In 1993, 623 people in the western U.S. fell ill with a little-known bacteria called E. coli O157:H7. Ultimately, four children would die from their infections; many others suffered long-term medical complications. The bug was later traced to undercooked hamburger served at Jack in the Box restaurants. This outbreak thrust foodborne illness onto the national stage as a real and present threat, sparking a sea change in the way Americans and the government treat this issue. To commemorate the 20th anniversary of the 1993 Jack in the Box outbreak, Food Safety News has produced a series of retrospective stories chronicling the outbreak itself and how food safety in America has changed since that time. Twenty years ago this month the State of Washington’s department of health announced that an E. coli outbreak was under way in the state and was likely linked to tainted, undercooked hamburgers served at a number of Jack in the Box restaurants. At the time, most Americans had never heard the term E. coli O157:H7. The Centers for Disease Control and Prevention (CDC) didn’t list it as a reportable disease. Only four state health departments even tracked the pathogen. Other than a few microbiologists and food scientists virtually no one knew the organism existed in food. But all of that changed as the outbreak rapidly spread throughout the West, tracked by the nightly news at all three major television networks, as well as virtually every big newspaper in the country. The idea that a hamburger could be lethal was a frightening wake-up call. Before the dust settled, over 600 people were poisoned and four children died. The Jack in the Box outbreak is considered the meat industry’s 9/11. As soon as hamburgers killed kids, everything changed. Congressional hearings were held.The national media put a spotlight on the industry. State and federal health codes were upgraded. E. coli became a reportable disease among all state health departments.Mandatory internal cooking temperatures for beef were raised to 155 degrees throughout the country. Even the warning labels that you see on all the meat and poultry sold in the supermarket today are a direct result of the Jack in the Box outbreak. It’s fair to say that the Jack in the Box case helped establish food safety as a serious public-health issue in America. The CDC estimates that foodborne disease causes about 48 million illnesses per year. Roughly one in six Americans get sick from bad food. Many of these cases are mild gastroenteritis, commonly referred to as the stomach bug. But too many food poisoning cases aremore serious, resulting in approximately 125,000 hospitalizations and 3,000 deaths annually. The fatalities are often among children and the elderly. Besides the obvious human toll, there’s an economic side to this. Foodborne illness in the United States costs about $152 billion a year. That’s the sum of medical expenses, insurance costs and lost wages. It’s a staggering number. But it’s not surprising given the number of major outbreaks in recent years. In 2010, more than half a billion eggs were recalled after nearly two thousand people became ill with Salmonella poisoning. A year before that, nine people died in a Salmonella outbreak linked to a peanut-manufacturing plant. Hundreds of food products from breakfast cereal to energy bars had to be recalled, costing food manufacturers over a billion dollars. E. coli O157:H7 is often more deadly than Salmonella. Although beef remains the most common vector of E. coli poisoning, the list of other foods responsible for major E. coli outbreaks is bewildering: spinach, unpasteurized apple juice, peppers, bagged lettuce, sprouts, raw milk, cilantro and cheese, to name just a few. E.coli even found its way into raw cookie dough in 2009. Meanwhile, six new strains of E. coli—known as non-O157s—have surfaced. The CDC estimates that these strains poison thirty-seven thousand people each year and kill nearly thirty. Here’s another place where the unintended consequences of the Jack in the Box case surface. The primary push to get these new strains banned as adulterants has come from food safety lawyer Bill Marler, publisher of Food Safety News, who got his start representing the children in the Jack in the Box case. In 2007, Marler had a thirteen-year-old client who died from eating food contaminated with one of these unregulated E. coli strains. That prompted Marler to commission IEH Laboratories & Consulting Group to conduct a five-hundred-thousand-dollar private study. The group analyzed five thousand samples of meat randomly purchased from grocery stores throughout the U.S. One percent of the store-bought meat was contaminated with these non-O157 strains of E. coli. That may not sound like much, but it is. Each year Americans consume billions of pounds of ground beef. If 1 percent is contaminated with these unregulated strains of E. coli, millions of pounds of poisonous meat are being eaten annually. During the summer of 2010, Marler turned his test results over to the USDA. The meat industry countered with a letter arguing that no reported outbreaks in the U.S. had been directly linked to beef products. Days later, the USDA announced that Cargill Meat Solutions, one of the biggest beef suppliers in the U.S., had recalled roughly 8,500 pounds of ground beef products that may have been contaminated with E. coli O26, one of the non-O157 strains. The announcement came after the CDC reported two patients in Maine and one in New York had contracted a rare strain of E. coli after consuming beef. The only reason the CDC found out about these three people was that their stool cultures happened to have been analyzed at one of the few labs in the U.S. that tests for non-O157 strains. To get the USDA to stop dragging its feet on implementing testing procedures for the non-O157 strains, Marler threatened to sue the agency in 2011. A few months later in 2011 a massive outbreak tied to a non-O157 strain of E. coli in imported fenugreek seeds from Egypt swept across Europe. More than four thousand people were sickened and fifty people died. On September 13, 2011, the federal government finally outlawed such strains of E. coli in the American food supply. Yet, the complexities associated with food safety continue to grow. In 2012 the beef industry was turned upside down when consumers— and then restaurants and grocery stores— stopped purchasing an additive to hamburger that the industry called lean finely textured beef (or LFTB), which had taken on the name “pink slime” in the media. Beef Products Inc., the maker of LFTB, quickly shuttered three of its four plants and within months sued ABC News, several reporters and producers and two former USDA employees for $1.2 billion. Marler is defending the two retired USDA workers pro bono. There has been some good news. On January 4, 2011, President Barack Obama signed the FDA Food Safety Modernization Act (FSMA), the most sweeping reform of our food safety laws in more than seventy years. It shifted the focus from responding to contamination to preventing it. The bad news is that Congress and the Obama administration have failed to fund the law. In the meantime, in September of 2011, the U.S. was hit with its deadliest food poisoning outbreak in one hundred years when thirty-three people died after eating Listeria-contaminated cantaloupes. One thing is certain. More than ever, consumers need someone keeping an eye on the regulators who are supposed to be keeping an eye on food safety. In 2011 Jeff Benedict wrote “Poisoned,”  the story of the Jack in the Box E. coli outbreak.  The book is coming out in paperback this Spring. In “Poisoned,” Benedict, an award-winning investigative journalist, delivers a jarringly candid narrative of the fast-moving disaster, drawing on access to confidential documents and exclusive interviews with the real-life characters at the center of the drama—the families whose children were infected, the Jack in the Box executives forced to answer for the tragedy, the physicians and scientists who identified E. coli as the culprit, and the legal teams on both sides of the historic lawsuits that ensued.