STAFF REPORT

February 14, 2000

To: Board of Health

From: Dr. Sheela Basrur, Medical Officer of Health

Subject: The State of the City's Health

Purpose:

This report provides an overview of the health of people in Toronto along with an outline of some Toronto Public Health strategies to improve health outcomes.

Financial Implications and Impact Statement:

There are no direct financial implications stemming from this report.

Recommendation:

It is recommended that this report be received for information.

Background:

At its January 25, 1999 meeting, the Board of Health received a report from the Medical Officer of Health outlining health trends in Toronto and key issues for Public Health programming and resource allocations. This report describes the state of the city's health according to life cycle stage and outlines some Toronto Public Health strategies to improve health. The report also highlights health trends for the coming years.

Comments:

Toronto is one of the most diverse cities in the world and one of the largest cities in North America. Toronto Public Health is responsible for the public health of almost 2.5 million people who live in the city as well as an estimated additional half million who come to the city for work, education, recreation and health care.

Toronto is a key destination for newcomers to Canada. The city receives about 30% of all immigrants to Canada and almost 50% of Canada's refugee claimants (about 10,000 per year) enter through the Toronto region. They come from over 200 countries and speak 160 languages or dialects.

The City of Toronto has 17,500 food premises, 73,500 workplaces, 780 licensed child care centres, 1,575 pools, spas and beaches and approximately 5,000 health and personal service facilities, all of which must comply with public health legislation and City by-laws.

Many Public Health strategies are aimed at specific age groups, while others address the health needs of the total population. In addition, many benefits of preventive strategies are reaped later in life for the individual as well as benefiting Toronto's population as a whole. Some public health strategies specifically address the health needs of vulnerable and high-risk individuals while others protect everyone and strengthen the health infrastructure.

Evidence-based research and planning, sound administration and effective communication form the foundation for all public health programs and services and ensure efficiency and responsiveness to client needs. This is fundamental to excellence in public health practice and is a requirement in the Mandatory Health Programs and Services Guidelines.

(1) Population-wide Strategies

Public Health provides a number of programs and services that protect the health of the whole population by reducing the risk and spread of disease and by reducing the public's exposure to chemical and biological hazards. These include: 24 hour response to disease outbreaks; controlling infection in institutions such as child-care centres, nursing homes, homes for the aged and hospitals; ensuring food safety in all premises that prepare, sell or serve food; monitoring the safety of water at pools and beaches and enforcing by-laws that protect people from exposure to animal bites and rabies; and encouraging responsible pet ownership. In addition, the Medical Officer of Health, on behalf of the City, calls extreme cold and hot weather alerts, and smog alerts.

Many high profile issues including emerging diseases and outbreaks require immediate response and are the unique mandate of Public Health. In 1999, Toronto Public Health responded to over 35,000 notifications of communicable diseases, and investigated and managed 275 disease outbreaks. However, the division currently lacks the capacity to respond to 25% of reported cases in a timely manner and is unable to implement new provincial requirements regarding infection control in the 5,000 personal service settings (e.g. tattoo parlours) that exist across the City.

The Healthy Environments program reduces the public's exposure to chemical, biological, physical and other health hazards in the environment by ensuring 24 hour response to health hazards (over 1000 after-hours calls per year) and promoting corporate policies such as the phase-out of pesticides in parklands. As well, they reduce the incidence of water-borne and food-borne illnesses, enforce compliance with the Tobacco Control Act and municipal by-laws, prevent the occurrence of rabies in humans and respond to emergencies and disasters in concert with other emergency personnel.

Toronto Animal Services is a high profile service whose mandate is to facilitate the harmonious co-existence of people and animals. Field services include enforcement of animal related by-laws, seasonal park patrols and cadaver pick-ups. Shelter services include sheltering of stray animals, lost and found searches, adoptions and sterilization clinics. Toronto Animal Services responds to over 187,000 public enquiries per year and provides approximately 175,000 animal care days per year. Animal Services are well regarded by the public, however, public demand for service far outweighs current capacity for both field and shelter services.

(2) Children and Youth

Approximately 33,000 babies will be born to Toronto residents in 2000. Public Health concentrates resources and strategies in the early years to support healthy growth and development that will prevent early problems from becoming threats to health later in life.

Prenatal:

For some babies, the services of Public Health begin even before birth. Pre-conception and prenatal programs focus on reducing the number of newborn babies weighing under 2500 grams or five and a half pounds. These low birthweight (LBW) infants are more likely to die in infancy, experience health or developmental problems and require other services. The low birthweight rate for Toronto for single births, is 5.7 per 100 live births compared to 4.7 for Ontario. Low birthweight may be related to a number of factors including the mother's age, nutrition and health status, income, housing, exposure to substances and contaminants, and pregnancy factors. In 1994, the low birthweight rate for Toronto's lowest-income areas was 30% higher than it was for the city's highest-income areas. By 1997, the difference had increased to 40%. This trend is of great concern to Public Health.

More than 4000 pregnant women and their partners attend Public Health prenatal classes every year. About 5000 high-risk pregnant women receive prenatal nutritional counseling and support, and, where needed, nutritional supplements. Because maternal risk factors such as drug use, or lack of permanent housing tend to decrease the chances that a woman will receive prenatal care, Public Health conducts outreach to provide support for these highly vulnerable women.

Newborns:

In 2000 Public Health staff will contact all new mothers within 48 hours of discharge from hospital and offer a home visit. Public Health Nurses contact approximately 120 mothers every day; about 80 receive home visits. This is provided through the 100% provincial funded Healthy Babies Healthy Children (HBHC) initiative. As well, the HBHC program provides home visit support and referral for high-risk families with young children, identified through hospital screening and Public Health nursing assessment. Public Health also works with high risk groups and the community to provide postpartum, breastfeeding, and parenting programs that promote parent-child attachment, infant nutrition and stimulation and healthy growth and development while seeking to prevent infant illness, injury and death.

Young Parents with No Fixed Address:

A group of babies facing exceptionally high health and safety risks are those born to women without stable housing. With the growth in youth homelessness over the past decade in Toronto, has come a corresponding increase in the number of young pregnant women without permanent homes. Over 200 babies are born in Toronto each year, to mothers who do not have permanent or stable housing. Approximately one third are teen-agers. Through the group, Young Parents With No Fixed Address, Public Health works in co-operation with local health and social service providers to help ensure the welfare of children born to women in these circumstances. This includes providing prenatal health care and counselling for the mothers, arranging addiction treatment where needed, and assistance in securing housing and other necessities.

Pre-schoolers:

There are 134,000 children in Toronto between the ages of 6 weeks and 4 years, comprising 5.3% of the population. Research has clearly demonstrated that the early years from 0 to 6 years are critical to brain development. The 100% provincially funded HBHC program provides young families with professional and peer support in their homes, aimed at supporting them in creating a home environment that supports healthy growth and development. This program also provides capacity for early identification and referral of problems. A key component of this program is provided by the family home visitors who come from diverse ethno-racial backgrounds, speaking over 35 languages.

In addition, Family Health programs provide group parent education, parent information lines, and assist in creating healthy communities for children.

One of the key milestones in healthy growth and development and readiness to learn is language acquisition. The Ministry of Health estimates that 10% of children in this age group have a speech and language disorder, although fewer than half are identified and referred to treatment before school entry. In 1998, the province allocated funding to coordinate a Toronto Pre-school Speech and Language system to promote early identification and provide treatment services.

There are 45,000 licensed child care spaces in Toronto. Public Health inspections help ensure safe food handling and adherence to adequate standards of cleanliness and playground safety. Communicable disease control staff review immunization records to ensure that childrens' immunizations are up-to-date. In addition, they respond to reports of communicable disease outbreaks to prevent and control disease transmission.

Sixty percent of Canadian children do not meet average fitness standards and childhood obesity has doubled since 1980. The Rainbow Fun initiative, a Public Health program promoting physical activity early in the life cycle, has reached an estimated 25,000 children in child-care, schools and family resource centres and trained 1,700 childcare workers. It received an Award of Excellence in 1999 from the City's Children's Services Division.

School-age Children:

There are 235,000 children aged 5 to 12 in Toronto. They make up 9.3% of the overall population. Public Health ensures that children under 18 years of age attending public schools, private schools and licensed childcare centres, are immunized against vaccine-preventable childhood diseases. Public Health offers Hepatitis B vaccine to all Grade 7 students.

The dental health of the majority of children has generally improved in the last two decades. However, local surveys show that 8 percent of 5 year-olds have urgent dental health needs (pain or infection) and that half of all children have experienced dental decay by age 13. Children in refugee or immigrant families are twice as likely as other children to need urgent dental care. Children who are identified with dental disease through either public health preventive services or by screening in elementary schools or child care centres, are referred for treatment. Children with urgent dental needs whose parents declare financial hardship or who are on social assistance are eligible for free dental services through provincially mandated programs (Children in Need of Treatment and Ontario Works). Children who are not eligible for provincial programs and whose families cannot afford dental services in the private sector, may be eligible for care through the municipally funded dental program.

Public Health improves the nutritional well-being of children by providing support, consultation, training and monitoring of school and community based child nourishment programs. A total of 53,000 children are served in 305 child nutrition programs at schools and community sites, through partnerships between Toronto Public Health, community agencies, Boards of Education and the province; an expansion from 8 programs in 1991. About 20% of elementary school children currently have access to some form of nutrition program. The City of Toronto currently contributes $1.3 million in grants to child nutrition programs, which comprises 17% of the overall budget for this initiative. The balance is made up by corporate, provincial and parent contributions.

Smoking, poor nutrition, childhood obesity and physical inactivity all increase the risk of heart disease, some cancers, diabetes and osteoporosis in adulthood. Healthy behaviours developed and supported in childhood are likely to be carried into teen and adult years. To help children, parents and caregivers make healthy choices, Public Health in collaboration with school boards and community coalitions, provides education on the prevention of tobacco use, substance abuse, violence and the promotion of self-esteem, physical activity and healthy eating. Examples of these are Ready or Not for parents of children aged 8 to 12, the Grade 5/6 Substance Abuse Awareness Program, Drug Prevention Grants, and the Walking School Bus.

Often, signs of maladjustment, stress or other problems which may be precursors to serious social problems in adolescence and adulthood, are exhibited in younger children. Elementary school-based mentoring programs which provide individual attention, guidance and support to children deemed at high risk for such serious problems, have proven remarkably successful in increasing self-esteem, motivation and school performance for at-risk youth. The One on One Mentoring initiative, was endorsed by the Task Force on Community Safety. This innovative program currently in 5 schools will be expanded to additional schools across the city if approved through the 2000 budget process.

Youth:

Youth aged 13 to 24 comprises 13.5 percent of the population for a total of 340,000. The major concerns for this age group are sexual health, drug use, mental health and self-esteem, access to affordable and appropriate education and sustainable employment. Most youth take their health for granted, which can be a problem in itself. This sense of invincibility and willingness to take risks can cause accidents and injuries, and can lead to abuse of alcohol, tobacco, or other substances. Peer pressure, coupled with the fact that young people are seen as a target by marketers of alcohol and tobacco, can put them at high risk for health problems resulting from consumption of these substances.

Injuries are the leading cause of death for children under 20 and the second most frequent cause of hospitalization in Ontario. For youth aged 12 to 24, the major cause of injury hospitalization is suicide. Motor vehicle collisions are the number one cause of death for youth 16-24 years of age. They represent only 15 percent of licensed drivers in Ontario, yet they account for 28 percent of impaired driving collisions and 32 percent of drivers involved in fatal crashes.

After a lengthy period of decline during the 1980's, the 1990's have seen an upsurgence in adolescent drug use. Since 1993, there have been steady increases in Ontario in the use of a number of substances including: alcohol (from 57 percent to 66 percent), cannibis (from 13 percent to 29 percent), MDMA (ecstasy), from 0.6 percent to 5 percent. The percentage of youth using four or more drugs increased from 8 percent to 17 percent while those who do not use any drugs dropped from 36 percent to 27 percent.

One of the deadliest drugs, tobacco, remains popular among teens. Recent reports indicate that approximately 29% of females and 26% of males aged 12-19 smoke cigarettes. In addition to population-wide strategies to decrease cigarette smoking, Public Health has intensified strategies to specifically reach this age group. These include smoking cessation programs tailored to meet the specific needs of this age and working with the Boards of Education on developing student media awareness of cigarette marketing. Health Canada has recently assigned four staff to work with Toronto Public Health to ensure compliance with the Tobacco Control Act which prohibits sales to minors.

Additional programs focusing on other serious risks to youth include many diverse initiatives in drug and alcohol prevention. Experience and research shows that youth-based initiatives which directly involve youth in planning and implementation are more effective. "In the Driver's Seat", is a school-based peer-led initative, in which youth develop their own reasons and rationale regarding alcohol and their risk-taking behaviour as they learn about drinking and driving. "Safe Grads: Party in the Right Spirit", mobilizes youth in local schools to promote safe graduation events. Another youth led initiative which emphasize the dangers of chronic drug use is the Ambassador Program, in which older youth who are recovering youth substance users, speak out about the negative consequences of their own drug use to students in junior high schools. In still another venue, educational materials regarding "club drugs" are distributed at raves.

Perhaps the need for prevention of teen violence has never been more clearly or tragically demonstrated than by a series of high school shootings over the past two years in the United States and now in Canada. In addition, several cases of gang-related youth violence in Toronto reinforce the need for early intervention and comprehensive prevention programs. Students with low self-esteem, those who are socially isolated, excessively teased or bullied, as well as individuals coping with chaos in their home lives are at highest risk. Unfortunately, this increased awareness of the need to provide guidance for troubled children and youth is occurring just as the number of guidance counsellors, public health nurses and social workers is being decreased in schools.

Youth and younger adults are at the greatest risk for sexually transmitted diseases (STDs), including HIV/AIDS and for unplanned pregnancy. Teen pregnancy rates are 64 per 1,000 in Toronto versus 47 per 1,000 for all Ontario. Incidence rates for all STDs are higher in Toronto than for the province. For example, there were 1,374 cases of chlamydia per 100,000 women aged 15-24 years in 1997 which is three times the provincial rate. In 1997, Public Health staff followed 5,744 cases of STDs including HIV/AIDS. There were an estimated 37,634 visits to sexual health clinics in 1999.

Toronto Public Health's work with youth is often locally based and conducted in partnership with youth and youth servicing agencies. However, Public Health is under-resourced to address the scope and breadth of these issues. The challenge for the city as a whole, is to provide a co-ordinated and comprehensive strategy to address the needs of youth.

(3) Adults

The adult population of Toronto represents the largest number and proportion of Public Health clients. It is estimated that there are almost 1,450,000 residents ages 25 to 64 years of age representing 57 percent of Toronto's population. The number of adults served by programs and services is even greater when one adds in the half million visitors, workers and students in Toronto, most of whom are adults.

Heart Disease and Cancer:

As is the case across Canada, heart disease and cancer are the two leading killers of Torontonians. In 1995, heart disease and strokes, lung cancer, prostate cancer, and colorectal cancer accounted for 37 percent of Toronto's 9,010 deaths of men. For women, heart disease and strokes, breast cancer, lung cancer and colorectal cancer accounted for 36% of the 8,480 deaths. Many of these deaths are preventable.

Between 1991 and 1995, there was an average of 3,250 deaths due to heart disease each year. While the majority of these occur after age 65, about 15 percent affect people between the ages of 20 and 64.

During the same time period, there were approximately 4,700 cancer deaths each year. A full 30 percent occurred between the ages of 20 and 64. During the same period, there was an average of approximately 10,000 new cases of cancer each year. Forty one percent of these were in 20 to 64 years olds. Toronto Public Health promotes screening and early detection of breast and cervical cancers for women, with emphasis on underserved and hard to reach populations. For example, immigrant women are three times less likely to have had a mammogram or pap test.

The number of adults suffering from these conditions will likely increase in the near future as older baby boomers (those born between 1946 and 1966) reach an age at which lung cancer, breast cancer, heart attacks and other forms of heart disease become more common. This will place an even greater strain on a health care system already dealing with major restructuring and the demands of an ageing population.

The control of chronic diseases include prevention, early detection, and treatment. While treatment and early detection efforts are important, it is prevention which has the greatest potential to reduce mortality, disability, and health care costs. Public Health's mandate is to implement a comprehensive multiple risk-factor approach towards the reduction of heart disease and cancer. The major risk factors in both heart disease and cancer are smoking, diet, exercise and stress.

Smoking:

In Toronto, 25% of men and 19% of women smoke. After two decades of decline, a troubling increase in tobacco use began in the last decade. These numbers may rise if the current trend in adolescent smoking continues, particularly for young women. In 1999, Toronto City Council took a major step forward in chronic disease prevention by passing a harmonized Environmental Tobacco Smoke by-law which ensures city wide access to smoke-free public places and work places. Public health is seeking financial resources from the province to support a public education campaign to further reduce smoking.

Physical Activity:

Almost 61 percent of Toronto's population is reported to be physically inactive.

Toronto Public Health has developed and offered a variety of physical activities programming for adults. These include: initiatives in workplaces such as training workshops for key workplace contacts, bulletin board packages, Health Works articles and pay cheque inserts. In addition, there are a number of events in various parts of Toronto to encourage parents to be active with their children (Snofest, Heart Hike, Family Active Nights, and Jingle Bell Skate). Public Health promotes walking trails in the Scarborough, North York and Etobicoke regions, and acts as a catalyst in developing mall walking programs and other walking groups throughout the city.

Nutrition and Food Security:

Public Health strategies for adults are to promote healthy eating practices that decrease fat consumption and increase intake of grains, fruit and vegetables. Strategies include health education, as well as initiatives such as the "Eat Smart" campaign. This campaign recognizes food premises that are smoke-free, demonstrate safe food handling, and offer patrons choices for better nutrition. These establishments are recognized in the award winning "Eat Smart" program book, distributed through the Tourist Bureau and the Public Health website.

The issue of food security has become a major concern as more people rely on foodbanks as a major long-term food source. Foodbanks have now become an entrenched part of Toronto's food system, assisting about 130,000 people a month in the GTA. Foodbanks rely primarily on industry donations of non-perishable goods and have limited supplies of fresh fruits, vegetables, meat and dairy products. They are therefore not in a position to guarantee nutrionally optional food for recipients; only access to adequate income can ensure this. Toronto Public Health has a mandate to ensure food safety guidelines are met. The division must continue to work in collaboration with donors, foodbanks, and recipients themselves, to ensure adherence to basic food safety standards and nutritional quality.

Stress:

The Heart and Stroke Foundation's recently released "Annual Report Card on Canadian's Health" found that 43 percent of all adults aged 30 and over are overwhelmed by either their jobs, families or finances. It is also found that workplace stress was the most common source of stress, with almost one in three employed respondents reporting difficulty coping with the demands of their jobs on a regular basis. Family and money worries were not far behind; 26 percent of respondents reported regular family stress, and 21 percent said they had financial stress.

Cancer Prevention Coalition:

Toronto Public Health has played a lead role in establishing the Cancer Prevention Coalition. This is a multistakeholder group whose goal is to reduce the incidence of cancer by co-ordinating and promoting cancer prevention initiatives, providing a strong voice for influencing policy decisions and providing a vehicle for public education, information sharing and advocacy. In 1999 the coalition was successful in securing a grant from the Public Health Branch of the Ministry of Health and the Central East Region of Cancer Care Ontario.

(4) Vulnerable Populations

Public Health targets some services specifically to populations most in need. Whether a refugee, a mother and her children about to lose their housing, a senior with a mental health problem or a pregnant teen on the street, these groups have more health problems, diseases, higher mortality rates and more barriers to accessing health services and the determinants of health, than the general population. Hence dedicated public health resources are required to provide the extra services and supports to achieve equal opportunities for improved health outcomes for all Toronto residents.

Homelessness:

The Toronto Report Card on Homelessness released by the City in early February 2000, shows that homelessness in Toronto is getting worse, not better, particularly for families with children. Toronto is in the midst of an economic boom, but the people who are most vulnerable - those with the lowest incomes - are not reaping the benefits. There is growing evidence of an increasing gap between rich and poor. Rents are rising while the vacancy rate for affordable housing remains very low at 0.9%. Employment earnings, especially for families, do not always provide enough income to escape poverty. Growing numbers of people must therefore spend more than 50% of their income on rent, placing them at serious risk of losing their housing. No new affordable or supportive housing is being built, and more people find themselves having to turn to emergency shelters.

The fastest growing group of shelter users is now two parent families with children; the number of children staying in shelters has risen from 2,700 in 1988 to 6,000 in 1998. In addition, the City's street patrols report that more people are living on the streets and many have mental health and/or substance use problems.

Toronto Public Health provides some support to homeless and underhoused people. Health nurses and community health workers provide mental health and other support to homeless people in shelters, drop-ins and hostels. They also assist agency staff in client assessment, counselling, referral and follow-up as well as with training in crisis intervention and disease prevention. In 1999, two additional public health nurses were hired to work with homeless families living in hostels or motels in Scarborough. However, the needs far outweigh the division's capacity to deliver services.

Tuberculosis:

There are 450-500 active tuberculosis (TB) cases reported in Toronto per year, comprising a quarter of all the cases in Canada. Ninety percent of Toronto cases occur in immigrants and refugees. Other groups at increased risk are the homeless, underhoused, and those infected with HIV. For people who are undernourished, immuno-compromised or who live in close quarters, there is a greater risk of becoming infected and of the disease becoming active and spreading. Public Health ensures that all active cases of TB are treated appropriately and that all contacts are assessed and followed up. This is accomplished through training for service providers, education and outreach, screening clinics and Directly Observed Therapy (DOT). Public health nurses work with individuals to ensure that medications are taken as prescribed, symptoms of drug toxicity are carefully monitored and the person gets the support they need to complete their treatment. Recent funding enhancements enable Public Health staff to provide DOT for 40 percent of cases, whereas the World Health Organization recommends that all cases get DOT.

Injection Drug Use:

There are an estimated 15,000 injection drug users within the City of Toronto, with an HIV prevalence rate of 9.5 percent. Canadian cities have had substantial increases in the HIV rate within this population. For example, Vancouver has a rate of over 25 percent and Ottawa over 15 percent. Research clearly indicates that HIV rates can increase rapidly in this population once it exceeds a 10 percent threshold. Toronto Public Health is in the process of expanding and harmonizing the needle exchange program across the city. "The Works" offers needle exchange, condom distribution, a low threshold methadone program, information about safer injection, testing for HIV, Hepatitis B and C, and TB as well as referrals to housing and other support services. The program distributes an average of 20,000 needles and 13,000 condoms a month in partnership with about 20 agencies.

(5) Seniors

There are 345,000 people aged 65 years and older in Toronto. They comprise an estimated 13.6 percent of the population. There are 195,000 seniors in the 65-74 age group and 150,000 in the group 75 years and over. Toronto has two-thirds of the seniors in the GTA, including 73% of the seniors who live alone. The proportion of people aged 75 and over is expected to increase by 31% between 1996 and 2003; a rate more than 3 times that projected for Toronto's population as a whole. It is this group and specifically those over 85, which is considered the most frail and in need of a range of health and social services, including long-term care and home support. These issues were highlighted in the report of the Seniors Task Force in September 1999.

The massive restructuring of hospitals, long-term care and community based care in the last few years has wrought upheaval and confusion, leading to an uneven patchwork of health and community services. The Community Care Access Centres [CCACs] are mandated to meet the overall health needs of vulnerable and frail seniors who do not require hospitalization. However, with increased numbers of people discharged from hospital who require acute health care in the home, the bulk of CCAC resources must go to acute homecare rather than to health and support services for chronically ill people and frail seniors in the community. Public health nurses continue to be called in by concerned neighbours, members of the public and community agencies to help the isolated or frail elderly people who are in precarious health or housing and who may otherwise slip through the cracks.

Public Health programs and services for seniors have included chronic disease and injury prevention, substance abuse prevention, communicable disease control, elder abuse prevention, informal/caregiver support initiatives and dental services. The Seniors Task Force recommended that City Council continue to fund these programs and services and that Toronto Public Health continue to work with Community Care Access Centres and other agencies to address the needs of the "at risk" frail elderly. It also recommends that Public Health advocate for policies and practices which ensure equal access to health care and other supports and services for seniors. In addition, they recommend that the province reinvest funding into the health care sector to ensure that the principles of access and high quality care are not compromised and that the funding be significantly enhanced for nursing services, Community Care Access Centres to expand community long-term care services and mental health services for seniors.

Falls Prevention:

One public health objective for seniors within the Mandatory Health Programs and Services Guidelines is to reduce the rate of death and injury from falls. In Toronto, falls-related injuries are the leading cause of injury hospitalization and death for people age 65 and over. Public Health works in partnership with health-care providers and community groups to support policies and education targeted at seniors to prevent injuries.

Dental Services for Seniors:

It is estimated that 12,000 low-income seniors are not able to access dental care. Prior to amalgamation, only 2 of the 6 former municipalities offered dental treatment services for seniors. In April 1999, Council approved $800,000 to harmonize the dental program for low income seniors and children by extending the hours of existing municipally funded dental clinics. In December 1999 Council approved $1.6 million for the continuation of the expanded non-mandatory dental program, however, funds have not been identified in the 2000 budget to underwrite this expenditure. It is estimated that if the program expansion proceeds, a total of 7,000 low-income seniors across the City of Toronto will be able to obtain dental services.

Retirement Homes:

Council has taken a leadership role in addressing issues related to seniors and vulnerable adults who live in unregulated retirement and lodging homes. The goal is to ensure minimum standards of care through province-wide regulation of facilities. As an interim solution, Council directed Toronto Public Health to establish a complaints hot-line and action team, staffed by health inspectors, to enable residents, family members or other members of the public to voice their concerns about conditions in particular facilities. Between mid October and the end of January, eight Public Health inspectors answered the hotline and co-ordinated and conducted investigations, sometimes with other divisions. The team responded to 539 phone calls and conducted investigation visits at a total of 79 facilities. In January 2000 Council approved the continuation of the hotline and action team and requested that the Provincial Government introduce province-wide standards of care for retirement and lodging homes.

Influenza:

Groups at increased risk of influenza are those 65 years of age and older, individuals living in a long-term care facility, and those with heart or lung disease or other significant underlying health conditions. In a "normal" epidemic, 80-90% of deaths occur in seniors. Annual immunization in the fall is the most effective preventative measure.

Public Health actively works with long-term care institutions, as well as acute care facilities, to provide information and education, which ensures that appropriate policies are implemented regarding vaccination of staff and residents, as well as infection control. The Communicalbe Disease Control program reponds to all reports of influenza/respiratory disease outbreaks to ensure that all measures for prevention and control are taken. In the 1999/2000 flu season to date, Toronto has responded to 57 confirmed influenza outbreaks, with no associated deaths.

Conclusions:

Toronto Public Health faces unprecedented need and demand for services in a climate of cutbacks and massive restructuring of health, social, education, housing and environmental protection services. All of this has a major impact on the health of the city overall. In addition, the combined effects of amalgamation, downloading from senior levels of government and Mandatory Provincial Guidelines that are more detailed and prescriptive than before have had a major impact on the division and the city as a whole.

Public Health must address both the needs of specific age groups and the population as a whole through comprehensive strategies that encompass health protection, promotion and prevention of disease and injuries. Public health strategies aim to keep people well and can benefit both individuals and communities.

Nonetheless, it is clear that the health needs of Toronto's population exceed the capacity of Public Health to meet them. Public Health will continue to strive for an optimal balance between programs that meet mandatory requirements and those that address local needs.

Contact:

Dr. Sheela Basrur

Medical Officer of Health

Tel: 392-7402

Fax: 392-0713

Dr. Sheela V. Basrur

Medical Officer of Health