Table 1

Restaurant Grades in NYC: South Asian Restaurants (Courtesy: New York City Department of Health and Mental Hygiene).


   GRADE A 7 51 125 82 7 272 81%
   GRADE B 1 8 5 12 1 27 8%
   GRADE C 0 1 5 1 0 7 2%
   GRADE PENDING 0 4 10 6 0 20 6%
   CLOSED 0 0 3 0 0 3 1%
   TOTAL 8 64 148 107 8 335  
   GRADE A 4 5 4 15 28 74%
   GRADE B 0 0 2 3 5 13%
   GRADE C 0 0 1 0 1 3%
   GRADE PENDING 1 3 0 0 4 11%
   CLOSED 0 0 0 0 0 0%
   TOTAL 5 8 7 18 38  
   GRADE A 3 10 5 9 1 28 85%
   GRADE B 0 1 0 2 0 3 9%
   GRADE C 0 0 0 0 0 0 0%
   GRADE PENDING 0 1 0 1 0 2 6%
   CLOSED 0 0 0 0 0 0 0%
   TOTAL 3 12 5 12 1 33  



Table 2

Critical violations in Restaurant Inspection and its possible implication for worker health and safety (Courtesy: New York City Department of Health and Mental Hygiene).

Violations Implication on Worker Health and Safety

Live roaches present in the facility’s food and/or non-food areas. Cockroaches are sources of allergens in the workplace especially for asthmatics and people with conditions like Allergic Rhinitis or atopic allergic conditions; Potent allergens are released from the saliva secretions, cast skins, dead bodies of cockroaches.
Cockroaches have been suspected of specific disease outbreaks; it can carry Salmonella typhimurium, Entamoeba histolytica, and the poliomyelitis virus
Filth flies or food/refuse/sewage-associated (FRSA) flies present in the facility’s food and/or non-food areas. Filth flies include house flies, little house flies, blowflies, bottle flies, and flesh flies. Food/refuse/sewage-associated flies include fruit flies, drain flies, and Phorid flies. Housefly (Musca domestica)’s a close association with people, its abundance, and its ability to transmit disease make it a great threat to humans. Each housefly can easily carry more than 1 million bacteria on its body. Some of the disease-causing agents transmitted by houseflies are Shigella spp. (dysentery and diarrhea = shigellosis), Salmonella spp. (typhoid fever), Escherichia coli, (traveler’s diarrhea), and Vibrio cholera (cholera). These organisms can be carried on the fly’s tarsi or body hairs, and frequently these are regurgitated onto food when the fly attempts to liquefy it for ingestion. Acute gastrointestinal problems can be related to these conditions and employees can become reservoirs for outbreaks of these deadly diseases.
Evidence of mice or live mice present in the facility’s food and/or non-food areas. Rodent-associated diseases affecting humans include plague, murine typhus, leptospirosis, rickettsialpox, and rat-bite fever.
Animal bites can cause lacerated wounds with the potential for secondary bacterial infections. Mice infected workplaces are hazardous for employees.
Allergies to vermins can also potentially cause or exacerbate one’s pulmonary, upper respiratory tract, and skin conditions (allergic dermatitis)
Hot food item not held at or above 140°F.
Cold food item held above 41°F (smoked fish and reduced oxygen packaged foods above 38°F) except during necessary preparation.
These conditions can cause bacterial growth in meat, poultry, eggs, seafood, dairy products. These can potentially cause the outbreak of gastroenteritis or other acute GI-related conditions for employees consuming this food. Sub-standard heating and cooling services for food storage/preparation point to a lack of other provisions and the necessary equipment to ensure a safe workplace.
Sanitized equipment or utensil, including in-use food dispensing utensil, improperly used or stored
No facilities are available to wash, rinse and sanitize utensils and/or equipment.
Wiping cloths soiled or not stored in sanitizing solution.
Musculoskeletal injuries and concussion-related to utensils falling over. Sprain/strain and slip and fall injuries from cluttered tight spaces with limited maneuverability. Lack of space to store equipment points to confined spaces and possible fire hazards. Improper storage in the dishwashing area can lead to slips, trips, and falls.
Inadequate space for dishwashing may lead to repetitive strain traumatic injuries
Food not protected from potential source of contamination during storage, preparation, transportation, display, or service.
Raw, cooked, or prepared food is adulterated, contaminated, cross-contaminated, or not discarded in accordance with the HACCP plan.
These conditions can cause bacterial growth in meat, poultry, eggs, seafood, dairy products. These can potentially cause the outbreak of gastroenteritis or other acute GI-related conditions if food is consumed by the employees.
Tobacco use, eating or drinking from open containers in food preparation, food storage, or dishwashing area observed. Indoor smoking in the restaurant can lead to tobacco-related exposures and second-hand smoking to the workers. Can be a fire hazard.
Food Protection Certificate not held by supervisor of food operations. Not displaying this certificate may indicate the behavior of ignorance, unawareness, or willful disregard. Ensuring a healthy and safe workplace is highly unlikely in such a workplace and underreporting of work injuries will be common.
Personal cleanliness is inadequate. Outer garment soiled with possible contaminant. Effective hair restraint not worn in an area where food is prepared. Non-adherence to the hygienic practices indicates a lack of proper training of the employees to adopt basic handling practices. Employees are unlikely to have any training in workplace safety.
In some cases, employees’ exhibiting of these behaviors could be related to anxiety, depression, or stress resulting from the extreme economic insecurity or uncertainty.
Food contact surface not properly washed, rinsed, and sanitized after each use and following any activity when contamination may have occurred.
Food worker does not use proper utensil to eliminate bare hand contact with food that will not receive adequate additional heat treatment.
Lack of adequate washing of the utensils or cleanliness indicates non-adherence to basic hygienic practices and may lead to a host of illnesses among employees.
Hand washing facility not provided in or near food preparation area and toilet room.
Hot and cold running water at adequate pressure to enable cleanliness of employees not provided at the facility.
Soap and an acceptable hand-drying device not provided.
Sink accessibility promotes handwashing. Similarly, glove accessibility is related to glove use.
Some workers may not know that food needs to be protected from dirty hands. Glove use may need less handwashing.
Workers wearing gloves may not be a common practice in these ethnic restaurant establishments.

The NY Health Department inspects about 24,000 restaurants a year to monitor compliance with City and State food safety regulations. The Health Department conducts unannounced inspections of restaurants at least once a year and since 2010, it has required restaurants to post letter grades showing sanitary inspection results where they can easily be seen by customers. Inspectors check for food handling, food temperature, personal hygiene, facility and equipment maintenance, and vermin control among other safety protocols. Restaurants with a score between 0 and 13 points are ranked A, those with 14 to 27 points receive a B, and those with 28 or more a C. These results are posted on the Health Department’s website as well and we have used this publicly and readily available data-source as a proxy or surrogate measure (Table 1).

We have compiled inspection data on Indian, Pakistani, and Bangladeshi restaurants in NYC. We have used 1) overall restaurant grade and 2) specific violations as a means of assessing workplace health and safety.

These overall grade findings suggest that 19% of the Indian, 26% of Bangladeshi, and 15% of Pakistani restaurants did not achieve grade A in these inspections. These suggest that workers in about 20% of these restaurants more than likely work in relatively hazardous or unhygienic working conditions. If these restaurants are not attentive to the quality or cleanliness of their core business – preparation and serving of food, it is quite likely that they are not paying adequate attention to protect or promote their workers’ health, safety, and wellbeing.

In the second approach, we prepared an inventory of the most common critical violations as reported in these inspection reports and examine here if these violations may have an implication for workers’ health and safety (Table 2).

In this report, we examine how regulatory or other business operations measures may be used for health surveillance. There is evidence correlating quality of customer service with workplace health and safety practice in some industries. In the healthcare industry, there is evidence that organizations with stronger patient safety culture are also safer workplaces for their employees. In the restaurant business, we have explored using restaurant inspection grade as a proxy measure for employee safety and working conditions. Learning more about the restaurant inspection method, criteria set, and grading mechanism used may provide us with additional insight into understanding the health and wellness of restaurant employees. We already know that migrant workers with lower socioeconomic conditions are less forthcoming and engaged in reporting their working conditions, hazards, injuries, and illnesses and this kind of proxy measure as explored in this study may prove to be a useful and practical measure for such an industry.

We need to further validate this proposed alternative surveillance tool as this grading system has evolved over the last several years. There appears to be a better understanding and appreciation of the grading system since its implementation in 2011, and there has been a continuous effort to improve the accuracy of this system. Incorporating a few worker health and safety measures in the current grading system can be a very useful next step.

There is a great need to develop workplace health and safety surveillance systems for small businesses to systematically understand the cause, nature, and severity of injuries and illness. Surveillance data would identify high-risk worker groups within these restaurants, as looking at time trends would help in evaluating interventions. We need a better understanding of work-related injuries and illnesses in these small ethnic restaurants and establishments. We need to understand the utilization pattern of the existing worker’s compensation system for the treatment and management of health conditions by the injured workers. As a next step, we may look forward to developing a customized program geared towards the prevention and remediation of work-related injuries in these ethnic restaurant environments. Occupational healthcare providers need to become more culturally sensitive in their delivery of care. Topics on immigrant health should be included in formal training programs and curriculum. Occupational health professionals should be particularly aware of immigrant workers in the informal sector or small businesses who may be at a disadvantage due to their limited understanding and reporting of occupational hazards and disenfranchised from the formal legal, social safety and health care delivery system.