Cure Your “Beef Habit” Today with a Little Mad Cow
The infectious agent causing Mad Cow Disease may soon be found in most
animal products, including beef, chicken, pork, gelatin, and glandular
supplements.
The
first change we made in our diet almost 30 years ago was to give up the
red meat – more specifically, the beef. If you haven’t already done so,
after reading this article, I am confident you will be well on your way to
making this long-overdue change. The threat from an unhealthy meat supply
has changed many others – after the appearance of Mad Cow Disease in
England in 1996 wholesalers from Spain to
Germany reported a drop of about 50 percent in beef sales, butchers saw
their businesses devastated and the number of
vegetarians in Europe was reported to have risen by one million to 12
million. But the change in people’s eating habits worldwide has just
begun, because information about the animal food industry is spreading
faster than the disease.
The
June 10, 2003 USA Today newspaper carried a front page article,
“Consumers may have a beef with cattle feed.” This article was about Mad
Cow Disease, also called bovine spongiform encephalopathy (BSE) -- a brain
and nervous system disease that has killed at least 150 people worldwide
since 1996. The infectious agent for Mad Cow, the prion, spreads by
feeding cows body parts of other cows. Naturally these hooved animals are
herbivores, but they have been forced to become carnivores, and to
practice cannibalism. Prions are proteins resistant to almost all attempts
to destroy them, including heating at high temperatures. The end result
of infection in animals and humans is massive destruction of the brain
tissues leaving holes in the brain that resemble a sponge on examination –
thus the name “spongiform.” With destruction of their brains they become
“mad cows” and “mad humans.”
The
following startling statements are worth repeating from this USA Today
article:
1)
Before 1997 it was standard practice to feed beef and dairy cows’ pieces
of “their herd mates.” “In response to the outbreak (of BSE) in Britain
and other European countries, the United States and Canada in 1997 made it
illegal to feed cows meat and bone meal made from ruminants (other cows).
The feed bans in both countries do allow use of that feed for poultry and
pigs.”
2)
“In parts of the country where cattle are raised near poultry production
areas, it is not uncommon to feed them (the cows) poultry litter –
basically excreta, bedding, spilled feed and feathers.” … “But there is
concern that the spilled feed (containing cow parts) as well as partially
digested feed might end up back in the cattle troughs, resulting in the
same potential cycle of infection that caused the British outbreak of mad
cow.”
3)
“The ‘waste plate’ exemption allows restaurants to sell plate scrapings
and leftovers (beef from your restaurant meals) to renderers, which turn
them into cattle feed, among other things.”
4)
“Retail pet food frequently contains ruminant meat and bone meal, but
unlike agricultural animal feed, there’s no requirement that it be labeled
‘Do not feed to cattle or other ruminants.’ However, out-of-date dry cat
and dog food is sometimes sold as salvage and ends up being fed to
cattle.”
5)
“Spray-dried cow and pig blood is used in feed to provide protein, as a
soluble product to mix in animals’ drinking water, and most commonly, as a
milk replacement for calves.”
6)
“Some people are so hung up on low-cost production that they will violate
whatever rules are there.”
Do
you want to know more?
You
will never be the same after reading this article reprinted with the
permission of the author Michael Greger, MD* from the May 21, 2003 issue
of the Organic Consumers Association (http://www.organicconsumers.org/).
American Beef Supply at Risk
The
Canadian Agriculture Minister announced yesterday that a cow in Canada has
tested positive for bovine spongiform encephalopathy, better known as mad
cow disease. The United States immediately imposed a ban on Canadian beef
and cattle imports, but the American beef supply may have already been
placed at risk. Canada has been the number one supplier of live cattle to
the United States.1 Last year alone we imported 1.7 million
head of cattle from Canada.2 We also imported $2.4 billion
worth of beef 3 --that's over a billion pounds of Canadian beef
in the last year alone.4 According to the National Cattlemen’s
Beef Association, about 7 percent of beef consumed by Americans is from
Canada.5 And because of NAFTA, there is no mandatory country
of origin labeling from Canada, so there is currently no way for American
consumers to know for certain if the beef they are eating came from Canada
or not.6 This is unfortunately not the first time the United
States has imported cattle and beef products from countries at risk.
The
United States General Accounting Office (GAO) is the investigative
watchdog arm of Congress. Last year, the GAO released their report on the
weaknesses present in the U.S. defense against mad cow disease.7 They noted that “the United States has imported about 1,000 cattle; about
23 million pounds of meat by-products; about 100 million pounds of beef;
and about 24 million pounds of prepared beef products during the past 20
years from countries where BSE was later found.”8 Furthermore,
the report said that if the disease did enter the country, current
safeguards might not be enough to detect it and keep it from spreading to
other cattle or to the human food supply.9 The report can be
downloaded at http://www.gao.gov/new.items/d02183.pdf
The
discovery of a case of mad cow disease in Canada highlights how
ineffective current safeguards are in North America. The explosive spread of mad cow disease in Europe has been blamed on
the cannibalistic practice of feeding slaughterhouse waste to livestock.10 Both Canada11 and the United States12 banned the
feeding of the muscles and bones of most animals to cows and sheep back in
1997, but unlike Europe left gaping loopholes in the law. For example,
blood is currently exempted from the Canadian13 and the U.S.14 feed bans. You can still feed calves cow's blood collected at the
slaughterhouse. In modern factory farming practice calves may be removed
from their mothers immediately after birth, so the calves are fed milk
replacer, which is often supplemented with protein rich cow serum.15 Weaned calves and young pigs have cattle blood sprayed directly on their
feed to save money on feed costs.16 Michael Hansen with the
Consumer's Union reports that cows won't eat feed composed of more than
ten percent blood, evidently because of the taste.17 Chickens,
on the other hand, reportedly will eat feed composed of up to thirty-five
percent blood.18
The
reason why the American Red Cross continues to restrict blood donations
from those who lived in Europe19 is because of mounting
evidence that indeed blood may be infectious.20 In fact, the
mad cow outbreak in Japan has been tentatively tied to milk replacer.21 Yet cow blood is still allowed to be fed to livestock in this country. And
the Canadian22 and U.S. feed bans23 also allow the
feeding of pigs and horses to cows. Cattle remains can be fed to pigs, for
example, and then the pig remains can be fed back to cattle.24 Or cattle remains can be fed to chickens and then the chicken litter, or
manure, can be legally fed back to the cows.25 And the cow
diagnosed with mad cow disease in Canada may have indeed been rendered
into chicken and pig feed.26
D.
Carleton Gajdusek was awarded the Nobel Prize in Medicine for his work on
mad cow-like diseases.27 He was quoted on Dateline NBC as
saying, “it's got to be in the pigs as well as the cattle. It's got to be
passing through the chickens.”28 Dr. Paul Brown, medical
director for the US Public Health Service, believes that pigs and poultry
could indeed be harboring mad cow disease and passing it on to humans,
adding that pigs are especially sensitive to the disease. “It's
speculation,” he says, “but I am perfectly serious.”29
Although the Canadian Food Inspection Agency admits the infected cow was
sent to a rendering plant, the agency has tried to reassure consumers by
describing rendering as a heat-treatment process used to 'sterilize' the
carcass.30 Unfortunately, the type of pathogen thought to cause
mad cow disease is not destroyed by the rendering process.
Mad
cow disease is thought to be caused, not by a virus, fungus or bacteria,
but by a prion, or infectious protein. One reason prions are so concerning
is that, unlike conventional pathogens, prions are not adequately
destroyed by cooking, canning, or freezing.31,32 Usable doses
of UV or ionizing radiation, stomach acid, and digestive enzymes are all
ineffective in destroying their infectivity.33, 34 Even heat
sterilization, domestic bleach35 , and formaldehyde
sterilization have little or no effect.36 One study even raised
the disturbing question of whether even incineration could guarantee
inactivation of prions.37 National Institutes of Health expert
Joseph Gibbs once remarked tongue-in-cheek to Cornell's Food Science
Department that one of the only ways to ensure one's burger is safe is to
marinate it in a concentrated alkali such as Drain-O.38 Prions
have been called the smallest,39 most lethal self-perpetuating
biological entities in the world.40
Europe has forbidden the feeding of all slaughterhouse waste to livestock.
The United States and Canada should do the same, according to William
Leiss, president of the prestigious Royal Society of Canada.41 The American Feed Industry Association calls such a ban a radical
proposition.42 The American Meat Institute also disagrees
stating, “No good is accomplished by...prejudicing segments of society
against the meat industry.”43 U.S. health officials44 and the Canadian Agriculture Minister45 were quick to emphasize
that only a single positive case was found. But Canada has been testing
less than 0.01 percent of their cattle population for mad cow disease.46 Canada now joins the ranks of other countries like Germany,
France, Belgium and Italy that all confidently pronounced that they, too,
were “free” of mad cow disease, until tests showed otherwise.47 Will the United States be next?
The
General Accounting Office was right to fault the USDA for inadequate
testing.48 Last year, the United States tested a little under
20,000 cattle for mad cow disease.49 That's less than Europe
tests every day.50 “This demonstrates that no cattle-producing
country can think it's safe,” Steve Bjerklie of Meat Processing magazine told USA Today in response to the Canadian discovery. “It
really is a clarion call to the U.S. Department of Agriculture to step up
surveillance in this country.”51 More information about the
inadequacy of mad cow disease surveillance in the United States can be
found at http://www.testcowsnow.com/
No
one yet knows the source of the Canadian outbreak. It remains possible
that the cow in question contracted the disease from local wildlife.52 Chronic wasting disease is a prion disease of wildlife affecting deer and
elk, and is endemic within the area where the infected cow was living.53 The disease was exported there by the United States. Chronic wasting
disease, also called “mad deer disease,” seems to have started in
Colorado, but has now been found in over a dozen states.54 Just
last year it crossed the continental divide into Wisconsin where a mass
killing zone has just been set up to eradicate tens of thousands of white
tail deer in a vain attempt to slow the spread of the disease.55 Chronic wasting disease seems unique in that the prions seem to be spread
by casual contact between the deer. One can only hope that this disease
would not be as infectious if it jumped from deer or elk into cattle (or
into human beings for that matter).56 Transmission to cows or
people has yet to be documented, but the best available science suggests
that it is possible.57
It
was only last week when the Food and Drug Administration finally drafted
up proposed voluntary guidelines recommending that deer and elk infected
with chronic wasting disease, or at high risk for the disease, be excluded
from animal feed.58 This is a measure the World Health
Organization and the United Nations Food and Agriculture Organization have
been urging for years.59 Thankfully, Canada has a trace-back
program in which all Canadian cattle are tracked throughout their lives.
This should facilitate locating the source of the outbreak. The United
States lacks such a program. U.S. officials argue that such extensive
tracking isn't necessary, because there has never been a case of mad cow
disease detected in the U.S.. As one Alberta veterinarian responded, “we
(Canadians) would have said that yesterday.”60
In
response to the Canadian crisis, the Chief Executive Officer of the U.S.
National Cattlemen's Beef Association released a statement urging
consumers to “continue to eat beef in confidence.”61 “First,”
the news release explains, “the Canadian case proves that the systems
designed to protect consumers do work. The animal in question did not
enter the food supply.” Based on the circumstances, though, it seems more
like random chance that the cow got tested at all.62 And had
the animal instead entered a U.S. slaughterhouse, chances that it would
have been tested seem even more remote.
The
Cattlemen's Association notes specifically that Americans can be confident
in the safety of U.S. beef because, “Animals with any signs of neurological disorder are not
permitted to enter the human food chain and are tested for BSE.”63 Yet the Canadian cow wasn't necessarily displaying neurological symptoms.64 The Alberta Agriculture Minister Shirley McClellan explained the 14 week
testing delay by noting that the cow didn't appear to have BSE when it was
condemned; it was underweight and thought to have pneumonia.65 Fortuitously, though, the cow in Canada was deemed unfit for human
consumption.66 There's reason to believe that if the cow had
entered a U.S. slaughterhouse, not only might it not have been tested, it
may have ended up on America's dinner plate. According to an investigation
of USDA slaughterhouse records, almost three quarters of cattle that were
even too sick to stand were passed as fit for human consumption, including
those who appeared sick with pneumonia.67 The slaughter of
these downed animals for human food is particularly risky now that mad cow
disease has been discovered in North America. The downed animal
investigation can be downloaded at http://www.nodowners.org/downedanimals.pdf
The
Cattlemen's Association also feels consumers can be confident in the
safety of American beef because “The BSE agent is not found in meat. It is
found in central nervous system tissue such as brain and spinal cord.”68 This can be viewed as irresponsible on a number of counts. As of this
month we now have published evidence that animals who are orally infected
may indeed end up with prions contaminating muscles throughout their body.69 And Americans do eat bovine central nervous system tissue. Quoting from
the General Accounting Office report: “In terms of the public health risk,
consumers do not always know when foods and other products they use may
contain central nervous system tissue... Many edible products, such as
beef stock, beef extract, and beef flavoring, are frequently made by
boiling the skeletal remains (including the vertebral column) of the
carcass...” According to the consumer advocacy organization Center for
Science in the Public Interest, spinal cord contamination may also be
found in U.S. hot dogs, hamburgers, pizza toppings, and taco fillings.70 In fact, a 2002 USDA survey showed that approximately 35 percent of high
risk meat products tested positive for central nervous system associated
tissues.71
The
GAO report continues: “In light of the experiences in Japan and other
countries that were thought to be BSE free, we believe that it would be
prudent for USDA to consider taking some action to inform consumers when
products may contain central nervous system or other tissue that could
pose a risk if taken from a BSE-infected animal. This effort would allow
American consumers to make more informed choices about the products they
consume.”72 The USDA, however, did not follow those
recommendations, deciding such foods need not be labeled.73
Even
if one avoids processed beef products, though, the possibility of prion
contamination remains. While concentrations of prions may start out in the
brain and spinal cord, they may not stay there. Before being
exsanguinated, many cattle in the U.S. are knocked unconscious with a
pneumatic gun, which uses an explosive burst of air that can blows bits of
potentially highly infectious brain throughout the bodies of animals
stunned for slaughter.74
Despite these shortcomings, both the U.S.75 and Canadian
agriculture secretaries76 have scrambled to express their
continued affinity for steak, reminiscent of the 1990 fiasco in which the
British agriculture minister appeared on TV urging his 4-year-old daughter
to eat a hamburger.77 Four years later, young people in
Britain were dying from an invariably fatal neurodegenerative disease
called variant Creutzfeldt-Jakob Disease – the human equivalent of mad cow
disease – which they contracted through the consumption of infected beef.78
The
General Accounting Office report concludes: “BSE may be silently
incubating somewhere in the United States.
If that is the case, then FDA's failure to enforce the feed ban may
already have placed U.S. herds and, in turn, the human food supply at
risk. FDA has no clear enforcement strategy for dealing with firms that do
not obey the feed ban... Moreover, FDA has been using inaccurate,
incomplete, and unreliable data to track and oversee feed ban compliance.”79
The
U.S. and Canada have basically the same safeguards in place, with the same
loopholes and the same inadequate surveillance. If Canada has mad cow
disease, then it stands to reason that the United States does as well.
Either way, whether from the millions of cattle, or the billions of pounds
of beef we imported from Canada previous to yesterday's ban, American beef consumers
have been placed at risk.
*
Michael Greger, MD, is a graduate of the Cornell University School of
Agriculture and the Tufts University School of Medicine. Dr. Greger has
been publicly speaking about mad cow disease since 1993. In 1997 he was
invited as an expert witness to defend Oprah Winfrey in the infamous meat
defamation trial. He has contributed to many books and articles on the
subject and continues to lecture extensively. Dr. Greger can be contacted
at 857-928-2778, or mhg1@cornell.edu.
References:
1.
The Associated Press 21 May 2003.
2.
Ibid.
3.
Financial Times (London) 21 May 2003.
4.
The New York Times 21 May 2003.
5.
The Atlanta Journal and Constitution 21 May 2003.
6.
Ranchers-Cattlemen Action Legal Fund News Release. United Stockgrowers of
America. 21 May 2003. http://www.r-calfusa.com/052003-canada.htm
7.
United States General Accounting Office. GAO Report to Congressional
Requesters. January 2002 MAD COW DISEASE: Improvements in the Animal Feed
Ban and Other Regulatory Areas Would Strengthen U.S. Prevention Efforts.
GAO-02-183. http://www.gao.gov/new.items/d02183.pdf
8.
Ibid.
9.
Ibid.
10.
Kimberlin, R. H. “Human Spongiform Encephalopathies and BSE.” Medical
Laboratory Sciences 49 (1992): 216-217.
11.
Canadian Food Inspection Agency BSE Fact Sheet. May 2003 P0091E-00. http://www.inspection.gc.ca/english/anima/heasan/disemala/bseesb/bseesbe.shtml
12.
Food and Drug Administration 2000 CFR Title 21, Volume 6, Chapter 1, Part
589. http://www.access.gpo.gov/nara/cfr/waisidx_00/21cfr589_00.html
13.
Canadian Food Inspection Agency, Regulations: Food for Ruminants,
Livestock and Poultry (Part XIV), “Prohibited Materials”
14.
Food and Drug Administration 2000 CFR Title 21, Volume 6, Chapter 1, Part
589. http://www.access.gpo.gov/nara/cfr/waisidx_00/21cfr589_00.html
15.
International Center for Technology Assessment. Citizen Petition Before
The United States
Food
And Drug Administration. 1/9/03. http://www.icta.org/legal/madcow1.htm
16.
Ibid.
17.
Kirchheimer, Gabe. Bovine Bioterrorism: The Perfect Pathogen. In
Everything You Know Is Wrong. The Disinformation Company. 2002.
18.
Ibid.
19.
American Red Cross Addresses the Human Form of Mad Cow Disease
http://www.redcross.org/services/biomed/blood/supply/tse.html
20.
Journal of General Virology 83(2002):2897-2905.
21.
Japan Today 24 August 2002.
22.
Canadian Food Inspection Agency, Regulations: Food for Ruminants,
Livestock and Poultry (Part XIV), “Prohibited Materials”
23.
Food and Drug Administration 2000 CFR Title 21, Volume 6, Chapter 1, Part
589. http://www.access.gpo.gov/nara/cfr/waisidx_00/21cfr589_00.html
24.
Public Citizen. Letter to the FDA and USDA RE: BSE. 21 April 2001. http://www.citizen.org/cmep/foodsafety/gsfc/articles.cfm?ID=1562
25.
Food and Drug Administration Sec. 685.100 Recycled Animal Waste (CPG
7126.34)
26.
National Post 21 May 2003.
27.
Unconventional viruses and the origin and disappearance of kuru. 13
December 1976. http://www.nobel.se/medicine/laureates/1976/gajdusek-lecture.html
28.
NBC Dateline 14 March 1997.
29.
Pearce, Fred. “BSE May Lurk in Pigs and Chickens.” New Scientist 6 April
1996: 5.
30.
Canadian Food Inspection Agency. Questions and Answers. Investigation of
BSE case in Alberta. http://www.inspection.gc.ca/english/corpaffr/newcom/2003/20030520qae.shtml
31.
Taylor, D. M. “Bovine Spongiform Encephalopathy.” Medical Laboratory
Sciences 49 (1992): 334-9.
32.
Lacey, Richard W. and Stephen F. Dealler. “The BSE Time Bomb?” The
Ecologist 21 (1991): 117- 122.
33.
Marsh, R. F., and R. A. Bessen. "Epidemiologic and Experimental Studies
on Transmissible Mink Encephalopathy." Developments in Biological
Standardization 80 (1993): 111-118.
34.
Dealler, S. F. and R. Lacey. "Beef and Bovine Spongiform Encephalopathy."
Nutrition and Health 7 (1991): 117-129.
35.
Dealler, S. F. and R. Lacey. "Transmissible Spongiform Encephalopathies."
Food Microbiology 7 (1990): 253-279.
36.
Holt, T. A. and J. Phillips "Bovine Spongiform Encephalopathy." British
Medical Journal 296 (1988): 1581-2.
37.
Brown, Paul, et al. "Resistance of Scrapie Infectivity to Steam
Autoclaving after Formaldehyde Fixation and Limited Survival after Ashing
at 360oC." Journal of Infectious Diseases 161 (1990): 467-472.
38.
Gibbs, C.J. "BSE and Other Spongiform Encephalopathies in Humans and
Animals: Causative Agent, Pathogenesis and Transmission." Fall 1994 Food
Science Seminar Series. Department of Food Science. Cornell University, 1
December 1994.
39.
Keeton, William T., et al. Biological Science New York: Norton, 1993.
40.
Hunter, G. D. Scrapie and Mad Cow Disease New York: Vantage Press, 1993.
41.
Ottawa Citizen 6 June 2001
42.
Evans, Eddie. "Agency to Ban Some Feeds to Block Mad-Cow Disease."
Reuters World Report 13 May 1996.
43.
"AVMA Casts Doubt on Spread of BSE Through Sheep Offal." Food Chemical
News 28 November 1994: 42-45.
44.
Washington Post 21 May 2003.
45.
Toronto Star 21 May 2003.
46.
The Record (Kitchener-Waterloo) 12 September 2002.
47.
Ibid.
48.
United States General Accounting Office. GAO Report to Congressional
Requesters. January 2002 MAD COW DISEASE: Improvements in the Animal Feed
Ban and Other Regulatory Areas Would Strengthen U.S. Prevention Efforts.
GAO-02-183. http://www.gao.gov/new.items/d02183.pdf
49.
USDA News Release No. 0166.03. Statement by Agriculture Secretary Ann M.
Veneman Regarding Canada's Announcement of BSE Investigation. May 20,
2003.
50.
European Union. Monthly reports of Member States on BSE and Scrapie. http://europa.eu.int/comm/food/fs/bse/testing/bse_results_en.html
51.
USA Today 21 May 2003.
52.
The Washington Post 21 May 2003.
53.
Ibid.
54.
USDA Center for Animal Health Programs. Chronic Wasting Disease. 13 May
2003. http://www.aphis.usda.gov/vs/nahps/cwd/cwd-distribution.html
55.
Wisconsin Department of Natural Resources. CWD Management Zone. http://www.dnr.state.wi.us/org/land/wildlife/whealth/issues/cwd/CWDzones.jpg
56.
Connecticut Post 22 September 2002.
57.
European Molecular Biology Organization Journal 19(2000):4425-4430. http://emboj.oupjournals.org/cgi/content/full/19/17/4425
58.
FDA Talk Paper T03-34. 15 May 2003.
59.
What Canadians Need to Know About Mad Cow Disease. Canadian Health
Coalition. 13 July 2001. http://www.healthcoalition.ca/bse.html
60.
USA Today 21 May 2003.
61.
National Cattlemen's Beef Association news release. 21 May 2003. http://www.beef.org/dsp/dsp_content.cfm?locationId=45&contentTypeId=2&contentId=2098
62.
Canadian Television Network 21 May 2003.
63.
National Cattlemen's Beef Association news release. 21 May 2003. http://www.beef.org/dsp/dsp_content.cfm?locationId=45&contentTypeId=2&contentId=2098
64.
Canadian Television Network 21 May 2003.
65.
Ibid.
66.
National Post 21 May 2003.
67.
A Review of USDA Slaughterhouse Records for Downed Animals (U.S. District
65 from January, 1999 to June, 2001) Farm Sanctuary, October 2001. http://www.nodowners.org/downedanimals.pdf
68.
National Cattlemen's Beef Association news release. 21 May 2003. http://www.beef.org/dsp/dsp_content.cfm?locationId=45&contentTypeId=2&contentId=2098
69.
European Molecular Biology Organization Reports 4, 5 (2003), 530.
70.
"Health and Consumer Groups Urge USDA to Keep Cattle Spinal Cord Tissue
Out of Processed Meat" Center for Science in the Public Interest News
Release. 10 August 2001.
71.
USDA, Food Safety and Inspection Service, USDA Begins Sampling Program
for Advanced Meat Recovery Systems, News Release.3 March 2002.
72.
United States General Accounting Office. GAO Report to Congressional
Requesters. January 2002 MAD COW DISEASE: Improvements in the Animal Feed
Ban and Other Regulatory Areas Would Strengthen U.S. Prevention Efforts.
GAO-02-183. http://www.gao.gov/new.items/d02183.pdf
73.
USDA Response To GAO Recommendations on BSE Prevention. Release No. F.S.
0071.02.
74.
Garland et al. "Brain emboli in the lungs of cattle after stunning" The
Lancet 348(1996):610.
75.
Chicago Tribune 21 May 21 2003.
76.
Toronto Star 21 May 21 2003.
77.
Chicago Tribune 21 May 21 2003.
78.
"Ministers Hostile to Advice on BSE." New Scientist 30 March 1996: 4.
79.
United States General Accounting Office. GAO Report to Congressional
Requesters. January 2002 MAD COW DISEASE: Improvements in the Animal Feed
Ban and Other Regulatory Areas Would Strengthen U.S. Prevention Efforts.
GAO-02-183. http://www.gao.gov/new.items/d02183.pdf |