February 26, 1998
To: City Council
Community and Neighbourhood Services Committee
Budget Committee
From: City Clerk
Subject: State of the City=s Health
Recommendation:
The Board of Health on February 23, 1998, requested that the report (February 19, 1998) from the Acting Medical Officer of Health which updates the view of health and health trends in Toronto and outlines key issues for Public Health programs and resource allocations, be forwarded to the Community and Neighbourhood Services Committee, the Budget Committee and City Council for consideration during the budget process.
Background:
The Board of Health on February 23, 1998, had before it a report (February 19, 1998) from the Acting Medical Officer of Health respecting The State of the City=s Health: Implications for Public Health.
The Board of Health also had before it the following with respect to the aforementioned:
- (October 6, 1997) from the Assistant City Clerk, former City of Toronto, forwarding the former City of Toronto=s action taken at its meeting on September 22 and 23, 1997 with respect to Clause 1 of the Board of Health Report 9, titled AThreats to Health in the Changing City: Choices for the Future@; and
- Transcript of the Acting Medical Officer of Health=s presentation titled AState of the City=s Health: Implications for the Future@.
City Clerk
Christine Archibald/bp
Item No. 4
February 19, 1998
To: Board of Health
From: Dr. Sheela Basrur, Acting Medical Officer of Health
Subject: The State of the City=s Health: Implications for Public Health
Purpose:
This report updates the view of health and health trends in Toronto contained in the report Threats to Health in the Changing City: Choices for the Future (September 9, 1997 - attached) and outlines key issues for Public Health programs and resource allocation.
Recommendation:
It is recommended that:
(1) This report be sent to the Community & Neighbourhood Services Committee, Budget Committee and City Council for consideration during the budget process.
Background:
At its final meeting on September 9, 1997 the Board of Health for the former City of Toronto directed that a report from the Medical Officer of Health titled Threats to Health in the Changing City: Choices for the Future (attached) be forwarded to the Board of Health for the new City of Toronto. At its meeting of January 26, 1998, the Interim Board of Health for the new City deferred consideration of the report to the first meeting of the new Board of Health and requested the Acting Medical Officer of Health to make a presentation based on it.
Comments:
The Board of Health and Medical Officer of Health of the new City of Toronto are responsible for protecting and promoting the health of the citizens of the largest urban health jurisdiction in Canada. The health of this community is a vital resource for the economic and social success of Toronto. Central to carrying out this responsibility is an understanding of the health issues and needs which face this City. This report is the first of many through which I will keep the Board of Health informed about the state of our City=s health, and support it in setting the course for Public Health in the years to come.
(A) The State of Toronto=s Health
The report AThreats to Health in the Changing City: Choices for the Future@ painted a picture of high health needs in the new City compared with other parts of Ontario; adverse trends in the factors which influence future health; emerging health threats requiring a public health response; and declining public resources with which to meet these challenges. This picture remains largely unchanged today.
The major causes of illness, disability and premature death in Canada remain central challenges for public health in Toronto - heart disease, cancer, stroke, respiratory disease, injuries and suicide. To these must be added AIDS, which in Toronto is the leading cause of premature death among men. The key risk factors which contribute to these health problems should continue to be major targets of public health programs - smoking, unhealthy diets, unsafe alcohol and drug use, and unsafe sex.
Worrisome trends continue in the determinants of health - income, housing, education, employment, social support networks, environmental safety and other factors which have a powerful effect on a community=s future health . These circumstances demand a public health response in the form of advocacy for healthy public policy, and programs which can mitigate the health consequences of these conditions. Of particular concern is the need for programs to support the one-third of Toronto children (89,000) in poor families, many of whose life chances for good health are diminished by poor nutrition, unhealthy home environments, and poor access to services.
Emerging and re-emerging threats to health continue to challenge us. Public health is striving to respond, with needle exchange and methadone programs to help stem the spread of HIV among injection drug users, directly observed therapy programs to prevent a resurgence of tuberculosis, tobacco prevention measures to reverse the rise in youth smoking, and clean air initiatives to reduce the toll of urban air pollution.
A striking characteristic of both our community and its health is diversity. Ethnocultural diversity continues to grow, with 44% of residents in the 1996 census reporting a mother tongue other than English and over 60% of births to mothers born outside Canada. Sharp differences in health between communities within Toronto are strongly associated with income levels. For example, median incomes in the wealthiest wards of the city are more than twice that in the poorest. Babies born in the least wealthy wards are 70% more likely to be underweight at birth and die in the first year of life than those born in the wealthiest. Understanding this disparity helps public health direct our efforts where it will do the most good, and it highlights the enormous scope for health improvement. If all areas of the city achieved the birth outcomes of the wealthiest, there would be 150 fewer babies born too small and 50 fewer infant deaths each year.
(B) Implications for Public Health
It is clear that as the new Board of Health takes up its role, Toronto faces both significant challenges and opportunities on the path to good health for all.
The AThreats to Health@ report urged the new City to make health a priority by investing in health services and healthy public policy, with active community participation under the strong leadership of the Board of Health. This prescription is even more vital now as we navigate the difficult decisions of the first months and years of the new Toronto.
The fiscal pressures facing the City are forcing the examination of a wide variety of options, including reducing public health expenditures. While all municipal services must continue efforts to deliver more benefit to the community with fewer resources, the possibility of public health service cuts must be considered with caution. Public Health is a key part of the network of public, private and volunteer services which make up the social infrastructure of the city. Like the physical infrastructure, investments in the social infrastructure today cannot be deferred indefinitely without incurring increased health, social and economic costs in future.
In the case of many public health services, the costs of not investing are incurred, in some cases irreversibly, soon after services are withdrawn. For example, new HIV infections which could have been prevented through health programs cannot be reversed with current knowledge, and foreshadow a bleak future for both the individuals and the communities affected. The consequences of service cuts beyond the current year=s budget must be part of any discussion of the appropriate level of public health investment.
One important signpost for public health service planning is the provincial Mandatory Health Programs and Services Guidelines. The post-downloading version of these guidelines, made more enforceable by amendments to the parent Health Protection and Promotion Act, was released this month. It describes in detail the minimum investment in public health required by law, which must be made in even the least needy health units in the province. A comprehensive assessment of how Toronto=s services stack up against the guidelines is being undertaken, but two things are clear even now. First, there will be some areas in which our programs fall short of requirements. More importantly, in many program areas, greater health needs in Toronto require a higher level of service than the lowest common denominator specified by the guidelines. I will report to the Board of Health on our compliance with the new guidelines as soon as the assessment is complete.
Public participation in deciding the level of investment which Toronto makes in public health is essential, in view of the importance of public health services as part of the social infrastructure, and the diversity of needs in the City=s communities. The Board of Health must show strong leadership by clearly articulating the City=s health needs and the benefits of investing in effective, efficient public health services.
(C) Outlook for the Future of Public Health
As the Board of Health begins to set the course for public health in the new city, there is reason for optimism despite the challenges outlined in this report.
The striking diversity of health needs among Toronto=s communities reminds us of the health deficit still to be overcome, but also highlights the potential for health improvement for those with the basic prerequisites for good health and effective public health services.
Maintaining strong public health services in the new city will bring future rewards in the form of better health, lower health and social costs, and a more successful city. The new Board of Health has an opportunity to pass on to future generations a legacy based on wise investment in their health and well being.
The amalgamation of six public health organizations has brought together a dedicated team of public health professionals whose skills and knowledge of Toronto=s communities are a valuable asset to the City. Working with the Board of Health, we have the capacity to create a public health service which will be a leader in Canada.
Public Health in Toronto is no stranger to challenges. Past Medical Officers of Health and Boards of Health have had to overcome significant obstacles to address the health needs of their time. Pasteurization of milk, chlorination and later fluoridation of drinking water, immunization to control communicable disease and AIDS prevention programs were all implemented in the face of fiscal and political concerns. Today they form an indispensable part of the public health infrastructure. The new Board of Health is heir to a long tradition of public health activism and leadership by its predecessors in the six former municipalities. I urge the members of the new Board to continue that tradition and champion the cause of public health in our city.
Contact Name:
Dr. David McKeown, Toronto Office
Tel: 392-7405
Fax: 392-0713
Sheela V. Basrur, MD, MHSc, FRCPC
Acting Medical Officer of Health
CITY OF TORONTO
PUBLIC HEALTH
September 9, 1997
To: Board of Health
Subject: Threats to Health in the Changing City: Choices for the Future
Origin: Medical Officer of Health, September 9, 1997 (p:\1997\ug\cms\hld\hl970072.hld)
Recommendation:
That this report be forwarded to the Board of Health for the new City Of Toronto.
Introduction
Toronto has been rated the number one city in the world in which to live and work. It is internationally recognized for initiating the healthy city concept and for its commitment to programs, policies and legislation which support health.
Toronto has kept its inner core vibrant and safe with a mix of commercial and residential activities and effective public transportation. Its economically diverse neighbourhoods take pride in working to improve quality of life. Its public institutions are open-minded and welcome debate. It seeks out and strives to meet the needs of those with the greatest disadvantages. It provides public services that help keep people and their environment healthy.
What makes Toronto healthy for people is also what makes it a good place for business. The Board of Trade knows this. Economists, The World Bank and UN agencies now use indexes based on the interdependence of health and social conditions, economic development and productivity when rating cities and nations.
The health of our city is vital to the social and economic health of the region and the province. While Toronto is experiencing economic and social stress it has so far avoided the urban health decline that has occurred in many large North American cities. However, there are warning signs which must be heeded if we are to avoid going down that path. In this report I will outline some of these signs.
We are in a period of unprecedented change in our public institutions. The choices we make in the months to come will influence the health of the new Toronto for many years into the future. This report calls for health to be at the top of the public agenda as we reshape our city.
Looking Back
As the City of Toronto Public Health Department and the Toronto Board of Health in their present form come to an end, it is appropriate to reflect on our long and proud history. Many of our past accomplishments remind us of the contribution of health to the success of Toronto.
The first medical officers of health in Toronto in the late 1880s and early 1900s were persuasive reformers. They convinced municipal politicians and taxpayers to support controversial and innovative solutions to problems of sanitation, waste disposal, adequate housing and disease prevention and control. Toronto was one of the first cities in North America to chlorinate drinking water in 1910 and make pasteurization of milk compulsory in 1914 , reducing typhoid, tuberculosis and scarlet fever. Home nursing services to high risk families started in 1900 and gave impetus to a tradition of action on poverty, including advocacy for fair wages and safe affordable housing. By 1915, Toronto had earned an international reputation as an innovator in public health administration, and by 1940 was heralded for its success in virtually eradicating diphtheria through public vaccination.
Fluoridation of water was a hotly debated public issue and a referendum item in the 1962 municipal election. A few years after it was begun, dramatic improvements were apparent in children's dental health. In the early 1980s, Public Health strengthened its community linkages and its advocacy role by creating Community Advisory Boards and hiring staff dedicated to community development and health advocacy. In the late 1980s, a unique Environmental Protection Office was created to address a pressing need to confront the health risks of urban environmental contamination.
Today, Toronto provides core health protection and promotion programs to the whole population and many special services to address the needs of high risk and inner city populations. These include dental services for low income seniors and children, needle exchange to prevent hepatitis and AIDS in injection drug users, community development assistance to diverse groups, peer home visiting for parents in seven ethnoracial communities, in-home prenatal nutrition and health counseling for women at high risk of low birthweight, and programs to enhance food security. The city is a municipal leader in tobacco and substance abuse reduction and sexual health services including AIDS prevention.
Our activism and responsiveness to changing needs has helped to make Toronto a healthy city. Yet today we are not meeting some pressing needs. Many health problems of the past remain priorities - old diseases threaten resurgence, and too many people lack the basis prerequisites for health. New threats to health continue to emerge to test our understanding and our resources. We must act wisely in redesigning Toronto
=s institutions if we are to preserve our capacity to respond to these health challenges.
The Outlook for Health in the New City of Toronto
My previous reports to the Board of Health have painted a picture of the city
=s health in the 1990s as one of increasing needs and shrinking public resources. The outlook for the new City of Toronto is worrisome, due to a combination of already high health needs, adverse trends in determinants of future health, emerging health threats, and diminishing capacity for public response.
1. Health Needs in the New Toronto
The impending amalgamation of six health units into one will create the most populous public health jurisdiction in Canada and the amalgamated city will have the highest health needs in Ontario. Housing and settlement patterns and demographic shifts concentrate more people with greater needs in this new urban center of the Greater Toronto Area (GTA). While the new city has 51.5% of the population of the GTA it has:
- 70% of its single parent families
- two thirds of its seniors including 73% of GTA seniors living alone
- two thirds of its households with incomes under $20,000 in 1990 and 75% of GTA households on social assistance in 1997
- child poverty rates as much as eight times greater than neighbouring municipalities in the GTA
- two thirds of GTA immigrants - about 14% were refugees in 1995
- 78% of those without a working knowledge of English
- 57% of GTA low birthweight births, 81% of Tuberculosis cases in 1995 and 93% of AIDS cases in 1995
2. Trends in the Determinants of Health
Education, work and income, social equity and social support, a safe environment, and freedom from discrimination are important determinants of health. Today increasing numbers of people lack full access to these basic conditions. Poverty and income inequities increase susceptibility to disease in a population and are strongly associated with higher (often double) rates of illness, disability and premature death.
The population age 75 and over is projected to increase 35% in the new city between 1995 and 2003.
Ethnoracial diversity is increasing and more recent immigrants require translation and other forms of assistance to access services and information.
There are more homeless on the streets of Toronto and hostel use continues to increase, with use by single men increasing 20% from 1995 to 1996. More women with children are coming to shelters because of parental or spousal abuse, a 45% increase from 1991 to 1995.
Recession, welfare and social service cuts are having their greatest impact on those already at the greatest risk. Incomes declined in Toronto between 1990 and 1993 and those with the lowest incomes, lone parent families, experienced the greatest losses, with median incomes dropping 18%. Provincial social assistance cuts in October 1995 affected one in eight residents of the new Toronto. With less income, more families lost their housing (mother-led families using hostels increased 53% in November 1995 compared to 1994) and lacked sufficient money for food (food bank use increased 54% in 1995).
Child poverty in Metro doubled between 1985 and 1996, increasing 40% since 1990. Estimated child poverty levels of 36% or more in 1996 mean that many children will miss the opportunity to reach their full health potential, and places an unacceptable burden on the future health of our city. That this is happening in Toronto shames us all.
3. Emerging Health Threats
New and resurgent problems threaten the health of the new City. The following are examples which have been the subject of reports to the Board of Health.
Tuberculosis
A number of large North American cities have experienced a resurgence of tuberculosis in recent years. Although this has not yet occurred here, their experience suggests that the conditions for such resurgence already exist in Toronto. These include: high levels of immigration from countries where TB is prevalent (78% of cases are foreign born), increasing prevalence of HIV infection, crowding in drops-ins and shelters for the homeless who are at increased risk, and increasing poverty. Currently 15 percent of TB cases are resistant to commonly used antibiotics, 9 percent are known to be infected with HIV, and nine percent are homeless.
Tobacco-related Disease
The current epidemic of lung cancer among women is the result of rising smoking rates two decades ago. In 1994, 400 women living in Metropolitan Toronto died from lung cancer. Smoking rates declined sharply during the 1970s and 1980s , but since 1990 have been on the increase nationally and particularly among young women. The 1995 Addiction Research Foundation survey of Ontario students in grades 7 to 13 shows that female smoking rates surpassed males in 1993 and both increased in 1995. These increases foreshadow a a future epidemic of tobacco related diseases due to the early death of many of the young people who begin to smoke today.
AIDS
Toronto is at a critical point in the HIV epidemic among injection drug users (IDU). Researchers at national conferences in 1997 report that in Montreal and Vancouver, rapid increases in HIV infection among IDU have recently occurred, and 20-25% of IDU in those cities are now infected with HIV. In Toronto the rate is still well below 10% - but experience elsewhere shows that if it rises above 10%, explosive spread can occur among injection drug users, their partners and their children.
The new city will have 68% of people in Ontario with AIDS and the importance of prevention and treatment among new risk groups remains a priority. Provincial rates of HIV are increasing among heterosexual partners including women, and their infants. HIV infection in 1997 among Ontario women of childbearing age is estimated at 6/10,000 women, three times estimates from 1992. If these estimates are accurate we need to step up prevention of heterosexual transmission and care and treatment for women and children who have not been a high priority in AIDS work to date.
Air Quality and Health
Growing understanding of the links between urban air quality and respiratory disease has led to increasing concern. In the last ten years we have seen reports of increasing numbers of children with asthma, of bicycle couriers and cyclists wearing masks, and of admissions to hospitals on poor air quality days. As anecdotal information has accumulated, so has scientific evidence. Our first major review of the health impact of outdoor air quality (1993) was followed by new evidence of a significant relationship between air contaminants and both hospital admissions and respiratory mortality. This evidence laid the groundwork for initiatives such as by-laws to limit idling vehicles and restrict incineration, and the recent City of Toronto and Metro clean air strategies to combat smog. These measures alone are insufficient to address this emerging health threat.
4. Declining Capacity for Public Response
Declining public resources, weakening of the social safety, and rapid institutional change have diminished our capacity to respond to the health challenges we face.
Federal contributions to provincial health, education and welfare were cut 28% in the early 1990s, will be reduced another 37% between 1995 and 2000, and will disappear in the early part of the new century.
Provincial policy reform since 1995 is occurring in a number of areas that reduce access to basic health prerequisites. These include reduced welfare eligibility and benefit reductions, reduced protections for renters and a moratorium on social housing construction. Provincial funding to community service agencies was cut 5% and a number of programs lost all provincial funding.
Environmental protection is weakened by provincial budget reductions and deregulation. There are 40% fewer provincial staff in 1997 than in 1990 to monitor air, soil and water quality, handle spills, set standards and coordinate remedial action plans. Plans by the province to address air quality standards by 1999 include only a third of the 226 chemicals identified in the ministry
=s own 1992 review. The decision not to proceed with the provincial state of the environment report and the elimination of intervener funding decreases public access to information and participation.
Changes in the structure and funding of schools could reduce the current commitment to health education. This could mean that students miss the opportunity to obtain tools they need to make healthy choices about behaviours which will impact substantially on their future health - smoking, eating, drinking, drugs, and sexual relationships.
Health care restructuring is long overdue after over two decades of debate and planning. But there will be tremendous additional pressures on existing health and community services unless key principles are followed that ensure access and equity, prevention, and the establishment and secure funding of community services before hospital services are discontinued. There are already long waiting lists for long term care. Mental health services are meager for children and adolescents and for addressing the complex needs of those who are also victims of violence, are homeless or have addictions. The planned $1.76 per capita reinvestment for community mental health is less than 4% of what the Metropolitan District Health Council says is needed.
Budget reductions have resulted a more than 20% reduction in staffing levels in Toronto Public Health between 1992 and 1997. Competing priorities are beginning to force some hard choices among high needs groups. For example we have had to shift nursing services away from homeless adults to respond to the needs of street youth parents who are trying to raise children in a stroller. Other metro health units have also been downsizing. When the six local health units amalgamate the combined gaps in public health service needs will be too large to fix by spreading our existing resources more thinly
Municipal restructuring is occurring across the province with the download of funding responsibilities to property taxes. The new City of Toronto will face a greater a greater financial burden than its predecessors. In looking for ways to cut costs some may be tempted to test provincial legislation requiring the funding of public health programs. This short-sighted approach would serve neither public health nor public finances well in the long run.
Planning for the amalgamation of municipalities in the new Toronto is already consuming enormous amounts of public health staff time, and experience from other amalgamations suggests that this commitment will continue for several years through the implementation period. Since no new resources have been provided to deal with institutional change, attention to services will inevitably be reduced. We must strive not to let the focus on organizational issues detract us from keeping on top of health needs and priorities.
An annual survey of changes in the capacity of community service agencies in the new Toronto shows 40% of agencies cut one or more programs in 1996 with immigrants and refugees, youth, low income families and women experiencing the greatest service losses. Thirty-three agencies closed in 1996. Agencies identified child care and health/rehabilitation as the two largest gaps in unmet community service needs. People with disabilities, addictions, pre-school children and ethnocultural groups were most frequently identified as having outstanding needs for health and rehabilitation services.
5. In Summary
The foregoing picture of high population health needs, downward trends in determinants of health, the continuing emergence of new threats to health, and declining capacity for public response accounts for the current extent of unmet health needs and should serve as a warning for the future of the new City. In other areas of public service need, temporary gaps cause inconvenience which can be tolerated in the interest of long-term objectives. Road paving can be put off for another day. In public health, unmet needs today cannot easily be remedied tomorrow. The child growing up in poverty, deprived of basis prerequisites of health at a critical point in physical and intellectual development carries forward a lifelong burden of risk which cannot be easily reversed. The teenager who begins to smoke faces a long term battle with addiction and the potential for disease and death. The transmission of HIV infection now cannot be undone later - and carries the risk of further transmission and early death.
If we are to reduce these future burdens on our city
=s health, we must act now to prevent them. Our capacity to do so will be shaped by the decisions we make in the present public sector transition.
Choices for the Future
The download of public health funding to municipalities removes any doubt about who is chiefly responsible for protecting and promoting the health of the population. The Board of Health is responsible for ensuring the provision of universally required and additional locally needed public health services. The new City of Toronto City Council is responsible for providing sufficient funding. The effectiveness of our efforts depends on our working in partnership with local communities. The decision rests with us whether to accept, or to prevent to the best of our ability, the future burden of health foreshadowed by current conditions.
1. Investing in Health
Current public health knowledge includes interventions which will prevent or mitigate many of today
=s health risks. These interventions represent a low cost investment that saves future public expenditures by preventing or reducing future health problems and service needs. Programs noted by the World Bank 1993 report AInvesting in Health@ as being especially cost-effective and that should be provided by all governments include: immunization, school based health services, nutrition education, programs to reduce tobacco use and alcohol consumption, regulatory action to improve the household environment, AIDS prevention, prenatal programs, family planning services, tuberculosis control, and STD control.
Based on the combined 1997 budgets of the seven current municipalities, public health represents 1.7% of the expenditures of the new Toronto. This is a minimal investment that the current Boards of Health have agreed needs to be maintained and expanded to address growing needs across the city. In order to reap the greatest returns on our investment, programs which will reduce our future burden of ill health should be made available to all those who can benefit. Examples which address some of the threats to health outlined in this report include:
- Prenatal interventions such as Healthiest Babies Possible are effective in reducing low birth weight among women at risk. However they are available only in the current City of Toronto and have long waiting lists. Babies born too small are more likely to dies as newborns and face health and development risks as they grow up. Hospital costs alone are four times greater for an underweight than a healthy weight baby.
- Direct observed therapy (DOT), an intensive case management program that is the most effective approach to treatment for tuberculosis. Its use in Texas and New York has resulted in a reversal of the resurgence of TB in those areas. Current resources allow only a small proportion of all cases to be treated in this way, missing opportunities to ensure people get full treatment, reduce reactivation and spread of the disease and contain the risk of expansion of drug resistant tuberculosis. This program should be make available to all reported cases where treatment compliance is at risk.
- Needle exchange programs such as Toronto
=s The Works are cost effective in reducing the risk of HIV and other communicable diseases and saving direct health costs estimated to be about $100,000 for each HIV patient. Current resources are insufficient to provide this service to all who could benefit across the new City.
Many other public health interventions can influence the future health of Toronto for the better, and these investments should be made based on local need. Health needs are not uniform across the new City, and public health services should be more intense where needs are greater.
Projected annual savings of $470 million resulting from hospital restructuring in the new Toronto provide an opportunity for reallocation to disease prevention, health promotion, environmental protection and community support. It makes sense to use these hard-won savings to invest in strategies and services that will prevent the need for future hospitalization and help communities care for people with greater and more complex needs now.
2. Working with Communities
Citizen action has been a driving force behind many good public health decisions and investments. Communities have identified health problems, pushed for action, and acted as partners in finding and implementing solutions. Environmental lead contamination, air pollution from incinerators, and AIDS prevention are recent examples. Today we continue to support communities to take an active role in addressing health issues through staff support, information, and financial grants.
Health grants to community groups strengthen local capacity and create effective partnerships. Communities with resources are often in the best position to develop strategies to address their health needs. Community grants in Toronto for food access, children
=s nutrition, drug abuse prevention and AIDS prevention are a small but effective investment in community action. They fund service to hard to reach groups and in some cases leverage additional funds many times greater from other sources.
The new City needs to build citizen participation into decision making and service delivery. This is necessary to ensure the voices and needs of diverse population groups are acted on and that services evolve according to changing needs. Citizens should be well represented on the Board of Health and local community health advisory committees. The new Board of Health should continue the practice of the current Toronto board and regularly invite public comment on health issues. A variety of mechanisms for community input on public health issues and services should be available to provide access for a diverse city.
3. A Strong Voice for Health
If we are to take advantage of all opportunities to preserve and protect our future health, health must be at the top of our public agenda. Giving priority to public health interventions and healthy public policy requires clear articulation of the health implications of public decisions. As a society we place a high value on health. Any decision to compromise our current and future health in order to achieve competing objectives should be made publicly and explicitly.
A strong voice for health in the form of an independent Board of Health with a broad health mandate and ready community access is an effective mechanism for keeping health on the public agenda. The new Toronto City Council should foster such a Board of Health and support it in its role.
Conclusion:
In this report I have outlined substantial threats to health in the new City of Toronto. Our knowledge of health allows us to forsee the future burden of ill health, disability and death which will result from today
=s conditions of increasing health needs and shrinking capacity to respond. Most worrisome are the predictable consequences of poverty, with its pervasive influence on life chances and long term health.
Our understanding allows us to prevent or mitigate many of these consequences if we make health a priority, ensure access to effective health interventions for all who can benefit, and create in the new Toronto an urban environment supportive of health through healthy public policy.
David McKeown, MDCM, MHSc, FRCPC
Medical Officer of Health
