Valerie Gerber’s sprint to Kamloops was a typical farmer’s day out: lots of supplies to load, too many errands to run. Hours later, she was bone-weary and anxious to begin the 160-kilometre journey home. “That’s when I remembered I had to get this antibiotic from the vet,” she says.
It’s also when Gerber, former president of the British Columbia Sheep Federation, ran headlong into Health Canada’s new antibiotic regulation — the one requiring a prescription for drugs that, until last December, farmers could buy off the shelf.
At the clinic, the receptionist told Gerber the vets hadn’t been to the ranch in more than a year and the ranch’s Veterinarian-Client-Patient Relationship (VCPR), a crucial, unwritten contract between vet and farmer, had lapsed. No VCPR, no prescription.
“I went out of there just about in tears,” Gerber says. “It just made me see red. We’ve been working with them as long as they’ve been operating. We always felt like we had a vet-client relationship.” (The clinic did not respond to requests for comment.)
Welcome to the new era of antibiotic stewardship, a global effort to preserve the effectiveness of our most important drugs. The goal is to use “medically important antimicrobials” more carefully, so that decades from now they’ll still work — for your cows, and for the hip replacement you’ll need after years of, well, looking after cows.
But the burden of these changes falls disproportionately on smaller farms, and farms and vet clinics off the beaten track.
“Generally speaking I’m in favour (of the regulations). I think the right step was taken,” says Newfoundland and Labrador Federation of Agriculture president, Merv Wiseman. But, he says the measures to combat resistance “will be hard on farmers, especially in remote areas.”
“In the short term there’s going to be some suffering from it and some economic consequences,” he adds. “There just aren’t enough vets, especially large animal vets. They’re scarce.”
In Gerber’s case a chat with her vet helped answer her questions. But she still needs to renew her VCRP with the clinic, something she estimates will cost $250-$400. “I feel a little embarrassed about the misunderstanding,” she says. “I really didn’t think the regulations would affect me . . . From almost everyone you talk to it seems there just wasn’t enough detailed information about the repercussions.”
Full disclosure
When it comes to fighting antibiotic resistance, I’m completely on board. In the early 1990s, I was the medical reporter at a daily newspaper, scribbling new acronyms in my notebook: MRSA, for methicillin-resistant Staphylococcus aureus, or VRE for vancomycin-resistant enterococci. Drug resistance, once a sporadic oddity, was expanding in hospitals and nursing homes. In Detroit, just across the river from my office, resistance was breaking out among street drug users. Drug-resistant tuberculosis was appearing in larger cities and on First Nations.
More than 25 years later our wonder drugs are still at risk. And this is no longer a “someday” problem.
In 2016, Nevada doctors encountered a patient whose fatal hip infection resisted every antibiotic available in the US — 26 drugs in all. Meanwhile, the US Centers for Disease Control estimates antibiotic-resistant infections are killing about 23,000 Americans a year. In Europe, the toll is closer to 33,000 a year. Deaths attributed to resistance in Europe more than doubled between 2007 and 2015.
The rise of antibiotic resistance is evolution at work, something farmers have already seen with herbicide-resistant weeds and anthelmintic-resistant internal parasites. When a drug knocks off nearly all the targeted organism, it may spare a few individuals with natural immunity. Repeated use continues to kill susceptible bacteria, opening up more space to be colonized by resistant microbes.
Bacteria also have an additional trick up their cytoplasms: they can develop resistance to drugs they’ve never even encountered. The key is “plasmids,” free-floating loops of DNA that microbes pick up the way carpenters grab a tool belt. If the belt comes loaded with resistant genes, it allows different strains and species of bacteria to swap those genes as if they’re on a job site, sharing tape measures and hammers.
In a world with billions of people and farm animals the result is the rapid and surprising spread of resistance. Drug-resistant bacteria float on dust, lodge in nostrils, circulate in guts and manure and (sorry if this is near lunch) show up in meat. “We’re one big ecosystem,” says Ontario Veterinary College professor Dr. Scott Weese, an expert in antibiotic resistance. “Anything that’s going into your animals is getting peed out; people get exposed to it, it goes into the soil.”
Weese warns that if antibiotic resistance hasn’t yet affected you or someone you love, it easily could. As he told me during an interview, “You’re writing this article, and whether it’s five years from now or 20 years from now, you will have readers who will face antibiotic-resistant infections.”
So how to keep the “wonder” in our wonder drugs? “The challenge is to use the resource responsibly,” says Dr. Dan Shock, an Ontario veterinarian working on the Farmed Animal Antimicrobial Stewardship (FAAST) Initiative. (www.amstewardship.ca)
Overuse tends to drive resistance, creating an environment that favours resistant bugs. Using drugs more prudently levels the microbial playing field, allowing susceptible species to better compete against resistant critters. “We’ll always need to use antibiotics, because animals and humans will continue to get sick,” Shock says. “By being more selective when we use these drugs, we’re ensuring they remain effective.”
That’s why federal authorities have tightened the screws on antibiotic use by:
- Delisting “medically important antimicrobials” as growth promoters in feed.
- Prohibiting farmers from importing antibiotics for their own use.
- Ending over-the-counter availability of common drugs including penicillin and tetracyclines. Now most livestock medicines (especially drugs also used for humans) require a veterinarian’s prescription.
Similar measures are already driving down antibiotic use in other countries. In the US, sales of medically important livestock antibiotics fell 43 per cent from 2015 through 2017 with the bulk of the decline in feed.
But it’s the ban on over-the-counter sales, initiated Dec. 1, 2018, that has the biggest impact on small farms and in places where vets are thin on the ground. Now to legally access drugs, every farmer requires a Veterinary-Client-Patient Relationship, typically established by a vet through an on-farm visit.
For intensive livestock operations in major farming areas, the transition should be seamless. They’ve had vet-directed herd and flock health programs for years.
But in parts of Newfoundland, or northern Ontario, or on Barbara Johnstone Grimmer’s farm on South Pender Island, BC, things haven’t gone so smoothly. With the island’s existing clinic busy handling small animals, Johnstone Grimmer looked after her 100-ewe flock pretty much on her own, ordering medicines by mail. When the new regulations shut down her antibiotic supply last year, she was left scrambling to find a vet.
“We were talking about maybe getting some of the farmers on the island together and having a vet come over (by ferry), but the vets are already pretty stretched,” she said.
When I talked to her in mid-March, she was nursing a ewe following a dog attack. “I do feel abandoned,” she told me. “(If government) requires us to get a vet, they should help us find a vet.”
Not far away, on BC’s Saturna Island, Jacques (pronounced “Jackie”) Campbell looks after about 100 ewes and a dozen cows, and like Johnstone Grimmer, she had largely operated without veterinary help. Now she’s working with a vet in Mill Bay on Vancouver Island — including ferry passages, a 10-12 hour round trip.
“I understand why the regulations have come in, so people won’t abuse the meds,” she says. “The hardest part is establishing a relationship with a vet when there aren’t any. Before they bring in a regulation like this they should really study what’s available. In a good portion of BC vets are not available.”
Compared to these west-coast colleagues, I have no reason to whine. For years, after bailing out of the big-city reporter job and starting a farm in northern Ontario, I could buy antibiotics at the nearby farm store. I developed a good working relationship and VCPR with a vet 40 minutes down the highway.
So after the new rules came in, I noticed my medicine cabinet was bare. I asked my vet for a bottle of long-acting penicillin “just in case” a ewe gashed her leg on a piece of wire, or there’s a difficult assisted lambing or calving. In short, I wanted the pharmaceutical version of Linus’s security blanket.
The answer was no. My request was too unfocused, too vague. We’ll need “more discussion in each case,” my vet wrote back by e-mail.
Before he hands over a bottle and syringe, the vet needs me to identify an individual patient or group of patients and outline symptoms. Working together, we’ll nail down the diagnosis (possibly with a visit or tests and samples), discuss medical options (including ones that avoid antibiotic use, or use antibiotics that are less important in human medicine) and look at options to prevent the problem in the future.
All good stuff. In terms of antibiotic use, it will up my game. But even though antibiotic use is a rarity at our place, I still feel naked without that bottle.
Other farmers know the feeling. As Max Burt, a farmer on Ontario’s Manitoulin Island says, “You like to have a product on hand, because the vet can’t possibly come all the time. We’re caregivers for our animals, and we need the right to judiciously use the product when it’s needed.”
Perhaps my discomfort is a small price to pay. But the new regime will likely bring higher costs for drugs, dispensing and shipping fees and tire rubber. With fewer animals to spread these costs over, “smaller farmers will be affected more than larger ones,” says John McNaughton, president of the Manitoulin Cattleman’s Association.
And while there’s a national system to track drug sales, “There’s no real economic analysis being done on the cost to producers. There’s no reporting in place to keep track of the cost increases for individual drugs, or shipping, ordering and dispensing costs,” says Beef Farmers of Ontario’s senior policy advisor, Katherine Fox.
Nor, as far as I can tell, is anyone tracking areas where VCPRs are difficult to establish and vets must cover inordinate distances to provide service. It’s as if the bureaucrats weren’t thinking of Barbara Johnstone Grimmer, or Jacques Campbell.
So how to navigate this new reality? One option is to ask your commodity group for help. “If you don’t have a vet, we can help find you one,” says BFO’s Katherine Fox.
Other groups, working with provincial vet regulators, have been able to tweak the rules to better fit their industries. When Emily Mills, vice-president of the Ontario Beekeeper’s Association (OBA) first heard of the ban on over-the-counter drug sales, “I thought it was going to be impossible,” she says. “Beekeepers don’t deal with vets. We don’t have a bee breaking its leg and we call the vet in.”
The major concern is American foulbrood, a fatal, infectious bacterial disease kept in check with a range of measures, including the occasional use of a low-cost, powdered antibiotic, previously available over the counter.
Mills worried that if vets need to visit large beekeeping operations to establish VCPRs, it could take hours, even days to tour hundreds or thousands of colonies spread over many kilometres. And what if backyard beekeepers just said to heck with the rules, and opted to buzz beneath the radar? By forgoing antibiotics, they could risk the health of neighbouring hives.
“We got to work right away,” Mills says. The OBA’s Technology Transfer Program developed workshops to educate vets on the needs of bees and beekeepers. Meanwhile, talks with the College of Veterinarians of Ontario produced a protocol allowing vets to establish VCPRs and write prescriptions without having to personally inspect bee colonies.
Throughout the process, “The question was how do we reach the people who have a few colonies and very little financial investment? They’re the ones who are the most difficult to reach, so we’re trying to make this as easy for them as possible,” Mills says.
The experience proves flexibility and solutions are possible. And farmers are eager for solutions.
Almost every farmer I talked to for this story argued for some sort of telemedicine approach. It may require significant changes to veterinary regulations, but in remote areas with good web connections, why not diagnose using real time video? For that matter, why not designate underserviced areas where even VCPRs could be established by video in cases where in-person calls are impractical?
Ultimately, “the big solution to all of these individual issues, including cost and access, is to look at the numbers of large animal vets,” says Katherine Fox. Ontario, for example, has about 4,800 members in the College of Veterinarians of Ontario, but only about 650, including government vets, working with food animals.
To boost those numbers, the BFO is pushing government to make establishing and expanding vet clinics a regional economic development priority, especially in underserviced areas. It also wants vet colleges to attract more kids from rural and farm regions. “Maybe a vet student who comes from northern Ontario is more likely to move back to northern Ontario when she graduates,” Fox says.
Still, that’s a long-term fix. Much as I wanted to talk to front-line vets for this story, none returned calls. One e-mailed to say he was too busy “working 16-18-hour days, just to keep up.” I began to wonder if these regulations are as much a burden on vets as they are on farmers.
Meanwhile, vets and farmers are working things out as best they can. Just as I wrapped up this story, Barbara Johnstone Grimmer called to say her local clinic was offering to help farmers on her island. Although primarily a small-animal practice, the local vets agreed to establish VCPRs with area farmers, write prescriptions and treat livestock brought to the clinic during normal office hours.
“It’s really good of them to do this,” Johnstone Grimmer said. “We were looking at trying to get a vet to come from off the island, but that would likely be cost-prohibitive.”
I can’t argue with the need to conserve our antibiotics. I too want to steward their power for future generations. But I can’t help thinking this most recent regulatory change would have been less disruptive if it had enlisted farmers as allies, and helped veterinarians, commodity groups and farmers build links before the rules come in. Why not treat us as part of the solution, rather than a problem to be regulated?
University of Liverpool researcher, Dr. Camille Bellet, came to similar conclusions after surveying British dairy farmers.
“If public authorities are serious about tackling drug resistance and supporting animal well-being,” she recently wrote on the science website, The Conversation, “when it comes to farming, farmers should be the first we listen to.”
Amen to that. Let’s hope someone in charge remembers that. Next time.
What is a VCPR?
The Veterinary-Client-Patient Relationship is an ongoing working relationship defined by a provincial veterinary regulator. Think of it as the basic ground rules of the partnership including the scope of services the vet provides, the vet’s adherence to professional standards of practice and the farmer’s agreement to retain the vet. As the Canadian Veterinary Medical Association puts it, the VCPR is also “a tool necessary to develop a prescription.” As of December 2018, you need a VCPR to access most antibiotics.
Saskatchewan’s VCPR, for example, features four conditions:
- The vet assumes “responsibility for making clinical assessments and recommendations”.
- The vet must have “sufficient knowledge of the animal(s)” to assess, diagnose and treat. (This is a complex issue; more about this later, in “Prescribing.”)
- The farmer agrees to follow the vet’s advice.
- The vet is available to care for the patient and will follow up on treatment (or have an alternate available.)
A VCPR is typically established by a farm visit, so the vet is familiar with farm management, infrastructure, livestock, ongoing health issues etc. During the visit, you’ll also discuss each other’s expectations, the range and scope of veterinary services on offer and emergency coverage. Fees vary by practice and location. While working on this story I’ve heard a range from $100 to $400, possibly more depending on time, travel and farm complexity.
It’s a long-term investment in better animal health and productivity, says Dr. Dan Shock, a Guelph-based large animal veterinarian and consultant. “I think we bring a lot of value to farmers, and regular contact is a good thing. We want to be there in a consultative and educational role.”
In a pinch, couldn’t a dog or cat vet help out on the farm?
Probably not, says Jan Robinson, registrar and chief executive officer with the College of Veterinarians of Ontario. Veterinarians must practise through an accredited facility, and your local small animal vet clinic may be accredited to treat companion animals, not farm animals.
Veterinarians also “have a duty, under our bylaws, to only provide those services which they are competent to provide,” College of Veterinarians of BC deputy registrar Dr. Stacey Thomas added in an e-mail. “A veterinarian who has practised only small animal medicine has most likely not maintained their skills and knowledge in the diverse area of production animal medicine . . . ”
Finally, Thomas adds, “the College cannot compel its registrants to provide services they do not wish to provide.”
Prescribing
To write a prescription or dispense medicine, regulators typically require veterinarians have “recent and sufficient knowledge” of the animal or group of animals being treated, based on physical examination, case history, test results etc. Some provinces set a time limit in their VCPR. In Manitoba, for example, the relationship can lapse if the vet hasn’t been on the farm during the past 12 months.
Generally, “The way the legislation is written is, it leaves it up to the professional discretion of the veterinarian and how comfortable we are with dispensing medicines to our clients,” says Dr. Dan Shock. With some clients, there’s more contact, a good relationship and greater confidence. In cases where the vet has less contact with the farmer, “you may want to go there and see their animals more often. It all depends on the comfort level of the vet and the relationship that’s established with the producer.”
Ultimately, vets must be able to show their regulator they meet professional standards. As Jan Robinson of the College of Veterinarians of Ontario says, “A vet can’t go below standards just because it seems like a good idea to the producer.”
Protocols and guidelines
The classic herd health approach requires vets and farmers to:
- anticipate health problems before they develop,
- work to prevent illness, and
- have plans for ongoing monitoring, treatment if necessary and follow-up.
Typically, farmer and vet develop written protocols for likely illnesses, such as mastitis or calf scours. Once the vet is satisfied with the protocol and confident in the farmer’s ability to carry it out, she may write a prescription for medicines to be used in accordance with the plan. (For an on-line example, search “Case Study: Establishing a Valid Veterinarian-Client-Patient-Relationship (Cow-Calf Producer)”, from the Canadian Veterinary Medical Association.
— Ray Ford
For more information:
--An excellent resource focused on Ontario but relevant elsewhere is the Farmed Animal Antimicrobial Stewardship Initiative (FAAST): www.amstewardship.ca
--See the Canadian Veterinary Medicine Association’s section on antibiotic stewardship listed under the “Policy and Advocacy” tab at www.canadianveterinarians.net
--See also the web sites of your commodity group, provincial veterinary regulator or agriculture ministry.