Nearly half of food-borne-illness outbreaks are linked to restaurant food. The microbes that cause them are invisible and taste just fine. So how can you lower your odds of getting sick?
"Go look at the bathroom," suggests Ken Gruen, a retired Philadelphia restaurant inspector ("sanitarian") who advises food establishments at Philadelphia International Airport. "If the bathroom is kept in good condition - it's clean, there is soap, there are paper towels, there is not a lot of litter on the floor - probably the kitchen is the same."
Other signs of general sloppiness, health, and hygiene could be indicators as well. Is the knife used to slice limes at the bar left on the counter without cleaning? Has the buffet been ignored for hours? If the kitchen is visible, are workers wearing gloves? Is your waiter a mess?
More specific measures, like storing cheese at temperatures that are too cold for dangerous microbes, are noted in official inspection reports - if you have the patience and knowledge to interpret them.
To make them easier to understand - there are hundreds of potential code violations - all restaurants in New Jersey must display overall findings as "Satisfactory," "Conditionally Satisfactory," or "Unsatisfactory," although the sign may not be visible from outside. Some cities (Toronto, Pittsburgh) post green, yellow, or red placards in the window. Another handful (New York, Los Angeles, San Francisco) put up consumer-friendly A-B-C letter grades.
Philadelphia does none of the above.
No scoring system "has been found to be effective for food safety," said Palak Raval-Nelson, who oversees inspections of nearly 12,000 food establishments for the Philadelphia Department of Public Health.
In fact, there is limited evidence that inspections themselves protect against food-borne illness. They are a snapshot in time: Only a stroke of luck would have the sanitarian present at the exact moment that a refrigerator malfunctions or a cook shows up sick.
But they may work in a different way.
"No one wants to be embarrassed," said Doug Powell, a food-safety consultant in Australia and anchor of barfblog. "So inspections and disclosure systems make [restaurateurs] try harder. And it also contributes to the public conversation about food safety."
Food-safety laws are written and enforced almost entirely at the state and local levels. Since the late 1990s, most jurisdictions, including Philadelphia, have adopted U.S. Food and Drug Administration recommendations that for the first time are based on the science of disease transmission. Cooking to a temperature high enough to kill microorganisms is a high-priority item; ceilings with missing tiles is low.
But the FDA says little about how the findings should be explained to the public. Most places don't do much more than post the entire report online, if that.
The reports are essentially a terse checklist with two categories, defined by the FDA. "Food-borne illness risk factors" are conditions or behaviors (like not washing your hands) that are known to play a role in transmitting disease.
"Good retail practices" (like working soap dispensers) are intended to prevent the conditions that make the food-borne-illness risk factors more likely.
Mouse droppings are a tricky one - unimportant in the basement but a big deal on a fryer.
"It is really hard, I think, for a consumer to make very much sense of these detailed reports," said food-safety specialist Craig Hedberg, a professor in the University of Minnesota's School of Public Health.
But Hedberg doesn't think inspections prevent much sickness anyway.
"We talk about food-borne illness like it's a single thing," Hedberg said. In reality, there are several kinds, each causing extremely uncomfortable (and sometimes dangerous) diarrhea and abdominal cramps, from one day to a week:
Between 10 percent and 20 percent of outbreaks are due to salmonella, increasingly carried on fresh produce that will be served without cooking. It's not visible, and washing often fails to remove it.
Chopping and mixing quantities of, say, parsley or tomatoes, as most full-service restaurants must do, could spread the contamination through the entire batch, however. "The restaurant will simply be a pass-through," Hedberg said. "The best they can do is try not to make the problem worse."
And an inspection will not stop it.
Another 10 percent to 20 percent of outbreaks are traced to Clostridium perfringens. The bacteria grow and produce a toxin when spores germinate after cooking if foods are not cooled quickly enough before storage. It used to be more common, and has been successfully reduced through the priority that inspectors place on temperature control and cross-contamination, Hedberg said.
More than 50 percent of outbreaks in the United States are norovirus. It is spread when infected workers handle salads and serve sandwiches. Frequent hand washing helps, but ill employees simply should not show up for work. "Workers can come in sick a few hours a year," Hedberg said, enough to start an outbreak but unlikely to be spotted during an inspection.
So what would work?
For a 2006 paper in the Journal of Food Protection, Hedberg led a team that compared various characteristics of 22 restaurants that had experienced outbreaks of food-borne illness and 347 that had not. The main difference was the presence of a certified kitchen manager - someone who has the power to change attitudes and atmosphere. These managers are regular kitchen employees or supervisors who have received additional training in food safety. They can spot and respond to risks, like sending home workers with symptoms of norovirus.
Having a certified manager present at all times is part of the first item on inspection reports. Although less of an "ewww" factor than rats or roaches, it is considered one of the more serious - and most common - violations. But it is only one.
Inspections in Philadelphia are at least as stringent as in other cities, said Dave-Roger Grosvenor, president and CEO of VII Principles, a Mount Laurel-based company that works with restaurants on food safety nationwide. He said that most proprietors have the same goal as government sanitarians - to prevent diners from getting sick. Grosvenor pushes his client restaurants by showing up for mock inspections unannounced during the chaotic dinner hour.
He may stand in a corner, noting whether food handlers wash their hands every time they pick something up off the floor, scratch their necks, handle money, smoke a cigarette, or answer a cellphone ("pockets are dirty"). His staff uses the same checklist as city sanitarians, and he says they never give a place a pass.
"Our task is changing the culture," Grosvenor said.
He believes that is best done from the inside.
Some other food-safety experts and regulators argue that the key to reducing disease is a very public process: Make inspection findings easy to understand (abbreviated, say, as A-B-C) and display them prominently.
Proponents argue that posting letter grades in the window isn't just popular. It creates public pressure on restaurants to do better.
Los Angeles introduced letter grades in 1998. When economists from Stanford University and the University of Maryland examined sales tax records for two years before and one year after, they found that restaurants given an "A" got a 5.7 percent revenue boost, while "B" restaurants gained 0.7 percent. "C" locations lost 1 percent.
"It's a good enforcement tool," said Joseph Corby, executive director of the Association of Food and Drug Officials in York, Pa.
Many restaurant owners hate it.
"The difference between 89 and 90 points" - a "B" vs. an "A" - "might be a dented can in the stockroom that is unlikely to have any safety effect on anyone," said John Longstreet, president and CEO of the Pennsylvania Restaurant and Lodging Association.
While inspections are a moment in time, grades stay up until the next visit. "A" restaurants may get complacent. "Scores on doors" require additional resources to administer, Longstreet and others said, and may actually "take away from improving safety."
Color codes are a middle ground.
Toronto's DineSafe program began in 2001. The most critical violations are noted in simple language on a green, yellow, or red sign posted out front. Ninety-two percent of restaurants get a "green" on their first inspection, said Sylvanus Thompson, associate director of Toronto Public Health. Polls show the program is overwhelmingly popular.
Celebrity chef Kevin Sbraga has mixed feelings about how inspections are conducted and the findings explained to the public.
Sbraga suggests that consumers who are concerned about food-borne illness "look for telltale signs. The cleanliness of the plates, flatware, glassware," he said. "Also how the staff looks."