Ethical food purchasing




Health care’s role in protecting workers

A Health Care Without Harm position statement

Health care can play a critical role in protecting workers, community health, and the planet through procurement and advocacy.

Hospitals and other health care institutions are embracing their mission to heal, going beyond the Hippocratic Oath to promote health and resilience in their communities and mitigate inequities. They are increasingly taking into account social, economic, and physical determinants of health.

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In a globalized world, hospitals have the opportunity to impact the communities involved in their supply chains through their purchasing choices. This includes all the farmers and farmworkers who supply food to hospitals – those local to their communities and regions and those from different parts of the world.

Health Care Without Harm has conducted a comprehensive review of third-party certifications and label claims to determine how they each address different aspects of farmworker health and safety. Labor and agriculture certifications that meet and ensure these criteria help hospitals utilize their influence and economic power to support resilience on all levels.

Lived experience of farmworkers

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Workers in a farm field along California State Route 1 in Nipomo, Calif. (Tony Webster/Flickr)

There is a stark difference between the laws and the lived realities of farmworkers, a gap that leaves farmworkers vulnerable to abuse and poor health. Individuals who work in the food chain – from harvesting to processing and beyond – have some of the most dangerous jobs in the country. For example, animal production and aquaculture workers have nearly twice the incidence of nonfatal occupational injuries than the national average. The dangers of these jobs are not confined to work.

Federal and state laws mandate certain protections for farmworkers, but they vary by business size and lack enforcement.

These legal protections include:

  • Housing must meet local and federal standards.
  • Employers must comply with the terms set out at recruitment and a federal minimum wage standard.
  • Federal Worker Protection Standards require personal protective equipment for farmworkers handling pesticides and other hazardous materials.
  • Farmworkers have legal protections from sexual violence, including sexual assault and rape, and sexual harassment, though harassment may not carry criminal charges.

Federal and state legal standards can all but disappear on farms, where oversight is minimal and the potential for abuse is ubiquitous. Undocumented immigrant farmworkers, who make up between 50 to 70% of the farmworker labor force in the United States, are particularly vulnerable as they can be turned over to Immigration and Customs Enforcement should they choose to report abuse.

Legal protections are slow to catch up and those who look to abuse find ways around legal protection.

The 2020 COVID-19 pandemic both exacerbated unsafe working conditions for farmworkers and called attention to their health and safety concerns. Many farmworkers faced increased demand as essential workers but were not provided personal protective equipment, social distancing measures, and other basic protections. 

These problems did not just appear during the pandemic. Rather they have long been a part of the food supply chain.

Meat processing plants consistently applied for – and were awarded – waivers to policies designed to protect workers. Regulations control the speed of production lines, but waivers allow companies to increase the number of processed birds per minute beyond the limit that is determined safe for workers. In 2020, communities with meat processing plants that had received waivers saw county-level COVID-19 rates almost twice as high as those with meat processing plants whose line speed followed the safety policy as written.

Dairy farms have been known to bring veterinarians from Mexico to work as animal scientists and instead put them to work for grueling 12-hour shifts without breaks to milk cows, clean manure, and carry sacks of feed. Migrant workers in Missouri with H-2A visas, which allow foreign nationals to fill temporary agricultural jobs in the United States, were forced to work in dangerously hot weather with little water and were provided living spaces that were cramped and dirty, with bedbugs and leaking toilets. Black veterans were allegedly targeted in Florida, brought to a farm, hooked on drugs, and forced to work to pay off exorbitant debts. Approximately 80% of female Mexican immigrant farmworkers have been sexually harassed in the fields.

Third-party certifications, which hold farmers and producers to higher standards than may be legally required and involve independent audits, can be an important first step in closing that gap and ensuring that food systems provide for the health of the workers, environment, and communities.


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Screenshot of "Caring for our communities" video showing local purchasing by hospitals (Healthcare Anchor Network)

The following considerations can inform your hospital procurement practices and allow your facility to utilize their influence and economic power to make a difference.

Farmworker health and safety

Farm work is some of the most dangerous labor being done – the heavy machinery, large animals, fast, monotonous movements, and weather and chemical exposure create an environment that puts farmworkers at risk for injury and disease. Because of the social, political, and legal situations that place many farmworker communities in positions of vulnerability, farms can be the first stopgap in a chain that is rife with injury and disease.

“Repetitive stress injuries, quite a bit of ergonomic related issues, exposure to cleaning chemicals, depression and anxiety, gastrointestinal problems are some of the main health concerns reported by farmworkers in the dairy industry.” – Dr. Teresa Mares, University of Vermont

To truly protect the well-being of farmworkers, hospitals should look for farms with standards in place that focus on the safety and health of farmworkers, including fair wages, bans on retaliation for reporting abuse, bans on discrimination, a safe work environment, days off, prevention of pesticide exposure, and limits on sun exposure. Individual health and safety also encompass the banning of child or slave labor, including indentured or otherwise oppressive and abusive practices.

Social and economic determinants of health

While there are a growing number of initiatives to address social and economic determinants of health in the general population, the basic labor rights of farmworkers continue to be unaddressed. In the United States alone, there are more than four million workers involved in farming and food production, which includes harvesting and processing of produce, meat, poultry, and seafood. Although this is a population that is difficult to study due to the conditions of their immigration status or work requirements, numerous studies have found farmworkers to have increased levels of cancer, likely due to pesticide and sun exposure. Pesticide exposure is also implicated in Alzheimer’s and Parkinson’s diseases, as well as various disorders of respiratory and reproductive tracts. Farmworkers often live in farm properties and rely on the employer to provide adequate living conditions. Many of these workers are not paid livable wages, work in hazardous conditions, are excluded from certain labor law protections, and face discrimination. These working conditions further exacerbate health disparities. Agriculture workers face the highest rates of both fatal and non-fatal work-related injuries among workers overall (including construction and mining workers). However, only 25% of costs related to these injuries are covered by employment compensation, while only 22% of farmworkers report having health insurance.

Resilient communities

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Workers harvest strawberries in Salinas Valley, Calif. (Nathan Walls/Flicker)

The planet is approaching the precipice of ecological and socioeconomic crises. The Earth’s temperature is increasing and weather patterns are becoming more volatile and less predictable. Meanwhile, accelerating global inequality continues to widen the gaps between the rich and the poor. "Community resilience” is the concept that refers to when a social system can withstand pressures from a variety of exogenous events or systematic challenges. It banks on the creation of strong social capital foundations and resilient farming practices, ranging from collective bargaining rights to crop rotation. Health Care Without Harm defines resilience as follows:

“The ability of a community/society to survive as a species and to sustainably meet its basic needs within limits of the larger ecosystem. Resilience is the capacity to prepare for, withstand and recover from acute and chronic adversity and emerge stronger than ever.”

Health care can play a critical part in realizing this vision. 

  • Endorsing sustainable food, labor, and agricultural practices through their procurement and advocacy activities.
  • Creating trust and goodwill with communities by purchasing locally, supporting the local economy, and highlighting ways that you've worked to support local farm workers.
  • Democratizing relationships with communities and community organizations, by working to change discriminatory structures of power, and by supporting socioeconomic growth in the communities they serve.
  • Supporting farmers and suppliers that provide fair pay and conditions to workers (including health and safety programs), provide medical insurance, support collective bargaining, reduce waste, maximize resources, and use agriculturally and ecologically sound practices.

Labor and agriculture certifications that meet and ensure these criteria are ways for hospitals to continue to utilize their influence and economic power to support resilience on all levels.

Review of current standards

Health Care Without Harm has conducted a comprehensive review of third-party certifications and label claims to determine how they each address different aspects of farmworker health and safety. The ● indicates the certification addresses that issue area. However, not all of the standards are strong enough to support a resilient, socially just food system. Below the table, we discuss important features of these labels and third-party certifications. When a certification addresses an issue area but without sufficient strength, shortcomings are included in the discussion. 


  Click on the [ ] icon to expand the chart or download the chart.

A model for community-driven certification
Milk With Dignity is a certification created by dairy workers based in Vermont. The certification was developed through deep worker engagement and is directly tied to the needs of the community. Certified milk is sold with a price premium that goes to the farmer, in a model similar to the financial model of the USDA Organic certification. Because of its grassroots nature, as of publishing (early 2021) the Milk With Dignity certification is only available in New England. It is included in this review of certifications because, in many ways, it sets a new standard for community engagement and protections for workers.

The current availability of dairy that is certified for labor standards is low, and while dairy farms are experiencing significant financial challenges, they also have specific challenges when it comes to their labor force. Because dairy farms tend to be less seasonal, workers are often on the farm for a longer term (years instead of a season). While the United States does not currently have a significant supply of dairy that is produced under third-party certifications, there is a clear opportunity to better support the health and well-being of farmworkers through worker-driven social responsibility programs and purchasing investments that support high labor standards on dairy farms, whenever possible. Because it does not contain environmental sustainability requirements, Milk With Dignity should be chosen in conjunction with the accepted Health Care Without Harm and Practice Greenhealth healthier food purchasing standards.

Farmworker health and safety

Each certification was reviewed and examined for their treatment of individual worker health and safety. The issues considered were bans on child or slave labor, fair wage, bans on retaliation for reporting abuse, bans on discrimination, safe work environment, days off, pesticide exposure, and sun exposure. Some of the standards go above and beyond these essential requirements as they offer increased support for the farmworkers. While these are important considerations, they go past the scope of this review.

All certifications reviewed make explicit that there will be no forced labor, slavery, or otherwise abusive labor and places severe restictions on child labor.

Among the other issues considered, five certifications had the most worker-friendly standards: a fair wage, bans on retaliation for reporting abuse, bans on discrimination, safe work environment, days off, prevention of pesticide exposure, and limits on sun exposure.

These certifications mandate that a fair wage is paid, including in the calculations for local cost of living, cost of education for children, and the local minimum wages. Retaliation around reporting abuse or discrimination is strictly prohibited. The anti-discrimination policies around hiring and working at the farm are explicit and extensive. Each certification ensures a safe work environment, including access to potable water, breaks, and sanitary bathrooms. Each certification requires 24 consecutive hours off for each week of work. They go above and beyond with their requirements around pesticide use, calling for personal protective equipment, training, signage in different languages, and no spraying around workers’ and surrounding homes. These certifications also require protection from weather, including the provision of shade to protect from heat and sun exposure.

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Cranberries are harvested in New Jersey (Keith Weller, U.S. Department of Agriculture/Flickr)

Social and economic determinants of health

Each certification was examined for their treatment of socioeconomic determinants of health focusing on the provision of health insurance/health care services and provision of paid sick and parental leave.

“For workers that are encountering really heavy and difficult machinery or large powerful animals, there’s a lot of risk that goes along with that and then coupled with the lack of access to health care results in some cases in some pretty significant health impacts.” – Dr. Teresa Mares, University of Vermont 

To ensure that essential issues, like provision of health insurance/health care services, are guaranteed and not left up for interpretation, we highlighted certificates that clearly specified that these provisions should be mandatory. Out of these, we narrowed down the certificates that also required (not only recommended) provision of paid sick and parental leaves and provision of emergency medical care onsite. The two certifications that met this criteria are:

Fair for Life requires that employers provide health insurance to permanent and temporary workers (government social security or employer contributions). Furthermore, it specifies that the coverage shall be sufficient to cover all health issues, including long-term/serious non-work related sickness. In addition, the certification requires that workers who carry out or have carried out activities identified to be dangerous or with high health risks (see guidance) are eligible to annual health examinations paid for by the employer. The certification also requires that the employers make emergency medical care (as relevant for potential accidents) available onsite or close to the workplace or cover the associated costs in cases of work-related accidents and illnesses. Finally, Fair for Life requires that all workers are provided with basic coverage and insurance for permanent disability or death.

Fair for Life requires that the employer grants at least five paid sick days per year to permanent workers in year zero of the certification. By the fourth year of the certification, a suitable sick pay allowance also has to be granted to temporary workers who work for the employer for more than three months per year consecutively in adequate proportion to their working time. Furthermore, an optional criteria suggests that the employer has especially well-adapted working conditions to enable employees to reconcile their personal life with their professional life (e.g., leave after business travels, leave for caring for sick family members, part-time positions, flexible hours for parents of young children, child care support, private space for breastfeeding).

Fair Trade USA also requires that all workers are provided with health insurance. The intent is that all workers have access to preventative, primary, and secondary health care. Employers may set a minimum employment time of up to 90 days in one calendar year to be eligible for this benefit. Health insurance and care may be provided through a government social security or health care system with employer contributions where applicable. Where government systems do not cover at least 50% of the insurance costs, the employer contribution shall cover at least 50% of the total cost of insurance for the worker, or the percentage required by law, whichever is higher. If the employee is unwilling to pay the remaining amount and refuses coverage, the employer must keep documentation of the employee’s decision. Furthermore, Fair Trade USA requires that the employer provides a minimum of three days of sick leave with full pay annually.

While Fair Trade USA’s standard requirements meet some important criteria above, further examination reveals potential issues with their scoring and certification suspension/withdrawal practices. Additionally, to extend the market saturation of Fair Trade USA products, they have certified some large-scale plantations and farms with historic and serious violations of labor standards. Although these products might be more accessible, this undermines many of the strategies that we know are supportive of sustainable and just food production. The supply chain of products produced under fair conditions continues to expand; in the meantime it is imperative that we have high standards of integrity for what "counts" as fair. There is opportunity for standards without adequate auditing to undermine emerging standards with higher-level oversight. Adhering to a high standard of adequacy ensures hospitals’ efforts and procurement dollars are appropriately directed.

Other certifications that are comparable to the two above are Equitable Food Initiative, Agricultural Justice Project, and Fair Wild; however, these certifications do not address provision to health care or sick/parental leave extensively. Additionally, there are legitimate challenges and cultural norms surrounding the gathering of wild products around the world that render some of the requirements less applicable. For example, some women will forage for wild goods with a child strapped to their back. The Fair Wild certification grapples with these issues in a thoughtful and culturally appropriate way, while still protecting workers and vulnerable people from exploitation.

Resilient communities

Fair For Life is the third-party certification that best covers concerns related to farmworker resilience. As stated in the section regarding the social and economic determinants of health, Fair For Life provides guidance for farmworker rights protection that creates a labor arrangement that is not exploitative in nature and provides each worker with a basic level of comfort and security. The requirements for their certification program proclaim collective bargaining as a worker’s right (while many of the certifications just proclaim freedom of association). Multiple studies tie the presence of collective bargaining to diminished inequality, broader worker protections, and a more equitable labor arrangement.

Environmental sustainability standards

Though many certifications had environmental sustainability standards, those of the Agricultural Justice Project, the Rainforest Alliance, and Regenerative Organic Certification were strong enough to stand on their own. Labor certifications that fall short on environmental sustainability may be coupled with environmental sustainability certifications to better protect both farmworkers and the environment. For further information on sustainability certifications, please see Health Care Without Harm's and Practice Greenhealth's healthier food purchasing standards

Collective bargaining, referring to the process of workers organizing to protect their health and safety, does two things. First, it gives workers direct input into their rights and labor conditions and leverages power for action, as union or workers association liaisons have much more power in generating action than an individual worker (especially since many farmworkers are either undocumented or visaed workers with fledgling protections). Second, it gives workers a sense of community and support, not only with each other but with employers and other stakeholders. It diminishes the likelihood of arbitrary or unilateral action and keeps employers beholden not only to their employees but to the community of the industry. If collective bargaining is not enough, Fair For Life certified ventures must direct workers to socioeconomic empowerment programs and are urged to support community programs bolstering social capital, like education programs and community composting. And if all else fails, Fair For Life requires internal control analysis machinery that monitors implementation and gaps therein.

Many health care institutions are nonprofit, and to maintain that status they are required to demonstrate a level of community benefit. Ethical purchasing practices offer an opportunity to accomplish both goals.

Take action

Farmworker appreciation signs photo collageSupporters show their appreciation for farmworkers on behalf of the National Farmer Workers Ministry in 2011 (NFWF/Flickr); Farmworkers from Immokalee, Florida joined students and staff at Ohio State University in Columbus demanding fast food restaurants take human rights into the cost of their meals (Becker1999/Flickr).

Learn: For more information on a holistic vision of racial equity in the food system, the Center for Social Inclusion’s report, “Building the Case for Racial Equity in the Food System,” gives an essential overview. Although this paper does not specifically endorse certifications, the Coalition of Immokalee Workers has been on the front lines of advocating for agricultural workers in the United States. Their certification, Fair Food Program, has a series of reports that shed light on a variety of labor issues in the food systems. Additionally, the Fair World Project’s 2020 International Guide to Fair Trade Labels offers a comprehensive overview of the issues at stake in fair trade labeling and analyzes the fair trade standards across various programs and the work that is needed to improve and strengthen each of these labels and certification programs.

Purchase: Follow the purchasing guidance in Understanding labels: Fair labor and sustainability practices. For those certifications that are listed above that do not address sustainability, look for products that also have a sustainability certification to ensure you are purchasing fair, sustainable food.

Communicate: If your distributors do not offer products sold under these standards, express to them that you are looking to increase your values-based purchasing to include products that come from a more equitable food system. What we’ve learned from local and sustainable food purchasing initiatives is that distributors often need to know there is a purchaser before bringing products into their trucks. If you are purchasing directly from local or regional producers, make it a standard practice to ask them about their labor practices. Health Care Without Harm has developed a list of potential questions to help guide you in this endeavor.


Health Care Without Harm thanks the team of researchers from Mark Bittman’s course at the Mailman School of Public Health at Columbia University, who contributed to the development of "Ethical food purchasing: Health care’s role in protecting workers." Anthony J. Cangelosi Jr., Qëndresa Krasniqi, and Margaret M. Palmer provided foundational information and framing for this position statement.