During the past few decades, public awareness and interest in the USA has steadily increased over the working conditions at formal and informal sectors in the developing countries. This phenomenon may have resulted from a combination of heated political debates about jobs leaving this country, awareness about exploitation of cheap labor overseas and worker rights repression, and news stories on frequent fatal factory fires and factory building collapses in other parts of the world. While making goods that are coming to the western consumers at a low price, workers in many of these outsourced industries are working in deplorable conditions, working very long hours at barely living wages with limited or no access to standard employment conditions and benefits. However, there are millions of immigrant workers, both documented and undocumented, working in somewhat comparable conditions within the USA and there is inadequate knowledge, evidence, awareness, and research on these workers’ health, safety and wellness issues who are living and working right in our backyard.

In 2013, the number of foreign-born individuals in the US was 14% of its total population [1]. With almost 46 million individuals, this makes the US the nation with the largest number of migrants. A major destination for these immigrants is New York City (NYC) and the largest population group is South Asia: India, Pakistan, and Bangladesh. Nearly 500,000 immigrants from India, Pakistan, and Bangladesh now live in NYC and its vicinity [2]. They prefer to settle here for availability of jobs and for family and social connections. A large proportion of them with low fluency in English, lower educational attainment and job-skills settle in lower socioeconomic neighborhoods in this very large city and often start to work as taxi drivers or in grocery stores, liquor stores, convenience stores, bars, restaurants and gas stations, or in other family owned businesses. These smaller establishments are critical to the economy of NYC and often serve as the primary source of low-wage jobs for many newly arrived unskilled immigrants.

Previous studies on immigrant workers have largely focused on immigrants from Latin America and a few studied Chinese, Vietnamese or other East Asian workers [3, 4, 5, 6]. The findings highlighted the additional health burden for these ethnic minority population from unsafe and unhygienic workplaces. The cost of receiving health care was reported to be crippling for these immigrants – both documented and undocumented. Integration into the mainstream economy often takes a long time for many immigrants. One study on Chinese-Americans noted that health problems are aggravated by language and cultural barriers in seeking medical care. Many Chinese immigrants are poorly informed about the availability of services or find existing facilities to be inaccessible because of their poor English literacy. Others may have poor understanding of Western medicine and still adhere to ancient Chinese remedies [3]. Another study reported that immigrants were primarily employed in jobs that required limited skills and offered few benefits. Only 20% participants had employment-related health insurance, and almost 60% did not have workers’ compensation coverage [4]. The disparity in health care benefits may be less a function of immigrant status than of the types of jobs held by these workers. We found no study focusing on South Asian immigrants working in NYC’s restaurants.

Restaurants can be hazardous workplaces for the nature of business, materials handled, and tasks completed. Working with hot equipment, oil, sharp knives, lifting heavy objects, working in hot work areas for a long period of time and on slippery floors or floors cluttered with objects may result in muscle strains, sprains, and tears; cuts and lacerations and burns and scalds [7]. OSHA reported 185,200 cases of nonfatal occupational injuries and illnesses with an incidence rate of 3 per 100 full-time workers for Restaurants and other eating places (Private Industry) in 2015 [8]. However, OSHA’s inspections and enforcement of the regulations may be limited for many of these ethnic restaurants which are often run by family members, supported by underage children of the owners, employ casual or part-time workers, and workers without formal contracts. Also, many have 10 or fewer employees making them exempt from OSHA injury and illness recordkeeping.

Some of the traditional South Asian establishments/restaurants rely heavily on traditional way of food preparation to create more authentic taste of their cuisine. Different types of ethnic cooking apparatus such as ‘kiln oven’ or ‘tandoor’ are used to prepare the traditional bread (chapati, roti), which may contribute to unique work-related hazards and injuries specific to these ethnic establishment.

Workers in these restaurants likely work in less than ideal conditions with minimal or no workplace health and safety regulations, programs, policies, or practices. Given the scarcity of evidence and difficulty in accessing these populations, we have explored a unique idea on how to shed some light on their vulnerability using NYC’s restaurant inspection reports as a possible surveillance tool (Table 1 and 2).

The NY Health Department inspects about 24,000 restaurants a year to monitor compliance with City and State food safety regulations [9]. 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 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 a relatively hazardous or unhygienic working conditions. If these restaurants are not attentive to 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 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 healthcare industry, there is evidence that organizations with stronger patient safety culture are also safer workplaces for its 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 in understanding 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 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 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.