Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Monday, December 10, 2007

Variance Approval for Ready-To-Eat Foods:A Failure of Public Health Policy – Dai Nguyen

According to the Centers for Disease Control and Prevention (CDC), there are 76 million illnesses and 5,000 deaths attributed to foodborne illness each year in the U.S. (1). The CDC also estimates 40% of foodborne illness results from poor hand washing practices (2). We can conclude that there are a lot of germs on the food handlers’ hands and that the food handlers still don’t understand how to clean their hands properly to reduce the number of germs. Therefore they must wear gloves when they contact with Ready-to-Eat (RTE) foods or they would contaminate the foods which result in an increase of foodborne illness. RTE foods are foods that do not need to undergo a heat or chemical treatment process and are ready for human consumption. Some examples of RTE foods are sushi, cold cuts including ham, turkey, and cheese, fruits and salads.

In 1999, the U.S. Federal Government passed a regulation requiring that food handlers must wear gloves when they make contact with RTE foods, unless they have a variance approval from the local board of health for an alternative to the bare hand contact policy (3). The State of Massachusetts Department of Public Health adopted the 1999 Federal Food Code regulations, and let the local board of health permit certain variances to the policy. Such a variance requires the food establishment owners/operators to submit a written plan in accordance with the Department’s policy on alternatives to bare hand contact with RTE foods (4). The plan must demonstrate how food operators will control contamination when they use bare hands to handle RTE foods. The plan should include: who will prepare the foods, if he or she is knowledgeable about the food safety concepts, whether the employee’s illness reporting agreement in place, employee’s hygienic practices including when and how to wash hands, and what foods will be prepared. These plans and procedures are put into place to reduce the amount of germs or unhygienic habits that food handlers may have to RTE foods. The plan will be reviewed by the local board of health for denial and or approval. If an operator’s plan is approved he or she must adhere to the plan in order to ensure the proper food protection. However, health inspectors find that it is hard for food operators to adhere to the plan because violations still being cited and the number of foodborne illnesses as a result of bare hand contact with RTE foods are still high.

The health inspectors enforce the Chapter II of the State Sanitary Code, Minimun Sanitation Standards for Food Establishments, Article X. One of their responsibilities is to inspect the food establishments as required by the State to make sure that the food establishment is following the rules and regulations; to ensure that the food establishments provide safe and sound foods to the consumer; and to minimize the number of foodborne illness. For the sushi types of restaurants, inspectors are recommended to inspect at least three times a year. From my personal experience as the health inspector for four different cities and towns in Massachusetts, the bare hand contact with RTE foods is still a major violation among the food handlers, especially sushi chefs. Although there is insufficient information to know the entire benefits of enforcing food handler policies, a lot of attention has been given to the safety of food consumption, and proper hand washing for RTE foods is important for the overall consumer safety. Proper hand washing may be hard to achieve for many reasons including lack of knowledge, too busy, or lazy to wash hands etc. Thus, the restaurant operators and law enforcement officers must enforce the wearing gloves policy when contact with RTE foods seriously. It is important to look at how RTE foods regulations are being implemented in restaurants with sushi chef handlers. In this paper, I will demonstrate that the variance approval to bare hand contact with RTE foods is a failure of public health policy for the following reasons: the policy fails the social and culture aspects of the sushi chefs; it fails to recognize that the chefs tend to modeling what other chefs do; it fails the principle of diffusion of innovation.

Policy fails the social and cultural aspects of sushi chefs
Sushi originated in inland China around 300 BC. At the time, sushi was a way to preserve food and make it portable. Then it traveled to Japan and evolved to be the most popular food there (5). Sushi today is a combination of acidified rice wrapped with seaweed and raw fish. Bare-hand contact is how the sushi chefs grew up, and that was how they were taught to make sushi. Since sushi became part of the Japanese culture, there are a lot of Japanese restaurants employ sushi chefs that learned how to make sushi in an Asian based country like Japan, China, and Korea. Therefore their training and food preparation is part of their cultural background and upbringing. Making sushi without gloves is something that was accepted and socially normal in their environment. Their behavior to use bare hand contact to make sushi is almost by nature. They tend not to think much about the science, the germs that on their hands may contaminate the foods they are preparing.

It has been my experience that sushi chefs’ behavior is difficult to change, because of their cultural teachings of how to make sushi. Inspectors that come into restaurant and tell sushi chefs to increase their hand washing and wear gloves while making sushi, can experience resistance from the chefs. Some sushi chefs think that they have been in the business for along time, they know it all, and that no one should tell them what to do. Sometimes, they would be offended and rebel against that demand. They will continue to violate the regulation as soon as the inspectors walk out the door. In addition, the restaurant business is a tough industry. Sushi chefs have to work long hours at a low paying jobs. Most of the time, they are tired and exhausted and sometimes they don’t care about the inspector’s request. It is a challenge for health inspector to tell the chefs what to do. An alternative to bare hand contact policy will increase that challenge because it reduces the importance of the issue which is to avoid contamination from hands. It gives them an option to handle foods with their bare hands. As a result, the chefs tend not to take the health inspector enforcement seriously.

Policy fails the modeling behavior among sushi chefs
The majority of the sushi chefs are by nature modeling other chefs. Cooks learn from watching others, this is true for sushi chefs too, so in accordance with the Social Learning Theory, people do what they see people like them do, and this could be problematic for restaurants that have variance approval from the health department(6). For example, one restaurant has a variance approval from a local board of health, so its chefs are allowed to use bare hands to make sushi. Other chefs from a different food establishment that does not have a variance see other chefs can make sushi with their bare hands. So, they start to use their bare hands to make sushi at work. They think that it is okay for other chefs to do, so it should be okay for them to do the same. Inspectors could also get tired of giving sushi restaurants citations for noncompliance for their sushi chefs, and could start overlooking their behaviors and stop citing them and writing them up. This would be a huge mistake and irregular enforcement among the health inspectors may result.

Policy fails the diffusion of innovation theory
Most cities and towns in Massachusetts do not have enough inspectors to conduct routine inspections for these types of restaurants at least three times a year as recommended. This shortage of resources may result from the tightening of the budget. It may also be as a result of the increasing responsibilities of local health departments. For example, after the incident of September 11, 2001, local health departments across the State spend a lot of resources and energy for emergency preparedness programs. As a result, it takes away a lot of resources from the inspectors to be able to keep up with the restaurant inspections. According to the diffusion of innovation theory, a behavior makes it way into the population and is adopted (7). As discussed, the policy allowed the chefs to model other chefs. So they start to adopt the concept of preparing RTE foods with their bare hands over time. Therefore, the chefs who violated the bare hand contact with RTE foods policy were not being told to discontinue the practice until a year or more later when the next routine inspection comes along. Most of the times, the inspectors come to conduct a routine inspection in the next visit will find the bare hand contact violation again. Telling the chefs to change their behavior once a year is not adequate. It takes time to adopt the behavior. The more education the inspector can provide the chefs the better; the more exposure to the materials, the more knowledge the chefs gain. Thus, each time the inspector comes for inspection the chefs learn more about the practice and likely to adopt the behavior. By not giving them an option to use bare hand contact, we may be able to avoid repetition enforcement.

Recommendation of a more effective approach
Using three kinds of theories of rational empirical, normative reeducative, and power cohersive approach in enforcing the food handling policies in sushi chefs would be more effective in their compliance with the policies. The rational-empirical approach will allow the inspectors to educate the chefs about the importance of hand washing and wearing gloves when in contact with RTE foods and the risks involved in failure to do so. The chefs think, analyze and have the knowledge to reason that bare hand contact may contaminate the foods they serve and cause foodborne illness. The normative-reeducative approach allows the inspector to persuade the traditional chefs to change their behaviors; to change the way that the chefs have been doing for a long time; to tell them that they are doing business in America and that everyone must adhere to the regulation. The inspector will continue to reeducate the chefs. The more training the chefs have the more knowledge they gain. Perhaps, we also need to institute the special sushi training certificate and make it mandatory state-wide. Since, many chefs are not well educated and often have a language barrier. There is often a miss communication involved. Perhaps we have a class in Chinese and or Japanese so that they have a better understanding to the science and the requirements of the regulation. Reeducating them to understand the risks involved and the requirements will allow them to change their behavior over time. Finally, the inspector can use the power-coerce approach for those who continue to violate the regulation. The inspectors can apply fines, suspend and or revoke the license to sell or serve foods.

Thus, there should not be an alternative permitted to the policy of no bare hand contact with RTE foods. The more effective approach using the combination of theories including rational empirical, normative reeducative, and power cohersive will allow the sushi chefs to change their cultures over time and modeling others to wear gloves when in contact with RTE foods. The chefs are trained and understand the importance of the issue and be aware of the consequences. The positive side of the diffusion of innovation principle will be adopted. The chefs will adopt the behavior to wear gloves when contact with RTE foods. The chefs see other chefs wear gloves when prepare RTE foods. It is the only way to do it. Over time, it will become their habits and hopefully their culture. The chefs are now in compliance with the regulation. They may not require more supervision from the local board of health. The more resources the local health department will have to use for other responsibilities to better protect the public.

1. Centers for Disease and Control Prevention. Division of Bacterial and Mycotic Diseases. Available at:
Accessed 10/25/2007
2. ABCs of Handwashing. Food for Thought. University of Illinois Extension
Available at: Accessed 09/25/2007.
3. 1999 Federal Food Code 3-301.11 (B), U.S Department of Public Health and Human Services, Washington DC
4. Minimum Sanitation Standards For Food Establishments State Sanitary Code, Article X. 105 CMR 590.004 (E), Massachusetts Department of Public Health, Boston MA
5. Sushi Now. Available at: Accessed 10/25/2007
6. Edberg M. Social, Cultural, and Environmental Theories (Part I) (pg. 51-53). In: Essentials of Health Behavior Social and Behavior Theory in Public Health. Jones and Bartlett Publishers, Inc. 2007
7. Edberg M. Social, Cultural, and Environmental Theories (Part I) (pg. 58-59). In: Essentials of Health Behavior Social and Behavior Theory in Public Health. Jones and Bartlett Publishers, Inc. 2007

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