While the issue of child poverty is not new in Canada, its incidence continues to grow. Recent reports have highlighted the extent of the problem in Metro. "The First Duty", a report of the Metro Task Force on Services to Young Children and Families, outlined the growing nature of the problem and made a number of recommendations for better service co-ordination and support which the Board of Health endorsed at its July 2, 1997 meeting. Subsequently, the United Way released a report entitled "Metro Toronto: A Community at Risk" which also documents the growing trend toward more low income families and greater income polarization. Public health, with its emphasis on the basic determinants of health (income, education, housing, food, etc.) and its community-based approach, has a vital role to play in supporting children and families in need.
In this discussion the focus is on young children from 0 to 10 years of age, not youth.
1.1 Canada
Child poverty, as the phrase implies, is rooted largely in the distribution of income and wealth which leaves many families without adequate income. Inadequate income reduces opportunities for health and increases exposure to conditions that adversely affect children from before birth through every stage of their life. While public services can do much to ameliorate the effects of low income, their impact can be much greater if families and communities are not in economic deprivation. Poor health outcomes are one of the most costly consequences of socioeconomic inequality.
Compared to other industrialized countries, Canada has a high level of children living in poverty. Canada and Australia have the second highest proportion of children in poverty after the U.S. (UNICEF, 1996). 45% of lone parent families in Canada have incomes below Stats Canada's Low Income Cut-off Point compared to 10% in Sweden and the Netherlands (Stats Canada, 1992). Stats Canada also reports that of those who relied on government transfer payments, the majority of both lone parent and two parent families have low incomes. In 1990 over one million children were growing up in families with low incomes.
Certain groups are more likely to have the problem of low/inadequate income:
- two parent families employed in low paying jobs;
- single parent (women headed) families;
- teen parents;
- unemployed;
- diverse ethnoracial groups;
- refugees and new immigrants.
A major reason for the growth of the problem is a reduction in government funding of basic family support services: child care, welfare, family benefits, child support, etc. as well as a decline in jobs and overall income levels. As a result, the gap between the poor and non-poor is widening and the depth of poverty is worsening (Little, 1996 and 1997). Relative living standards have been shown to be more closely related to negative health outcomes (i.e., mortality) than absolute income (Wilkinson, 1997). In turn, income disparities can lead to residential segregation, isolation, loss of social cohesion and erosion of public institutions and standards (Kawachi, 1997).
An effective way to ameliorate poverty is through a social safety net: government tax and income transfer policies. In some countries these policies have been very effective; for example, the UK and Ireland would have poverty rates of 30% but for such policies which have reduced the rate to 10% and 11% respectively. Both the US and France have poverty rates of around 25% before taxes and transfers but France has reduced its rate to 7% whereas the US remains at 22% (UNICEF, 1996).
How does Canada fare with its policies? Compared to many other industrialized countries with a similar per capita level of GNP, Canada still has a higher level of child poverty after taxes and transfers: Australia is the same while only the US has higher levels (See Table #1).
TABLE 1: LEVEL OF CHILD POVERTY IN SELECTED COUNTRIES
Child Poverty Child Poverty
GNP Per Capita (Before Taxes (After Taxes
Spent on Safety Net) Spent on Safety Net)
$ % %
United States 25,860 26 22
Australia 17,980 20 14
Canada 19,570 23 14
Italy 19,270 12 10
United Kingdom 18,410 30 10
Netherlands 21,970 14 6
Belgium 22,920 16 4
Finland 18,858 12 3
Source: UNICEF, "The Progress of Nations" 1996.
Note: Poverty line is defined as 50% of national median income.
In Canada provincial welfare levels vary but all fall below the poverty line: from 46 to 72% of a poverty line income in 1994 and only 24 to 38% of average provincial income. Social assistance levels are higher in Europe: in the Netherlands a lone mother receives about 75% of a production worker's net average wage; in Sweden 109%. Other supports to child care, such as, income, for mothers to stay at home etc. are also available (Canadian Council on Social Development, 1996).
1.2 Metro Toronto and the City
Child poverty is primarily an urban problem. Because 82% of children in Canada live in cities, national and provincial trends and policies have their biggest impacts on the urban areas. In Metro Toronto and the City of Toronto, which have been hard hit by the recession of the 1990s, the situation is worsening as the data below indicate:
- According to a recent report by Metro Community and Social Services Department, 36% or 89,000 children under 11 years old are living below the poverty line. A similar proportion holds for the City with the number being 35,000. Child poverty estimates for Metro and the City of Toronto are as much as seven times greater than neighbouring municipalities in the GTA.
- If children of the working poor are included, the proportion could be as high as 40%.
- Metro serves approximately 60% of all Ontario homeless people, of whom half (1,828) of those served nightly in shelters are families. About 30,000 people use Metro hostels for emergency shelter each year.
- Between 1990 and 1993 a total of 158,478 jobs were lost in Metro. The City lost over 81,000 jobs or half of all jobs lost in Metro. Unemployment rates have dropped since the early 1990s when the recession was at its peak but the unemployment rate remains over 10% higher in Metro than the provincial average.
- Low birthweight rate for Metro rose to over 7% in 1993 and 1994. The rate for the province was 6.2% in 1993 and 6.6% in 1994 and for Canada 5.5%. Metro accounted for 48% of the provincial increase in the number of babies with a low birthweight between 1991 and 1994.
- The birth rate among adolescents (15 to 19 years old) is stable at about 24 births per 1,000 and about 4% of all births in the City. This is higher than the Metro and Ontario rates which are 21 and 23 respectively. In 1995 362 babies were born to women under age 19 in Toronto. Many of these women are likely to be poor and 58% were single.
- Ethnoracial diversity is increasing. Metro Toronto has 53% of the non-european ethnoracial population in Ontario and most of these ethnoracial communities have average incomes that are 50 - 70% of the Metro average.
- A 1994 study showed young families (with a head under 35) in Metro were worse off than older or previous generations in terms of income, temporary jobs, unemployment, part-time work and social assistance. Specifically, while two-thirds of those under 25 years old were employed in 1989, only one-half were in 1993 and the number who could only find part-time work doubled.
- Between 1985 and 1990, family poverty increased 16% in the City which was 76% higher than the provincial increase.
- In Metro, children in families receiving social assistance increased from 70,000 (16.8%) in 1990 to 127,037 (29.3%) in 1995.
- Over 27,000 Toronto children lived in households on social assistance in 1995. The proportion of people on social assistance increased in all City neighbourhoods between 1990 and 1995. Ninety-five percent of children under 6 in families on social assistance were affected by the 21.6% cut to welfare payments in October 1995. As a result, more than two-thirds of families with children have to use money for food and other basic needs to pay for housing.
- Hostel use by mother-led families increased by 53% from 1994 to 1995 and homeless families who were clients of Metro Children's Aid doubled.
- Children are the fastest rising groups of hostel/shelter users increasing from 3,991 in 1991 to 5,584 in 1995.
- In 17 out of 45 neighbourhoods in the City, one-third to three-quarters of children live in families on social assistance.
- The median incomes of lone parent families dropped 19% between 1990 and 1993.
- In Toronto, only 15% of all potentially eligible children are receiving subsidized care in 1993. Families who qualify for subsidized care have a waiting period of more than 18 months and in June 1997 there were 3,508 children in the city on the waiting list.
- Pre-school children are the most over-represented in food bank using families. Children under 5 are 25% of all children in the GTA but 31% of the children supported by the Daily Bread Food Bank. A recent study found that almost one child in 20 in any given month lives in a family needing food bank help (Daily Bread Food Bank, 1996).
- The latest survey of food bank users in the GTA found that two out of five of the children of parents using the food bank went hungry occasionally, largely because the reduced cuts to social assistance means that more single mothers pay a higher proportion of their income for rents. The situation was similar for couples with children: the proportion of couples unable to cover their rents from the shelter allowance increased from 23% in 1995 to 78% in 1996. Consequently, almost 20% of children in these families occasionally went hungry, almost 10% once a week (Daily Bread Food Bank, 1996).
- Hundreds of social service agency programs have been cut and others severely reduced as provincial funding has been drastically reduced. Many of these programs serve low income families and children (Metro Social Services, 1996).
1.3 Conclusion
At a time when the economy is picking up and forecasts are for future strong growth, it is easy to miss the hardship and deepening crisis that is happening for a substantial number of families in Metro. The data cited above presents a picture of an increasingly polarized society in which those at the lowest end of the income scale are less and less able to provide their children with the basic care and support necessary for healthy development. At the same time, the services which can provide the essential underpinnings to keep these families going are being gradually eroded. If left unchecked, the current trends will have severe consequences.
SECTION 2: POVERTY: WHY IS IT A PUBLIC HEALTH CONCERN?
The roots of public health lie in developing measures to deal with the effects of poverty and inadequate income. In 1918 Dr. Charles Hastings, who was later to become the Medical Officer of Health in Toronto, placed health and adequate income squarely in the same camp as other essential rights:
"Every nation that permits people to remain under the fetters of preventable disease, and permits social conditions to exist that make it impossible for them to be properly fed, clothed and housed, so as to maintain a high degree of resistance and physical fitness and that endorses a wage that does not afford sufficient revenue for the home, a revenue that will make possible the development of a sound mind and body, is trampling a primary principle of democracy under its feet." (MacDougall, 1990).
A major focus for public health interventions is in the area of child health and, given that low income is a barrier to good health for children, child poverty, especially in the context of child development, is a fundamental issue for public health. This was recognized by the public health nurses in the early 1900s who, then as now, saw that citizens could not adopt modern health practices because they were poor, and joined forces with the network of charitable organizations in the community (MacDougall, 1990).
A recent Ontario study found a significant correlation between low income (especially under $10,000 income) and psychosocial morbidity (defined as psychiatric disorders, poor school performance and social impairment). The authors conclude that "poverty, particularly for the very young, is a strong independent predictor of poor psychosocial health" (Lipman et al, 1994).
Other studies (National Forum on Health, 1996) have found a similar link. Inequity, marginalization and powerlessness which accompany poverty add to the distress of low income families, creating an environment that disadvantages their children. The outcomes for children of a life in poverty include higher rates of conduct disorders, school problems, emotional disorders, chronic diseases and hyperactivity among poor as compared to non-poor children. In both Britain and the U.S., the statistical links between increasing relative deprivation and growing psychosocial problems (crime, drug use and suicide) among young people has been demonstrated in a number of studies (Roberts, 1997).
Studies of income distribution, infant mortality and public policy show a strong relationship between income inequality and the rate of infant mortality (Sullivan, 1996) as well as low birthweight which predisposes children to neonatal mortality as well as infant and childhood morbidity. Compared with children from rich neighbourhoods, children in communities in economic hardship and with high housing costs more likely have low birthweight (Roberts, 1997).
Incidence of injuries, which are the leading cause of death for children over 1 year of age, is higher among families with low socio-economic status (Morrongiello, B., 1996).
Poor nutrition in early childhood can continue to hinder intellectual performance into adulthood. Households with low incomes are much less likely to consume foods rich in protective nutrients (like fruits and vegetables) and more likely to eat sweet and salty foods. As a result, children suffer from more dental caries, recurrent infections and anaemia (James, 1997). Even for children living in poor social and economic circumstances, having adequate nutrition during infancy and later can lessen the cognitive deficits created by poverty (Brown & Pollitt, 1996).
Children who have lived in poverty a long time are at a developmental disadvantage which reduces their life chances considerably (Campaign 2000, 1996). Child welfare research has found that the stress of poverty results in higher incidence of child neglect and abuse among poor families (op. cit.). Shout Clinic in Toronto for homeless youth reported an increase in visits from single mothers and their children under 2 from 66 in 1994 to 508 in 1996 (Shout Clinic, 1997).
Studies have found that unfavourable socio-economic conditions in childhood predispose to increased risk of coronary heart disease in adulthood due to poor fetal development and childhood growth (Smith, 1997).
Many homeless people have had violent, abusive experiences in childhood which has led to emotional disorders, suicide attempts and chronic medical problems (Babiuk, 1996). As homelessness is becoming more common for families due to economic factors, more and more children are exposed to dangerous and uncertain circumstances which will have lasting consequences. Of particular concern are health problems, hunger, poor nutrition developmental delays, anxiety, depression, behavioural problems and educational underachievement (Rafferty, 1991).
Children living in poverty may be at greater risk to exposure to environmental contaminants in air, soil, drinking water, and food and have higher rates of morbidity. While some possible linkages between environmental contaminants and children’s health have been identified, including respiratory, reproductive, neuro-developmental, immunological, hormonal and cancer outcomes, the nature and magnitude of exposures of children living in poverty to these contaminants are less well understood. Much of the research has focussed on children living in inner-city areas of the United States and it is not known to what extent their findings would apply to children living in poverty in Canada.
Public Health studies in South Riverdale, an economically disadvantaged neighbourhood of Toronto with adjoining industrial areas, documented significantly higher blood lead levels in children as young as two years old, versus children in comparison neighbourhoods. Research in the United States indicates that the prevalence of elevated blood lead levels remains highest among inner-city, underprivileged children living in deteriorating pre-1970's housing containing lead-painted surfaces (U.S. Department of Health and Human Services, 1997). Lead poisoning in children has been associated with a range of potential adverse health impacts, including IQ deficiencies, reading and learning disabilities, and impaired hearing, reduced attention spans, hyperactivity, and antisocial behaviour.
Recent studies have shown that the following interventions can reduce inequalities in health for children and their families (Smith, 1997):
- Targeting effective healthcare promotion and services at those groups with the greatest health needs;
- Providing social, financial, and psychological support during pregnancy and childbirth;
- Providing smoking cessation programmes to pregnant women;
- Providing folic acid supplements before and around the time of conception;
- Providing personal support for breast feeding;
- Providing free school milk;
- Targeting effective interventions to reduce accidents of children who live in low-income communities;
- Providing sex education and available, accessible, and acceptable services to reduce teenage pregnancy;
- Improving oral hygiene, reducing sugar intake, and promoting use of fluoride among people in deprived communities.
These are basic public health interventions, most of which can be provided through the existing community health system.
In summary, income inequality places children at risk for a lifetime of health problems. It is now a basic tenet of public health that the key to the health of the population lies in providing a range of socio-economic interventions and supports in the social and physical environment beyond the traditional health care system. The role of public health practitioners and agencies is to ensure that all vital elements are in place, including the basic prerequisites for health and lack of discrimination and racism, for all members of society.
SECTION 3: PUBLIC HEALTH RESPONDS
While strategies that permit families to have a reasonable income (through government transfers, full employment policies, etc.) are the critical factor in alleviating poverty, family and community support initiatives are also vital. For example, it has been shown that non-economic factors , such as low maternal education, family dysfunction and social isolation, also have negative outcomes for children (Lipman, 1994). Also, controlled studies have shown that a well-designed home visiting program for mothers of newborns can reduce child abuse by 75% (Steinhauer, 1996) and comprehensive interventions which include health services, such as the Head Start program in the U.S., prepares children for school and enhances physical health and well-being through public health interventions such as nutrition, public health nursing and dental (Zigler, 1993).
Public health professionals play a unique role in dealing with the breadth of needs in families which try to cope with and/or overcome major problems related to low socio-economic status. In Toronto, this is the area where considerable public health service lies. Although there is overlap among current programs, there are 6 main areas where staff are working on this issue:
3.1 Providing the Basics
All children need to grow up in a safe, clean environment in secure, stress-free families with access to food, housing and education. Much of the work of the Department of Public Health is directed to ensuring a basic level of health service to all members of the community. Initiatives which provide general health services also reach children in need, such as the following:
- communicable disease control, especially through immunization of school and day care children;
- environmental health protection through food safety, monitoring of water quality for drinking water, pools and beaches, inspections and enforcement of environmental safety regulations, and public education to minimize exposures to contaminants in air, soil, drinking water, and food;
- food handling and infection control education to staff in schools and day cares;
- food quality workshops for daycare personnel given by a community nutritionist and environmental health officer;
- breastfeeding promotion and corporate breastfeeding policy; mother to mother breastfeeding support groups;
- work directly with local hospitals to provide 24 hour home follow-up to new mothers who are experiencing shorter hospital stays.
- preconception and prenatal education and health promotion;
- food coupons and food to ensure adequate nutrition for mothers in the prenatal programs;
- programs to prevent teen births which often result in children living in poverty, specifically, school-based education and clinics, and access to supportive, confidential medical services and counselling;
- provision of dental screening, treatment and education for children and mothers with high need but low income through nine clinics located throughout the City;
- promotion of fruits and vegetables in community programs, such as markets, school meals, and parenting programs;
- parenting programs to enhance the capacity of families to foster the development of their children, including visiting child drop-in programs, working with schools and agencies to provide community resources, provision of snacks, babysitting and TTC tickets at high risk parenting programs;
- youth employment through special programs, such as the Peer Sex Education Program;
- co-ordination of school food programs in partnership with boards of education to provide nutritious meals/snacks to school children. Department of Public Health co-chairs the School Food Program Committees for both public and separate schools, assists with menu planning, provides food handler training, conducts facility inspections and participates in program reviews;
- administration of $1.9m of the Food Access Grants from City Council which have expanded school food programs, increased food skills education and alternative food distribution systems and the formation of community networks which are increasing food access in their neighbourhoods. In addition, five community groups are running community economic development projects and a commercial Incubator Kitchen has been established;
- support to community, school and rooftop garden projects which provide additional food to families and information on home preserving;
- community development which helps groups and agencies to get funding, eliminate systemic barriers to healthy development and develop appropriate programs for disadvantaged groups;
- community economic development to provide skills on food preparation and business development.
3.2 Ensuring Healthy Growth and Development
A great deal of the work of public health is in the area of prevention: providing education on ways to lay a solid foundation for future good health. Much of this work focuses on children either directly or through parents and caregivers.
For instance, the first three years are critical in ensuring that children have a good start to their lives. Recent research shows that brain development, which determines overall development, in the early years is extensive and highly vulnerable to environmental influences (Carnegie Task Force on Meeting the Needs of Young Children, 1994). Children who are resilient (able to adapt in the face of severe stress) are able to survive and succeed even in the face of adversity (Steinhauer, 1996). Many public health interventions are directed to addressing issues that arise in the early years; specifically:
- prenatal and postnatal programs directed to improve mother’s nutrition, reduce smoking and alcohol drug use during pregnancy and to improve social support and a successful role transition to parenthood;
- postnatal programs which help mothers cope with stress and promote attachment (e.g., infant parenting, breastfeeding, home visits, response to early discharge);
- nutrition promotion with parents and in schools to assist with making healthful food choices;
- mental health promotion through stress management, conflict resolution, violence prevention, abuse disclosure workshops to parents and staff of community agencies and information on accessing community resources;
- parenting groups (including raising sexually healthy children). In 1995 about 20% of first time mothers were reached;
- injury prevention initiatives;
- education programs aimed at reducing substance use;
- skills for Food Shopping is a community presentation for new immigrants to assist them make wise food choices in a new setting. "What Should My Children Eat to Be Healthy?" is a slide presentation for youth by community groups following training by Department of Public Health nutritionists;
- programs to prevent teen pregnancies and births.
3.3 Intervening for High Risk Groups
Low income families can be strengthened through targeted interventions that focus on building capacity in key areas, such as parenting, accessing the health system, developing employment skills and so forth. Over the years, the Department has developed a range of programs in this vein.
- Home visiting for high risk families on a range of issues from helping new mothers adjust, stress management, breastfeeding etc. Nurses, lay visitors and others provide support for parents facing barriers to good parenting outcomes. The Ministries of Community and Social Services and Health have recently allocated $762,150 to the City of Toronto and a total of $10 m to Ontario Health Units to provide assessment, referral and home-visiting to expectant parents and young children. These monies will enhance current services to high risk families.
- Parents for Better Beginnings, a primary prevention research demonstration project involving numerous organizations in Regent Park and Moss Park areas combining infant home visiting, parent relief with community development and integration of services.
- Growing Together provides home visiting by public health nurses and other services to high-risk multicultural families with young children living in a dense apartment complex in downtown Toronto.
- Cooking Healthy Together is a nutrition education program for community groups that provide hands on experience in cooking, menu planning and safe food handling.
- Healthiest Babies Possible supports mothers at risk for having low birthweight babies by providing milk supplements, nutrition and lifestyle behaviour counselling by Department of Public Health dietitians and health education and counselling by PHNs.
- The Parkdale Parents’ Primary Prevention Project is a community collaborative in Parkdale that provides a variety of supports, including nutritional supplements, pre and postnatal counselling and supports, information sessions, parent relief with community development and co-operation among local services, arts and crafts as well as community economic development for women, etc.
- Parents Helping Parents is a peer support program in which trained lay home visitors, with nursing support, provide support and assistance to high risk, mothers from eight ethnoracial communities to improve their parenting skills and enhance the mental and social development of their babies and toddlers.
- Prenatal classes to pregnant teens, single mothers, specific ethnic groups and newcomers to Canada to improve birth outcomes and parenting skills.
- Nobody's Perfect is a parenting program for young, single, low income, isolated mothers of children under six with limited formal education. It assists parents to develop the knowledge skills, self-confidence and social support essential to child rearing.
- Mental health education (stress management, violence prevention, etc.) for parents and children, as well as crisis intervention.
- Perinatal nutrition and support programs. In 1995 more than 200 pregnant women and their families were served weekly by six prenatal food supplementation programs.
- Breaking the Cycle and the Family Reconnection Centre assist women who are pregnant or parenting a child under 6 years of age deal with problems of substance abuse and recovery along with enhancing their parenting capacity.
- Ready or Not parenting program is a series of 6-8 sessions directed to parents of pre-teens who may have difficulty accessing other programs related to social isolation, literacy and income. The program is designed to increase parent-child communication and provide information regarding prevention of substance abuse by their children. Training of community and parent facilitators have been culturally specific for three communities and parent booklets have been translated and culturally adaptated in Portuguese.
- As members of the Family Sub-Committee of the Mayor’s Task Force on Drugs, public health staff have been involved in the planning, development, implementation and evaluation of the City of Toronto One-On-One Mentoring program, which was piloted in two schools during the 1996-1997 academic year. Volunteers were recruited through two Divisions of the Corporation to provide time with an individual child on a regular basis in a school setting. The pilot will be expanded this year.
- Community Kitchens are group education programs targeted to low income people, including single mothers with children, and assist with menu planning, food preparation and nutrition knowledge.
- Support to the underhoused and homeless.
3.4 Advocating for Socio-economic Policies Supportive of Children’s Health
With the goal of achieving greater health equity, public health professionals have long recognized the importance of reducing income disparities. The Department and Board of Health have urged federal and provincial governments to enact policies which provide adequate income support for vulnerable populations and maintain the social safety net. As well, Department of Public Health supports many networks and coalitions working towards this end.
In particular, staff:
- work with Campaign 2000 to pressure governments to provide better income supports for poor families as well as the other basic prerequisites for children's health;
- call for enhanced social services support for supplies for breastfeeding mothers and to reduce fees such as the $25 charge for birth registrations;
- provided submissions and support through a range of venues, such as, to a collaborative nurses conference on Child and Family Poverty in 1995; presentations to community hearings on child poverty in Toronto and the UN Convention on the Rights of the Child; deputations for federal committees;
- support the Food Policy Council which develops long-term strategies and short-term interventions to ensure access to adequate nutrition. One example is a recent discussion paper on "Food Retail Access and Food Security for Toronto's Low-income Citizens" which recommends long-term strategies for ensuring more equitable access to food retail stores for all communities;
- participate in strategy development and implementation with the Metro Coalition for Better Child Care.
3.5 Supporting Service Integration
Recognizing the need for co-ordination among social and health services to fully address community needs, public health has put considerable effort into building networks, coalitions and partnerships in all aspects of its work from policy formation to program delivery. Some specific examples:
- Prevention and Early Intervention Initiative. Members include wide representation from all sectors working with parents and children up to age 6.
- Child Health and Breastfeeding Promotion Workgroups of the Ontario Public Health Association have poverty as a focus.
- Metro Task Force on Services to Young Children and Families.
- Infant Mental Health Promotion Project of Metro Toronto.
- City of Toronto Perinatal Coalition of Nutrition and Support Programs.
- Multicultural perinatal network of Metro Toronto.
- Parent Coalitions, such as PAIS and FILHOS, based in the Portuguese community and the African-Caribbean Cultural Coalition.
- Metro Toronto Breastfeeding Network includes 250 community, public health and hospital members.
- SETO which is a network of agencies working in South East Toronto developing several joint projects, such as food buying clubs, gardens and meal programs.
- OPHA Food Security Network.
- Metro Toronto Coalition for Child Nutrition.
- Metro Community Kitchen Network.
- Parkdale Coalition Against Woman Abuse.
3.6 Tracking the Problem
A key component in dealing with the problem of child poverty is identifying its depth, nature and location so that specific measures can be taken to deal with it. The Department has been monitoring changes in income levels and health status outcomes for a number of years and using this information for program planning. Specific work in this area includes:
- development of "neighbourhood profiles" which identify key indicators related to poverty and health on a geographic basis. Using this information, trends can be tracked and programs delivered on a small area basis;
- production of a regular health status report which documents a wide range of social and health indicators over time and identifies specific geographic areas of the city at high risk;
- annual epidemiological reports on specific diseases and services which also identify high risk populations including children;
- special studies which examine a specific health issue or social problem ( low birth rate study; analysis of food bank users; survey of health needs among the homeless; hunger in schools);
- linking with the University of Toronto to undertake research on related issues, such as, kidstrack, a project to develop and monitor indicators to support neighbourhood action for children; working with child welfare agencies to develop a common data base to track child maltreatment trends and contexts;
- facilitating community needs assessment, such as the Parkdale Audit project and maintaining an up-to-date listing of community development projects on child poverty;
- development of a nutrition monitoring system in collaboration with North York Health Unit and University of Toronto to track data on indicators relating to food access and nutritional status.
SECTION 4: ISSUES FOR PUBLIC HEALTH
At the moment there are a number of factors in the overall environment in which public health is operating which present challenges to our efforts to deal with this problem. They are described here and addressed with solutions in the Recommendations Section.
- The size of the problem and shrinking resources. Cutbacks in government support across the board have both increased the magnitude of child poverty and reduced the capability of social and health agencies to deal with it.
- How to avoid adding to the problem. Within public health departments fiscal restraint has resulted in service cuts. Often this has been done expediently but without an overall framework of priorities. Such cuts may have added to the overall fragmentation of services to high risk families.
- Child poverty is not generally seen as a public health issue. Although the health consequences of low income are recognized as important in the field, the role of public health units in tackling the roots of the problem has not always been widely recognized. Fortunately, this attitude is changing in some areas. The recent announcement of $10 m a year to boards of health in Ontario to run the Healthy Babies/Healthy Children program for high risk families is an acknowledgement of the importance of home based visiting and supports under public health supervision. Also, hospitals in Toronto are now contracting with the Department of Public Health to follow-up new mothers after hospital discharge.
While the programs and initiatives listed in this report are available in City of Toronto, they are not necessarily provided throughout Metro, even though there are comparable serious needs across the megacity. Services such as offered by public health in Toronto should be equalized across the new Toronto so that all citizens in need are served.
- Funding downloading. Provincial downloading of major funding responsibility to the municipalities in the areas of social assistance, social housing, long-term care and child care places a fiscal burden on local governments which threatens their capacity to continue to provide discretionary community support programs. Municipal community grants programs currently support parent/child resource centres, multicultural services, neighbourhood service centres, to name a few. Under the new municipal funding burden, the continuation of discretionary grants programs is in jeopardy. Low income families are primary consumers of these services and would lose significant supports with service reduction or elimination.
In addition, the Toronto Board of Education is anticipating major funding reductions with the assumption of educational funding by the province. This move threatens the continuation of key programs which support education access for low income and ethnoracially diverse students.
Conclusions:
In many ways it is difficult to reconcile the image of Toronto as portrayed in international studies as one of the best cities in the world in which to live, with the image of a city with growing poverty as shown in this report. Yet both pictures are true. The question is, which image should prevail? If asked, most Torontonians would reject the model of big cities south of the border with their decaying urban cores where the homeless and members of the drug subculture live in the abandoned buildings, where the disadvantaged have access to fewer supermarkets and other amenities and where there is what is called "the urban health penalty" (Andrulis, 1997). But unless positive measures are taken, this could be our fate. The signs are already there.
One necessary step is to maintain the services we know can make a difference, especially those that are preventive and community-based. In the long-run, they are more cost-effective than treatment or rehabilitation. Recently, the Minister of Health Jim Wilson stated "Health-care restructuring is not about saving money. Every penny found in getting rid of waste, duplication and unnecessary administration will be invested in expanded and improved services... There will be no cuts in services. In fact, the government will expand services....we need to develop a truly seamless system where every penny is spent on providing services like....health promotion, prevention programs and public health." (Wilson, 1997). In the face of drastic cuts to welfare and provincial downloading of health and social program funding to municipalities, this is good news indeed.
Presently, only $87 m is spent on public health services in Canada’s largest city which is only 1.7% of the total health spending in Metro Toronto and which does not even meet current needs. By restructuring hospitals in Metro Toronto the Ministry of Health says it will save $470 m annually. An addition of $13 m from these savings directed to public health would allow more services for disadvantaged children and their families. This would amount to less than 3% of the savings from restructuring and bring the public health budget up to only 2% of total health spending in Metro.
Public health is in a unique position to assist in the fight against child and family poverty: the nature of their mandate and ways of working has long put them in the forefront of preventing and ameliorating the effects of poverty. The specific features of public health that make it a key player in this area are:
- it is multidisciplinary, combining a range of health and other practitioners;
- it is collaborative working with a variety of disciplines, community groups and agencies to co-ordinate services and programs;
- it is community-based; staff work directly with clients and agencies in their neighbourhoods;
- it is preventive in orientation and therefore very cost-effective;
- it combines epidemiology and social epidemiology with needs based planning;
- it combines both a population and individual focus where appropriate;
- it engages the community in identifying and solving its own issues through community development and support;
- it provides a linkage between the community, individual clients and the health care and social service systems.
If the new City Council chooses to make child poverty a priority, a number of steps should be taken early in 1998; namely:
- review and implement the recommendations 1 and 3 to 35 of the Metro Task Force on Services to Young Children and Families report, as previously recommended by the Board of Health;
- identify current gaps in public health services for children and families across Metro and ensure consistent provision to address needs;
- allocate sufficient funding for public health to maintain and enhance necessary services for children and families;
- request the Ministry of Health to reinvest $13 m of the savings from hospital restructuring immediately back into public health. The reallocation should raise the public health component from 1.7% to 2% of health care spending in Metro.
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The Board of Health also had before it the report (September 2, 1997) from the Medical Officer of Health and Regional Directors, Public Health, which is included in the additional material and on file with the City Clerk.
