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The Commonwealth games and “Delhi belly”: what India can learn from LA

BMJ 2010; 341 doi: (Published 01 September 2010) Cite this as: BMJ 2010;341:c4507
  1. Karunesh Tuli, independent consultant in public health, South Pasadena, California
  1. karuneshtuli{at}

    Waiting to be seated in a restaurant in Delhi, patrons are likely to see pictures of Ganesha, Lakshmi, and Mohandas Gandhi and a plaque with the phrase “Cleanliness is next to godliness.” Ganesha, the elephant headed deity, is the remover of obstacles but may owe his place in the eatery to his fondness for sweets and his great belly. Lakshmi, the goddess of wealth, sits next to the cash register. Gandhi, who perfected hunger as political protest, is the odd one in the bunch; hollow cheeked and lean framed, he was better known for his fruit and goat’s milk diet than for worldly cravings. It is his experiments with sanitation, rather than his status as the “father of the nation,” that justify his presence next to the sign and the gods. Oppressed by the stench at a session of the Indian Congress in Calcutta in 1901, he assigned himself the task of cleaning the latrine.

    Delhi is getting ready to host the Commonwealth games in October. Joining the many concerns that attend major sports events worldwide—security issues, traffic bottlenecks, and hotel room shortages—is one that frequent visitors to the city know well: “Delhi belly” (traveller’s diarrhoea). The question is not whether the purge will strike during their visit but when.

    Los Angeles has a lesson or two for the planners of the Delhi games. Twelve years ago reporters from the US broadcaster CBS carried hidden cameras into restaurant kitchens around Los Angeles county. Their report, “Behind the Kitchen Door,” and subsequent broadcasts over the next few years featured cockroaches, rat droppings, “chickens sitting on the floor soaking in their own blood,” and “liquid waste pouring out of the ceiling.” Alarmed by the reports, the county government ramped up its response to the problem of poor food handling, shutting down a number of restaurants for violations of health codes, including, for a day, one owned by the mayor of Los Angeles, Richard Riordan. The health department, borrowing an idea first applied in the 1920s by the US Public Health Service to the sale of milk bottles, introduced the now familiar letter grades that greet customers as they enter restaurants in the county and increasingly in cities around the world.

    Each Los Angeles letter grade represents intense effort by health department inspectors, who visit each restaurant at least three times a year, blessing poor performers with an additional “bonus visit.” Inspections take over an hour and include rigorous examination of bathrooms, kitchens, and food storage. Restaurant owners know they cannot bribe their way out of a low grade; one owner, who has been in the business for 30 years, told me he does not offer even water to the inspectors, for they will accept nothing. Current inspections are much more thorough than the cursory checks of the pre-grade era. The result: customers can step into restaurants without worrying about food safety; and studies over the years have established improvements in restaurant hygiene and a reduction in hospitalisations related to foodborne illnesses.

    Indian officials, too, are planning to issue grade cards to food vendors in the nation’s capital. Their concern for the health of athletes and spectators at the Commonwealth games is welcome, but their past record doesn’t inspire confidence. The Municipal Corporation of Delhi is severely understaffed. A handful of food hygiene officials struggle to cover tens of thousands of establishments. Unable to carry out systematic checks or to counsel food handlers about hygiene, they resort to raids, during which teams of officials dash into localities where vendors operate (often without a licence), confiscate food, and leave within minutes. Vendors move out temporarily, returning after a few hours. This cat and mouse game does little to ensure good food hygiene.

    Indian bureaucrats are eager to improve the country’s image. Glossy full-page advertisements in magazines and billboards at airports proclaim that India is “incredible.” At the same time, Indians—with their rapidly growing economy, achievements in information and space technology, and a rich cultural tradition—resent comments from outsiders about the filth and disease that billboards cannot hide and spurn advice on lowly matters such as hygiene. Offended by Katherine Mayo’s critique of India’s health conditions in her 1927 book Mother India, Gandhi dismissively called it the report of a “drain inspector.”

    The 1982 Asian games brought colour television to India. The Commonwealth games offer corporation officials an opportunity to make a bigger contribution to the wellbeing of Delhi residents. Grade cards by themselves will not deliver food hygiene; they need to be backed by methods and human resources of the kind that have worked so well in Los Angeles.


    Cite this as: BMJ 2010;341:c4507


    • Competing interests: KT was born in India before moving to the US in 1993. He lived in Delhi for six years and often travels there.

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