January 25, 1999

To:Budget Committee

From:Secretary, Board of Health

Subject:The State of the City's Health: Achieving Public Health Goals in the Millennium

Recommendation:

The Board of Health reports, for the information of the Budget Committee, having:

(1)adopted the report dated January 14, 1999, from the Medical Officer of Health, with a direction that such report be forwarded to the Budget Committee as part of a package with other reports requiring budget approval; and

(2)requested the Chair of the Board of Health to seek a meeting of the Board with the Mayor, prior to consideration of the budget and in addition to the Budget Committee process, to discuss public health priorities.

Background:

The Board of Health on January 25, 1999, had before it a report (January 14, 1999) from the Medical Officer of Health respecting The State of the City's Health: Achieving Public Health Goals in the Millennium, and recommending that the Board of Health endorse this report and refer it to the Community and Neighbourhood Services Committee, Budget Committee and City Council.

The Medical Officer of Health gave a presentation to the Board with respect to the foregoing matter.

Secretary,

Trudy Perrin/es.2

Attachment

Sent to:Budget Committee

Community and Neighbourhood Services Committee

Chair, Board of Health

Medical Officer of Health

(Report dated January 14, 1999, addressed to the

Board of Health from the Medical Officer of Health)

Purpose:

This annual report to the Board of Health provides citizens of Toronto with information on their health, the health of their City, and measures needed to ensure that health needs continue to be met.

Recommendation:

It is recommended that the Board of Health endorse this report, and refer it to the Community and Neighbourhood Services Committee, Budget Committee and City Council.

Background:

At its meeting on February 19, 1998, the Board of Health received a report from the Medical Officer of Health reporting on health trends in Toronto and key issues for Public Health programming and resource allocations. This report provides an update of trends over the past year and highlights some of the significant issues that the Board of Health must address to ensure we enter the millennium with an effective and efficient public health infrastructure. It also points out that there are major deficiencies across Toronto with respect to meeting provincially mandated core programs and in providing an equitable level of service to all residents. The issues highlighted in this report make up only part of the activities of Toronto Public Health. Detailed information on programs will be provided in separate reports as we proceed through the budget process.

Comments:

(1)Creating a Healthy City:

In its first year as a new city, Toronto is emerging as one of North America's most vital urban centres. Despite the challenges of downloading and amalgamation, scores of initiatives are underway to strengthen and develop Toronto's economy to ensure that it maintains its reputation as the number one city in the world in which to live, work and play. Developments in the cultural, entertainment and sports industries will increase tourism, attract major conferences and conventions, and contribute to the health of our city.

Critical to the development of a healthy city is a strong social infrastructure that includes safe, affordable public transit, healthy parklands, improvements in water and air quality, maintenance of roads and the strengthening and development of accessible and effective Public Health services to promote health and prevent disease. With 2.4 million residents in a 620 square mile area, Toronto is more populous than many Canadian provinces. Its health is vital to the social and economic health of the region, the province, and the country as a whole.

Contrary to what has happened in many American cities, where the flight of the middle and upper classes has left many inner city residents without the services, commercial areas and transit that help keep cities safe, wealthy and low income people continue to live in close proximity in Toronto. The new city has a diverse population with different cultures, ethno-racial groups and well defined community identities, and, as with all major cities, a higher proportion of people requiring special services.

Amalgamation has meant that Public Health has had to find new ways of working together, as well as building on the best of the former municipalities. The past year has seen us striving to make our services more efficient, accessible across the city and responsive to diverse needs so that we can improve the equity of health outcomes and the overall health of the population.

We are still in the early stages of restructuring and have a long way to go before our six former health units are truly amalgamated. In our first year, with the support of the Board of Health and City Council, we made significant progress in delivering and expanding our services. For example, we:

(a)created a new management structure to meet the demands of the amalgamated city;

(b)implemented the provincially funded Healthy Babies Healthy Children program, providing screening, assessment and lay home visiting services for families according to need across the city;

(c)expanded the school food program to include more than 34,000 children in 170school and community locations across the city, supported by municipal and provincial funding and contributions from community partners;

(d)amalgamated and redesigned the vaccine preventable disease program;

(e)undertook a massive investigation of an outbreak of Cyclosporiasis and made recommendations to the federal government on the improvement of food importation and safety standards;

(f)established a meningitis hotline in response to public concern about a serious outbreak in a nearby municipality, answering more than 10,000 calls in a three-week period;

(g)launched a major new city-wide Heart Health partnership to increase awareness of the role that diet, exercise and smoking play in heart disease; and

(h)maintained delivery of high quality core public health programs.

(2)The State of the City's Health:

The major causes of illness, disability and premature death in Canada are heart disease, cancer, stroke, respiratory disease, injuries and suicide, and, in Toronto, AIDS in young men. These, as a I reported earlier, remain central challenges for Public Health and are the focus of major public health programs to reduce smoking, improve diets, reduce unsafe alcohol and drug use, and unsafe sex. As well, cities by their very nature have unique issues. While they attract people with higher education and wealth, they also attract people who need access to the basics for survival. The fact that Toronto has a well educated and relatively well off population gives Torontonians the opportunity to ensure that we provide services for those of us who require them. It is not only our obligation to do so, it is in our interest to do so if Toronto is to remain an attractive place for people to live and businesses to develop.

Toronto is now the most populous municipal public health jurisdiction in Canada. The City has some of the highest health needs of all urban areas in Ontario. As reported earlier, in terms of its position within the Greater Toronto Area, Toronto has 51.5 percent of the population of the GTA and a disproportionate number of people with high needs, including the majority of low-income people, single parent families, seniors, poor children, low birth weight babies, immigrants, AIDS and tuberculosis cases. In February 1998, following up to the report "Threats to Health in the Changing City: Choices for the Future", I reported that the overall health of the public remains positive, but that there are warning signs for the future. Those warning signs persist today and there are disturbing trends in some areas, particularly in regard to poverty, homelessness, HIV infection and tuberculosis.

(3)Trends in the Determinants of Health:

Education, work, income, social equity and social support, a safe environment and freedom from discrimination are important determinants of health. Poverty and income inequities increase susceptibility to disease and are strongly related with higher rates of illness, disability and premature death in the population.

(i)Poverty:

Toronto has significant and disturbing levels of poverty. Data from the 1991 and 1996 Census show the number of low income families increased in more than 90 percent of Toronto census tracts, and median incomes declined in each of the former municipalities. As of June 1998, 40,000 households, representing 100,000 people, were on the waiting list for social housing in Toronto. From October 1990-96, the number of people using food banks increased by 44percent. In Ontario, child poverty has increased by 116 percent since 1989, and one of every three Toronto newborns is born into a family where poverty is a risk factor. A 1998 study of women and children using Toronto food banks found inadequate intakes of iron, magnesium, vitamin A folate, protein, zinc and calcium - nutrients that affect prenatal and infant health, child development and increase the risk of chronic disease. The birth weight of babies born to teens and the percentage of underweight babies increased in areas with the highest poverty and unemployment rates. Public Health food access programs help only one-quarter of the estimated 100,000 people that could benefit from such programs.

(ii)Homelessness:

City Council has identified homelessness as a crisis. One of the most troubling aspects of homelessness in Toronto is the number of youth sleeping on the streets, which has been estimated at 10,000 during a period of one year. Among these youth, there are about 200pregnant teens and teen mothers. Their future is grim. More than 4,000 people use city shelters each night, about 20 percent of them children. Public health nurses and outreach workers report more people sleeping in alleys and stairwells. The number of women and children using shelters because of parental or spousal abuse increased 45 percent from 1991 to 1995. Between 11 percent and 33 percent of homeless people have severe mental health and/or addiction problems.

(iii)Immigration and Ethno-Cultural Needs:

Public Health services must continue to recognize the diversity of our population in terms of cultures, faith, race, language and literacy. Almost 50 percent of Toronto's population is made up of immigrants and refugees; more than 70,000 immigrants and refugees come to Toronto every year, and just over 40 percent speak neither English nor French. They require a broad range of public health services that are accessible, equitable, and non-discriminatory and respond to the variety of values, norms, needs and practices of the various ethno-racial, cultural, linguistic and faith communities that make up Toronto.

(4)Emerging Health Threats:

(i)Tuberculosis (TB):

The World Health Organization has declared TB a global emergency. A resurgence of TB in Toronto seems inevitable unless we have a strong infrastructure to ensure effective prevention and control. We have high levels of immigration from countries where TB is endemic and no effective system to ensure infected immigrants are identified and treated. (Ninety percent of cases are foreign born.) We also have crowded drop-ins and shelters, more poverty and increasing HIV co-infection. From 1992-96, 3.7 percent of Toronto TB cases had HIV listed as a risk factor. In 1996 that figure increased to 4.2 percent of cases. While current TB levels are stable, it takes several years for a resurgence of TB to become evident. Drug resistant TB is a major concern. Of the 450-500 cases of TB that are reported in Toronto each year, 16percent are resistant to one or more commonly used antibiotics. This compares to 8.7percent nationally. It costs close to $300,000.00 to treat one case of multi-drug resistant TB, compared with less than $20,000.00 to treat a case of non-resistant TB. The World Health Organization recommends directly observed therapy (DOT, a supervised treatment method) for all cases. Less than 20 percent of Toronto cases are on DOT.

(ii)Tobacco-Related Disease:

As reported earlier, a disturbing increase in tobacco use began in the 1990s, after two decades of decline. Statistics from the Ontario Tobacco Research Unit show that 29 percent of females and 26 percent of males age 12-19 now smoke. One of the reasons for this high level of smoking is the low cost of cigarettes in Ontario following the lowering of federal and provincial taxes. As well, the rates of lung cancer deaths in women continue to rise. The increase in tobacco use by youth will result in illness and early death in the next generation of adults. Exposure of children and youth to environmental tobacco smoke (ETS) at home and in public places where smoking is still permitted (e.g., restaurants, bars, bowling alleys, billiard halls) is also a major concern. Tobacco related illness and death is preventable. Prevention requires education, smoking cessation programs, and policies and legislation to reduce youth exposure to tobacco products and environmental tobacco smoke.

(iii)HIV/AIDS:

HIV infection among injection drug users in Toronto has increased from 5 percent in 1991 to 9.5 percent today. Once the figure reaches 10 percent, studies show that an explosive spread of HIV can occur in users, their partners, and their children. In Montreal 20 percent of users are infected, in Vancouver 25 percent. If the local increase continues, Toronto will see increased HIV/AIDS rates in women and newborns and children. HIV infection in Ontario women of childbearing age is estimated at 6/10,000 women, three times estimates from 1992. Conditions that contribute to increased infection, and the spread of other blood-borne diseases, such as Hepatitis B and C, include lack of stable housing, transience and sharing needles. Street youth are at significant risk of HIV infection, with estimated HIV rates triple those of the general population.

(iv)Air Quality and Health:

In response to concerns about the quality of Toronto's air, in 1998 the Medical Officer of Health chaired a corporate-wide smog alert program that came into effect in the spring. Three smog alerts were called advising citizens, municipal operating divisions and other sectors to restrict activities that pollute the air. The City turned off all but essential gas powered equipment. These measures raise awareness but much more needs to be done, particularly in light of increasing rates of asthma in children and increasing hospital admissions on poor air quality days. Sustainable transportation options are needed to reduce our reliance on the car, one of the main causes of poor air in Toronto, and reductions are needed in the sulphur content of fuel, emissions from coal-fired generating stations, and in the use of pesticides.

(v) Food-Borne Illness:

The nature and scope of food-borne diseases are rapidly changing, resulting in greater public risk. There are more than 1,700 cases of food poisoning reported each year, but with under-reporting actual incidents of food poisoning may be as high as 42,500 cases. In the last decade there have been widespread food-borne outbreaks in industrialized countries from agents previously unrecognized as food-borne pathogens; e.g. E.coli 0157:H7, Salmonella typhimurium, DT104, Cyclospora. There is increasing virulence and prevalence of food-borne pathogens and an increasing number of previously unrecognized "hazardous" foods. Globalization of the food supply, new production technologies and inadequate safety practices in homes contribute to outbreaks. This year Toronto experienced a large outbreak of Cyclosporiasis, precipitating a major investigation involving Canadian and United States agencies. This was the third such outbreak in North America linked to contaminated raspberries from Guatemala and could have been prevented by more stringent policies regarding importation of food.

(5)Maintaining a Healthy City:

To maintain a vibrant, healthy city, we must ensure we have effective services to address growing health needs. As noted previously, declining public resources, a weakening of the social safety net and rapid institutional change, including hospital restructuring and inadequate long term care beds, have diminished our capacity to respond to the health challenges we face. Federal contributions to health care are undergoing constant change and it is uncertain what funding will be available in the new millennium. Provincial policy reforms have reduced welfare eligibility and benefits; there is reduced protection for renters, and a moratorium on social housing construction. All these factors affect poverty levels and impact on health. The pressures of amalgamation and the downloading of Public Health to municipalities are diverting attention from serious public health issues at a time when needs are growing.

In many areas, Public Health is not meeting the minimum legal standards prescribed in the Mandatory Guidelines. Examples of areas currently below standard include prevention and control of tuberculosis, needle exchange for the prevention of HIV transmission, and the safe handling of food. As well, non-mandatory programs that have evolved over time in response to local needs are not equitably distributed across the new City. These include services to help homeless people, strategies to help people access nutritional food and needle exchange and harm reduction services to reduce substance abuse. There are large pockets of unattended needs throughout the City.

We are looking at all of our programs to see how we can meet the Mandatory Guidelines and local needs with efficient use of resources and maximum effect. However, as I reported last year, additional resources will be required to meet provincial standards and to address local needs. We currently estimate we will need an additional $13 million to meet the new Mandatory Guidelines. An adjusted estimate of costs to harmonize and level services and meet information technology needs will require further review on a program-by-program basis.

Conclusions:

Public Health is a critical part of the social infrastructure, as important as the bricks and mortar for new buildings. As we enter the new millennium, it is important that we not lose sight of the improvements in health that have occurred as a result of effective public health programs. Helping new mothers breast feed; making sure children are immunized; teaching nutrition; preventing smoking; teaching hand washing in day cares; inspecting restaurants; tracking and controlling disease; maintaining dental health so people can eat properly and maintain good health - these are just some of the nuts and bolts of public health, and they are the reason we have improved life expectancy, eradicated communicable diseases like smallpox, and reduced the spread of new diseases like AIDS. Public health services, such as ensuring clean water and safe food, provide the foundation for a healthy population. Toronto has significant health challenges, and while the overall health of the population continues to be positive, the warning signs I pointed to last year still pose significant concern. Continued vigilance and investment in services that prevent disease and promote health are essential in order to ensure that our City grows with vibrancy. The decisions made today will affect the health and prosperity of our City tomorrow, and for decades to come.

Contact Name:

Dr. Sheela V. Basrur, Medical Officer of Health, 392-7402, Fax: 392-0713.