A Doctor Speaks on the Public Health Reasons Behind Paid Sick Days: Why California Should Pass the Healthy Families, Healthy Workplaces Act

California Progress Report, April 15, 2008

By Rajiv Bhatia, MD, MPH
Director, Occupational and Environmental Health
San Francisco Department of Public Health

[Editor’s note: Last week, AB 2716 by Assemblymember Ma, the Healthy Families, Healthy Workplaces Act passed its first committee in the legislature on an important policy with great significance for public health: paid sick days.]

In November 2006, San Francisco became the first city in the United States to require employers to provide paid sick days. Understanding Paid Sick Days as both an essential labor right and a public health necessity, sixty one percent of the voters approved this initiative and the law took effect February 5, 2007. Let’s consider the impact of the proposed bill on five important public objectives. These include:

1. Avoiding transmission of infectious disease in communities
2. Preventing food borne illness
3. Reducing expensive hospital care.
4. Providing essential care for family members and dependents;
5. Addressing health disparities

Preventing Communicable Disease

It is both common sense and established science that going to work or school with an infectious disease can mean transmitting it to others. Many common infectious diseases are transmitted in workplaces, schools, and other public institutions through simple casual contact. These diseases include influenza or “the flu”, viral gastroenteritis or the "stomach flu," viral meningitis, and the common cold. Collectively, the burden of these infectious illnesses are enormous.

• Each year in the United States, 5% to 20% of the population gets the flu; more than 200,000 people are hospitalized from flu complications; and, about 36,000 people die from flu (CDC 2008).
• Rotovirus, the most common cause of severe diarrhea among children, causes the hospitalization of approximately 55,000 U.S. children each year.
• There are between 25,000 and 50,000 hospitalizations due to viral meningitis each year.

For each of these common diseases­influenza, stomach flu, viral meningitis, or the common cold­ensuring a sick worker can stay out of their workplace and that sick children can stay home from school helps keep infections from spreading. In fact, this is exactly what doctors and public health agencies advise. The U.S. Centers for Disease Control website provides the very common sense recommendation to people with influenza: “stay home from work and school when you are sick” (CDC 2008). Sick children with contagious diseases are excluded from childcare because they contribute to the higher rate of observed infections in day care centers (Loda et al. 1972; Sullivan et al. 1984; Dahl et al 1991; Mottonen and Uhari 1992; Strangert 1976; Doyle 1976).

What is disturbing however is that, unlike all of our peer countries, labor laws do not guarantee U.S. workers leave when they or their family members are ill (Heymann et al. 2007). This inconsistency between public heath guidance and labor law creates a potent barrier for workers to follow common-sense advice from their doctors and public health agencies.

For the 42% of California workers without paid sick days­almost six million workers­a common illness in their household means having to make an extremely difficult choice. Should they take unpaid time off from work; or, should they go to work sick or send their children to school sick? For low income workers, not going to work for even a few days may mean not having enough money to pay the rent, keep their children in childcare, or buy groceries. Some workers may also be insecure in their jobs, not knowing whether an absence from work may translate into the loss of a job. We know from public health research that the choice is difficult; parents without paid sick days are much less likely to care for their children when they were sick as those with these benefits. (Heymann 1999).

Ensuring Food Safety

For occupations such as health care workers, child care providers, and food service workers, it is critical to keep sick workers out of the workplace. Foodborne diseases cause approximately 76 million illnesses, 325,000 hospitalizations, and 5,000 deaths in the United States each year (Mead) More than half of all U.S. reported food borne illness outbreaks occur in restaurants (Jones 2006).

A review of food borne disease outbreaks resulting from contamination of food by food workers, found that ninety-three percent of these outbreaks involved food workers who were ill either prior to or at the time of the outbreak (Guzewich 1999). In 2005, an ill worker without paid sick day benefits at a sandwich shop in Kent County, Michigan was responsible for the illness in over 100 customers (MMWR 2006). In 2006, a restaurant-worker without paid sick day benefits mediated outbreak of norovirus at Carrabba Restaurant Chain in Lansing, Michigan infected over 500 customers (MMWR 2007).

Contamination of food by an infected food worker is the most common mode of transmission of hepatitis A in food borne disease outbreaks (Guzewich 1999). A review of food-borne Hepatitis A outbreaks in the United States found that in many cases the infected food handler either did not seek medical care or delayed getting medical care (Fiore 2004).

Of course, food industry workers with infectious illnesses should not be going to work. The California Retail Food Code (2007) requires the local health officer to exclude a food service worker from a food facility if the employee is diagnosed with an infectious agent, symptomatic, and still considered infectious. In reality, we rely on workers to recognize the illness and their employers to self-enforce requirements that protect the public. Unfortunately, only 15% of workers in the food service industry have paid sick days­the lowest rate among major groups of industries meaning that many may delay or avoid seeking care for infectious diseases (Lovell 2006).

Preventing Costly Hospital Care

Getting timely primary and preventative care requires not only access to services and a way of paying for services, but also transportation, time, and the ability to leave work. Thus, paid sick days and access to heath care insurance are complimentary in helping to ensure access to early and preventative care, reducing the need for leave.

Because paid sick days remove a barrier to the utilization of primary and preventive care they can reduce the utilization of more expensive therapeutic and hospital care. The State of California considers many of the admissions to our hospitals for chronic diseases such as asthma, hypertension, and diabetes entirely preventable with timely and effective outpatient and primary care (Billings 1996). For example, early treatment of a flare-up of asthma in a doctor’s office or clinic can prevent deterioration to the point where hospital care is required. Every year several hundred thousand preventable hospitalizations occur in California (OSHPD 2008). A single hospitalization for asthma costs over $13,000.

Caring for Children and Dependents

At the individual level, taking the necessary time to rest and recuperate when sick enables a faster recovery and prevents the progress serious illnesses. For dependents, including children and elders, having access to an adult caregiver can be a matter of life and death. Children left home alone may be unable to see physicians for diagnoses, needed medications, or emergency help if their conditions worsen.

Today, 70% of mothers with children under 18 are in the workforce (BLS 2006); 25% and 35% of working Americans are currently providing care for someone over 65 (Bond et al 2002); and 2 in every 7 families report having at least one member with disabilities (Wang 2005). However, 52% of employees do not receive paid sick day benefits. The disparities between low-wage and high wage workers are even more striking: 72% of high-wage (highest quartile) receives paid sick day benefits compared to 21% of low wage workers (lowest quartile) receive (Lovell 2006). More troubling is that mothers of children with chronic condition are more likely to lack sick leave and less likely to receive other paid leave or flexibility (Heymann 1999).

What this means for public health should be obvious and unacceptable. Studies of hospitalized children have shown that sick children have shorter recovery periods, better vital signs, and fewer symptoms when their parents share in their care (Palmer 1993). The presence of parents has also been found to shorten children’s hospital stays by 31% (Taylor and O’Connor 1989). When adults receive support from family members when sick, they recover faster and more fully from conditions such as heart attacks and strokes (Bennet 1993; Gorkin et al 1993; Tsouna-Hadjis et al 2000).

Reducing Health Disparities

If we look at the patterns of disease within Cities, California and United States, we see the unacceptable reality of health being a product of race and class. People in the highest income group can expect to live, on average, at least six and a half years longer than those in the lowest. Among neighborhoods stratified by income and wealth, we see life expectancy vary by a decade or more (BARHHI 2008). Benefits for paid sick days are strongly correlated with income, making them one of the many factors explaining our nation’s growing health disparities. Providing paid sick days for all workers is a common-sense solution that addresses health disparities and reduces the strain on public safety net services.

Moving Towards a Common Sense and Fiscally Sound Health Policy

A fundamental purpose of government is to ensure that day-to-day living and working conditions support health and welfare. Labor and occupational safety laws, including limits on child labor, the minimum wage, and the work week, were essential contributors to the gains in life expectance in the 20th century. Today, it is equally important to think of labor policies as health policies.

According to the Organization for Economic Cooperation and Development, the U.S. spends $6102 per person on health care services­15% of our GDP and more than any other country the world (OECD 2006). Despite outspending our peers, life expectancy in the United States is a full year less than in Canada and England and three years less that Spain, Sweden, and Switzerland. One reason these other countries are outperforming us with respect to health is that they have paid attention to ensuring healthy living and working conditions for all residents.

Overall, we should view paid sick leave benefits as a practical and cost-effective public health policy to prevent disease, avoid unnecessary hospitalizations, care for our children and elders, reduce health disparities, and control health care costs. Furthermore, adopting paid sick days would eliminate the perplexing inconsistency between our public health and labor laws.

Rajiv Bhatia received a Medical Doctorate from Stanford University and a Masters in Public Health from the University of California at Berkeley. He has practiced medicine since 1989. Since 1998, he has served as the Director of Occupational and Environmental Health for the City and County of San Francisco’s Department of Public Health. Bhatia is also an Assistant Clinical Professor of Medicine at the University of California at San Francisco and teaches a course in the Health Impact Assessment of Public Policy at UC Berkeley.