Welcoming Six Farms in Lebanon, Florida, Texas, Nebraska, and Michigan to RAWMI Community

The Raw Milk Institute (RAWMI) sends a warm welcome to six more farmers who have completed our Listing program!

RAWMI offers free mentoring to all dairy farmers. Whether they are milking one cow, a handful of goats, or a large herd, the principles of safe raw milk production form a foundational toolset that benefits all dairy farmers and their customers. 

Some of the farmers we mentor choose to keep it casual, and are satisfied to just ask us a few questions before continuing their raw milk journeys. There is another set of farmers, though, that is not content to just dip their toes in the water; they want to dive right in and take their entire milk process to the next level. 

For these farmers, we offer our (free) RAWMI Listing program, wherein we assist farmers in developing their own unique on-farm Risk Analysis and Management Plan, documenting their processes with written Standard Sanitary Operating Procedures, and identifying the Critical Control Points that are essential to their production of safe raw milk. RAWMI Listed farmers test their milk at least monthly for ongoing assurance that their processes are working well to produce low-risk raw milk. RAWMI Listing is the gold standard for raw milk producers.

Six raw milk farms have recently completed the RAWMI Listing process, and we extend them a warm welcome into our growing community!

• Fresh Flow Farm - Marjaba, Metn, Lebanon

• Full Table Ranch - Lockhart, Texas, USA

• Like Wildflowers Homestead - Lamesa, Texas, USA

• Little Acres Farm - Morrill, Nebraska, USA

• Lone Oak Homestead - Fowlerville, Michigan, USA

• Udders and More - Astor, Florida, USA

Fresh Flow Farm - Marjaba, Metn, Lebanon

Elias Hajj’ quest for raw milk began three decades ago, as a curious child who wondered why breastmilk was safe to drink yet cow’s milk was always pasteurized. After visiting dairy farms and seeing the filthy conditions, he understood why they drank pasteurized milk but still wondered if there was a better way. Decades later, Elias became determined to find a source of raw milk safe for human consumption, but his search proved fruitless. Frustrated but resolute, he decided to take matters into his own hands and start his own dairy farm.

The day Elias tasted his first cup of raw milk, straight from the udder of his cows, was nothing short of magical. The richness and purity of that milk were unlike anything he had ever experienced. He felt an overwhelming urge to share it with the world. He was pleased to find the RAWMI website, with it’s focus on clean cows and rigorous standards for producing truly clean and safe raw milk. Now, Elias is on a mission to make raw milk safe again, safe for everyone to enjoy its natural goodness. It's more than just farming; it's a re-education, a re-connection to a forgotten source of nourishment, and an unwavering commitment to health, integrity, and the simple, profound taste of milk as nature intended.

You can check out Fresh Flow Farm’s Risk Management Plan and test results here: https://www.rawmilkinstitute.org/listed-farmers/#freshflow

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Full Table Ranch - Lockhart, TX

Full Table Ranch is owned and operated by the Schulze family. They are a big, farm-loving family with 6 kids and some sweet cows. 

They started out with plans to provide milk just for their own family, but quickly discovered a supportive community full of raw milk lovers. They intend to provide others with milk the way it was intended, unprocessed and straight from pasture raised, happy cows.

You can check out Full Table Ranch’s Risk Management Plan and test results here: https://www.rawmilkinstitute.org/listed-farmers/#fulltable

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Like Wildflowers Homestead - Lamesa, TX

Like Wildflowers Homestead is a family of four deeply rooted in West Texas, where their journey into homesteading started with a couple young dairy goats and a hope for a healthier life. What started as a simple love for their goats quickly led them to showing them, growing their herd, and ultimately offering raw goat milk to a couple local families.

A few years later, welcoming a couple of heifers really sparked their raw dairy venture. As their passion for quality, local, healthier food deepened, so did their farm — and today, they’re proud to not only provide fresh raw dairy but also host local West Texas vendors through their market, supporting other growers and makers in their community. They now serve three cities each week — Midland on Mondays, Lubbock on Thursdays, and Lamesa on Fridays — and are honored to nourish families across West Texas while helping build a stronger, local food network.

You can check out Like Wildflowers Homestead’s Risk Management Plan and test results here: https://www.rawmilkinstitute.org/listed-farmers/#likewildflowers

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Little Acres Farm - Morrill, NE

Little Acres Farm began as a small garden with a few goats and has grown into a labor of love rooted in faith, family, and a passion for wholesome living. What started as a way to feed their family better turned into a full-fledged dairy focused on producing fresh, nutrient-rich raw goat milk and handcrafted products made with care. They believe raw milk is one of nature’s most perfect foods — filled with life, goodness, and the nutrients our bodies were meant to have.

Their goats are happy, healthy, and well cared for, and that care shines through in the quality of the milk they give. They take great pride and care in producing safe, nourishing products for their community, ensuring that everything they offer reflects values of honesty, quality, and respect for the land and animals they tend. What began as a small dream has become their way of life, and they’re grateful to share it with their community.

You can check out Little Acres Farm’s Risk Management Plan and test results here: https://www.rawmilkinstitute.org/listed-farmers/#littleacres

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Lone Oak Homestead - Fowlerville, MI

Lone Oak Homestead is a family-owned and operated organic herd-share dairy farm, where wholesome food, happy animals, and community connection come first. Their farm began with a simple goal: to provide better-quality food for their family. They wanted milk that was fresh, nutrient-rich, and came from cows that were treated with respect and care. What started as a small family effort soon grew into something bigger and a way to share that same quality and goodness with their neighbors and community. Their four children, Grace, Haylin, Kinsley, and Kamdyn have made this possible! Without their help and commitment, Lone Oak Homestead wouldn't have made it to this point! 

At Lone Oak Homestead, their cows are grass-fed, pasture-raised, and organically cared for. They never use hormones, antibiotics, or chemical fertilizers, just natural farming practices that honor the land and the life it supports. Every bottle of milk comes from cows they know by name and care for daily.

You can check out Lone Oak Homestead’s Risk Management Plan and test results here: https://www.rawmilkinstitute.org/listed-farmers/#loneoak

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Udders and More - Astor, FL

Udders and More is a small homestead with a few family milk cows. They absolutely enjoy the cows, the work, and the milk! Their girls are A2/A2, disease tested, grass fed, and no soy products. The cows get daily cuddles and treats from the family. Udders and More’s milk is tested regularly using their in house lab and a 3rd party lab. They only use glass for bottling and pride themselves in producing high quality, low-risk, raw milk. 

You can check out Udders and More’s Risk Management Plan and test results here: https://www.rawmilkinstitute.org/listed-farmers/#udders

VIDEO: Raw Milk Benefits, History, Production Practices, Sources, and More

Raw Milk Institute Chairman and Founder Mark McAfee was recently interviewed by Caspar Szulc for the “Your Health, Your Story” podcast. In this one-hour interview, they discussed raw milk health benefits, history, laws, production practices, sources, and much more!

Glyphosate in Feed May Impact Food Safety and Health

Synthetic pesticides and herbicides pose a number of problems, so raw milk farms are advised to minimize their exposure for soils, crops, water, feeds, and livestock. While there are numerous synthetic pesticides and herbicides of concern used in conventional agriculture, glyphosate-based herbicides (often sold under the brand name Roundup) are by far the most widely used.  Glyphosate residues are slow to degrade and can accumulate in the soil, manure, water, and feed. 

Common Feed Sources of Glyphosate on the Farm

Cows and goats should ideally obtain most of their feed from pasture during the growing season. When purchasing feed, beware that alfalfa, corn, wheat, canola, and soybean are crops most likely to be engineered to tolerate glyphosate herbicide.  Because of these and other genetically-engineered (GMO) crops, global usage of glyphosate has proliferated to billions of pounds annually[i].  Besides use on herbicide-tolerant crops, glyphosate is also often sprayed on many small grains and other crops as a desiccant applied shortly before harvest.  When sprayed on wheat, oats, legumes, sugar cane, and barley, glyphosate residues will then be present in the grain and other plant parts.[ii]   

Harms of Glyphosate Exposure

Livestock exposed to glyphosate in feed or as bedding are more likely to have serious animal health disorders causing loss of production.[iii]  Glyphosate is a strong mineral chelator that binds tightly to essential minerals to render them non-functional physiologically.  Exposure of crops and livestock to glyphosate can intensify mineral deficiencies of Ca, Cu, Co, Fe, Mg, Mn, Ni, and Zn. 

Besides interfering with mineral nutrition, glyphosate has antibiotic properties that disrupt the gut microbiome. An in-vitro study looking at potential impacts of glyphosate found that some pathogenic bacteria such as Salmonella and Clostridium botulinum are “highly resistant to glyphosate. However, most of beneficial bacteria as Enterococcus faecalis, Enterococcus faecium, Bacillus badius, Bifidobacterium adolescentis and Lactobacillus spp. were found to be moderate to highly susceptible.”[iv] This raises concerns about the potential for glyphosate to kill beneficial microorganisms while allowing pathogenic bacteria to proliferate. 

Weeds Can Be Beneficial in Pastures

On the farm, pasture and forage feed sources for ruminants can be produced without pesticides through intentional management practices.  Beneficial pastures are composed of a mix of diverse species including nitrogen-fixing legumes.  Pastures and hay fields do not need to be perfectly weed-free for feeding livestock.  In fact, some “weed” species are palatable and can serve as acceptable feed.  In general, weeds can be controlled by good rotational grazing management and by sometimes clipping pastures immediately after grazing. Beware that a few weed types, such as pokeweed, hemlock, and nightshade, are poisonous. 

Other Potential Sources of Glyphosate on the Farm

It is not enough to just avoid using glyphosate and synthetic pesticides on your own farm. To minimize exposure to glyphosate, dairy farmers need to be aware of potential sources such as well water, imported feeds, bedding materials, drift from neighboring farms, and soil fertility inputs.  Ideally, feeds and bedding materials for the dairy herd should be produced on-farm.  Feeds and bedding materials obtained from common commercial sources are generally suspect for glyphosate contamination.[ii]

Grain Supplementation Can Be Important for Dairy Herds

Although milk can be produced from entirely grass-fed animals through high quality forages, it can be challenging to supply enough energy to dairy animals without feeding some grain in order to maintain good health and body condition.  For small dairy farms, it may be more economical to purchase grains rather than becoming grain producers. Feed sources that commonly have glyphosate residue include alfalfa, canola, corn grain or silage, soybean, wheat, oats, barley, sugar beets, cottonseed meal, sugar cane, molasses, and distillers grain. 

Purchasing pesticide-free, non-GMO, and/or certified organic feeds is one approach to minimizing exposure to pesticides and genetically engineered feed crops. Certified organic feeds are typically more expensive; however, farmers can search for feed sources from reputable producers who farm with ecological practices, even if they are not certified organic.  Questionable feeds and materials can be tested for the presence of glyphosate, such as with the testing supplies available from Health Research Institute in Fairfield, Iowa.

Reducing Glyphosate Exposure on the Farm

It is recommended for farmers to look holistically at all aspects of their environment for ways to reduce exposure to glyphosate and pesticides. Bedding materials such as soybean hulls and straw from small grain crops may also be contaminated with glyphosate or pesticides.  Additionally, poultry and other livestock manures, such as those imported from conventional farms to build soil fertility, often contain glyphosate residues.[v] 

Raw milk customers often ask raw milk dairy farmers pointed questions about production practices.  Many customers are discriminating in food quality and purposely seek out farms that avoid the use of GMO’s and free of pesticides and herbicides. Fortunately for dairies, pasture and forages can be relatively easy to manage without the use of synthetic pesticides or herbicides. Farms that implement good production practices can answer such customer questions directly.  They can honestly report on how they use ecological farming practices to manage pests without using synthetic pesticides. 

References

[i] Wilson, C.L. and D.M. Huber. (Ed.) 2021. Synthetic Pesticide Use in Africa, Impact on People, Animals, and the Environment.  Chapter 2: Glyphosate’s Impact on Humans, Animals, and the Environment. CRC Press, Taylor & Francis Group. Boca Raton, London, New York. 2021 https://www.taylorfrancis.com/books/edit/10.1201/9781003007036/synthetic-pesticide-use-africa-charles-wilson-huber

[ii] Jingwen Xu, Shayna Smith, Gordon Smith, Weiqun Wang, Yonghui Li. Glyphosate contamination in grains and foods: An overview. Food Control, Volume 106 (2019) https://www.sciencedirect.com/science/article/abs/pii/S0956713519302919

[iii] Wilson, C.L. and D.M. Huber. (Ed.) 2021. Synthetic Pesticide Use in Africa, Impact on People, Animals, and the Environment. Chapter 8: Animal Health Issues with Increased Risk from Exposure to Glyphosate-Based Herbicides. Chapter 9: Agricultural Pesticides Threats to Animal Production and Sustainability. CRC Press, Taylor & Francis Group. Boca Raton, London, New York. https://www.taylorfrancis.com/books/edit/10.1201/9781003007036/synthetic-pesticide-use-africa-charles-wilson-huber

[iv] Shehata AA, Schrödl W, Aldin AA, Hafez HM, Krüger M. The effect of glyphosate on potential pathogens and beneficial members of poultry microbiota in vitro. Curr Microbiol. 2013 Apr;66(4):350-8. doi: 10.1007/s00284-012-0277-2. Epub 2012 Dec 9. PMID: 23224412. https://pubmed.ncbi.nlm.nih.gov/23224412/

[v] Harle, D., McNeill, M. J., Huber, D. M., Maney, M., Cano, R. J., & Carlin, M. (2024). Saga of Soggy Sauerkraut. HortScience, 59(11), 1618–1628. https://doi.org/10.21273/HORTSCI18041-24

STUDY: Raw Milk Legalization ≠ Increased Illnesses

When researchers analyzed the CDC’s U.S. outbreak data for 2005–2020 from all transmission sources, they found that there is no trend of increasing raw milk illnesses associated with increased raw milk legalization. The analysis, published in the Journal of Epidemiology and Global Health, looked for trends in the burden of infectious disease and foodborne outbreaks.

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Fatal Foodborne Illnesses From 2005-2020

Interestingly, the researchers found that fatal foodborne illnesses were dominated by fruits, vegetables, peanut butter, and pasteurized dairy. If government agencies were really concerned with targeting foods that cause the most illnesses, they would be banning cantaloupe! Instead, they continue to demonize raw milk.

Foods associated with U.S. outbreaks reporting more than 2 deaths (2005–2020)

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Illnesses and Outbreaks from Pasteurized and Raw Milks

The researchers also compiled illness and outbreak data to compare pasteurized and raw milk. “A total of 3,807 illnesses were reported for fluid milk. Both raw and pasteurized milk were associated with outbreaks, illnesses, hospitalizations, and deaths over the 16-year period, with raw milk associated with 162 outbreaks, 1,696 illnesses, 170 hospitalizations, and 2 deaths in 37 of 50 U.S. states, and pasteurized milk associated with 18 outbreaks, 2,111 illnesses, 32 hospitalizations, and 4 deaths.”

Numbers illnesses, outbreaks, hospitalizations, and deaths by year for unpasteurized (raw) and pasteurized milk (2005–2020)

It is clear that pasteurization of milk is no guarantee of perfect safety. There is no such thing as a perfectly safe food.

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Illnesses Do Not Increase with Legalization of Raw Milk

The researchers performed several different analyses to determine whether raw milk-attributed illnesses and outbreaks are increasing. Even though legalization of raw milk increased over the 16-year study period, “raw milk-attributed illnesses and outbreaks did not increase over the period.”

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Raw Milk is Not Inherently Dangerous

According to the researchers, “Claims that raw milk is inherently dangerous appear founded in ideology and dogmas based on late 19th-century science, not the recent data.”

Furthermore, “CDC NORS data do not support the claim that raw milk is an inherently dangerous food. Nor do current microbiology data support this claim, as data from monitoring programs for raw milk produced for direct human consumption are rarely positive for the presence of any of the major foodborne pathogens (≤ 0.01% positive).”

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RAWMI Method for Low-Risk Raw Milk

Here at the Raw Milk Institute, we know that raw milk can help people achieve robust health with strong immune systems and resistance to asthma and allergies. However, those benefits can be overshadowed if farmers aren’t diligent about managing the real food safety risks that accompany raw milk. Ethical farmers need to take these risks seriously and work actively to mitigate them. 

The three pillars of the Raw Milk Institute Method for safe, low-risk raw milk are:

• Farmer training and mentoring

• An individualized risk management plan for each farm

• Ongoing bacterial testing for Coliforms and Standard Plate Count, aiming for rigorous-yet-achievable standards

Although there is no way to guarantee perfectly safe food, the RAWMI Method dramatically reduces the risk of illness from consumption of raw milk.

Researchers from Canada and Europe have studied the safety of raw milk intended for direct human consumption. They found that raw milk can be a low-risk food when farmers are trained in risk management practices, implement careful production practices, and test their milk regularly. Researchers concluded that “raw milk can be produced with a high level of hygiene and safety.”

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Where to Learn More

You can read the full study here: https://link.springer.com/article/10.1007/s44197-024-00216-6

RAWMI extends thanks to Michele Stephenson, Peg Coleman, and Nicholas Azzolina for this important perspective on foodborne illnesses.

RAWMI Annual Report for 2024-25

The Raw Milk Institute (RAWMI) is on a mission to improve the safety and quality of raw milk and raw milk products through farmer training, rigorous raw milk standards, raw milk research, and improving consumer education. In 2024, RAWMI received a grant for $42,500 from the Regenerative Agriculture Foundation (RAF) to further our work. RAWMI accomplished the following in the last year.

• Presented a 3-hour seminar on World Class Raw Milk at the PASA Sustainable Agriculture Conference in Lancaster, Pennsylvania to 45 farmers from Pennsylvania, New Jersey, New York, Maryland, and Delaware  

• Trained hundreds of farmers, families, legislators, university professors, and consumers on raw milk benefits and risk management via our internet-based video resources, for a total of 6,432 views of our videos with over 808 hours of watching time

• Presented about raw milk benefits and risk management to students at Rutgers University in class on “Fertile Soil to Fresh Milk, Science, Standards, and Policy”

• Attended the International Milk Genomics Consortium Symposium and were cordially invited to speak at the 2026 conference in Oregon

• Served as the raw milk hotline for farmers in need across the USA and Canada

• Developed guidance for farmers to safely navigate avian influenza affecting dairy herds

• LISTED thirteen farms in who we mentored through the process of developing individualized Risk Assessment and Management Plans (RAMP) for managing the health and hygiene of their unique farms

  • Bells Bend Farms in Tennessee

  • Canaan Farm in Missouri

  • Mini Mosaic Acre in Missouri

  • Mountain Heritage Farm in Tennessee

  • Raising Arrows Creamery in Nebraska

  • Raspberry Lane Ranch in Idaho

  • Westerlook Farm in Oregon

  • Blueberry Dairy in Tennessee

  • Milk Creek Dairy in Tennessee

  • Towering Oaks Farm in North Carolina

  • Redmond Heritage Farms in Utah

  • Atkins Raw Milk Dairy in Iowa

  • Anonymous Farm in Wisconsin

• Provided one-on-one mentoring in the production of low-risk raw milk to over 55+ additional farms in 25 states (Florida, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, Montana, Nebraska, North Carolina, Ohio, Oregon, Pennsylvania, South Dakota, Tennessee, Texas, Virginia, Washington, Wisconsin, Wyoming), New Brunswick Canada, Azores in Portugal, and Lebanon

• Provided 40+Essential Principles for Low-Risk Raw Milk booklets to farmers in 30 states (Alabama, Arkansas, California, Florida, Hawaii, Iowa, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maryland, Michigan, Minnesota, Missouri, North Carolina, New Jersey, New Mexico, New York, Ohio, Oklahoma, Oregon, Pennsylvania, Tennessee, Texas, Utah, Virginia, Washington, Wisconsin, West Virginia, and Wyoming), British Columbia Canada, Queensland Australia, and United Kingdom

• Hosted quarterly meetings for LISTED farmers, which allow the farmers to stay up-to-date on the latest lessons learned for safe raw milk

• Amassed hundreds of raw milk test data from LISTED farms to further raw milk research

• Provided educational support towards increased legal access to raw milk in North Carolina, Ohio, and Wisconsin

• Published 17 articles on raw milk benefits, testing, legalization, and risk management strategies

• Provided $500 on-farm lab sponsorships to 9 family farms in Iowa, Florida, Kansas, Kentucky, Oregon, South Dakota, Texas, Wyoming

Why Farmers Should Test Their Raw Milk

Ongoing bacterial testing is a crucial part of raw milk risk management.

Consumer demand for raw milk is increasing, as people learn about the health benefits of raw milk and the negative effects of pasteurization. Raw milk farmers can thrive in this burgeoning market and help their customers achieve robust health with strong immune systems and resistance to asthma and allergies. 

Unfortunately, that service to humanity can be overshadowed if farmers aren’t diligent about managing the real food safety risks that accompany raw milk. Some people and organizations have asserted that raw milk is inherently safe because of the natural bacteria that is present. However, this is demonstrably not true. Pathogens can indeed be present in raw milk and those pathogens can make people sick. Ethical farmers need to take these risks seriously and work actively to mitigate them. 

Scroll or click below for information about the following topics:

• Top 4 Pathogens of Concern for Raw Milk

• “But My Family Drinks My Milk with No Problems”

• Careful Milk Production Isn’t Enough

• Which Tests to Perform

• Where to Test Raw Milk

• Testing is a Proven Part of Low-Risk Raw Milk

Top 4 Pathogens of Concern for Raw Milk

The four most common human pathogens that have been associated with raw milk-related illness are verotoxin producing Escherichia coli (VTEC, such as E. coli O157:H7), Salmonella enterica spp., Campylobacter jejuni, and Listeria monocytogenes. When any of these bacteria are present in the milk at levels that are sufficient to cause infection, susceptible people may experience intestinal illness that may include severe illness or death.

E. coli 0157:H7 is of particular concern because it can produce severe illness even with a low pathogenic load.  With even just a few bacteria present, E. coli O157:H7 can lead to hemolytic uremic syndrome (leading to kidney failure) or thrombocytopenic purpura (blood clots that can restrict flow of oxygen to the organs).

Thus, pathogens in raw milk need to be taken very seriously by farmers. Some of the most common sources of pathogens in milk are manure, mastitis, and improper cleaning of milking equipment resulting in biofilms of bacteria.

"But My Family Drinks My Milk with No Problems"

Farmers, please don’t make the mistake of assuming that, just because your family can drink your raw milk with no problems, there are no pathogens present.

We commonly hear farmers say they would know if there was a problem with their milk, because their own family drinks it without issues. However, this is not necessarily true. Farm families generally have more-robust immune systems than the population at large. Being around animals and the farm environment tends to build strong immune systems, but many raw milk customers have no such advantages.

Some people choose to drink raw milk specifically to help build up their immune systems. As such, they may have leaky gut, compromised immune systems, improper gut flora due to antibiotics, extreme vulnerability while recovering from chemotherapy, etc. These customers will have a much lower threshold for illness from pathogens than farm families. Just because the farm family can drink the milk with no issues does not mean that the raw milk consumers will be able to do so.

Careful Milk Production Isn't Enough

Important risk management strategies for low-risk raw milk include careful udder preparation, rapid milk chilling, thorough equipment cleaning, and much more. Our experience in mentoring hundreds of farmers has shown that these careful practices aren’t enough, though. They must be backed up with bacterial testing to ensure that nothing important is being missed.

We’ve seen it happen time and time again that farmers can get an unpleasant surprise when they first test their milk. Low-risk raw milk requires careful attention to a multitude of details, and even one little missed detail can turn into a big problem. Bacterial testing serves as a confirmation step to make sure the overall milk production process is working well to reduce the risks.

Farmers: if you don’t test your milk, you won’t know. As Raw Milk Institute Chairman Mark McAfee says, “What gets tested gets done.”  It could be that:

• the milk isn’t chilling as fast as expected, or

• there is a bacteria biofilm growing in the crevices inside the bulk tank valve, or

• one of the cows has a quarter that is developing subclinical mastitis, or

• the milk hoses didn’t dry out well in-between milkings, or

• the water heater is going out so the wash temperature of the pipeline is too low, or

• there is a crack in an inflation liner that is allowing bacteria growth in an area where the cleaning solution doesn’t flow, or

• the milk jars aren’t clean enough, or

• any of a multitude of other potential problems.  

All of these can lead to increased bacteria counts, so testing is a way to double-check that nothing important has been missed.

Which Tests to Perform

Pathogen testing of raw milk can be used to determine whether specific pathogens are present by testing for Escherichia coli VTEC, Salmonella enterica spp., Campylobacter jejuni, and Listeria monocytogenes. Pathogen testing can have both false positives and false negatives, so it is not a perfect guarantee of food safety. Additionally, pathogen testing can be cost-prohibitive and is only meaningful if it is performed frequently. Nonetheless, for farmers who can afford it, frequent pathogen testing can be helpful in determining whether any specific pathogens are present over time.

Regardless of whether or not pathogen testing is performed, Raw Milk Institute (RAWMI) recommends that all raw milk farms perform bacterial testing at least monthly for coliforms and Standard Plate Count (SPC). The RAWMI Common Standards aim for a rolling three-month average of:

• <5,000 cfu/mL for SPC

• <10 cfu/mL for coliforms

Although these two tests do not directly detect the presence of pathogens, they serve as general indicators that the milk is being produced hygienically and in such a way that pathogens are less likely to be present.

NOTE: None of these tests are a perfect guarantee that there will never be a pathogen present. No food can ever be perfectly safe. Nonetheless, these tests can help dramatically decrease the risk of having pathogens present.

Where to Test Raw Milk

Depending on location, milk testing may be performed at a local university or independent testing lab.  Additionally, some labs have created specialized testing packages for raw milk. 

• Microbial Research lab in Fort Collins Colorado has a raw milk testing package that makes it more affordable for farmers to perform pathogen tests.  The standard tests which are included are Coliforms, Standard Plate Count, Salmonella, and E. coli O157. Other tests such as Campylobacter and Listeria are also available.  Additionally, there is a raw milk shipping kit available.

• MB Labs in British Columbia Canada has a testing package for raw milk. The test package includes Total Coliforms, Standard Plate Count, Fecal Coliforms, E. coli, Campylobacter, Listeria (Total & L. monocytogenes), Salmonella, and Shigella.

On-farm labs are a good option for many raw milk farmers. After an initial investment in equipment, on-farm labs can greatly reduce testing costs in the long-term because the testing cost is only $1-3 per test.

• On-farm labs can be used for coliform and Standard Plate Count testing, with results in 24-48 hours.

• On-farm labs make it easy and economical to test milk such that farmers can test more often, such as weekly or even daily. Testing more frequently allows farmers to identify and troubleshoot any problems much more quickly.

• We have a comprehensive guide to on-farm testing here.

Raw Milk Institute does not generally recommend on-farm testing for specific pathogens (such as E coli 0157:H7, salmonella, listeria mono, etc), due to potential hazards from accidental release of pathogens on the farm. However, specialized test systems are being developed for on-farm testing of pathogens. In those systems, the test samples are destroyed after each test. Those test systems are stand-alone and may be cost-prohibitive for some farmers. Nonetheless, these test systems may be a good option for farmers who want to perform more frequent pathogen testing.

• Spectacular Labs has developed a stand-alone pathogen test system with results in 6-12 hours (depending on which pathogen is being detected).

• The Spectacular Labs system is self-contained and destroys the sample once the test is completed (thereby eliminating the risk of pathogen escape).

Testing is a Proven Part of Low-Risk Raw Milk

It is important to note that there is no such thing as a perfectly safe food. A CDC analysis of foodborne illnesses from 2009-2015 showed that the top food categories commonly linked to illnesses were chicken, pork, and seeded vegetables. Multi-state foodborne illness outbreaks have been linked to foods ranging from unpasteurized apple juice to ground beef to soy nut butter to lettuce. Pasteurized milk is not perfectly safe, either, and is implicated in foodborne illnesses and outbreaks every year.

The three pillars of the RAWMI Method for safe, low-risk raw milk are 1) farmer training, 2) risk management plan for each farm, and 3) bacterial testing of raw milk at least monthly for coliforms and Standard Plate Count per the Common Standards.  Although there is no way to guarantee perfectly safe food, the RAWMI Method dramatically reduces the risk of illness from consumption of raw milk.

Researchers from Canada and Europe have studied the safety of raw milk intended for direct human consumption. They found that raw milk can be a low-risk food when farmers are trained in risk management practices, implement careful production practices, and test their milk regularly. Researchers concluded that “raw milk can be produced with a high level of hygiene and safety.” The evidence is clear that raw milk can be a low-risk food and ongoing milk testing is an important part of the overall risk management strategy.

Raw milk farmers have an ethical responsibility to take pathogens and food safety risks seriously. The production of safe raw milk is a long-term mission, never fully completed or fully perfected. There will always be something to learn and much to teach. Farmers can engage in our free mentoring program here: https://www.rawmilkinstitute.org/how-to-become-rawmi-listed

Disclaimer: The Raw Milk Institute provides information for educational purposes only. Raw Milk Institute does not assume any responsibility or liability for the use of this information.

Welcoming Three Farms in Utah, Iowa, and Wisconsin to RAWMI Community

The Raw Milk Institute (RAWMI) sends a warm welcome to three more farmers who have completed our Listing program!

RAWMI offers free mentoring to all dairy farmers. Whether they are milking one cow, a handful of goats, or a large herd, the principles of safe raw milk production form a foundational toolset that benefits all dairy farmers and their customers. 

Some of the farmers we mentor choose to keep it casual, and are satisfied to just ask us a few questions before continuing their raw milk journeys. There is another set of farmers, though, that is not content to just dip their toes in the water; they want to dive right in and take their entire milk process to the next level. 

For these farmers, we offer our (free) RAWMI Listing program, wherein we assist farmers in developing their own unique on-farm Risk Analysis and Management Plan, documenting their processes with written Standard Sanitary Operating Procedures, and identifying the Critical Control Points that are essential to their production of safe raw milk. RAWMI Listed farmers test their milk at least monthly for ongoing assurance that their processes are working well to produce low-risk raw milk. RAWMI Listing is the gold standard for raw milk producers.

Three raw milk farms have recently completed the RAWMI Listing process, and we extend them a warm welcome into our growing community!

• Redmond Heritage Farms - Redmond, Utah

• Anonymous Farm - Wisconsin

• Atkins Raw Milk Dairy - Atkins, Iowa

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Redmond Heritage Farms - Redmond Utah

In 1958, brothers Milo and Lamar Bosshardt started mining the salt under their farmland in Redmond, Utah—and Redmond®, Inc. was born! Through innovation and a deep respect for people and the land, Redmond grew.

In the early 1990s, the Bosshardts brought Rhett Roberts onto their team.

Growing up on a farm, Rhett was used to eating natural, nutrient-dense food, but as an adult he found out how truly challenging it was to find in stores. So he and his team started a raw dairy farm on the same property as the salt mine and opened the first Redmond Marketplace in Orem in 2003.

Today, Redmond Marketplace is the main outlet for our A2/A2 raw dairy, pastured eggs, farm-fresh meat, and House Made foods. Their Farm Kitchens are also a fast-casual dining option that provides nourishing and delicious meals.

Redmond exists to elevate the human experience in body, heart, mind, and spirit. At Redmond Farm Market and Kitchen, they nourish the body with high-quality, nutrient-dense foods from their land and local partners.

You can check out Redmond Heritage Farms’ Risk Management Plan and test results here: https://www.rawmilkinstitute.org/listed-farmers/#redmond

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Anonymous Farm - Wisconsin

Due to the legal situation with raw milk in Wisconsin, this dairy chooses to be anonymous on the RAWMI website.

Their raw milk journey started with dairy goats which quickly transitioned to a jersey cow to fulfill a childhood dream of owning a family milk cow. While they initially planned to produce clean raw milk solely for their own consumption, they quickly realized the desire for it in our local community. What was once a single milk cow homestead has grown into a farm with a small herd of A2A2 jerseys. 

They believe that raw milk is a perfect food that has unjustly gotten a bad reputation. They are passionate about breaking that incorrect thinking. They strive to provide milk that is both healing, and low risk. Their cows are primarily grass-fed and exclusively organic. They do their best to care for both their jersey girls and milk with the utmost care ensuring both the health of cows and customers. 

You can check out Anonymous Wisconsin Farm’s Risk Management Plan and test results here: https://www.rawmilkinstitute.org/listed-farmers/#wisconsin2

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Atkins Raw Milk Dairy - Atkins Iowa

J and Barb Schanbacher have been dairy farming their entire married life together. J grew up dairy farming and graduated from Iowa State with a degree in Dairy Science. When Iowa changed its law in 2023 to allow the sale of raw milk, the couple wanted to be a part of it. They felt using their decades of knowledge could provide a safe and great tasting product to their community. While the couple still operates their commercial dairy on another site, they select their healthiest animals to be milked at Atkins Raw Milk Dairy LLC.

Producing raw milk for human consumption has given the couple a new purpose. Their goal now is to provide their customer families with safe and delicious dairy products from their select herd of A2/A2 cows. The Schanbacher’s pride themselves on the transparency of their operation and welcome conversations on all things dairy.

You can check out Atkins Raw Milk Dairy’s Risk Management Plan and test results here: https://www.rawmilkinstitute.org/listed-farmers/#atkins

On-Farm Lab Testing for Raw Milk Farmers

On-farm labs are a valuable and economical tool for dairy farmers who want to produce low-risk raw milk

The three pillars of the Raw Milk Institute’s (RAWMI) Method for safe, low-risk raw milk are 1) farmer mentoring, 2) risk management plan for each farm, and 3) regular bacterial testing of raw milk.  This method works well and has been documented to lead to a significant reduction in raw milk-related illnesses and outbreaks. Researchers who have studied the safety of raw milk produced with the RAWMI Method have concluded that “raw milk can be produced with a high level of hygiene and safety.”

RAWMI’s farmer mentoring program and assistance in developing an individualized risk management plan are free for all farmers. However, milk testing costs can be an ongoing financial burden which make small-scale farmers hesitant to test their milk often. But there is a great solution to this: on-farm testing!

Scroll or click below for information about:

• What is an On-Farm Lab?

• Benefits of On-Farm Labs

• Which Tests You Can Perform in an On-Farm Lab

• Materials for Building Your Lab

• How to Test Your Milk

• How to Interpret Your Results

NOTE:  Raw milk can be a low-risk food and ongoing milk testing is an important part overall of risk management. Nonetheless, there is no way to perfectly guarantee the safety of any food. Pasteurized milk is not perfectly safe, either, and is implicated in foodborne illnesses and outbreaks every year. The Raw Milk Institute provides the information below for educational purposes only. Raw Milk Institute does not assume any responsibility or liability for the use of this information.

What is an On-Farm Lab?

Pioneered by Edwin Shank from The Family Cow dairy in Pennsylvania, on-farm labs are a tremendous resource for dairy farmers. On-farm labs can be set-up on the countertop in a small, clean workspace. Once the lab area is ready, farmers can easily test their milk for coliforms and Standard Plate Count with the use of a small incubator. 

Set-up costs for on-farm labs are in the range of $800-$1,000.  RAWMI is currently offering grants of up to $500 to offset lab costs for farmers who are Listed or going through our Listing program. After the initial set-up costs, raw milk testing costs are only $1-$3 for each test performed in the on-farm lab.

Benefits of On-Farm Labs

On-farm labs have numerous benefits for raw milk farmers. As RAWMI Chairman Mark McAfee says, “What gets measured gets done.”  Ignorance is not bliss when it comes to raw milk. Testing allows farmers to dependably produce low-risk raw milk with confidence.

With on-farm labs:

• Farmers can test their milk for coliforms and Standard Plate Count (SPC).

• Ongoing testing costs are only $1-$3 per test.

• Farmers can inexpensively test their milk as often as desired, so they can identify patterns in their bacterial counts which help in identifying trouble spots ahead of time.

• The effects of new equipment or procedures on bacterial levels can be evaluated.

• Farmers can test more often as needed for troubleshooting high bacteria counts.

• Annual water tests can also be performed.

Which Tests You Can Perform in an On-Farm Lab

The bacterial tests performed in an on-farm lab (coliform and Standard Plate Count) are used to provide a general indicator that the milk is being produced in a way that is unlikely to lead to pathogens and pathogen growth. 

The RAWMI Common Standards aim for a rolling three-month average of:

• <5,000 cfu/mL for SPC

• <10 cfu/mL for coliforms.

NOTE: RAWMI does not generally recommend on-farm testing for specific pathogens (such as E coli 0157:H7, salmonella, listeria mono, etc), due to potential hazards from accidental release of pathogens on the farm. Specialized test systems are being developed for on-farm testing of pathogens. In those systems, the test samples are destroyed after each test. Those test systems are stand-alone, may be cost-prohibitive for small-scale farmers, and are not discussed further in this article.

Materials for Building Your Lab

general list of supplies

1. Standard Plate Count and Coliform Count testing discs (either petri-films from Neogen or peel-plates from Charm Sciences)

2. Sterile pipettes (individually wrapped)

3. Sterile water

4. Incubator that will maintain at 90 F / 32 C

5. Lightbox, magnifier, and spreader (if using Neogen testing discs)

NOTE: Standard Plate Count (SPC) is also known as Rapid Aerobic Count (RAC), Aerobic Count (AC), and/or Aerobic Plate Count (APC).

Neogen vs Charm Sciences testing Systems

There are currently two different systems for performing on-farm testing, developed by Neogen (formerly known as 3M) and Charm Sciences.  Both of these systems work well for on-farm raw milk testing. The basic lab equipment (incubator, pipettes, sterile water, etc.) is the same with either system.

Neogen’s testing system uses petri-films and provides results in 24 hours for both coliforms and SPC. Unopened packages of Neogen petri-films are stored in the refrigerator or freezer for up to 18 months, with opened packages being stored at room temperature for up to one month.

Charm Sciences testing system uses peel-plates and provides coliform results in 24 hours and SPC results in 48 hours.  The peel-plates can be stored at room temperature for up to 12 months. Testing costs are currently a bit lower with Charm Sciences peel-plates than with Neogen petri-films.   

VIDEO COMPARISONS:

• Charm Sciences Peel Plates

• Neogen (3M) PetriFilms

• Neogen (3M) Petrifilms vs Charm Sciences Peel Plate side-by-side demo

NOTE: Charm Sciences has two options for coliform testing. The basic Coliform Count test peel-plates are fine to use, as are the E Coli and Coliform Count EC peel-plates (which have different colored dots for E. coli bacteria).

E. coli is a large family of bacteria of which most are NOT pathogenic. The Charm Sciences EC peel-plates do NOT give an indication of the presence of specific pathogenic bacteria. Furthermore, some pathogenic E. coli do not result in the color-change dots on the Charm Sciences EC peel-plates. Nonetheless, some farmers find these plates helpful to use as presence of E. coli on the plates can help with determining the source of the bacteria in the milk (such as environmental contamination).

Materials Lists for Testing with Charm Sciences or Neogen

Charm Sciences Peel-Plate Materials List from Kelsey Barefoot (RAWMI Board Member and owner of The Barefoot Cow Dairy): 2-page materials list for performing on-farm testing with Charm Sciences peel-plates

Raw Milk Lab Materials List from Edwin Shank at The Family Cow Dairy: Short 1-page list of materials required for performing on-farm testing with Neogen (3M) Petri-Films

How to Test Your Milk

GENERAL TESTING PROCEDURE

1. Turn on the incubator to 32 degrees C / 90 degrees F.

2. On a clean surface, prepare the milk samples for testing with petri-films or peel-plates.

   • For coliform count, you will test the milk “neat” (undiluted).

   • For SPC testing of clean, well-produced milk, a 1:10 dilution will generally work best.

3. Using a clean pipette for each test, squeeze the milk or diluted milk onto the peel-plate or petri-film.

4. Place the testing discs in the incubator for 24-48 hours (depending on which testing discs are used).

5. Remove the testing discs from the incubator and count the dots to determine your results.

Detailed Testing Procedures

RAWMI VIDEO: How to Test Raw Milk with Charm Sciences Peel Plates

Charm Sciences Peel-Plate Procedures from Kelsey Barefoot (RAWMI Board Member and owner of The Barefoot Cow Dairy): 2-page procedures for performing on-farm testing with Charm Sciences peel-plates

Raw Milk Lab Procedures from Edwin Shank at The Family Cow Dairy: Short 2-page list of procedures for on-farm lab testing with Neogen (3M) Petri-Films

On-Farm Lab Testing: A Guide to Raw Milk Bacteria Testing from Jenny Skelonc at Six S Dairy: Comprehensive 20-page guide to on-farm testing with Neogen (3M) Petri-Films, including materials list, procedures, results interpretation, and tips for success

How to Interpret Your Results

BASIC PROCEDURE FOR interpreting test results

1. Remove the testing discs from the incubator.

2. Count the dots on each plate.

   • For coliform count test, your result is the number of dots.

   • If you used a dilution for the SPC test, such as 1:10, make sure to multiply the number of dots by your dilution factor.

   • For example, if you counted 31 dots on your SPC test and used a 1:10 dilution, multiply 31 X 10 = 310 cfu/mL for your SPC.

3. Record your results.

Detailed Resources for Interpreting Your Test Results

• Charm Sciences coliform count interpretation guide

• Charm Sciences SPC interpretation guide

• Neogen (3M) coliform interpretation guide

• Neogen (3M) SPC interpretation guide

Raw Milk and Bird Flu: A Deep Look at the Lack of Evidence for Transmission Via Raw Milk

A new paper has been published which takes a deep dive into examining all the evidence related to transmission of bird flu via raw milk consumption.

There is a "lack of scientific evidence" that bird flu can be transmitted through drinking raw milk.

Despite this lack of evidence, "Serious errors in extrapolation are apparent in the treatment of evidence for H5N1 in the media and some journal papers that unintentionally or intentionally amplify risk."

The paper goes on to say that, when the "extensive body of experimental and observational evidence" is considered, it is clear that:

Transmission of H5N1 to humans is "rare and sporadic" and happens" by direct contact of dairy workers with infected animals, not by oral transmission."

The paper finds that, overall, the messaging about risks of raw milk are unbalanced and do not reflect the body of scientific evidence. “The wisdom of continuing to promote risk perceptions that raw milk is ‘inherently dangerous’ and there is no ‘downside’ to pasteurizing breastmilk and bovine milk also merits deliberation. These risk perceptions are based on factors other than the recent scientific evidence for benefits and risk of raw and pasteurized milks from humans and bovines.

“While concern about avian influenza A mutations and reassortments are warranted, the pandemic potential of H5N1, lacking person-to-person and aerosol transmission as main drivers of pandemic potential has not increased since the first avian cases were reported in 1996.”

The full paper can be read here: https://onlinelibrary.wiley.com/doi/10.1111/risa.70077

Thanks to RAWMI Advisory Board member Peg Coleman for continuing to analyze ALL of the evidence so that families, farmers, and lawmakers can make informed decisions.

The Fascinating History of Milk Kefir

Milk kefir is a fermented probiotic drink that is renowned for its healthful properties. Studies have shown that milk kefir is correlated with a wide range of health benefits, including improved digestion [1], lower blood pressure and cholesterol [2], cancer prevention [1], improved immune systems [3], and reduced asthma and allergies [2]. Milk kefir is a thick and slightly effervescent drink, with a sour, creamy taste.

Milk Kefir is Unique

Although there are many different types of fermented milk around the world [4], milk kefir is unique because it is made with kefir “grains.”  Kefir grains are not true grains, but are actually symbiotic colonies of bacteria and yeast in a protein and lipid matrix. Kefir grains resemble pieces of cauliflower, and they ferment the milk through breaking down the lactose into lactic acid and other beneficial components.

Milk kefir is now widely known and consumed in many countries throughout the world, but for many centuries, milk kefir was a closely-guarded secret of the Northern Caucasus region in Russia. The people of the Northern Caucasus region are renowned for their longevity, with one of the highest proportions of centenarians in the world. Milk kefir is a dietary staple in this region. 

Traditionally, milk kefir was made by combining fresh milk and kefir grains inside goatskin bags. During the daytime, the goatskin bags were hung in the sunshine of the doorways, and prodded or pushed by each person who went through the doorway. As the milk kefir was consumed, more fresh milk was added to the goatskin bag, forming a continuous fermentation cycle.

Grains of the Prophet

The people of the Caucasus mountains have been making kefir for hundreds (or even thousands) of years. In this region, kefir grains are known by the name “Grains of the Prophet” [5]. Their traditional legend about the origin of kefir grains is that the prophet Mohammed gifted kefir grains to the Orthodox Christians in this region [6]. Mohammed is said to have taught the people how to make kefir, and the people revered kefir as a health-promoting food.  

The kefir grains and methods for making kefir were kept secret by people in the Caucasus mountains for many generations. Owning kefir grains was equated with wealth in this region. The people believed that the benefits of kefir would somehow be diminished if the secrets of making kefir were shared outside of their region. Marco Polo is said to have tried kefir, and kefir was prized as a medicinal food, yet the keys to making kefir were not shared until the early 1900’s.

A True Tale of Deceit, Capture, and Retribution

Since milk kefir was a closely guarded secret, how did it ever become more widely known? This is where the story of milk kefir gets even more interesting.

The Russian immunologist Dr. Ilya Ilyich Metchnikoff (who received the Nobel Prize for his work on immunity in 1908) became interested in learning about the causes of the exceptional longevity of the people in the Caucasus region and other regions. Metchnikoff came to the conclusion that soured milk, including milk kefir, was one of the keys to longevity and well-being. Following the publication of Metchnikoff’s book, The Prolongation of Life, in 1907, the All Russian Physicians’ Society became determined to use milk kefir as a medicinal treatment for their patients.

Caucasus Region. Image from freeworldmaps.net

The Blandov brothers, from Moscow Dairy, were commissioned by the All Russian Physicians’ Society to obtain kefir grains from the tribes in the Caucasus mountains. However, the tribes refused to sell any kefir grains to the Blandov brothers. Undaunted, the brothers came up with a scheme to obtain the kefir grains: they would send a beautiful woman to the court of tribal Prince Bek-Mirza Barchorov, and with her allure she would obtain the kefir grains. Irina Sakharova, an employee of the Blandov brothers, was chosen for this important mission [5].

Irina Sakharova and Prince Barchorov, 1908. Image from Revolution Fermentation

Although Irina succeeded in attracting the interest of Prince Barcharov, he refused to give her any kefir grains. Irina departed from the Prince, but tribesmen were sent to capture her with the intention of forcing her to marry the Prince. The Blandov brothers mounted a rescue of Irina before the forced marriage could take place.

When Irina presented her grievance before the Czar, Prince Barcharov was ordered to make retribution to Irina. Although she was offered gold and jewels, Irina refused. She could only be compensated for what she had endured in one way: with kefir grains. The Czar ordered Prince Barcharov to give Irina 10 pounds of kefir grains!

Kefir as Medicine

Once the Blandov brothers had the milk kefir grains, they began making kefir for the All Russian Physicians’ Society. Kefir was used in Russian hospitals to treat a wide variety of conditions including digestive disorders, cancer, artherosclerosis, and tuberculosis [5]. Even now, kefir is routinely used for hospital patients, infants, and infirm people in Eastern Europe [7].

By the 1930’s, kefir was being produced on a large scale to meet widespread public demand in Russia. It took several decades for the commercial process of making kefir on a large scale to be perfected. Milk kefir was introduced to the western world by the 1960’s. Recently, milk kefir has become a much sought-after food with a rapidly growing global market.

Currently, many health-conscious consumers use kefir grains to easily produce their own milk kefir at home. Unlike the commercial kefir that was developed in Russia, most of the commercially-prepared kefir on the market today is made with direct-set powdered kefir cultures. These powdered cultures contain considerably fewer probiotic strains than kefir grains, but they produce a more consistent commercial product. From its ancient origins to today, milk kefir is a superfood that has enriched the health of humanity. 

References

[1] Zeynep B. Guzel-Seydim, Tugba Kok-Tas, Annel K. Greene & Atif C. Seydim. "Review: Functional Properties of Kefir." Critical Reviews in Food Science and Nutrition, 51:3, 261-268, 2011. doi: 10.1080/10408390903579029

[2] Bourrie, Benjamin C T et al. “The Microbiota and Health Promoting Characteristics of the Fermented Beverage Kefir.” Frontiers in microbiology vol. 7 647, 2016. doi:10.3389/fmicb.2016.00647

[3] de Oliveira Leite, Analy Machado et al. “Microbiological, technological and therapeutic properties of kefir: a natural probiotic beverage.” Brazilian journal of microbiology : [publication of the Brazilian Society for Microbiology] vol. 44,2 341-9, 2013. doi:10.1590/S1517-83822013000200001

[4] “Fermented milk products”, Wikipedia, Wikimedia Foundation, August 11 2020. https://en.wikipedia.org/wiki/Fermented_milk_products

[5] Shavit, E. “Renewed Interest in Kefir, the Ancient Elixir of Longevity.” Fungi, vol. 1-2, 2008. http://www.medicinabiomolecular.com.br/biblioteca/pdfs/Doencas/do-1175.pdf

[6] Seifi, P. “Magical Kefir.” Russian Life website, 2016. https://russianlife.com/stories/online/magical-kefir/

[7] Nielsen B, Gürakan GC, Unlü G. “Kefir: a multifaceted fermented dairy product.” Probiotics Antimicrob Proteins 6:123–135, 2014. https://pubmed.ncbi.nlm.nih.gov/25261107/