AMA Journal of Ethics^®

Abstract

Health professionals have the opportunity and responsibility to apply their expertise to address the current trajectory of chronic disease in the United States. Half of American adults have one or more preventable chronic diseases, many of which are diet related, so it is critical that health professionals engage in public health prevention strategies. These can take the form of public and private sector partnerships. Food procurement—the processes through which institutions such as hospitals and schools purchase and serve food—offers powerful opportunities for health professionals to partner with public institutions to prioritize accessibility to nutritious, sustainable, and fairly produced food and to generate sustained benefit to population health.

Opportunities for Clinicians to Serve as Food Procurement Advocates

Professional codes of ethics articulate the responsibilities of health professionals to communities and society and inform decisions clinicians make during the course of treating a patient. The American Medical Association (AMA) Principles of Medical Ethics states: “A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and betterment of public health.”¹ As social and environmental determinants increasingly pose the greatest threats to population health rather than acute events and illnesses, the principles that guide responsible engagement with the local community and environment become of greater consequence and import. How these principles are applied in practice is at the discretion of the health professional, who must respond to the question, What are the most effective and strategic actions we can take to strengthen our commitment to improving public health?

Physicians and other health professionals have a unique opportunity to engage in partnerships with public and private sector organizations to prioritize disease prevention and encourage shifts in the systems that presently contribute most to diet-related chronic diseases and health disparities. Primary among these is our food system—a complex network of practices and policies that determines how food is produced, distributed, and consumed and that exerts immeasurable influence on the social determinants of health. By and large, the prevailing system works against, rather than with, public health: it creates a food supply and a culture that undercut dietary recommendations; it relies on resource-intensive industrial agricultural practices that degrade natural resources and threaten the future availability of food; it exploits a large labor force, leaving many who produce our food with inadequate access to it; and it is plagued by racial and socioeconomic inequity that compounds disparities in health and economic opportunity.^2-5 To act as agents of change within this system, health care professionals can begin with their own institutions, which provide food to their staff, patients, clients, and communities.

Institutional Food Procurement Policies as Public Health Strategies

Noncommercial food service operations, including hospitals, senior care centers, and other health care facilities, supply about $120 billion worth of food each year to some of the nation’s most vulnerable populations.⁶ Food procurement, the process by which these institutions purchase raw and prepared foods and beverages, is a valuable tool to prioritize accessibility to foods that are not only nutritious but also produced in a way that upholds the principles of equity and sustainability throughout the supply chain. Hospitals around the country have already begun to leverage their purchasing power to this effect: to date, more than 580 facilities have signed the Healthy Food in Health Care pledge,⁷ signaling a commitment to practices such as increasing access to more nutritious and responsibly produced food through onsite farmers’ markets and gardens, integrating environmental sustainability standards into food service contracts, and prioritizing the purchase of local foods. Many hospitals are also mitigating climate impacts of industrially produced meat by reducing portion sizes, serving more plant-based proteins, and purchasing meat from farms employing more sustainable and regenerative agricultural practices, such as crop diversification and integrated livestock management.⁷

Although food service operations in health care facilities may be the most intuitive place for health professionals to support procurement efforts, other public institutions such as schools and city or county departments offer opportunities to implement procurement policies or initiatives with far-reaching impacts. One of the most comprehensive food procurement policies to date, the Good Food Purchasing Policy (GFPP), has been adopted by a number of public institutions with demonstrated success.⁸ The GFPP awards certifications to participating public institutions such as schools, hospitals, and county departments based on their procurement practices and provides a set of transparent, flexible metrics-based standards and benchmarks to help facilitate and track their progress. As we have described elsewhere,⁸ 5 key “value categories” provide the foundation of this procurement framework: (1) local economies, (2) environmental sustainability, (3) nutrition, (4) valued workforce, and (5) animal welfare. Codifying these values through food procurement allows institutions the opportunity to offer more nutritious foods to the populations they serve while also supporting community health by exerting a positive influence on some of its broader social determinants.

In 2012, the Los Angeles Unified School District became the second institution to adopt GFPP, following the city of Los Angeles.⁸ The policy has helped the district, which has a student population of 640 000 and an annual food budget of $150 million, direct 20% of its budget to local purchases, develop healthier school menus, achieve reductions in its carbon footprint and water usage, and secure higher wages and better working conditions for 165 workers in a major food distribution company.⁸ The GFPP was subsequently adopted by the San Francisco Unified School District and Oakland Unified School District in 2016 and by the Chicago Public Schools in 2017.⁸ Active campaigns for adoption of the program are now underway in Austin, Cincinnati, Denver, Madison, New York City, the Twin Cities, and Washington, DC.⁸

Health Professionals as Agents of Change

Securing administrative and procedural changes in a food service facility requires support and commitment from a range of stakeholders. In the case of the policies named above, diverse coalitions of institutional leaders, food service staff, dietitians, physicians, farmers, union representatives, and animal rights activists have played an instrumental role in communicating the importance of these initiatives to the general public and in working with local leaders and elected officials to codify them.⁸ Such broad coalitions are essential in advocating for food systems that better serve public health, and health professionals play a vital advocacy role within them. It is only logical that physicians, dietitians, and other health care practitioners be fully supportive of such initiatives—particularly within the walls of their own institutions. The ethical standards by which health professionals abide must be sufficiently comprehensive to encompass the notion that the food served in medical establishments and other major public institutions should be health promoting, should be consistent with evidence-based dietary recommendations, and should not contradict the very aim of medical treatment or intervention.⁹ Procurement as a public health strategy is doubly compelling when one considers the economic logic. Research has demonstrated that disproportionate benefits result from investments in public health prevention: for each dollar invested in prevention, an estimated $5.60 of health care spending is saved.¹⁰ Using existing institutional food budgets to promote public health prevention efforts, such as healthy food procurement, benefits not only patients but also health care practitioners and facilities with limited resources.

Conclusion

The challenges facing our food system, including lack of healthy food access and affordability, strain on natural resources and food production systems, and the persistent inequity and economic inequality embedded in the food chain, pose significant and urgent threats to population health. Addressing this broad spectrum of issues will require systemic prevention strategies that bring public and private sector partners into alignment with prevention-based public health strategies. Health professionals have a vital role to play in these efforts, particularly in leading and participating in food procurement initiatives that leverage the food budgets of large institutions in a manner consistent with their health-promoting missions by prioritizing food purchases that can contribute to a more healthful, equitable, and sustainable food system. Transforming the food system so that it works for public health is one of the most powerful and underutilized intervention points in this field. Failure to act on this intervention point could well contravene the Hippocratic principle that broadly governs medical ethics: do no harm. Given the current state of public health—and what might prove to be a critical junction in health care practice—it is essential that health professionals act as leaders in advocating for and implementing strategies that promise to deliver sustained well-being to the population.