I’m trying to get through some of the required readings for the week, and I have “Kitchen Nightmares” playing in the background. For those of you who have not seen that television show, it’s about Chef Gordon Ramsay going from one restaurant to another and helping the owners get back on their feet. One of the things he does, besides sampling the food and commenting on how awful it is and why he’s not surprised that the place is having money problems, is step into the kitchen and inspect it. He goes all over the kitchen and looks at the walls, the corners, the back of the stoves, under the ovens, etc. He then goes into the walk-in freezer and looks at how fresh — or not — the food is in there.
That part is funny in a way because Chef Ramsay loves for food to be fresh. He doesn’t tolerate anything that is frozen or comes out of a box. God help you if you cook anything with a microwave. One of the things that always seems to happen is that he starts dry heaving and almost loses his lunch when he finds, for example, a tub full of mayonnaise with an expiration date of a few years back and still chock-full of mayo. That part of his reaction I can totally relate to because of a similar experience I had a few years back.
I was working at the state health department and one of our FoodNet epidemiologists got a report that a whole family had tested positive for an enteric pathogen, a bacteria (and sometimes a virus) that causes gastrointestinal disease. As it happened, that family lived in the general vicinity of another family who also tested positive for the same bug. When the laboratory scientists compared the DNA of both bugs, there was a match. The bugs were 99.9% similar to each other, meaning that the likelihood of the two families getting sick from the same food was almost 100%. As a result, a report was passed on to the local health department where the families lived, and epidemiologists there interviewed the two families.
Before I go any further, I need to let you know that the rest of the story has been mixed into a narrative of one place at one time. The actual story involves three different restaurants, but, in order to maintain the confidentiality of the whole thing, I’ve decided to mix it into one story. Otherwise, some of you may put two and two together and figure out where this took place. It’s been six years, and I’m sure things have changed. Now, on to the rest of the “Kitchen Nightmare”…
The two families reported eating Italian food from the same location hours apart. Myself and a colleague joined a food inspector at the restaurant to conduct an environmental assessment (i.e. surprise inspection). The inspector was a very experienced woman who had been doing that job for decades. She was very no-nonsense when it came to her approach of the inspection. She said she knew that lives depended on her work. And she was right. People die from food poisoning the world over, even here in the United States.
All three of us arrived at the restaurant around 2pm, just after lunch. It was a small-ish place. They had pizza and pastas sitting under warming lights for people to pick. The food would be put into the over for a while before being served to the customer. There were ten or twelve tables but no wait staff. A small bathroom sat at the back of the customer area. It had a toilet and a faucet. Five men worked the kitchen. One was a dishwasher and table cleaner. Three were cooks. One was the manager. When we explained the situation to them, all claimed to be feeling well and not having any symptoms of disease in the previous month.
The food inspector started off by interviewing the manager. The food in the front was prepared in the morning and put out under the lights the rest of the day. According to the manager, all food was thrown out at the end of the day. Nothing was kept for the next day. While she interviewed the manager, I made my way into the kitchen and struck up a conversation with the dishwasher. Like me, he was from Mexico. He had been working there for a few years, sending most of his money back home. He said he wasn’t sick and had not been sick in a long time. He also said he couldn’t afford to get sick because his family in Mexico depended on his money.
The food inspector and my colleague then moved on to interviewing the three men who prepared food. Again, they reported not being sick. They then showed how they prepared the different foods. All started off by putting on plastic gloves and getting the ingredients from a table next to the cooking area. Of particular interest was a big mayo tub. According to one of the food preparers, it was used to make a tomato sauce that was used on most of the dishes. At the end of the day, it was washed by the dishwasher and put back on the table for the next day.
The inspection then moved on to the dishwashing area. The dishwasher showed us how he washed the dishes. He’d rinse them off with hot water, then used soap and water to wash them, then he would put them on a rack to air dry. The inspector recommended an extra “kill” step of dipping the washed dishes in a sanitizing solution (made with ammonia or bleach, but not both!). This three-step way of washing dishes assures that anything that could have survived the hot water and soap is killed in the final step. The manager told us that he would work with the dishwasher to start doing this immediately.
The final part of the inspection was checking out the walk-in freezer. Contrary to what the manager had said, there were plenty of old pizzas and pastas stored in the freezer. Some of them had dates written on the plastic containers. Some other did not. The inspector ordered all of that food to be thrown away in front of her immediately. She also asked that they clean the floor of the freezer and that they rearrange some of the food. The raw food should not be kept above cooked food or foods that were to be served without heating, like the lettuce for the salads.
All things considered, the inspection part of our visit went fine. Some of the deficiencies were corrected, and there wasn’t anything telling us if the restaurant staff were to blame for the cluster of cases up to that point. Still, because we wanted to be thorough, we asked all of the employees to submit to us a stool sample. Even if they were not sick, there has been plenty of times when asymptomatic carriers pass on a gastrointestinal infection through the food they prepare. (Typhoid Mary was the most famous one.) While my colleague instructed them on how to collect a stool sample and where to take it for analysis, I translated the instructions to the dishwasher.
Suddenly, as we’re giving them these instructions, the manager asked if he could just give a sample right then and there. It was a little confusing because he stopped us in the middle of the presentation of how to collect the samples. That, and he was covered in sweat. The inspector gave him a sample kit and he went into the bathroom at the end of the customer area. When he came out a few minutes later, he gave us a very, very loose stool sample. I asked him how long he’d been passing stools that were that loose. He said it had been a week or so, but that he felt fine. The food inspector asked him to stop working immediately and go home. We’d test the sample right away and get back to him, but he was not allowed back to the restaurant until he heard from us.
We asked the other employees for specimens as well. In a couple of days, all of them submitted samples… All except the dishwasher.
As it turns out, the manager tested positive for the pathogen that caused the disease in the two families. It was a genetic match as well. He was referred to a physician for care and told not to return to work until he submitted three specimens collected a day apart that were free of the bacteria. It took him a couple of weeks, but he finally cleared it. All the other employees who submitted specimens tested negative. We figured that the manager had been sick and using the bathroom where the customers went. They would get infected there or from handling the money that the manager touched. Or he would help out once in a while when the place was busy and actually touch the food.
The take-home message at this point is that any and all employees in a food-serving facility must be kept from work if they have anything resembling an infection of any kind (be it digestive, respiratory or otherwise). Even if they don’t have direct contact with food or customers, they can have contact with things that come into contact with food or customers. Some pathogens, like Norovirus, only require a small dose to make people really sick. As an owner of a food business, it should be very important to keep your employees and your customers safe. One well-placed lawsuit over something like this could ruin you.
But what about the dishwasher? I’m glad you asked.
The dishwasher did not submit a specimen ever. He then stopped working at the restaurant and would not pick up his phone when we called. I heard a rumor that he went to work at another location, also as a busboy and dish washer. I called that location and had a chat with him about why he didn’t submit a specimen. He said that he was afraid to be sick and get fired. He also said that he was afraid to be turned into the authorities for being an undocumented immigrant. I told him that we don’t do report to law enforcement unless there is a clear violation of the law. I wasn’t going to ask him for his immigrant status because it wouldn’t matter at all in the course of the investigation. After I talked to him, he left that place and was never heard from or seen again, probably blending into the background of all the service employees in this country.
When I see television shows about restaurants, I can’t help but think of what went on during our investigation of that disease cluster. Running a restaurant is not easy, and I can see how employees and owners will band together against “the man” or “outsiders” when they come knocking on their doors. After all, it’s their livelihoods (and, in the minds of some, their liberty) that is at stake. Still, as public health workers, we need to make it clear to them that we are not there to shut them down. Rather, like Chef Ramsay, we are there to give constructive criticism and help them run a cleaner place that everyone can enjoy.
René F. Najera, DrPH
I'm a Doctor of Public Health, having studied at the Johns Hopkins University Bloomberg School of Public Health.
All opinions are my own and in no way represent anyone else or any of the organizations for which I work.
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