An experiment in making hospital food actually taste good
These days hospitals in Ontario are scrambling to cope with the spread of the coronavirus. But in recent years, Toronto chef and activist Joshna Maharaj had a chance to observe one often-neglected aspect of the health-care system: food.
In her new book, “Take Back the Tray: Revolutionizing Food in Hospitals, Schools, and Other Institutions,” Maharaj reflects on her experiences. This chapter looks at the Scarborough Hospital.
Picture it: it’s 1980, and you’ve just woken up from surgery. You’re a bit achy and dopey, and once you’ve spent a bit of time with your eyes open, you get a message from your stomach. You’re hungry. You’ve been hungry since yesterday, and now, you need something to eat.
The smell of cooking wafts through the hallway as lunch trays get delivered to patients. A friendly face enters your room and places a tray in front of you, and as soon as that dome gets lifted, the first thing that hits you is the smell of a toasty fresh roll, still warm from the oven.
The roll is soft, and the perfect thing to dip into the rich gravy of a beef stew, which sits atop a pile of fragrant, fluffy rice. The beef in that stew was butchered on-site, and the stew was made with a beef broth that simmered in a kettle for hours to achieve maximum flavour and nutrition. Beside the stew there are crisp, lemony green beans and a fresh tomato salad.
Asmall bowl holds a piece of apple cake topped with a little hit of custard, and later this afternoon someone will come by offering tea or coffee. You’re moving slowly, but you cannot resist the urge to start eating.
The food is simple and seasoned and portioned conservatively. But it is real, made from whole ingredients, and, perhaps most importantly, it tastes good. There is life in the food, and once you place your fork down on an empty plate, you feel full and restored.
Now, let’s fast-forward 32 years to 2012: I’m visiting a hospital in Toronto that has just invested hundreds of thousands of dollars in new retherm units used to heat up patient meals.
We enter one room with tiled walls and about 15 electric plugs on cords, evenly spaced out, hanging from the ceiling. I ask if this room is still under construction, but no — this is a finished space, where the retherm boxes get plugged in to do their job. This isn’t the beginning of something, this is the end of it.
My tour continues through a labyrinth of cold hallways, each heavy, industrial door opening to a walk-in fridge or freezer the size of a room. In here, staff work with winter gear on, their hands in fingerless gloves that get covered by disposable gloves, to plate up patient meals. If all this feels dystopian, that’s because it is.
Let’s take a minute to review what that meal from 1980 looks like now: that beef stew is prepared somewhere off-site, portioned and frozen into pucks. Same thing with the rice. And the gravy on the stew is so full of powdered base and cornstarch that you’re likely not that interested in mopping any of it up with your bun, which has one pretty flat texture, no crusty outside, and minimal flavour.
It is also made beforehand and frozen, and then brought back to life in a steamer or oven. The tomato salad arrives with a foil seal and a bunch of preservatives to keep it shelf stable. Dessert is some kind of apple cake that is baked off-site, portioned into a cup, frozen, and then thawed out — or, mostly thawed, because you inevitably find an icy core. There’s certainly no custard.
There’s a lukewarm cup of tea or coffee already on your tray and a cup of water, again sealed with foil.
Beyond the flavour and textural differences, you can tell that one of these two meals is made just a few floors below you, and the other is distinctly from somewhere else — nobody has any information about where, it all just arrived in a cardboard box on a skid a couple of days ago.
If patient trays reflect the values of the institution serving them, what does this plummeting service standard tell vulnerable folks in hospital? That ease and affordability are more important than their health and dignity.
The average patient stay in Ontario is four to six days, so patients get told a minimum of12 times during their stay in the hospital that they’re not worth any more effort than that miserable tray of industrial, processed, overpackaged food.
So how did we get from freshly baked rolls to frozen pucks of stew?
I’ll focus on Ontario, which is where I do most of my work, but you’ll see similar themes and patterns elsewhere. From 1995 to 2002 Ontario’s Progressive Conservative Party, led by Mike
Harris, implemented what they called a “Common Sense Revolution.” In an attempt to reduce both a deficit and personal income taxes, the Harris conservatives slashed and burned budgets, notably in health care, education and social services.
These short-sighted austerity measures are familiar moves from the government playbook. The health-care sector was not told specifically where the cuts should happen, and because food in hospitals is considered little more than an irritating necessity, food and nutrition services budgets took some of the biggest hits.
We started letting accountants make decisions about how we feed patients, often forcing nutrition staff to accept a standard of food that was “nutritionally adequate” for patients and tossing aside any notion of food’s therapeutic role in patient care.
We also decided that paying a human to prepare fresh food in hospitals was inefficient and expensive — most kitchens lost some staff, and some hospitals completely outsourced their food service to a third-party operator.
When things still needed to get leaner and meaner, snacks were taken off of the menus or portions were reduced. Menu cycles were pared back, offering less choice and variety. Canada Bread was asked to squeeze 14 slices out of a loaf instead of 12, and the three-cent packet of Mrs. Dash, a sodium-free seasoning, was removed from trays.
It is fair to say that scratch cooking patient meals is a thing of the past in the vast majority of hospitals and longterm-care facilities in the country today. The budgets for both labour and ingredients have been hollowed out, with help from the industrial food system.
Some administrators continue to think there is fat to trim from food service budgets, but the truth is there is little to no fat on those menus anymore. Any budget cuts will mean scraping bone.
One day in 2011, I got an email from Paul DeCampo, a dear friend and colleague who was on the steering committee at Slow Food Toronto.
He told me that they had received a request from a hospital in Scarborough that wanted to make some changes to their food service and were looking for some support and guidance. The folks at The Scarborough Hospital wanted to improve the patient experience and smartly realized that food was a big part of that.
In fact, a brief by HealthCareCAN and the McConnell Foundation on the state of hospital food in Canada reported that “patients were four times as likely to rate their whole hospital stay with a
perfect score when their rating of the food was excellent.” Basically, the more patients like the food, the better they feel about their whole stay.
I’ve chatted with some hospital administrators who tell me that the patients rate their food on the low end of satisfied. (Keep in mind: these surveys are usually given at discharge, when you’ll say anything to get out of there or don’t see any immediate benefit from negative feedback. What if we offered surveys on day two or three?)
And while these scores highlight a big opportunity to do things differently, they’re also (if you can believe it) not bad enough to really motivate much change. I even heard one hospital administrator say, “If they’re well enough to complain about the food, they’re well enough to go home.”
Needless to say, I was excited to hear about a hospital that was looking to improve the patient experience and I jumped at the opportunity and met with Anne-Marie Males, the then-vice-president of patient experience, and Susan Bull, the director of nutrition services.
Both of these women were full of ideas and questions about how I could help them elevate the patient food experience. What was scheduled for a 90-minute meeting actually ended up lasting about three hours, and we were all bursting with excited possibility at the end of it.
Fortunately for us, there was some newly available grant money via the provincial Greenbelt Fund to put more local food into public sector institutions. This grant money could pay for a consultant to manage the project, training for staff and new equipment for the kitchen.
Although the focus was local food, I took this rare opportunity to jam my foot in the door and talk about other aspects of the food service too, like scratch cooking and more cultural diversity on the menus.
In my first days at the hospital, I spent a lot of time observing the operation. While the space may have looked like any other kitchen, with tiled walls, stainless steel counters and walk-in fridges, it actually functioned in a very different way.
For instance, there were no knives, oil and salt. Not much is cooked without these three things.
No knives meant that no raw ingredients were being broken down. The vast majority of produce was already chopped and frozen, and when staff started prepping meals, they would put on a parka and pull frozen bags of whatever they needed from the walk-in.
No oil meant that the meals were not being built on a base of sautéed aromatics. Nothing was being browned — there was no conscious building of flavour happening here at all. Frozen ingredients were combined in a giant soup kettle and simply warmed up for service.
And finally, the absence of salt shouldn’t have been too much of a surprise, in a health-care context, meals were all intended to be low-sodium. But no salt in the kitchen told me two things: there was no focus on flavour and the processed food that was being served already contained enough sodium, usually as a preservative.
As long as the nutritional data was where it needed to be, that was enough. The whole did not need to be any greater than the sum of the parts. (Editor’s note: Despite the successes during this project, the author later writes that making changes stick in the long term proved a much different challenge, and would require changing the ethos of the institution and the system itself.) Excerpted from “Take Back the Tray: Revolutionizing Food in Hospitals, Schools, and Other Institutions” by Joshna Maharaj. © by Joshna Maharaj. Published by ECW Press Ltd.