Public Health's Tamale Problem
And how Harm Reduction can help resolve it
Some personal news is in order: one fantastic new opportunity I received this year is participating in a writing fellowship sponsored by the Young Voices organization. They have been helping me with opportunities to publish pieces about economic policy in various outlets, many of which will hopefully come out over the next month! My first piece for them was published last Monday, in which I argue that LA County’s Public Health (LADPH) needs to reform its regulation of street vendors:
LAPDH should use this discretion to abandon its current zero-tolerance approach and embrace the harm-reduction model widely used in other areas of public health. Harm reduction recognizes that Public Health regulation has a legitimate role in discouraging the riskiest public health practices to ensure consumer safety in street vending. Consumers who buy from vendors can’t always see how their food has been handled. Thus, they don’t fully understand whether a given vendor is following basic food safety precautions.
However, the status quo’s zero-tolerance approach, which sets an unrealistically high bar for a permit, has not stopped “unsafe” vending practices. It’s just driven the market underground, where consumers have little to no information on food safety. For instance, for years, tamale vendors, some of the most popular in our city, had no legal options for buying carts in Los Angeles. Only in April of 2021, through the work of activists and creative inventors, did LADPH finally approve a permissible prototype for a tamale cart.
This approach runs counter to the heart of Angelino culture: Eating from street vendors isn’t just acceptable, it’s a beloved activity in our city. Nothing bonds Angelinos of different backgrounds like sharing the location of a taco spot “off the beaten path.” Street vending lies at the beautiful intersection of the city’s rich cultural diversity, foodie obsession, and entrepreneurial hustle. It’s also a thriving meritocracy — one of the places in our society where people who’ve been denied a host of opportunities in life can leverage their talents to rise to the top. The result is a booming economy surrounding a lot of really good food. It is impossible to imagine Los Angeles without street vendors.
You can read the full article here! Getting internet traction is helpful to get more chances to write down the line. Of course, In trying to fit my thoughts into an op-ed length piece, I did have to omit a significant amount of context, which is not my typical writing style. So consider this blog post in all of that context!
Harm Reduction During COVID
This piece was an outgrowth of a thesis I have worked out on this blog. The idea is that:
Public health is a theoretically vital discipline and government function.
In practice, public health has a series of systemic biases that make it less effective at achieving its goals in practice.
I argued this thesis most clearly last spring in this piece:
Broadly, these biases made Public Health far too rigid in its guidelines and messaging throughout the pandemic. As a result, people gradually lost trust overtime in an age of free-flowing information. They felt like public health guidelines were more oriented towards changing behavior than giving them accurate, up-to-date information. The biggest casualty in this simplistic messaging was that it marginalized a series of “harm reduction” strategies to substitute low-risk behaviors for high-risk behaviors.
Within a couple of months of COVID’s emergence, science was starting to show us a great deal of information we did not know at the beginning:
Outdoor gatherings are extremely unlikely to lead to super-spreader events
Ventilating and using air filters in indoor spaces significantly reduce the spread of COVID aerosols
Masking with high-quality masks like N-95 and KN95 were excellent at reducing the spread of COVID
Frequent testing, including cheap and fast rapid tests, could catch COVID before it could spread broadly to others
Implementing these practices early in COVID could have de-risked many activities core to society’s functioning. Yet well-intentioned experts broadly did not communicate this clearly:
Experts downplayed masks in the early days of COVID, only to switch to a simplistic message (wear any mask!) and did not encourage people to upgrade their masks as soon as possible.
While outdoor gatherings were generally encouraged, cities like LA kept public spaces, including parks and beaches, closed for months, and playgrounds for almost a whole year.
Ventilation and filtration were seldom talked about in official messaging.
Worst of all, testing has never been made cheap and easily accessible in the US compared to most wealthy, even after two years!
Harm reduction is not always the right tact; instead, it is a tool to be strategically deployed. The countries that best managed COVID used “zero-tolerance” strategies of locking down early on. But the key is recognizing that zero-tolerance was best deployed only for a limited period. Countries that did this pivoted to harm-reduction measures once the spread slowed. Extended Lockdowns and zero-tolerance messages can be counter-productive if no one pays attention.
Memories of December 2020 during LA’s brutal winter surge of COVID-19 still haunt me. At the time, the county was in a partial lockdown where outdoor dining and gatherings in public places were strongly discouraged. Yet I would go for evening runs in my neighborhood and count the half-dozen parties and groups that were happening inside people’s homes. While it is impossible to quantify what was happening, I strongly suspect that general COVID exhaustion had set in, and many were ignoring guidelines. Some folks may have sought safer opportunities (like outdoor dining) had they been available but instead opted for riskier gatherings outside of government surveillance. Unfortunately, a zero-tolerance approach did not stop meetings; it pushed them underground into more risky environments.
One particular contradiction here is that public health is often willing to use harm reduction in areas of society that traditional moral taboos. For instance, a harm reduction approach is often used in drug addiction. This idea has multiple discrete applications, including ensuring that first responders keep naloxone and other opioid-overdose reversing medication on hand. Another application is trying to get drug users to use less risky drug paraphernalia, like fresh needles instead of reused and shared needles, to cut down on risks like HIV transmission. Finally, you can also attempt to get drug addicts to substitute drugs with less impact: for instance, trying to get smokers to switch to vaping. The logic here is pretty straightforward: drugs are hard to kick, and realistically, many will fail to kick their addiction. Harm reduction accepts that reality and tries to minimize the harm of addiction without the high barrier of sobriety. But the trade-offs of harm reduction are also clear: a traditional zero-tolerance approach would argue that drug use needs to be addressed at the root cause. However, without kicking addiction entirely, you still allow for a lot of harm!
To see this fight playing out, look no further than the recent controversy when it was reported that the Biden Administration was planning to give out crack pipes as part of a grant given for harm reduction in drug use. While it is unclear if crack pipes were intended to be given out under the program, the program would attempt strategies that would not ask drug users to stop drug use. From my perspective, this ends up being a very messy question: there are sharp trade-offs on both sides of the use of harm reduction regarding hard drugs, and I do not think there is an easy answer.
However, returning to COVID, most of the behaviors that COVID restricted were far less morally thorny than drug use. For example, there is nothing ethically problematic about going to church, dining with friends and family, taking your kids to the zoo; it is undoubtedly socially and culturally enriching to engage in these behaviors! Recognizing this and trying to help people de-risk them would have been a far better approach than trying to discourage them altogether.
Tamales and Public Health
There has always been a strong contradiction in Los Angeles being the city’s purported progressive rhetoric and the actual conditions of working-class people in LA. For workers without a high school diploma, LA is among the five cities with the lowest standard of living. Much of what makes it so hard to survive economically in Los Angeles is well-intentioned regulations that have gone awry. To see this at play, look no further than street vending, which is deeply embedded in the culture of Los Angeles. Former Twilight actress Kristen Stewart recently said she never eats tacos in LA except for stands and trucks. I have gotten to know several vendors through my church, coaching, and other neighborhood work. I have consumed a lot of street vending, including waiting in a 90-minute line to buy from the infamous Lincoln Heights “Corn Man,” who sets up a few blocks from my church. Within two blocks of my residence in East LA, 15-20 trucks and vendors are usually set up on a Friday night.
One particular vendor on our corner sells fruit and Aguas Frescas (for non-LA folks, these are popular homemade Mexican fruit drinks). He is always eager to greet our 2-year-old son with a big smile and jolly waves and has frequently gifted our son leftover fruit from the day. We have tried to respond to his unsolicited kindness by regularly buying from his stand, but this has only made him even more generous in giving us fruit! This generosity is especially impactful given that most street vendors are the most economically marginal people in LA: many vendors are immigrants, and few have formal education beyond high school. In addition, vendors often have thin profit margins, making as little as $15,000 a year on average and experiencing huge swings in income depending on weather and foot traffic.
So given the immensely positive role that street vending has played in our neighborhood, the fact that this commerce is de facto illegal, rendering the proprietors unable to grow their business, is a jarring contradiction. There has been a long-running campaign to legalize street vending in Los Angeles. In 2016, the city of LA voted to decriminalize street vending, and in 2018, the state legalized vending. But legalizing street vending has only marginally made life easier for vendors. Instead, it pushed the regulatory block to the public health department, which has not been willing to work with vendors to create a realistic standard that vendors can meet.
These hurdles are fully detailed in the Unfinished Business report published by a host of non-profits in Los Angeles that I cite in my piece. As I have seen in my limited experience consulting vendors, there are many significant barriers to legal permitting, too many to go into here. However, the report attempts to visualize these in this flowchart that demonstrates the complexity of the permitting process (this is only page one!):
This visual gives some insight into how opaque this process is! Many individual steps are demanding: vendors are required to get multiple credentials, which are expensive and time-consuming. Not all materials are available in other languages, which is a huge barrier to many. The requirement to operate out of a licensed commissary is costly. Standards for vendors needing to access handwashing and on-site food storage are unrealistic and often unnecessary.
But the most egregious part of current regulation is that no actual equipment exists for many vendors that can meet LADPH guidelines. For example, one of the most famous street foods in LA is tamales, and until 2021, there was not a single commercial tamale cart that could meet the county guidelines. Even $15,000 commercial carts used in other cities did not have enough storage space or large enough space for LADPH’s regulation. There was not even a theoretical design that could be approved! Thankfully, Richard Gomez, a local engineer, has created a $7,500 cart that has been pre-approved by LADPH:
But even Gomez is still working on scaling up the design from his initial 28 carts to supply them broadly to vendors.
Harm Reduction in Street Vending
Like with COVID, I believe some public health regulations of food are essential. Just like it was vital for public health to play a role in slowing the spread of COVID 19, it was and is necessary for the public health department to play a role in minimizing the risk of food-borne illnesses. Recent research estimated 9.4 million cases of food poisoning per year in the United States, resulting in 1,351 deaths. The CDC estimates the actual number of food-borne illnesses is likely as high as 179 million a year, causing 6186 deaths.
Now, these are big numbers and real risks! But given that we are bad at contextualizing risk, it is worth comparing this to other public health risks:
From 2011 to 2015, approximately 95,000 people died from excessive alcohol use
Comparing these risks with food-borne illness is fraught: Flu kills mainly the very young and very old, and drug and alcohol deaths (primarily) affect those who choose to engage in the risky behavior. But when creating a mental model of public health risks for individuals, it is worth noting that food-borne illness is much lower than others: food illness is at most, about 1/5th of the risk of driving.
There is public health regulation in many areas: we license drivers and use police for traffic enforcement. However, we as a society generally take a harm reduction approach, not a zero-tolerance approach to these risks. Most Americans would find life intolerable if the government tried to eliminate all of our risks. And even public health professionals, many of whom might want to take a strict approach to these public health areas, recognize that public health capacity is limited and thus should focus on the most significant risks. One can argue that many people are driving who probably should not drive, but we really can only sanction the most egregious offenders at any given moment.
My lay research on the drivers of food-borne illness did not provide much clarity. According to the CDC’s information, most reported food-borne infections in the US are traceable to restaurants. But it is also true that this is because restaurants are the element of the food supply chain that are most heavily regulated and, thus, the most accessible point to collect data. For example, a study across 25 countries in Europe found that cooking at home was twice as likely in restaurants to cause food-borne illness. Furthermore, when an outbreak happens, it is often difficult to know whether the cooking was where food is contaminated. In many cases, the contamination occurred at the packaging or farming stage, and food handling at a restaurant or home had nothing to do with it. On the other hand, there is research in Kansas showing that restaurants in immigrant communities tend to have higher rates of code violations, and there is data showing that Salmonella rates are highest in urban neighborhoods. But this is very messy data, and it is hard to prove what is driving food-borne illness, which certainly complicates the idea that street vendors pose a unique public health risk.
This uncertainty does not mean regulation is pointless: consumers who take risks in eating food at home generally know what risk they are taking, but they often cannot easily verify if precautions are taken when eating at a restaurant or vendor. Public health inspections help risk-averse consumers avoid the riskiest establishments, which is helpful for the market to function well! However, the current zero-tolerance regime has not convinced the general public to abstain from eating street food. More than 10,000 street vendors operate any given day in LA county, and only 165 are permitted. With almost all these vendors operating without permits, consumers are given little to no information about taking proper precautions.
Rather than holding out for the world that public health wishes existed, why not accept the world as it is, and try to minimize the risks that consumers face as much as possible? As I said in the original article:
LADPH must simplify the permitting process to the truly essential elements of the food safety code, thus enabling the majority of vendors to access a permit. This would enable widespread legalization, allowing food permits to truly serve as a signal to consumers which street vendors take common-sense precautions and which ones do not, allowing risk-averse consumers to eat with confidence. Many consumers may still choose to eat at unpermitted stands, but they would do so with a much clearer sense of their risk than they do currently.
We must ensure regulation does its intended job. All of the policy recommendations in the Unfinished Business report are reasonable and incremental reforms that would be a substantial economic boost to vendors, including:
Greatly reduce permitting fees
Ensuring materials are available in multiple languages
Pre-approve more prototypes for carts
Hire staff who can work with vendors collaboratively to help them come into compliance
Simplify storage and fire safety requirements
Allow vendors to utilize auxiliary sinks in the vicinity of their cart
Making it easier for vendors to operate out of community centers, churches, existing restaurants, and homes
Taken as a whole, these would also almost certainly make vending safer, as it would bring more vendors into compliance without compromising safety.
Thanks for reading The Pontification! Subscribe for free to receive new posts and support my work.
Economic Protectionism is Counter-Productive
One of the common objections to street vending (including in the comments on the article I saw on social media) is a strong intuition that this is unfair to traditional businesses. After all, should we be making the rules equal and fair for all entrepreneurs?
But this intuition is wrong. Different contexts call for different regulations, even if the ultimate public health goals (handwashing, safe food storage) are the same. For example, standalone restaurants provide bathrooms, while food trucks and food courts do not. Likewise in another domain, we mandate bicyclists to wear helmets, while we mandate cars have airbags and follow speed limits. Both are intended to promote safety while traveling, but the context is very different.
That said, to be politically realist, a significant driver of anti-vendor sentiment is simple old-fashioned economic protectionism. Many believe that street vendors’ success comes directly at the expense of traditional restaurants and thus oppose it. While it may be true on some margins, it is a largely misguided idea. As detailed in economic research done in LA, street vendors help brick and mortar businesses in many ways. Street vendors often source their raw materials from local traditional retail shops. But more directly, street vendors are often complementary to conventional restaurants. Many street vendors serve items not usually sold in restaurants: fruit, dessert, late-night weekend snacks. Bars and breweries often solicit street vendors to set up on their premises because it compliments their business so well. News flash: people enjoy eating tacos and beer at the same time!
Even when vendors are located alongside restaurants, a density of food options often persuades more customers to visit the street. By creating a “cluster” of businesses, you become a destination for consumers. Consider how a traditional food court works: yes, the restaurants in a food court are competitors, but because customers know they can probably find whatever dish they want, the food court becomes a destination, drawing in more customers. The Economic roundtable report found that brick and mortar businesses in an area with street vendors tended to add jobs, not subtract. While one cannot prove street vendors caused this change, it certainly appears that rather than competing over a fixed pie, street vendors help the pie grow larger.
We have already seen this debate play itself out with food trucks. As recent as 15 years ago, food trucks were de-facto illegal in many American cities because of regulatory rules. But as food trucks became more and more a product produced by and for more affluent people, regulation shifted to allow for easier and more widespread compliance without sacrificing safety standards. Many restaurant associations bitterly opposed the expansion of food trucks, but many dropped their opposition over time. Restaurants discovered that the food business is so massive that there is room enough for both of them.
Free Markets Require Accepting Disorder
As decorated urbanist Alain Bertaud has written extensively about, cities often look messy and disorderly, especially when they embrace markets. But the chaotic commercial activity of a city is arguably the most powerful tool for economic opportunity in society. Sometimes this can make people who prefer order and clear rules uncomfortable, and often that discomfort can lead residents to call for shutting down parts they do not like. And I suspect that is, deep down, one of the most significant barriers to the acceptance of street vending.
During the COVID-19 pandemic in Lincoln Heights, a night market started to grow around the famed Ave 26 Taco stand, setting up in an underutilized industrial area in the neighborhood. It went viral on Tik Tok, and the market became a thriving hub for commerce and social gathering during a pandemic that limited people’s joy. It also created noise, traffic, and parking concerns for residents. These concerns were legitimate, and the city should have addressed them promptly and proportionately. Unfortunately, the city shut down the market entirely, taking away all the vendors’ means of economic livelihood. Now the street is a barren wasteland:
I have no problem with those who want their neighborhood to be orderly and clean. These are good things! But one must acknowledge that there are actual material costs to regulation, especially costs to economic opportunity. To those who might find the disorder of the city discomforting, I would ask: are we better off without street vending? Are streets better off as sanitized, orderly places where you also have to walk an extra 10 minutes to get the food you want? I have a hard time believing this is true. And hey, if you disagree, you might consider this famous American invention that prioritizes central planning and order over all else: