Similarities and Differences between Philadelphia, Pennsylvania, and Columbus, Ohio, Food Protection Programs
The Columbus program and the Philadelphia program are similar regarding regulatory foundation, trained regulatory staff, foodborne illness and emergency response, compliance and enforcement, and program assessment. They differ in that the Columbus program utilizes HACCP principles as part of the inspection process and regarding the potential for food terrorist acts, the close relationship with industry groups in problem solving, the use of training materials and staff members speaking the native languages of the new Americans in our current society, and the color-coded signs project which makes the public aware of the conditions within food service entities. The Columbus program uses the advanced technology of today, whereas the Philadelphia program used the advanced technology of the late 1950s and early 60s. The regulatory foundations in Philadelphia and Columbus were similar. The programs were based on the most current scientific recommendations of the United States Public Health Service through its Sanitarian Engineering Section in the 1950s and the FDA in 2009. Also both programs were based on actual codes, laws, and ordinances of either city or state. In Philadelphia, the sanitarian had to have a 4-year degree in science or environmental health science plus 1 year of progressive field experience and had to take a comprehensive written exam designed by the Public Health Service and the equivalent of today’s registration examinations for employment as a Sanitarian I. After employment, the individuals went through intensive field training by existing experienced sanitarians and district environmental health supervisors. They also underwent a minimum of 40-80 hours of in-service training each year, presented by the Public Health Service. In Ohio, the individual has to have the same academic qualifications plus be a State of Ohio Registered Sanitarian to be qualified. Foodborne illness investigations were conducted in Philadelphia by a public health nurse and a sanitarian in a team approach. This worked well because both individuals were part of the same district health office. Additional assistance was available at the central office level, state level, and national level through CDC. In Columbus, the Primary Nurse Investigator or a member of the Communicable Disease Prevention Team does the initial study and then additional support is provided at the local, state, and national level. Where a food establishment is involved, a sanitarian becomes part of the team and investigates the establishment and its past records. Unfortunately, because of severe budget cuts there have been sharp reductions in the various programs of the Philadelphia Department of Public Health at the present time.
In Philadelphia, emergency response was initiated through a call to the Philadelphia Department of Public Health or the Mayor’s Office of Complaints. The emergency typically fit into the categories of fire, flood, raw sewage present, inadequate water supply, inadequate hot water supply, unapproved water supply sources, contaminated water supply, loss of electricity or gas, unapproved food handling process, contamination from structural defects, extreme insect and rodent infestation, and gross insanitary conditions. The complaint was handled either immediately depending on the severity of the public health emergency, or at most within 24 hours. The full range of legal authority was available for use by the environmental health practitioners, including immediate closing of facilities and condemnation and disposal of contaminated products. The Columbus program has approximately the same process. A 3-1-1 telephone process is in place and residents may call the number for any city services complaint. The 3-1-1 operator enters the complaint into the electronic system where it is tracked and then routed to the proper agency.
Consistency of inspections was achieved in Philadelphia when the Public Health Service certified the district environmental health supervisors and the supervisors certified the level of consistency in field personnel. In Ohio, the state certified supervisory individuals who also certified field personnel.
Compliance and enforcement are basically similar in both departments. In Philadelphia, the procedure followed included initial inspection or survey. If serious problems related to potential outbreaks of foodborne disease or poor sanitation were found the following procedures were used:
- 1. A warning letter citing the nature of the problems was sent to the proprietor, and the individual was given a short but definitive time period to make the necessary corrections.
- 2. A follow-up inspection was made. If considerable problems or severe problems persisted, an administrative hearing was scheduled for the District Health Office, with the health officer acting as presiding officer and the environmental health supervisor identifying the problems and situations.
- 3. A follow-up inspection was made prior to the hearing.
- 4. At the hearing, the individual could either be given additional time to complete the necessary corrections or a recommendation would be made for license suspension or revocation.
- 5. An inspection was made to determine the status of the establishment prior to the court hearing.
- 6. The judge of the Quarter Sessions Court could fine the individual and/or shut down the establishment. If the judge issued a court injunction and the owner violated it, the owner would be held in contempt of court and go to jail.
- 7. Depending on the severity of the problem, any or all portions of this enforcement procedure could be suspended and a court injunction could be issued at once. In Columbus, although the enforcement procedures were somewhat different, they followed the same basic principles.
In program assessment, in Philadelphia, the United States Public Health Service determined the effectiveness of the food inspection program. The health department determined through the use of IBM cards filled out by all field sanitarians and supervisors, the number of inspections made, the type of inspections made, the amount of time spent on the inspection, the amount of travel time, and the amount of office time. There was no computerized determination of the effectiveness of the inspections. However, the district environmental health supervisors could quickly review the key points of inspections, those we would call today critical points, and have brief training sessions at the staff meetings to teach or discuss with the field staff the most urgent problems to look for when inspecting. Also, the district environmental health supervisors would at a minimum pick up a day’s work, each year, for each sanitarian and go out and redo the inspections the following day. Also, as a minimum, each year the supervisor would spend an entire day with the field sanitarian. The field person and the supervisor would make separate inspections of the various sites including food, insects and rodents, nuisances, water problems, etc. The strengths and weaknesses were then discussed privately with each field person. In reality, the supervisor would spend several days in the field each year with each person to strengthen the field person’s observation, inspection, consultation, and educational skills. Further, the supervisor would handle all special problems with the field person. A reduction in repeat inspections and in numbers of warning letters, office hearings, suspensions and revocations of licenses, and court hearings, was a rough way of measuring a successful program. In Philadelphia, it was frowned upon if the field sanitarians spent more than roughly 30 minutes in the morning and 30 minutes in the afternoon in the office. It was also frowned upon if the district environmental health supervisor spent entire days in the office reading reports. This was considered to be a waste of time. The individual was supposed to be the most knowledgeable person in the district office and therefore should be working on special problems in the field as well as assisting field personnel.
Obviously, with today’s computer capacities it is possible, as Columbus Public Health does, to gather a substantial amount of very useful information and determine what are the most important issues to be followed closely. The computerized approach helps digest data and reduces the office time needed by the field staff and supervisory staff. The question is always how much data is needed to do a good job, and how much data becomes mind boggling and its analysis a waste of time and money.
Program support in Philadelphia was through the regular budget for 60 field sanitarians, 9 district environmental health supervisors, 7 chiefs of programs, 9 assistant chiefs of programs, and the environmental health director. All licensing fees went directly to the City of Philadelphia and did not affect the environmental health budget. In Columbus, Ohio, the financing of the environmental health division is through licensing fees, grants, and other sources, which affects the numbers of personnel and the type of programming, and may vary as frequently as annually based on funds available. Columbus, Ohio, went beyond the Philadelphia experience by use of HACCP principles, excellent industry and community relations, food defense and preparedness.
Prioritizing of Inspections In Philadelphia, the first priority for inspections was outbreaks of disease, complaints about contaminated food or improper handling of food, and follow-up on establishments that had serious deficiencies which could potentially cause foodborne disease and those establishments going through the enforcement process. All establishments were inspected at least once a year and the more complex food preparation facilities were inspected more frequently because they would tend to have a larger number of unsatisfactory items related to potential food- borne disease. Less attention was given to items such as the physical facilities, unless they were very dirty or they potentially could contaminate the food.
In Columbus, Ohio, a priority system was set up based on the potential risk for foodborne disease. Risk level 1 has the least risk of spread of foodborne disease. It consists mostly of storage areas and prepackaged food. Risk level II is higher in importance because there is a higher potential risk to the public regarding heating or improper holding temperatures for potentially hazardous food. Risk level III has a higher potential risk because of improper cooking temperatures, improper cooling temperatures, improper holding temperatures, and contamination through preparation of food by handling, cutting, grinding raw meat products, cutting or slicing ready-to-eat meats and cheeses, preparing or cooking potentially hazardous food, and reheating of foods. Risk level IV has the highest potential for the production of foodborne disease because the handling and preparation of food involves several steps and multiple temperature controls. The foods include ready-to-eat raw potentially hazardous meat, poultry, fish, or shellfish or foods containing potentially hazardous items or ingredients. Also, Risk level IV can be reached by supplying food to high-risk individuals including those who are immune-compromised or elderly in either a healthcare facility or assisted living facility. There are two types of inspections: the Standard Inspection Report, which is of a routine nature, and the more in-depth Retail Food Establishment Process Review, which is concerned with the proper temperatures, holding time, and transportation of potentially hazardous foods.
In Philadelphia, each inspection was made using the systems approach and flow from the point of origin of the food entering the establishment through all processing and consumption. The sanitarians were instructed to look for key problems such as those involving running hot and cold water, temperatures of food storage and preparation (both hot and cold), the health of the food handler, insects and rodents, sewage, contamination of food preparation surfaces, etc. These were determined to be major problems and therefore any actions taken by the health department would be to reduce the potential for disease by elimination of these problems. The inspection form was only filled out after the actual inspection was done, therefore the role of walls and floors and ceilings were not considered to be significant compared to the conditions which could lead to disease outbreaks.
In Columbus, Ohio, the seven HACCP principles were followed:
- 1. Conduct a hazard analysis to determine food safety hazards and locations, and appropriate preventive measures for control.
- 2. Identify critical control points where a procedure can be provided to prevent, eliminate, or reduce a food hazard.
- 3. Establish critical limits for each critical control point with maximum or minimum allowable physical, biological, or chemical agents to be controlled to prevent, eliminate, or reduce these agents to acceptable levels to prevent disease or injury.
- 4. Establish critical control point monitoring requirements, that is, what activities are needed to monitor the control of critical points in the food delivery, storage, preparation, and serving process to prevent, eliminate, or reduce the level of a food hazard.
- 5. Establish corrective action when there is a deviation from the critical limit of a potential hazard.
- 6. Establish appropriate record keeping procedures.
- 7. Establish procedures to verify that the HACCP is working.
Obviously, this process is certainly better and more detailed than the Philadelphia technique of 1961. However, the question becomes the reality of time usage by environmental health field personnel and the amount of time they tie up for the person in charge at a food preparation and serving facility and if this is acceptable to avoid problems in that particular facility.
Food Security Food defense preparedness and security is obviously a very new concern, especially since the terrorist attack of September 11, 2001. There is now a very serious concern about terrorists using food as a vehicle to inflict serious sickness and death in the population. See “Emergency Handbook for Food Managers,” a project of the Twin Cities Metro Advanced Practice Center (APC), funded by NACCHO, September 2005.
Working with Industry and Community Relations There is a substantial difference between the Philadelphia and Columbus programs in the area of industry and community relations. In Philadelphia, little attention was paid to either group. However, in the Community Rodent Control Program, there was a very close relationship between the Philadelphia Department of Public Health, other city agencies, other community agencies, and various community groups. Unfortunately, at that point this type of cooperation had not been extended to the food service area.
Columbus Public Health has been an active participant in the Ohio Retail Food Safety Advisory Council. Columbus Public Health is a long-time partner with the retail food industry and industry groups such as the Ohio Chinese Restaurant and Business Association, etc., academia and consumer groups. Columbus Public Health works closely with people who are new to America and American customs and language. A bicultural/bilingual field sanitarian is fluent in English and Spanish. The health department contracts out for assistance with the Mandarin language. Although other environmental health personnel are fluent in Somali, Russian, German, Italian, Farsi, and Arabic, they are not necessarily assigned to the food protection section, but could be utilized in the event of an emergency. Numerous workshops and special food service training courses in English, Spanish, Mandarin, and Somali are made available to supervision and management personnel in a variety of restaurants. Further, a highly innovative means of presenting information in a Food Safety Toolbox provides placards in several languages. A toolbox is given to restaurants as needed. The essential areas of food safety most commonly utilized to control foodborne disease are the subjects of detailed description on the placards. They are dishwashing (three-compartment sink); thermometer calibration; advisory on eating raw or undercooked meat, poultry, seafood, and shellfish and eggs; cooking temperatures; cooling of foods; foodborne illness investigation; hand washing sink; no bare hand contact with food; refrigeration safety; and personal hand washing.
The comparison of the two programs is significant because basic environmental health procedures used to protect consumers from food borne infection have not changed significantly in the last 50-60 years. Yet there are now global sources of food and although some organisms that were not apparent years ago are now causing outbreaks of disease in addition to the usual culprits, approaches to protecting the food supply by highly competent individuals has not changed that much. What has changed is the use of HACCP principles, which has been both good and problematic. The good is in the identification of critical points where emphasis is placed on known potential problems which can lead to disease outbreaks. What is problematic is the use of time by local and state government officials to carry out these surveys, when there are such limitations on the number of highly competent environmental health personnel who are available because of very strict budgetary demands. Critical safety elements have to be sacrificed in other program areas in order to meet the needs of the food protection and safety program.
What has also changed is the establishment of working relationships with numerous partners interested in and concerned with the spread of disease through food, and the ability to present information in such a manner that it is possible to reach a diverse population and better inform them of appropriate measures to be used. Also, it is evident that local health departments need excellent laws, appropriate budgets to obtain and retain highly qualified individuals, and constant supervision of field staff. Budgets cannot and should not depend on the whim of legislators or the ability to obtain grants to carry out necessary activities to protect the public. Grants also may distort the priorities of the community because they are addressing a special problem at times at the expense of other major concerns in potential environmental health problem areas.
These budgets should and must be based on the ability of the environmental health division to respond to all environmental concerns. This includes potential emergencies that can affect the health and safety of the community.
In each of these two departments, only those with appropriate educational backgrounds should be hired to carry out the work of the environmental health professional. Both of these departments have had extremely strong, very well-qualified, highly disciplined administrators with a comprehensive vision of the needs of their communities, in order to achieve the ultimate award of excellence, the Samuel J. Crumbine Consumer Protection Award.