US Violates WHO Guidelines
For Mad Cow Disease
A Comparison of North American and European Safeguards

By Michael Greger, M.D.
For the Organic Consumers Association
Updated July 15, 2003

The National Cattlemen's Beef Association describes government and industry efforts to safeguard the American public from mad cow disease as "swift," "decisive" and "aggressive."[1] The US Secretary of Agriculture adds "diligent,"[2] "vigilant" and "strong."[3] The world's authority on these diseases disagrees.
Dr. Stanley Prusiner is the scientist who won the Nobel Prize in Medicine for his discovery of prions, the infectious agents thought to cause bovine spongiform encephalopathy (BSE), or mad cow disease. The word Dr. Prusiner uses to describe the efforts of the U.S. government and the cattle industry is "terrible."[4] What are these "stringent protective measures"[5] that the Cattlemen's Association is talking about, and how do they compare to global standards and internationally recognized guidelines?
In 1996, in response to the revelation that young people in Britain were dying from variant Creutzfeldt Jakob Disease (vCJD), the human equivalent of mad cow disease, the World Health Organization (WHO) issued seven "Recommendations." Numbers 5-7 were observations and/or recommendations for further research. The first four recommendations, however, were concrete proscriptions to reduce the likelihood of mad cow disease spreading to human populations.[6] To this day, the United States government continues to violate each and every one of these four guidelines.
#1. Stop Feeding Infected Animals to Other Animals The number one recommendation of the World Health Organization was that no "part or product" of any animal showing signs of a transmissible spongiform encephalopathy (TSE), or mad cow-like disease, should be fed to any animal.[7] "All countries," the guideline reads, "must ensure the slaughter and safe disposal of TSE- affected animals so that TSE infectivity cannot enter any food chain."[8] Yet, in the U.S., it remains legal to feed deer and elk known to be infected with a transmissible spongiform encephalopathy called chronic wasting disease to livestock such as pigs and chickens. [9]
Although science has yet to investigate whether pigs and chickens are susceptible to "mad deer" prions, there is a concern that even if these animals don't develop clinical symptoms of the disease, they could become so-called "silent carriers." Dr. Richard Race is a Senior Investigator with the National Institutes of Health.[10] In 2001, he published a landmark paper showing that even species thought to be resistant to particular strains of prions could invisibly harbor the disease and pass it on to other animals.[11] He also found that these deadly prions were somehow able to adapt to the new species, becoming even more lethal and replicating faster and faster. [12]
At a 2002 symposium on chronic wasting disease, Dr. Race expressed concern that U.S. cattle could be invisibly harboring chronic wasting disease and passing it on to humans.[13] The reason Dr. Race is so concerned is because chronic wasting disease seems unique in that it's the only prion disease thought to be spread by casual contact [14] between deer through exposure to, or exchange of, bodily fluids such as saliva.[15] And, the best available research suggests that CWD prions can infect humans as well, perhaps even as readily as mad cow disease can.[16] Dr. Race wonders if people could become silent carriers as well.[17] And, "If these people are subclinical carriers," Race asked, "do they represent a threat to other people?"[18] All transmissible spongiform encephalopathies are invariably fatal.[19] Consumer advocates argue that these prions should not be allowed to enter into the food chain.[20]
In May 2003, the Food and Drug Administration finally drafted up proposed voluntary "suggestions" for the rendering industry, recommending that deer and elk infected with chronic wasting disease, or at high risk for the disease, be excluded from animal feed.[21] However, even if this proposal is enacted, it represents only non- binding, non-enforceable "guidance" recommendations for the industry. The FDA made these same kinds of "guidance" recommendations to pharmaceutical companies over a decade ago, discouraging the use of bovine-derived materials from countries with mad cow disease in manufacturing their vaccines,[22] only to learn 7 years later that major pharmaceutical manufacturers simply ignored the guidelines.[23]
Europe's Scientific Steering Committee met in 2003 and agreed that the United States should comply with the World Health Organization guidelines and ban the feeding of animals infected with chronic wasting disease to other animals.[24] The United States seems to remain the only country that knowingly allows prion infected animals to be fed to other animals, including those destined for the dinner plate.
#2. All Countries Need to Establish Adequate Testing and Surveillance The World Health Organization's second guideline was for all countries to establish adequate testing and surveillance for mad cow disease according to the standards set down by the Office International des Epizooties (OIE), World Animal Health Organization. [25] The beef industry and the USDA claim that the level of U.S. testing "far exceeds" these international testing standards.[26] If one goes to the USDA website and clicks on "for the latest info on BSE Surveillance," for example, one can read that "OIE recommends a surveillance level of 433 samples per year."[27] And that, in 2002 alone, the U.S. tested almost 20,000 cattle for the disease.[28] But if one reads the actual recommendations,[29] one can see that the USDA isn't telling the whole story.
The oft-cited "433" figure[30-32] is indeed found in Article of the OIE's International Animal Health Code.[33] But it just represents the required minimum number of cattle showing suspicious signs that should be examined each year.[34] For examples, these are cows that show "excitability," or "persistent kicking when milked."[35] The Animal Health Code then directly goes on to recommend, in Article, that "Cattle that have died or have been killed for reasons other than routine slaughter (including 'fallen' stock and emergency slaughter) should be examined."[36] This is where the United States (and Canada) fall seriously short.
The combination of these two populations, "fallen stock and emergency slaughter cattle," is essentially equivalent to the U.S. nonambulatory, or "downer" cattle population.[37] Every year, an estimated 195,000[38] to a million[39] cattle collapse in the U.S. for largely unknown reasons and are too sick or injured to rise.[40] Even though these downed animals are not even fit enough to stand, an investigation of USDA slaughterhouse records showed that most of them are still ruled fit enough for human consumption.[41] Quoting from a USDA document released in 2002, "Thus, if BSE were present in the U.S., downer cattle infected with BSE could potentially be offered for slaughter and, if the clinical signs of the disease were not detected, pass ante-mortem inspection. These cattle could then be slaughtered for human food."[42]
Based on findings in Europe,[43] and evidence of at least a rare form of mad cow disease already striking downer cows in the U.S.,[44] downer cattle are considered to be a particularly high risk population. The OIE recommends they be tested for mad cow disease. [45] Over the past ten or so years, though, the USDA has tested less than 2% of the downer cattle in United States.[46] And, those tests were almost exclusively limited to animals that were sent to slaughter.[47] The U.S. tests even fewer of the downer cattle on farms and ranches that never make it to the slaughterhouse, considered the single highest risk cattle population in the United States..[48] These dead, dying or downed cattle can still then be fed to other livestock.[49] It's no wonder that Dr. Prusiner, the world's expert on prion disease, describes the number of tests done by USDA as "appalling."[50]
When asked what level of testing in the U.S. he'd be comfortable with, Prusiner replied, ""Well, I'd like to see every downer cattle, every fallen cow tested. That's a beginning. And then after that, at some point, I'd like to see every cow tested, just as they do in Japan. Every single cow is being tested in Japan."[51] In Europe, 100% of all adult downer cattle are tested,[52] as well as 100% of all healthy cows over a certain age that are slaughtered for human consumption.[53] If the animal isn't tested, then by law, the animal must be destroyed.[54] July, 2003, an amendment was brought before the House that would have banned the sale downed animals for human food in the United States. The amendment lost by two votes.[292]
The United States and Europe have similar cattle populations,[55] yet Europe tests almost a million cattle every month.[56] France, which has only a fraction of the U.S. cattle population, tests more cattle in a single week then the U.S. has tested in a decade.[57] According to Europe's latest annual report, Europe is testing cattle at a rate of almost two thousand times that of the United States.[58] Yes, the beef industry argues, but they have the disease, and we don't.
The beef industry's position is an illustration of circular reasoning: We don't rigorously test, because we haven't found any cases.[59] In the Summer of 2000, the Scientific Steering Committee of the European Union, an internationally recognized group of BSE experts, conducted and published elaborate risk assessments for a wide variety of countries.[60] They concluded that the risk status of a country like Austria ("Unlikely, but not excluded"),[61] was identical to that of the United States.[62] This didn't stop Austria, though, from learning from the rest of Europe's example and testing all cattle slaughtered for human consumption over a certain age.[63] Though they too declared their country "BSE-free,"[64] within months of initiating their testing program they discovered their first case. [65]
The meat industry, however, opposes more testing.[66] Dan Murphy, the spokesperson for the American Meat Institute, responded to criticism by stating, "Further testing would cost taxpayers more money, could slow production and would yield no benefits."[67] He reiterated, "It's a matter of asking the question, 'Where would the benefit be?'"[68] I'm sure Don Simms has an answer for Mr. Murphy. His teenage son lies twitching in a hospital bed in Belfast. Jonathan Simms, once healthy, strong and athletic, is in a coma, wasting away on the verge of death from mad cow disease, like so many dozens of teens before him.[69]
Dan Murphy argues that the U.S. government "already tests the animals that are at risk."[70] He likened expanding the testing program to a larger number of animals "to testing elementary students for Alzheimer's disease."[71] Or "like testing children for breast cancer," the President of the American Feed Industry Association adds. "It simply makes no sense."[289] But again, the United States tests only a minuscule percentage of the animals at most risk--the downer cattle.[72]
Beyond high risk populations, though, Dan Murphy is correct when he implies that the U.S. cattle population is younger than that in Britain. Less than half of American dairy cows make it past their fourth birthday, before being retired into hamburger meat.[73] In fact the majority of U.S. cattle are slaughtered before they reach age two.[74] While this may mean that the prion load in an infected animal may be less at slaughter (since prions accumulate with age), it also means mad cow disease may be harder to detect in the United States.[75]
On that fated Oprah show, the spokesperson for the National Cattlemen's Beef Industry assured consumers that no animal could ever enter a U.S. slaughterhouse displaying BSE symptoms.[76] As the European Commission's risk assessment of the U.S. points out, though, the "young age at slaughter makes it unlikely that fully developed clinical cases would occur (and could be detected)..."[77] Younger cattle could be infected and infectious, but be slaughtered for human consumption before they started showing symptoms.[78] In fact, that first case of mad cow disease in Austria was detected in a cow who presented no clinical signs.[79] The only reason that the infected Austrian cow was prevented from entering the human food supply is because, even though they had no recorded cases[80] and even though the country was deemed as low risk as the United States,[81] Austria instituted a surveillance program that tested every cow slaughtered for human food over 30 months of age.[82] The chief reason that the present mad cow surveillance program has not confirmed cases in the U.S. could be because the surveillance program is inadequate.[83]
Another country that was ruled just as unlikely as the United States to have mad cow disease was Canada.[84] Saying Canada has mad cow disease is not far from saying the United States does, because the cattle industries of both countries are fully integrated across an open border.[85] Every year, the U.S. imports over a million head of cattle[86] and billions of pounds of beef from Canada.[87] How can the U.S. still call itself BSE-free when over three quarters[88] of Canadian cattle exports end up in the United States? Mad cow disease has been detected in North America.
Dr. Bruno Oesch of Zurich University recently told the BBC that US consumers may well have been eating infected beef for some time now. [89] The New Scientist, a weekly British science digest, reports that, based on the Canadian case, it is "likely" that the mad cow disease is also present in the United States.[90] So the question of whether or not the U.S. had in the past been meeting international testing standards for BSE-free countries may now be moot. Now that mad cow disease has been found in a downer cow in North America, is the USDA drafting plans to at least step up its surveillance of downer cattle? According to a spokesperson for the USDA, "at the moment, no changes [in the U.S. testing program] are being discussed."[91]
#3. Stop Feeding Bovine Brains, Eyes, Spinal Cords or Intestines to People or Livestock The third key recommendation of the World Health Organization is that "Countries should not permit tissues that are likely to contain the BSE agent to enter any food chain, human or animal."[92] Basically, this means excluding cattle brains, eyes, spinal cord and intestine (from small intestine to rectum) from the human food supply, and from all animal feed.[93] Unfortunately, the U.S. still feeds those potentially risky tissues to people, pigs, pets and poultry.
High risk tissues in human food
Although beef brains, guts, eyes and spinal cords are available to consumers as "variety meats," they are labeled as such and therefore represent only a small fraction of the American public's exposure to these organs.[94] People are more likely to consume potentially infectious tissues such as spinal cord disguised within all-American favorites, like hot dogs and hamburgers.
After a cow is slaughtered and the standard cuts of beef removed, one is left with a bloody skeleton with a few scraps of meat still attached. To recover any last shreds of meat, the bones, prebroken or whole, may be placed in a giant vice-like device that crushes the carcass into bone "cakes."[95] Out through a sieve at the bottom runs a "batter-like"[96] paste of "spread-like consistency" referred to as mechanically separated meat.[97] The potentially highly infectious spinal cord and fluid may be forced out of the backbone and spewed in the final product.[98] Mechanically separated beef has been "used as a meat ingredient in the formulation of quality meat food products"[99] in the United States since the 1970's.[100] Examples of such "quality meat food products" include hot dogs, sausages and burgers.[101] By law, hot dogs can contain up to 20% of this mechanically separated beef.[102]
Although food containing mechanically separated beef must be labeled as such, there are no labels on food in restaurants.[103] So people could be exposed to spinal cord tissue in hot dogs, sausages, hamburgers, and ground meat products when dining out.[104] Although Europe heeded the World Health Organization's warnings and banned such meat recovery systems years ago, these devices remain one of the best opportunities for prion-infected tissues to enter the human food supply in North America.[105]
In 1994, meat processors began using a new technology, called advanced meat recovery (AMR), to help "increase yields and profitability."[106] These systems also extrude meat from the remains of the carcass under pressure, but without crushing the bones.[107] The American Meat Institute describes the process: "Just as fruit processors use machines to remove fruit from peels thoroughly and efficiently, meat companies use similar equipment to remove meat from some hard to trim bones."[108]
The end-product varies from a ground beef-like texture to the consistency of thick tomato sauce.[109] Prior to 1994, only cattle skeletal muscle, tongue, diaphragm, heart, and esophagus could be labeled as beef.[110] But by the end of that year, the USDA had already amended the definition of "meat" to include the product of advanced meat recovery machinery.[111] This meant that unlike mechanically separated meat, AMR meat was considered 100% beef and could be labeled as such.[112] With no special labeling requirements, adoption of AMR machinery spread rapidly throughout the industry, largely replacing mechanical separation equipment.[113]
Today, the majority of cattle are now processed using AMR.[114] Over twenty thousand tons of AMR beef is produced every year in the U.S., valued at over $100 million.[115] AMR beef typically ends up as a hidden ingredient in hamburgers, hot dogs, sausages, and beef jerky, as well as part of ground beef in meatballs, pizza toppings and taco fillings.[116] The danger, once again, is that if the spinal cord isn't removed before entering one of these machines, it is bound to be incorporated into the meat that is produced.[117]
Companies are supposed to remove the animals' brains and spinal cords before processing the carcasses through the AMR machinery, but getting out all of the spinal cord can be challenging. "It requires special tools and skills," says Glenn Schmidt, a meat scientist at Colorado State University. "The workers have to reach down to the neck region of the carcass to remove the spinal cord by scraping or suction, and sometimes they don't get all of it."[118]
In 1997, the consumer advocacy organization Public Citizen obtained USDA inspection records through the Freedom of Information Act showing that a significant percentage of AMR samples were turning up contaminated with central nervous system (CNS) tissue (brain or spinal cord).[119] Instead of simply requiring that spinal columns be removed from carcasses before being placed in advanced meat recovery systems, the USDA responded by merely directing its inspectors to continue testing samples of AMR meat for the presence of central nervous tissue.[120]
Despite their promise to initiate testing, the USDA took fewer than 60 samples over the next 3 years, yet still found spinal cord in a number of them.[121] The first major study of AMR meat was published in 2001.[122] Colorado State University researchers found that "well over 50%" of the samples of AMR beef from neck bones were contaminated with CNS tissue.[122] Then they went to 7 major suppliers of large fast food chains across the country to sample hamburger patties. Six out of seven suppliers had detectable CNS tissue in their burgers.[123]
The USDA again responded only with promises to do more testing.[124] The results of the USDA's tests were made public in 2002.[125] Eighty- eight percent of the meat processors (30 out of 34) were producing AMR beef which contained unacceptable nervous tissue, and almost all of the samples (96.5%) contained bone marrow,[126] which may also be infectious.[127]
In 2001, the World Health Organization, in consultation with the World Animal Health Organization and the Food and Agriculture Organization of the United Nations, reiterated the need for countries to remove and destroy all tissues proven capable of transmitting mad cow disease, such as spinal cord.[128] And, the only way to guarantee that AMR beef, or mechanically separated "beef," is free of spinal cord is to require meat processors to remove the entire spinal column before sending cattle carcasses through their machinery.[129] So that year, the consumer advocacy group Center for Science in the Public Interest (CSPI) petitioned the USDA to do just that.[130] The petition was supported by the American Public Health Association, the Consumer Federation of America, the Government Accountability Project, the National Consumers League, and Safe Tables Our Priority. [131]
The petition was opposed by the National Cattlemen's Beef Association, [132] the National Renderers Association,[133] the National Meat Association,[134], the Pork Producers Council, the sheep industry, the milk producers, the Turkey Federation, and eight other industry trade groups.[135] After all, about 50 percent of AMR meat comes from the neck bones and spine which contain the spinal cord.[136] U.S. meat industry analysts claim that any public health measure to remove these bones would simply be too costly for the industry.[137]
The meat industry has invested at least $40 million in AMR machines since their introduction in 1994, some of which that can process 9,000 lbs. of bones per hour.[138] Industry analysts place the final figure of complying with any proposed USDA regulation that bans neck bones and backbones at close to $200 million dollars.[138] The European Commission considers the removal of cattle brains, eyes, spinal cord and intestines from the human food supply as "the single biggest contribution that can be made to reducing the risk to humans."[139] Rather than learning from the outbreak in Europe though, the U.S. livestock industry seems to oppose even the most minimal tightening of U.S. feed regulations.[140]
The meat industry argues that voluntary compliance is enough.[141] Seven years of testing by USDA inspectors, however, has demonstrated otherwise.[142] This same inability to rely on industry efforts was discovered in Britain. British meat processors also weren't able to completely remove the spinal cord, so the law was changed to simply remove the entire spine prior to processing.[143]
However, here in the United States, the USDA continues to allow tissues in the American beef supply which are so potentially dangerous that the Food and Drug Administration has excluded them from cattle feed.[144] As CSPI's Director of Food Safety put it, "U.S. cattle aren't allowed to eat cattle spinal cord - and neither should people," especially children--AMR beef is still allowed in the National School Lunch Program.[145] Thanks to CSPI, [146] at least AMR beef from downer cattle is now excluded from the school lunch program.[147] And, for years the government has excluded mechanically separated meat from baby food, but only because the product might mottle an infant's teeth as a result of increased fluoride intake[148] from all the crushed bone particles that get extruded into the paste.[149]
And, even if Americans just stick to steak, they may not be shielded from risk. The "T" in a T-bone steak is a vertebra from the animal's spinal column, and as such may contain a section of the actual spinal cord.[150] Other potentially contaminated cuts include porterhouse, standing rib roast, prime rib with bone, bone-in rib steak, and (if they contain bone) chuck blade roast and loin.[151] These cuts may include spinal cord tissue and/or so-called dorsal root ganglia, swellings of nerve roots coming into the meat from the spinal cord which have been proven to be infectious as well.[152] This concern has led the FDA to consider banning the incorporation of "plate waste" from restaurants into cattle feed.[290] The American Feed Industry Associations's Rex Runyon defends the current exemption of plate scrapings from the 1997 feed regulations: "How can you tell the consumer 'Hey, you've just eaten a T-bone steak and it's fine for you, but you can't feed it to animals'? "[291]
Even boneless cuts may not be risk-free, though. In the slaughterhouse, the bovine carcass is typically split in half down the middle with a band saw, sawing right through the spinal column. This has been shown to aerosolize the spinal cord and contaminate the surrounding meat.[153] A study in Europe found contamination with spinal cord material on 100% of the split carcasses examined.[154] Similar contamination of meat derived from cattle cheeks can occur from brain tissue, if the cheek meat is not removed before the skull is fragmented or split.[155] The World Health Organization has pointed out that American beef can be contaminated with brain and spinal cord tissue in another way as well.[156]
Except for Islamic halal and Jewish kosher slaughter (which involve slitting the cow's throat while the animal is still conscious), cattle slaughtered in the United States are first stunned unconscious with an impact to the head before being bled to death. Medical science has known for over 60 years that people suffering head trauma can end up with bits of brain embolized into their bloodstream; so Texas A&M researchers wondered if fragments of brain could be found within the bodies of cattle stunned for slaughter. They checked and reportedly exclaimed, "Oh, boy did we find it."[158] They even found a 14 cm piece of brain in one cow's lung.[159] They concluded, "It is likely that prion proteins are found throughout the bodies of animals stunned for slaughter."[160]
There are different types of stunning devices, however, which likely have different levels of risk associated with them. The Texas A&M study was published in 1996 using the prevailing method at the time, pneumatic-powered air injection stunning.[161] The device is placed in the middle of the animal's forehead and fired, shooting a 4 inch bolt through the skull and injecting compressed air into the cranial vault which scrambles the brain tissue. The high pressure air not only "produces a smearing of the head of the animal with liquefied brain,"[162] but has been shown over and over to blow brain back into the circulatory system, scattering whole plugs of brain into a number of organs[163] and smaller brain bits likely into the muscle meat as well.[164]
Although this method of stunning has been used in the United States for over 20 years,[165] the meat industry, to their credit, has been phasing out these particularly risky air injection-type stunners. The Deputy Director of Public Citizen argues that this industry initiative should be given the force of federal regulation and banned, [166] as they have been throughout Europe.[167]
The stunning devices that remain in widespread use drive similar bolts through the skull of the animal, but without air injection. [168] Operators then may or may not pith the animals by sticking a rod into the stun hole to further agitate the deeper brain structures to reduce or eliminate reflex kicking during shackling of the hind limbs.[169] Even without pithing, which has been shown to be risky, these stunners currently in use in the U.S. today may still force brain into the bloodstream of some of these animals.[170-173]
In one experiment, for example, researchers applied a marker onto the stunner bolt. The marker was later detected within the muscle meat of the stunned animal. They conclude: "This study demonstrates that material present in... the CNS of cattle during commercial captive bolt stunning may become widely dispersed across the many animate and inanimate elements of the slaughter-dressing environment and within derived carcasses including meat entering the human food chain."[174] Even non-penetrative "mushroom-headed" stunners which just rely on concussive force to the skull to render the animal unconscious may not be risk free. People in automobile accidents with non-invasive head trauma can still end up with brain embolization,[175] and these bolts move at over 200 miles per hour.[176] The researchers at Texas A&M conclude, "Reason dictates that any method of stunning to the head will result in the likelihood of brain emboli in the lungs or, indeed, other parts of the body."[177]
And, finally, even if consumers of American beef just stick to boneless cuts from ritually slaughtered animals who just happen to have had their spinal columns safely removed, the muscle meat itself may be infected with prions. The National Cattlemen's Beef Association continues to assure consumers that beef is safe because the deadly prions aren't found in muscle meat.[178] Even putting aside contamination issues, it seems they are simply behind the times. In 2002, Stanley Prusiner, the Nobel laureate who discovered prions, proved in mice, at least, that muscle cells themselves were capable of forming prions.[179] He describes the levels of prions in muscle as "quite high," and describes the studies relied upon by the Cattlemen's Association as "extraordinarily inadequate."[180] Follow- up studies in Germany published May, 2003 confirm Prusiner's findings, showing that an animal who are orally infected may indeed end up with prions contaminating muscles throughout their body.[181]
This newly discovered muscle infectivity highlights how little we know about these diseases. For example, the American Meat Institute released a fact sheet on BSE stressing that while the new variant of Creutzfeldt Jakob Disease (vCJD) was known to be caused by eating infected cattle parts, the more common classic form of CJD, the so- called "sporadic" form, had nothing to do with mad cow disease. The November 2002 fact sheet emphatically stated, "There is absolutely no evidence to suggest that CJD is caused by any food, including beef. [182] But by the next month, December 2002, there was evidence.[183]
The surprising new finding linking mad cow disease with classic CJD has been used to explain the rising numbers of those stricken with the classic form of CJD in Europe.[184] We don't the incidence of this fatal disease in North America, because the disease isn't tracked here like it is in Europe.[185] We do know though, that when researchers have actually gone back and looked at the brains of presumed Alzheimer's deaths--where Alzheimer's was indicated on the death certificate--anywhere from between 3%[186-187] to 25%[188-190] had actually died of Creutzfeldt Jakob Disease. According to the CDC, Alzheimer's Disease is now the 8th leading cause of death in the United States,[191] affecting as many as 4 million Americans.[192] Despite the fact that an unknown number of Americans are already dying from this disease, the beef industry continues to ignore the evidence.[193]
The uncertainties inherent to this mysterious class of diseases make it even more important for the U.S. to follow the directives of the World Health Organization, and the lead of affected countries around the world, to implement concrete, practical measures to safeguard the American public.
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