIDS among the G8 league of rich nations in 2003, has now “downscaled resources for HIV/AIDS, shifting support to maternal and child health,” MSF notes.

But by focusing aid on “strengthening health systems,” MSF complains in its call for a continued focus on AIDS, Britain has adopted “a broad and largely unmeasurable goal.” Is this turn toward diversifying disease-fighting programs alongside AIDS efforts — rather than continuing to boost AIDS budgets — a perverse effort aimed at punishing the success of AIDS fighters? Maybe so, MSF says. The group’s choice of a title for its report punched home exactly that point: “Punishing Success? Early Signs of a Retreat from Commitment to HIV/AIDS Care and Treatment.”

Well before MSF challenged the prospect of a diversion of foreign aid away from HIV/AIDS toward other health priorities, resentment within the international health community about the focus on AIDS had begun to percolate. Some voices critical of what has been labeled “AIDS exceptionalism” have been very blunt. The U.S. faith-based group Bread for the World, for example, has been particularly upfront. In a recent report, the group pointedly noted that in the case of Ethiopia, in 2008, “approximately 80 percent of U.S. poverty-focused development assistance — roughly $400 million — went to fight HIV/AIDS.” In a country where famine and malnutrition kills far more people than AIDS, the group would like to see more resources given to agricultural assistance alongside AIDS programs.

In the struggle to control HIV/AIDS, nutrition is critically important, Bread for Life notes. To drive that point home in a report several years ago, the group quoted Peter Piot, a former executive director of UNAIDS, recounting his experience in talking with HIV-positive women in Malawi: “As I always do when I meet people with HIV/AIDS and other community groups, I asked them what their highest priority was. Their answer was clear and unanimous: food. Not care, not drugs for treatment, not relief from stigmas, but food.”

Bread for Life’s perspective is not an isolated one. A spike in global food prices in recent years has pushed at least 100 million more people into hunger, according to a World Health Organization estimate, which means that at least 1 billion people now go hungry. Even where starvation does not pose a direct threat to life, malnutrition poses huge health risks, especially to children and mothers suffering from disease.

Jude Kimbowa, a pediatrician at the Mbarara Regional Referral Hospital who works with Kabakyenga, notes that malnutrition is almost always a complicating factor in diseases he treats — whether it is HIV, malaria, TB or any of a dozen or more major killers. But funding for research into how to tackle anything but HIV/AIDS is almost nonexistent, he laments.

During a recent shift on the malnutrition ward where Kimbowa works, 13 babies were being nursed back to life in a room almost devoid of basic medical equipment. Much of the care was being administered by family members, many of whom were living outdoors on the hospital grounds. The hospital itself operates on a shoestring budget, Kimbowa noted. And that means there are few resources to investigate ways to help improve children’s health — unless HIV/AIDS is involved. “I wouldn’t say we’re at the point of hopelessness,” Kimbowa said, “but there is a lot out there that we have not been able to look at. Take malnutrition. We did a small retrospective in 2008 and found that 80 percent of admissions had some degree of malnutrition, and 40 percent were severe. Almost no one is looking at other common childhood illnesses — diarrhea, pneumonia, intestinal infestations.”

In a review of the global malnutrition crisis published in 2008, the U.K. medical journal The Lancet estimated that about 3.5 million mothers and children die annually due to nutrition-related factors. Suboptimum breast-feeding alone was estimated to cause 1.4 million child deaths. So how expensive would it be to tackle this problem? According to an analysis prepared for the World Bank by Sue Horton, a Canadian economist who specializes in costing child and maternal survival strategies, about $10 billion. Currently, international donors stump up about one-tenth of that amount.

Malnutrition crusaders are not the only ones clamoring for resources to match the HIV/AIDS war chest. A recent report on immunization published by the U.N. children’s fund and the World Health Organization poses — and then swiftly answers — a blockbuster question: “If children’s lives are worth saving — and who would doubt that they are; if vaccines save lives — and the evidence is clear that they do; and if the world has the means of making, buying, and using vaccines, as it surely does: then why are children still dying from diseases that vaccines can prevent? The answer to this conundrum lies perhaps in the difficulty of choosing between conflicting priorities.”

The numbers compelling action on immunization are galvanizing: Along with clean water and better sanitation, immunization is credited with reducing the number of children under 5 dying every year from 17 million in 1970 to 10.5 million in 2000 and 9.2 million in 2007. “With the exception of safe water, no other modality, not even antibiotics, has had such a major effect on mortality reduction,” note the editors of Vaccines, a medical school textbook.

Progress on immunization in 72 of the poorest countries has been substantial in recent years, and for that, according to UNICEF and the World Bank, credit goes to the GAVI Alliance, (formerly known as the “Global Alliance for Vaccines and Immunisation”) a vaccine-financing partnership whose members include UNICEF, WHO, the World Bank and The Bill & Melinda Gates Foundation, as well as donor and developing country governments, private companies and innumerable community groups.

GAVI helped fund the center that administered this yellow fever vaccination.
(Courtesy of GAVI)

GAVI has vaccinated 200 million children and averted an estimated 3.4 million premature deaths since 2000, all at a cost since 2000 of $2.7 billion, even as funding commitments for immunization programs shrank. By any measure, at about $18 per child, immunization is a startlingly cost-effective health intervention. Even so, it’s estimated that 24 million children — almost 20 percent of the children born each year — still do not get the routine immunizations required in the first year of life. Ensuring they did so, however, would be far cheaper than almost any other approach to mass public health assistance in developing countries: For a mere $1 billion per year on top of current immunization expenditures, new and existing vaccines could be delivered to all children in the 72 poorest countries, GAVI says.

According to the WHO, if all the vaccines now available against childhood diseases were widely adopted, and if countries could raise vaccine coverage to a global average of 90 percent, by 2015 an additional 2 million deaths a year could be prevented among children under 5 years old — all at a fraction of the cost of existing HIV/AIDS programs with similar targets.

Achieving comprehensive global child immunization is among the greatest, entirely doable and comparatively affordable humanitarian opportunities in history — one that would dwarf the benefits of the eradication of smallpox, which cost $100 million over a 10-year period up to 1977 and has been saving vast numbers of lives, and an estimated $1.3 billion a year in treatment and prevention costs, ever since.

The calls for a rebalancing of the focus on HIV/AIDS to include equal attention to malnutrition, vaccination and neglected diseases grew from a significant body of peer-reviewed research strongly inflected with an explicitly moral complexion.

One of the earliest and toughest such assessments was published in 2006 in PLoS Medicine — a medical journal dedicated to open access without commercial constraint — under the seemingly obscure title “Incorporating a Rapid-Impact Package for Neglected Tropical Diseases with Programs for HIV/AIDS, Tuberculosis, and Malaria.”

The paper’s authors were a team composed of the distinguished British and American parasitologists Peter Hotez, David Molyneux, Alan Fenwick and Eric Ottesen, writing alongside the famous American development economist Jeffrey Sachs and his wife, Sonia Ehrlich Sachs, an international public health project coordinator. Hotez and his team were intent on using the journal as a scientific platform to bluntly call for a reconsideration of the focus on HIV/AIDS in moral terms cast around the need for a “comprehensive pro-poor health policy.”

To do so, Hotez and his co-writers took the unusual step in a scientific journal of tacking a quote from Elie Wiesel — the Nobel Prize-winning Holocaust writer — above their scientific review. The words that they borrowed from Wiesel are stark: “The age of hypocrisy has been succeeded by that of indifference, which is worse, for indifference corrupts and appeases: It kills the spirit before it kills the body. It has been stated before, it bears repeating: The opposite of love is not hate, but indifference.”

Having directed readers to see their paper not only as a piece of detached scientific analysis but as a call to moral action, Hotez and his team phrased a tough argument, calling attention to a wide array of “neglected” tropical diseases and infections — the list included leishmaniasis, human African trypanosomiasis, Chagas disease, trachoma, leprosy, Buruli ulcer, hookworm, ascariasis, trichuriasis, lymphatic filariasis, onchocerciasis, guinea worm, schistosomiasis, Cysticercosis, and food-borne trematodiases.

According to Hotez’s group, evidence was growing that this set of neglected tropical diseases may not only “threaten the health of the poor as much as HIV/ AIDS, tuberculosis, or malaria, but even more importantly, may have effective treatment and prevention strategies that can be delivered for less than US $1 per capita per year.”

Noting that increased efforts by G8 nations and U.N. agencies to improve the health of the world’s poorest 3 billion people has focused on fighting HIV/AIDS, tuberculosis and malaria, Hotez and his team complained that “conspicuously absent from these activities, however, has been commensurate advocacy for a group of diseases that exclusively affect the poor and the powerless in rural and impoverished urban areas of developing countries.”

The time had come, they argued, for a rethink: “Given the compelling logic and the very modest costs of embracing neglected tropical disease control efforts, it is surprising that those aiming to control the big three have largely ignored these opportunities,” they charged. “For too long the big three partnerships have worked in isolation.”

If any single individual deserves greatest credit for mobilizing rich nations, international agencies, corporations and individuals to devote money to AIDS in recent years, he may well be Stephen Lewis, a former Canadian diplomat who served as the U.N. Secretary General’s Special Envoy for HIV/AIDS in Africa from June 2001 until the end of 2006. It was during this period that the G8, the U.S. and many other wealthy governments, as well as corporate leaders and mega-philanthropists like Bill Gates, were finally persuaded — largely by Lewis and other high-flying advocates, including former President Bill Clinton — to begin devoting serious money to fight the AIDS pandemic in the world’s poorest, sickest places, especially sub-Saharan Africa.

These days, Lewis acts as a fundraiser for international AIDS programs, and he serves as the only non-American on the board of the Clinton Health Access Initiative, which aims to build on the Clinton’s success in persuading pharmaceutical companies to dramatically lower drug costs in 70 countries. As deputy director of UNICEF for five years in the late 1990s before taking on the job as the world’s senior AIDS diplomat, Lewis notes, “I spent as much time on oral rehydration and on malnutrition and on diarrhea and on acute respiratory infections and on pneumonia as on the emerging AIDS dilemma.”

Having seen all sides of the disease disaster, Lewis passionately decries any suggestion that money might now be diverted away from AIDS toward fighting other diseases.

Whether more lives could be saved by tackling different diseases that are cheaper to treat is a question he rejects. “It is a false and destructive dichotomy to pit one set of diseases against another,” he insists. “Everybody talks about the AIDS exceptionalism. Nobody talks about the moral obligation of the Western world to provide the money to do both.”

That money, Lewis notes, was promised long ago, in 1969, when the world’s wealthy nations agreed that seven-tenths of 1 percent of their gross national products should be devoted to helping poor countries. “We’re less than halfway there. And now, with the so-called international financial crisis, we’re declining further,” he says. “And the money that should be available for this — which is a larger pie, not a diminution of money for AIDS — is what everybody should be fighting for. Instead, the AIDS activists have been rendered on the defensive.”

While making this protest, Lewis adds that the money amassed for international AIDS control has cleared a path for new programs now required to fight other diseases as well. AIDS treatment and prevention efforts, Lewis believes, have become a kind of vector for the control of other diseases in numerous countries formerly bereft of such capacity: “Much of the health systems’ strengthening in these countries — much of the human resources necessary to respond to the entire basket of issues — is happening because of AIDS,” Lewis says. “It’s hard to get one’s mind around the positive things that have flowed from so ghastly an experience. But it is true that the development of laboratories across the continent, the development of research across the continent, the extraordinary sophistication for vaccine development has spawned a degree of public health awareness and activity that is really quite marvelous.”

Having come this far, Lewis argues, the “sheer criminal delinquency” of rich nations that fail to provide sufficient funding for comprehensive disease control cannot be ignored or used to justify scaling back the attack on AIDS: “All of them have to be funded and not one at the expense of the other. You don’t sacrifice AIDS because the Western world has defaulted on its obligations and on its promises.”

For Jerome Kabakyenga, what started as a nagging issue has now become a burning concern.

After 20 years of watching while international support for HIV/AIDS programs multiplied, the imperative to start tackling the health of children and mothers alongside HIV/AIDS has become unavoidable. Driven by frustration with the endless preventable carnage, late last year, Kabakyenga decided to step down as dean of Medicine at the Mbarara University of Science and Technology and get back to Bushenyi, a rural district with tremendously high death rates among mothers and children. It was in Bushenyi that he first started practicing medicine — much of it focused on women and children — 20 years ago as a young doctor.

In the years ahead, Kabakyenga plans to save as many lives as possible. “For the next phase of my career, I want to focus on studying obstructed prolonged labor,” Kabakyenga explained in a meeting at his spacious medical school office a few weeks after he made the decision to quit. “We are losing a lot of kids’ mothers in childbirth. I want to do something about it.”

To kick-start this new work, Kabakyenga will draw from a substantial cash award he received last year from the Global Health Research Initiative, a Canadian agency that has pushed in recent years to diversify international heath research to include other killers alongside HIV/AIDS.

In stepping back from the prestige of his position as dean, Kabakyenga acknowledges that he’s surrendering the power to direct other researchers toward new priorities. But with funding still almost nonexistent for anything but HIV/AIDS research in Africa, Kabakyenga says he won’t wait.

“The challenge is to get the prominence of child health and maternal health to reach the level that HIV has achieved,” he says. But rather than waiting for the international donors to figure this out, Kabakyenga has decided to plunge in. “For me, it’s a personal decision,” he explains. “The death rate for mothers and children is simply overwhelming. I’ve been taken up by the passion of this issue.”

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Here’s how the process works: A nearby egg hatchery sends chicks to Opsteen’s raising shed just a few days after birth. They’re given another 40 days to mature and fatten in the raising shed, and then they’re trucked away to a slaughterhouse operated by a grocery chain. After they leave, Opsteen scrapes six weeks’ worth of excrement off the shed’s concrete floor. Then the next huge flock of chicks arrives.

To help the birds cope with infections — the shed is forever teeming with the many types of bacteria and parasites that thrive in chicken excrement — drugs are mixed into the birds’ supplies of food and water. Opsteen’s not sure exactly what type of drugs they get; he relies on his feed supplier to get the mix right. But on one specific drug issue, Osteen is extremely clear: Although eggs are routinely injected with antibiotics at many North American poultry hatcheries, this was not done with the chickens on Opsteen’s farm, located in Ontario, Canada.

Opsteen’s uncertainty about the types of drugs used on his farm seems incongruous with his insistence that drugs were not used at the hatchery. But Opsteen, after all, is no ordinary farmer. He’s the farmer assigned to handle reporters looking for farm tours here in Ontario, heartland of the chicken industry in Canada, where exports to the U.S. are booming. And today, Opsteen’s been designated by professional chicken-industry media handlers to deliver one major message: On his farm at least, the chickens come from drug-free eggs. “I’m absolutely certain these chicks came from eggs that were not injected with antibiotics,” he says. “In fact, I can guarantee it.”

It’s a long way from Murray Opsteen’s raising shed to the gleaming, ultramodern headquarters of the U.S. Food and Drug Administration near Baltimore. But Opsteen’s preoccupation with denying the practice of injecting antibiotics into eggs — a procedure widely used to help prevent disease in densely packed chicken raising sheds — follows directly from a directive issued by the FDA last year.

Citing concerns that injecting eggs with antibiotics “presents a risk to the public health,” the FDA issued a rule in July 2008 that severely limited antibiotic use in hatcheries. The aim, the FDA said in a carefully reasoned statement backed by government studies from the U.S., Canada and Europe, was to restrict use of a class of antibiotics due to fears that misuse on farms reduced the antibiotics’ effectiveness for humans — a concern long voiced by the American Medical Association, the World Health Organization and public health agencies in numerous countries.

Coming from a federal agency with sweeping legal powers and powerful law-enforcement capabilities, the FDA’s rule was tough stuff — or so it seemed at first. But that was before the powerful U.S. chicken lobby — sometimes dubbed “Big Chicken” — stepped in. Within weeks of the FDA’s antibiotic prohibition, a barn burner of a fight, pitting scientists against farmers and physicians against veterinarians, ignited across the continent. Then, three weeks before the ban was to go into effect, FDA policymakers — mindful of an earlier ban on antibiotic use in poultry that was won only after years of litigation — suddenly abandoned their own ruling.

The target of the FDA’s concern was a category of antibiotics known as cephalosporins, which are highly valued because of their ability to knock out a wide range of otherwise hard-to-treat human ailments, including urinary tract infections and pneumonia. Cephalosporins were first marketed decades back, but doctors rely increasingly on newer, more powerful generations of cephalosporin antibiotics as bacterial resistance to other heavily used antibiotics — including penicillin — has grown. Although they were long considered a back-of-the-shelf drug, to be used only in rare situations when other antibiotics failed, third-, fourth- and fifth-generation cephalosporins have now moved to medicine’s very forefront.

It was with antibiotic resistance in mind that the FDA announced a ban on certain uses of cephalosporins — most notably their injection into poultry eggs, a practice the FDA had never studied or approved. Unrestricted cephalosporin use “is likely to lead to the emergence of cephalosporin-resistant strains of food-borne bacterial pathogens,” the FDA explained. “If these drug-resistant bacterial strains infect humans, it is likely that cephalosporins will no longer be effective for treating disease in those people.”

Cephalosporins are popular on poultry, cattle and pork farms, where the FDA has approved their use for numerous veterinary purposes. But farmers have also adopted “extra-label” uses of cephalosporins. In one such use, just before the egg hatches, robots pierce the shells of chicken eggs, injecting doses of a third-generation cephalosporin antibiotic, ceftiofur, to suppress disease.

This practice, known as preventive use, harnesses ceftiofur’s remarkable medicinal power not just to treat infection outbreaks but to suppress them. By preventing outbreaks from occurring in crowded raising sheds that hold as many as 50,000 birds, antibiotic egg injections help chickens to grow faster. The injections also allow farmers to send more birds to slaughter, even while they grow up in their own excrement.

Over the past decade, however, resistance to cephalosporin antibiotics has increased dramatically in North America, Europe and Asia, causing experts, including Robert Moellering of Harvard Medical School, to warn that thanks to misuse of antibiotics by veterinarians and physicians alike “we are perilously close” to not having drugs to treat tough-to-beat infections such as gonorrhea. “There are very few situations where we have no therapeutic options,” Moellering says, noting that eight patients recently died in New York City when cephalosporins and other antibiotics failed, “but we are getting close.”

From the farmer’s perspective, using antibiotics as growth promoters — an approach that U.S. Department of Agriculture antibiotics expert Todd Callaway estimates accounts for half of all drug use on farms — is simply money in the bank. Obviously, widespread agricultural use also greatly benefits ceftiofur’s manufacturer, Pfizer Inc.

And money brings popularity: According to a 2004 study of 24 hatcheries in the Canadian province of Quebec, ceftiofur was injected into eggs in every hatchery studied. In the U.S., according to a summary of a 2001 FDA investigation of 27 chicken and turkey hatcheries obtained by a Chicago-based group, the Food Animal Concerns Trust, four hatcheries reported injecting eggs, while four others reported injecting already-hatched birds. The real extent of ceftiofur usage may have been greater; more than a third of the hatcheries “kept poor or no treatment records,” the FDA reported.

When it comes to tracking drug use on factory farms, says Toni Poole, a USDA specialist on the use of antibiotics, secrecy is a serious problem. Penetrating that secrecy has become an urgent priority for a small but influential group of scientists. Alarmed about the global spread of bacteria resistant to up to as many as 10 types of antibiotics, governments in Europe, Canada and the U.S. established national surveillance systems late in the 1990s in an attempt to track human resistance to antibiotics in relation to usage of antibiotics on farms. What they have found — especially regarding links between ceftiofur use in poultry and human resistance to cephalosporins — has not been welcomed by the meat and poultry industries.

The scientists’ opening salvo came in 2006, when a group of the most senior antibiotic-resistance experts from the FDA, the Public Health Agency of Canada, France’s National Microbiology Laboratory and Belgium’s Veterinary and Agricultural Research Centre warned in a comprehensive review of published data that cephalosporin-resistant bacteria “are frequently recovered from animals and food, with poultry as primary food source, suggesting that humans are often infected by these routes.”

A subsequent series of studies in Europe and North America has convinced researchers — including Frank Aarestrup, a specialist on antibiotic resistance with the Danish Technical University in Copenhagen who helped introduce a system of comprehensive surveillance of veterinary drug use in Denmark — that the link between veterinary antibiotic use and human resistance has been proven. “Taken in context with all the other knowledge we have,” Aarestrup says, “anyone still opposing a link between antibiotic use in food animal production and direct human health impact does so for other reasons than science.”

In a recently published review of international studies on the issue, Aarestrup noted that a Canadian study found the adoption of universal use of ceftiofur in hatcheries in Quebec earlier this decade matched a rapid increase in human resistance to the drug. When this problem was brought to the attention of public health authorities, hatcheries voluntarily stopped using ceftiofur — and there was a rapid decrease in resistance to cephalosporins in humans.

The data cannot conclusively link drug use in poultry with human resistance, says James Johnson, an infectious disease specialist with the Veterans Administration Medical Center in Minneapolis. But like Aarestrup, Johnson thinks the data “is as good as it gets” in terms of signals about the dangers of ceftiofur use in hatcheries. Canadian veterinarians agree: Last year, the Canadian Veterinary Medical Association instructed its members not to use ceftiofur for extra-label purposes such as hatchery injections. The Canadian government also acted, last year ordering Pfizer to include a warning against extra-label use on ceftiofur packages.

Rebecca Irwin, who manages the Canadian farm antibiotic surveillance system, says that strong as the data implicating ceftiofur use in hatcheries with human resistance is, it would be even stronger if the poultry industry weren’t so secretive about drug use. “People can hide behind whatever,” she told a gathering of scientists in early May. “We’re still getting the ‘hear no evil, see no evil, speak no evil’ from numerous sources.”

Although chicken farmers seldom discuss their use of drugs — especially high-profile drugs such as cephalosporin — the veterinarians they employ are obliged to be more open, thanks to professional codes requiring at least a degree of scientific transparency. So when it came to mounting a response to the FDA’s prohibition of extra-label use of cephalosporins on farms, the industry turned to the American Veterinary Medical Association. The AVMA represents 78,000 veterinarians working in private and corporate practice, the government, industry, academia and the military.

In a toughly worded, 18-page letter drafted by a panel of veterinarians employed on chicken farms across the U.S., the AVMA broke ranks with its Canadian counterpart veterinarian organization, arguing that the FDA’s rule against extra-label cephalosporin use was completely unjustified. The Canadian, American and European studies cited by the FDA fail to directly demonstrate that veterinary use of ceftiofur impairs human medicine, the AVMA insists, and the FDA prohibition would put animals at risk. “Because veterinarians have a relatively limited number of FDA-approved drugs for treatment of the numerous animal species,” the American veterinarians’ group said, “extra-label cephalosporin use is medically necessary to relieve animal pain and suffering and allow veterinarians discretion to use drugs judiciously.”

Just weeks after the group filed its protest, the FDA reversed course. Late in November 2008, amid a crescendo of last-minute regulatory interventions by the outgoing Bush administration, William Flynn, acting director of the FDA’s Center for Veterinary Medicine, announced the restrictions on cephalosporin use were being withdrawn to allow the agency to “fully consider” comments, including the AVMA’s. “We responded through the AVMA,” says the National Chicken Council‘s Steve Pretanick. “They worked up the argument as to why the FDA should not take this action. As a result, the FDA withdrew it. And that’s the last I’ve heard of it.”

In Pretanick’s account, the business of getting the FDA to knuckle under sounds like a routine event. But Margaret Mellon, head of the food and environment program for the Washington-based Union of Concerned Scientists, describes a “take no prisoners attitude” on the part of the chicken industry at a time when it knew it could count on the White House.

“The past administration didn’t believe in regulation,” Mellon says. But she also believes the FDA itself “miscalculated the blowback” from the industry and its powerful rural political allies.

The FDA now refuses to discuss the matter. But speaking to scientists in Kansas in May, Flynn suggested the FDA’s retreat may not be permanent. The agency, he said, may try again to reintroduce restrictions sometime soon. Until that happens, however, poultry farmers will remain free to play chicken with some of the most important antibiotics in human medicine.

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