October 6, 1997 Please reply to: Frances Pritchard

Telephone No. 392-7025

Please refer to: 97hlh 9-1.let

To: Board of Health for the New City of Toronto

Council adopted the Recommendation as contained in the Clause without amendment that citizen members of the Toronto Board of Health work with citizen members of the five other health boards in Metro Toronto and other concerned citizens to organize a public hearing on the future of public health in the new City of Toronto and the importance of focussing on local health needs in planning and delivering services.

Council endorsed the following action taken by the Board of Health:

1. Directed that the report (September 9, 1997) from the Medical Officer of Health be forwarded to the Board of Health for the new City of Toronto;

2. Forwarded the report (September 9, 1997) from the Medical Officer of Health to all Boards of Health in Metropolitan Toronto, the Liaison Committee of the Boards of Health in the Toronto Area and to the Boards of Education in Metropolitan Toronto;

Yours truly,

Assistant City Clerk

_____la

FMP

cc: Medical Officer 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.

The Outlook for Health in the New City of Toronto

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.

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.

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

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.

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.

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:

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.