CHAPTER 1
THE INSPECTION-BASEDENFORCEMENT APPROACH TONONCOMPLIANCE
The inspection-based enforcement system has positive, necessary aspects,aspects that will make change, however important, slow and incremental.Here is a synopsis of the process, provided for non-sanitarians and toestablish a common ground for discussion.
The sanitarian's task is to evaluate sites and facilities for public healthrisk factors (the latter are established by legal mandate, varying degreesof severity and epidemiological association with environmental concerns[illness, contamination]) and take action to abate those risks. Availabletime and resources are oriented around documenting risk conditions andproducing a complete, objective report of these findings. Data about thesite is gathered using a wide range of equipment such as meters, test kits,thermometers, measuring tapes, levels and probes; computers are used todocument findings and create a report. Last, site personnel are observedon the job and interviewed, to determine their knowledge, skills andabilities to apply safe sanitation procedures.
The completed site report is then discussed with the client, includingaspects such as (a) the site's overall sanitation status; (b) problems andtheir solutions, those cited on the report and developing trends thesanitarian has observed; (c) compliance times; and (d) repercussionsof continued noncompliance (e.g., more frequent site visits, hearings,fines, tickets, court actions). Other notifications may be issued, such asplacards or tags, if the site's status is unacceptable.
While the sanitarian specifies the end result for each citation (e.g.a floor in good repair, clean hands, clean and sanitized equipment),a specific comprehensive method or process (e.g. linoleum, quarryor ceramic tile, texture and type of wall paint, precise methods forwashing hands or cleaning equipment) may not always be stated. Suchdescriptions take space on the report, take time to write and may excludea method better suited for the client and site. Too much detail couldcost the facility added expense, yield a worse result or give the client anexcuse to delay compliance. This is an important point in the complianceprocess; clients and site personnel must be educated and experiencedenough to institute changes that are legal, correct and best suited fortheir facility.
After the initial site evaluation, the sanitarian monitors thesite's progress toward compliance, using site visits, telephone calls,correspondence and office conferences, until acceptable sanitation statusis achieved. Secondary functions to the site visit include consultations,conferences, educational programs and other resources, to clarify reportresults and corresponding coping strategies. If return visits demonstratea significant risk reduction, the sanitarian moves to another site andclient. If, however, items of significant risk continue to be cited, returnsite visits occur, using progressively more severe legal remedies (tickets,fines, license revocation, injunctions) until these items are resolved. Ifnecessary, action is taken to remove the offending site or facility fromoperation. This is an entirely different process, involving additional legalhearings, the gathering of evidence, and the writing of reports.
Considerable time, training, and resources are devoted, not only toproducing an objective, comprehensive report but also to maintain andcalibrate the equipment needed for the job, Note that this equipment isvital, not just to gather data, but to produce an accurate report with legalstanding.
Aside from the legal mandate, and the sanitarian's essential roleas environmental protector, this report is important for political,professional and legal reasons. Detached observation, along with theuse of progressively more complicated equipment, gives the sanitariancredibility as a scientist and technician. A complete and comprehensivereport is a more reliable legal document. The public sees such adocument as evidence that tax dollars are used constructively. The failureto produce such a report could result in legal liabilities, citations forprofessional malfeasance, or much worse, the loss of operating funds dueto a failed audit. The time, resources, and professional pride involved increating this "product" reflect the investment health agencies have in thissystem.
Note: This book makes frequent references to repeat contact withclients. It might appear, therefore, that single visit services such as waterwell and septic system evaluations would not apply. That is not the case,however. Repeat contacts are not just site visits but may include anycontact between the client and health agency personae (printed literature,media releases, communication campaigns, school system curricula, localfairs, exhibitions or festivals, and word of mouth reports from otherclients or visits to nurses, doctors, dentists, hospitals or clinics). Any ofthese contacts will influence the health agency's credibility as well as theclient's motivation to act, perhaps even more so than direct contact witha sanitarian.
SUPPORT FOR THE INSPECTIONSYSTEM
The description above illustrates the considerable pride and investmentsanitarians have in what they see as objective, balanced, and scientificwork. Most sanitarians working with public agencies do so to servethe community; if money rather than professional pride was the mainreason for working, private industry offers sanitarians a larger income.Therefore, suggestions of bias or harassment receive a dim view, similarto a patient's questioning of a physician's regimen. The sanitarian'sacademic training and professional orientation both advocate a balancedholistic environmental approach to problems: sanitarians believe thatthey are reflecting that ideal in their work (Fig. 1).
To some extent, their belief is supported: there is compellingevidence of this approach. Most public health regulations are clear,logical, well publicized, and, with the exception of more complicatedupgrades to structure or equipment, easily resolved through behavioralchange. There are education programs, media releases, newsletters, andpamphlets to explain the rules. Many clients comply without legalpressures, indicating a good understanding of public health requirementsor at least an effective use of information about them. The inspectionprocess is the same approach used by other civil authorities (e.g., police,fire, municipal) and therefore is familiar to the community. If there areto be errors in the use of the system, it certainly appears more prudent tobe too severe and be certain imminent high-risk violations are found andabated. Tentativeness caused by being familiar with clients or discussingimprovements could inadvertently create confusion and encouragenoncompliance.
More anecdotal supportive evidence comes from field experience.Regular, repeated observations of high risk concerns lead sanitariansto believe that a client's excuses must be irrational or inexplicable, i.e.psychological in nature. This makes some sense: thinking about thecosts and potential impact of food borne illness, who can conceive ofa rational explanation for statistically significant causal factors such asimproper hand washing?
Yet, these repeat occurrences appear to indicate a significantdisconnect between site personnel and accepted scientific knowledge.When confronted with these concerns, clients are frustrated, apologeticand mystified about their occurrence; this suggests, again, that no goodexplanation exists, at least not to the client and certainly not to thesanitarian. From these observations evolves the idea that either the causesare psychological and inexplicable or simply recalcitrant, i.e. not the faultof inefficacious environmental health services.
Compliance with infrastructural defects (e.g., floors, walls, orequipment in disrepair) is more complicated than high risk-behavioralconcerns, due to strong causal links to environmental factors such asresources, time, cost or availability. The most motivated client may findbarriers to change overwhelming and out of their control. High-riskbehavioral concerns, however, while certainly linked to environmentalbarriers, are much less resource dependent. Proper hand washing,utensil washing, and food storage are three commonly accepted hygienicpractices, at home or in restaurants. From the sanitarian's perspective,the rational approach to this type of violation should be staff trainingand routine monitoring of the problem. Since this does not requirea significant investment of resources, at least from the sanitarian'sperspective, training should happen and compliance should occur. Onthat basis, noncompliance must be irrational and recalcitrant behavior.(This book will try to suggest a different approach).
Furthermore, the sanitarian's primary function, defined and drivenby legal mandate, is always risk abatement, not analysis. This function islocked in by legal mandate and community demand. Documentation andcorrective action remain the foundation of the legal mandate and matchingfunds requirements, not the analysis of noncompliance. If a sanitarian isintent on learning a client's motivations, more time must be generatedduring the site visit, not an easy proposition. While some sanitarians persistin this effort, administrators generally discourage this effort as moot, a wasteof time and resources. Since causes of noncompliance must be irrational andrecalcitrant (at least under the present system), analysis is futile. Analysisdoes not contribute anything toward risk abatement. To its advocates, theinspection system has worked well to limit the impact of overt public healthproblems; any noncompliance not covered by existing enforcement can beaccredited either to the client's recalcitrance or the need for more stringentinspections.
The inspection-based system and its corresponding view ofnoncompliant behavior as recalcitrant are both supported by publichealth administrators, the public, the sanitarian's anecdotal fieldexperience, and the literature; thus sanitarians are reluctant to changethe system. In addition, external audits and associated budget dollars arelinked to the system.
Even if these audits did not exist, however, public health professionalswould still be comfortable with the system. The public and many clientssee the system as an efficient use of tax dollars and a fair, equitableadministration of the law. Historically, sanitarians have been expected tocontain the spread of imminent public health hazards (e.g., tuberculosis,community disasters), as in the case of epidemics or communitywidecontamination.
The public expects this protective function and looks for legalactions as an effective use of tax dollars. A comprehensive site report ofsanitary violations feeds into this expectation. Anecdotal field experienceshows the citation of severe sanitation risks, providing enough evidenceto support this system. Finally, the system provides respect for thesanitarian's professional development as a scientist and technician. Eachsite report supplies a viable legal document and establishes credibility andrespect for the sanitarian. (Professional respect is vital when competingfor a portion of a shrinking public health budget.)
Public health professionals rarely cite literature to support their system;this may explain why assumptions about noncompliance are based on fieldexperience, not on behavioral science. Conceptual explanations, however,resemble psychodynamic theory. This theory states that noncompliant or"deviant" behavior is attributed to a "manifestation of the dynamic interplayof inner forces, most of which operate below the level of consciousness."Causes of noncompliance are thought to be psychological, hidden andunavailable for further inquiry. The sanitarian's perspective is based onoutcome, not cause (the cause in this case, by definition, is within theindividual, unavailable for inquiry). This fact forces further use of legalenforcement to influence outcome.
A CRITIQUE OF THE SYSTEM
The preceding section describes necessary parts of the inspection- andenforcement-based system, why it seems perfectly justified, and howit has become entrenched in the public health psyche. This lengthydiscussion was needed to illustrate the deep investment sanitarianshave in the system and the difficulty of subsequent change, howeverwarranted. As with any attempt at change, there will be individualsreluctant to endorse it. In line with behavioral science concepts, potentialobjections to change must be addressed. After that, we can examine whythese changes are important and necessary.
CONSIDERING OBJECTIONS TOCHANGE
As a precursor to a critique of the system, we need to consider whypublic health professionals might not endorse a systemic change (later,there will be specific changes to consider). There are several possiblereasons: (a) there is no research to suggest there is a problem; (b) if therewere problems, solutions must originate with legislators, not sanitarians;and (c) there has not been prior criticism of the system.
It is true that there is no exploratory research; this is unlikely tochange until a crisis highlights problems with the system. The emphasisof current environmental health service is retroactive, not proactive. Thisis due to legislative mandate, budget constraints, sociopolitical pressuresand the nature of the science itself. Administrators are reluctant to budgetexploratory research that is expensive to conduct and difficult to justify.Environmental concerns are subclinical or chronic, not acute as with thework of doctors or nurses. Any documentation is often biased, relying ona self-interested client's report or on anecdotal evidence. Since problemsare difficult to document, the not entirely unreasonable assumption isthat they do not exist.
Legislative mandates restrict the sanitarian's options duringinspections, locking in certain enforcement-based components to theinspection and written report (see "The Inspection-Based EnforcementApproach"). While program funding is linked to satisfying thesemandates, however, these restrictions should not be an excuse to avoidchanges to the system or to resist screening for developing trends. Acertain amount of reluctance is understandable; however, there stillis ample room within the existing system to incorporate the changessuggested in this book. Once these improvements are instituted anddocumented by research, public pressure may cause legislators to amendthe system.
While there is little concrete data to use in program evaluation, thereis compelling anecdotal information and personal experience to suggestthe need for change. Many individuals have experiences in which they actcontrary to legal mandates, friends' advice, or scientific research. Otherfactors or information influence their decision. Similarly, sanitarians seeclients who, faced with legal action, still are unable to rectify violations:these people appear reasonable and sincere yet cannot make the requiredchanges. They simply do not fit the expected "recalcitrant" stereotype.
Finally, critics use the absence of supporting data or research tosuggest that these ideas are overemphasized and unrealistic, and are thework of "ivory tower" academics. However, if this discussion is new tosanitarians, it is not new to health educators or behavioral scientists.In 1975, Goldsmith and Hochbaum observed the shortcomings ofenvironmental protection, stating that
Neither strict enforcement of environmental codes norconcerted consumer education has prevent people fromsubjecting the environment to continuous insults, eventhough these insults will be to their ultimate detriment. Yetthese measures have been the main ones on which publichealth environmentalists have relied in their environmentalprotection efforts.
The authors suggest a reason why these `insults' continue and whysanitarians do not change their approach: "they (sanitarians) have beentrained to deal primarily with the symptoms or the results ... rather thanwith the determinants of human behavior." They go on to decry the lackof available information for motivated clients wishing to comply, statingthat "environmental health agencies ... have all too often made informationavailable only to those who know where to obtain it and are willing to makethe effort to do so." This would suggest that some changes and exploratoryresearch are needed to explore both behavioral science applications and thenature of consumer education.
