There are few factors that shape a person’s health as strongly and predictably as income. And while enforcing wage and labor laws may at first seem outside the purview of public health agencies, Rajiv Bhatia adamantly disagrees. In fact, he says that public health may wield the most persuasive stick in town.

Bhatia is the director of environmental health at the San Francisco Department of Public Health (SFDPH) and is behind an innovative policy change that uses the agency’s existing regulatory authority to prevent wage theft and support basic labor rights among restaurant workers. Begun in response to community demand, the agency now routinely employs its authority to revoke or suspend restaurant permits to help enforce official wage theft findings and ensure that employers carry adequate workers’ compensation insurance. The permitting authority has a direct and immediate financial impact on employers, “so we probably have the strongest stick in town to get a restaurant to act,” Bhatia said.

“Instead of developing a public health agenda from within an institutional box, we said we’re going to use our power to support the goals of social movement groups,” he told me. “What we’ve done if fairly unique and it’s certainly replicable, but it’s not replicable without a struggle.”

Bhatia co-authored an article about the agency’s experience — “Protecting Labor Rights: Roles for Public Health” — that was published in the current supplement issue of Public Health Reports. In the piece, he and co-authors Megan Gaydos, Karen Yu and June Weintraub note the connections between labor conditions and health, writing that “income is a prerequisite for nutrition, housing, transportation and leisure and is associated positively with health outcomes, including longevity.” They added that with the decline in enforcement capacity at federal and state labor agencies — the number of workplaces is up while the number of investigators is down — cross-agency collaboration could go a long way in protecting workers. They write:

Interagency collaboration among local, state, and federal government agencies — as well as collaboration with community-based organizations and the private sector — is a promising mechanism of efficiently meeting regulatory commitments in a resource-constrained environment. Local health departments can support compliance with labor laws by monitoring working conditions, educating workers and employers, using existing enforcement authorities, and recognizing exemplary businesses. Improving working conditions should be viewed as a key function of public health.

In San Francisco, the Office of Labor Standards Enforcement (OLSE) monitors violations of local wage laws (the city’s minimum wage is $10.74 an hour as of January) and mediates complaints of wage theft. About one-third of OLSE cases involve restaurants, and the city is no stranger to the problem of wage theft. In one study conducted by the Chinese Progressive Association, half of restaurant workers in the city’s Chinatown neighborhood were not receiving minimum wage. The conditions made restaurants the perfect test subjects for a cross-agency approach to wage law enforcement.

The process works like this: An OLSE investigation finds an employer guilty of violating wage laws and orders an employer to pay back wages and penalties. Unfortunately, the employer doesn’t always comply — that’s where the San Francisco Department of Public Health comes in. As part of its inspection duties, the public health agency can suspend or revoke a restaurant’s permit for failing to meet food safety standards. But it can also suspend or revoke a permit if a business is breaking any other local, state or federal laws — including wage laws. In other words, by engaging public health authority, the labor office is able to significantly expedite compliance and in the long run, hopefully prevent wage theft in the first place.

“We were able to rapidly quicken the enforcement process,” Bhatia said. “Even from a food safety perspective, we have a common interest because businesses that violate some laws are more likely to violate other laws. …There’s probably nothing more important to health than income, so I see this as public health demonstrating its commitment to the social determinants of health.”

Since the effort began a handful of years ago, there’s only been about a dozen instances in which the public health agency has threatened to sanction a restaurant’s permit, Bhatia said. But in every instance, the move has worked and the restaurant has complied with the enforcement order.

Expanding to insurance monitoring

After the wage theft success, Bhatia and his colleagues wondered if they could use their regulatory authority to improve other workplace conditions as well. They knew from previous assessments that although restaurants are legally required to carry workers’ compensation insurance, many either don’t have coverage at all or underestimate their workforce numbers. Inadequate insurance causes significant barriers for workers seeking care for work-related injuries or disability benefits. So in 2010, Bhatia decided to integrate routine insurance monitoring into the permitting process. Now, restaurants are required to show proof of workers’ compensation insurance or risk their permit renewal. According to the Public Health Reports article:

Of businesses in the first sample, 10% did not have workers’ compensation insurance prior to SFDPH’s request for proof of coverage. While some acquired insurance after this request, 4% did not provide proof of coverage until SFDPH threatened to suspend their permits. After being compelled to attend public hearings, all businesses except one provided proof of insurance coverage.

On the surface, the work Bhatia describes may seem like a natural fit for public health. But he said it didn’t come without a struggle. In fact, he said it was restaurant inspectors who put up the most resistance, raising concerns that the new measures would draw attention away from food safety and muddy their relationships with restaurant owners. (On a side note, a similar labor tactic was proposed in New York City, but local health officials argued it would water down its food safety focus and the legislation eventually died.)

Even though the San Francisco model seems like an easy, low-cost way to support workers, Bhatia said he isn’t entirely optimistic that many public health agencies would follow San Francisco’s lead on their own.

“It has to come from an organized political movement demanding that the public health agency take on a broader set of roles,” he said.

For a full copy of the Public Health Reports article, click here.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.