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Board of Health


Meeting No. 33   Contact Candy Davidovits, Committee Administrator
Meeting Date Friday, August 20, 2010
  Phone 416-392-8032
Start Time 1:00 PM
  E-mail boh@toronto.ca
Location Committee Room 1, City Hall
  Chair   Councillor John Filion  

HL33.1

ACTION

Amended 

 

Ward: All 

Sodium Reduction Strategy

Committee Decision

The Board of Health:

 

1.         urged the Federal Minister of Health to support the immediate implementation of the Sodium Reduction Strategy for Canada and to provide adequate funding to support the Strategy;

 

2.         requested the Sodium Working Group to accelerate the development of the monitoring and evaluation plan in the Sodium Reduction Strategy, including clear indicators upon which progress is measured;

 

3.         urged the Federal Minister of Health to introduce and enforce a regulatory approach within two years if annual monitoring shows that the recommended targets are not met;

 

4.         requested the Ontario Ministry of Health Promotion and Sport to establish funding initiatives to promote and support sodium reduction programs provided by public health units in Ontario;

 

5.         urged the Ontario Minister of Education to include the Sodium Reduction Strategy in Ontario’s new Nutrition Standards for schools; and

 

6.         forwarded this report to the Federal Minister of Health, the Ontario Minister of Health Promotion and Sport, the Ontario Minister of Health and Long-Term Care and the Ontario Minister of Education.

Origin
(August 11, 2010) Report from Medical Officer of Health
Summary

Canadians consume more sodium than necessary to maintain good health. According to the 2004 Canadian Community Health Survey, a Canadian adult consumes an average of 3100 mg of sodium daily, which far exceeds the recommended amount of 1500 mg.

 

A high intake of sodium increases the risk of high blood pressure, which is a risk factor for stroke, heart and kidney disease. It has been estimated that more than one in five adult Canadians suffer from high blood pressure and that over 90% of adults in Canada will eventually develop high blood pressure if they live an average lifespan.

 

To address the health risks associated with a high sodium intake, Health Canada established The Sodium Working Group (SWG), a multi-stakeholder working group to develop and oversee strategies to reduce sodium intake. The Working Group released a Sodium Reduction Strategy report on July 29, 2010.

 

The purpose of this report is to update the Board of Health on the public health impact of excessive sodium intake, review the Sodium Working Group’s report and recommendations, and outline local strategies to reduce individual and population level sodium intake in Toronto.

Background Information
HL33.1 - Sodium Reduction Strategy - Staff Report
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33043.pdf)

Speakers

Allan Jones, Advocates for Black Health Improvement
Alice Terpstra, Certified Nutritional Practitioner

Motions
1 - Motion to Amend Item (Additional) moved by Valerie Sterling (Carried)

That the Board of Health request the Ontario Ministry of Health Promotion and Sport to establish funding initiatives to promote and support sodium reduction programs provided by public health units in Ontario.


2 - Motion to Amend Item (Additional) moved by Soo Wong (Carried)

That the Board of Health urge the Ontario Minister of Education to include the Sodium Reduction Strategy in Ontario’s new Nutrition Standards for schools.


3 - Motion to Adopt Item as Amended (Carried)

HL33.2

ACTION

Adopted 

 

 

Federal Decision to Cancel the Long Form Census in 2011: Implications for Toronto Public Health

Committee Decision

The Board of Health requested the Federal Government to reverse its decision to discontinue the mandatory long form census.

Origin
(July 29, 2010) Report from Medical Officer of Health
Summary

The Federal Government has decided to replace the mandatory long form census with a voluntary “National Household Survey” in 2011.  The criticism of this decision has been swift, strong and crosses all sectors.

 

Over the past 35 years the mandatory Census has included a short form, which collects basic data on age, gender, marital status, household characteristics and mother tongue, and a long form, which collects a broader range of socio-economic data.  This data is critical for ongoing health surveillance and assessment which includes understanding the social determinants of health in Toronto.  The knowledge derived from this process underpins Toronto Public Health’s (TPH) foundational principles of identifying priority populations and using evidence to plan services and develop policies.

 

In addition to these principles, the Ontario Public Health Standards (OPHS) mandate Toronto Public Health to conduct health surveillance and assessment of the city’s population using, in part, the data collected in the long form.  The Federal Government’s proposal to eliminate the census long form will compromise Toronto Public Health's ability to fulfill this mandate.

Background Information
HL33.2 - Federal Decision to Cancel the Long Form Census in 2011: Implications for Toronto Public Health - Staff Report
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33006.pdf)

HL33.2 - Federal Decision to Cancel the Long Form Census in 2011: Implications for Toronto Public Health - Attachment 1
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33007.pdf)

Motions
Motion to Adopt Item moved by Councillor Gord Perks (Carried)

HL33.3

ACTION

Amended 

 

Ward: All 

Advertising to Children

Committee Decision

The Board of Health requested:

 

1.         the Toronto Transit Commission to reaffirm their existing practices by incorporating requirements in their advertising contracts to prohibit commercial advertising targeted to children under thirteen years of age;

 

2.         the City of Toronto Public Realm Section, Transportation Services, to reaffirm their existing practices of not targeting children under thirteen years of age with commercial advertising;

 

 3.        the City Manager to develop a corporate policy on commercial advertising at City facilities, events and public locations that includes the prohibition of advertising targeted to children, for City Council’s consideration; and

 

4.         the TTC and other City ABCs to develop policies on commercial advertising that include a prohibition of advertising targeted to children.

Origin
(August 12, 2010) Report from Medical Officer of Health
Summary

In February 2010, the Board approved a recommendation calling for “a total ban on all commercial advertising targeted to children under 13 years of age”, in order to support parents and protect children as part of an overall health strategy. This report responds to a request from the Board of Health to assess local children’s advertising practices at the Toronto Transit Commission (TTC) and Transportation Services - Public Realm Section, which manages the Street Furniture program.

 

Children today continue to be exposed to a greater intensity and frequency of advertising messages through a variety of media than any previous generation. However, the vast majority of child-targeted advertising appears via television, the Internet and through a myriad of sophisticated techniques such as product placement, viral marketing, product tie-ins, sponsorships, and more.

 

Based on the regulations used in Quebec, children’s advertising is defined as an ad whose content specifically appeals to children so as to arouse their interest and is broadcast, shown or displayed in a child-targeted context (such as a children’s TV program). At the local level, Toronto Children’s Services and the Toronto Public Library Board have implemented rules to restrict commercial ads to children in their facilities.

 

An examination of advertising practices at the TTC and the City’s Street Furniture program found no evidence that either regularly engage in commercial advertising targeted to children. However, both organizations rely on private sector contractors to administer advertising contracts and neither the TTC nor Public Realm Section has explicit policies or guidelines prohibiting advertising targeted to children.

Background Information
HL33.3 - Advertising to Children - Staff Report
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33061.pdf)

Motions
1 - Motion to Amend Item (Additional) moved by Councillor Janet Davis (Carried)

That the Board of Health:

 

1.         request the City Manager to develop a corporate policy on commercial advertising at City facilities, events and public locations that includes the prohibition of advertising targeted to children, for City Council’s consideration; and

 

2.         request the TTC and other City ABCs to develop policies on commercial advertising that include a prohibition of advertising targeted to children.


2 - Motion to Adopt Item as Amended (Carried)

HL33.4

Information

Amended 

 

Ward: All 

Shade Guidelines for the City of Toronto

Committee Decision

The Board of Health:

 

1.         requested the Medical Officer of Health to distribute the Shade Guidelines to the Ontario Association of Landscape Architects to use in their professional practice;

 

2.         forwarded the Shade Guidelines to the Chief Planner and Executive Director and the Design Review Panel for consideration in the appropriate planning policies, design guidelines and site plan review process for the City of Toronto; and

 

3.         circulated the report on the Shade Guidelines for the City of Toronto to the Toronto District School Board, the Toronto Catholic District School Board, the Conseil scolaire de district du Centre Sud-Ouest and the Conseil scolaire de district catholique Centre-Sud and encouraged all the school boards to adopt these Guidelines in their playground renovation and redevelopment.

Origin
(July 29, 2010) Report from Medical Officer of Health
Summary

Solar radiation and more particularly, the ultraviolet portion of solar radiation is a human carcinogen for skin cancer. The provision of shade in City-owned and operated outdoor venues, in particular where children are in attendance, is an important measure for the primary prevention of skin cancer and its associated health and economic burden.

 

The Shade Guidelines have been created by the Shade Policy Committee of the Toronto Cancer Prevention Coalition in collaboration with Parks, Forestry and Recreation and with the support of Toronto Public Health, as directed by the Board of Health and City Council. The Shade Guidelines are intended to complement the Shade Policy for the City of Toronto and to assist all City agencies, boards, commissions and divisions (ABCDs) to provide UVR protection and sun safety measures for their outdoor environments.  The Shade Guidelines are posted at http://www.toronto.ca/health/resources/tcpc/shade_guidelines.htm.

 

The guidelines contain recommendations and principles for increasing shade at facilities operated by the City of Toronto such as waterplay and swimming pools, playgrounds, beaches, and public squares. These facilities are used primarily during the summer when direct UVR levels are at their highest, when high levels of indirect UVR reflect from surfaces and when users typically wear minimal clothing.

 

A preliminary assessment of Toronto Parks, Forestry and Recreation playgrounds and waterplay facilities in 2008 revealed that most of the facilities required significant improvements in the level of shade provided. A shade audit of eight Toronto playground and waterplay sites in 2008-2009 was funded by a grant from the Cancer Care Ontario GTA Cancer Prevention and Screening Network which was awarded to Ryerson University in partnership with Toronto Public Health and Parks, Forestry and Recreation. The project’s objective was to provide City of Toronto staff with information on the cost-effectiveness of conducting shade audits. In addition, the project offered the opportunity to develop a consistent shade audit process, a set of standards for shade and the knowledge to implement and maintain additional plantings and development of shade structures on Toronto sites. The knowledge gained from the City of Toronto Public Playgrounds and Waterplay Facilities Shade Audit Pilot has been instrumental in the development of the Shade Guidelines. Toronto Public Health, Parks, Forestry and Recreation and the Shade Policy Committee will continue to collaborate to refine the Shade Guidelines as appropriate.

Background Information
HL33.4 - Shade Guidelines for the City of Toronto - Staff Report
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33008.pdf)

Motions
1 - Motion to Amend Item (Additional) moved by Valerie Sterling (Carried)

That the Board of Health:

 

1.         request the Medical Officer of Health to distribute the Shade Guidelines to the Ontario Association of Landscape Architects to use in their professional practice; and

 

2.         forward the Shade Guidelines to the Chief Planner and Executive Director and the Design Review Panel for consideration in the appropriate planning policies, design guidelines and site plan review process for the City of Toronto.


2 - Motion to Amend Item (Additional) moved by Soo Wong (Carried)

That the Board of Health circulate the report on the Shade Guidelines for the City of Toronto to the Toronto District School Board, the Toronto Catholic District School Board, the Conseil scolaire de district du Centre Sud-Ouest and the Conseil scolaire de district catholique Centre-Sud and encourage all the school boards to adopt these Guidelines in their playground renovation and redevelopment.


3 - Motion to Adopt Item as Amended (Carried)

HL33.5

ACTION

Adopted 

 

Ward: 2, 11, 12, 14, 17, 18, 19 

Review of Metrolinx Noise and Vibration Assessments

Committee Decision

The Board of Health requested that, during the detailed design phase of the Georgetown South Service Expansion and Union-Pearson Rail Link project, Metrolinx update the noise and vibration assessments to reflect current information on train volumes, locomotive technologies, and the noise and vibration characteristics of those technologies.

Origin
(August 4, 2010) Report from Medical Officer of Health
Summary

This report provides comments on Metrolinx’ noise and vibration assessments for the Georgetown Rail Expansion and Air-Rail Link.

 

A review of the consultants’ report identified several limitations in the noise and vibration assessments. In particular, noise impacts at City parks in the vicinity of the Georgetown Corridor were not evaluated and could be significant. Furthermore, the noise and vibration impacts associated with Tier 4 compliant trains, the new MP40 model locomotives and the new Air-Rail Link trains are not known, measured or considered in the analysis.

 

Assumptions were used in the noise and vibration assessments to fill data gaps with respect to the noise and vibration characteristics of certain current and future trains. These assumptions introduce potentially large uncertainties that are not addressed in the assessments.

 

The assessments were completed based on projected train volumes that are much higher than Metrolinx now predicts. This overestimation of train volumes could over-predict impacts; however, the potentially large uncertainties in other areas of the assessments may underestimate impacts. Given the data gaps, it is not possible to assess the accuracy of the current noise and vibration assessments.

Background Information
HL33.5 - Review of Metrolinx Noise and Vibration Assessments - Staff Report
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33009.pdf)

HL33.5 - Review of Metrolinx Noise and Vibration Assessments - Attachment 1
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33045.pdf)

Motions
Motion to Adopt Item moved by Councillor Gord Perks (Carried)

HL33.6

ACTION

Adopted 

 

Ward: All 

Toronto Public Health 2010 Budget Adjustments for Low Income Dental Program

Committee Decision

The Board of Health recommended that City Council adopt the following recommendations contained in Executive Committee Item EX46.63 entitled “Toronto Public Health 2010 Budget Adjustment for Low Income Dental Program”:

 

1.         City Council approve a one-time budget adjustment of $2,439,397 and $0.0 net to the Toronto Public Health (TPH) 2010 Approved Operating Budget including $2,240,000 gross and $0.0 net to expand the existing community-based infrastructure of dental clinics, and $199,397 gross and $0.0 net to support initial start-up of the new Low Income Dental Program, with 100 per cent funding provided by the Ontario Ministry of Health and Long-Term Care.

 

2.         City Council approve the creation of an in-year Capital project to be added to the Toronto Public Health 2010 Approved Capital Budget for the acquisition of a mobile dental clinic in the amount of $450,000 with one-time 100 per cent funding provided by the Ministry of Health and Long-Term Care (MOHLTC).

 

3.         City Council approve a base budget adjustment of $2,848,809 gross and $0.0 net to the TPH 2010 Approved Operating Budget and 41 permanent positions with on-going 100 per cent funding provided by MOHLTC.

 

4.         City Council authorize the Medical Officer of Health to negotiate, award, amend and execute contracts with the following five agencies to construct and equip dental clinics in their facilities and that the contracts will be in a form that is satisfactory to the City Solicitor and the City Treasurer:

 

a.         Parkdale Community Health Centre;

b.         Anishnawbe Community Health Centre;

c.         St. Michael’s Hospital;

d.         Stonegate Community Health Centre; and

e.         Carefirst Family Health Team.

 

5.         City Council authorize the Medical Officer of Health to negotiate, award, amend and execute purchase of service contracts for the ongoing implementation and delivery of the new dental program for children and youth in low-income families with the five agencies engaged to construct dental clinics and that the contracts will be in a form that is satisfactory to the City Solicitor.

 

6.         City Council request the Medical Officer of Health to report to the Board of Health and the Executive Committee in 2011 on the contracts awarded to the five agencies to construct and equip dental clinics, and annually on the purchase of service contracts awarded for the ongoing implementation and delivery of the new low income dental program.

Origin
(July 29, 2010) Report from Medical Officer of Health addressed to the Budget Committee and the Board of Health
Summary

The purpose of this report is to request budget adjustments to the Toronto Public Health (TPH) 2010 approved Capital and Operating Budgets due to confirmation of funding from the Ministry of Health and Long-Term Care (MOHLTC) received after approval of the TPH Operating and Capital Budgets for 2010.

 

This funding will be used to implement a dental program for children and youth age 0-18 years old within the current fiscal year. This program will be funded 100 per cent by MOHLTC. The funding will be annualized in future years.

 

TPH received approval from the Province to work with partner agencies to expand its current dental clinic infrastructure and to continue delivering dental care using a mixed model of fee for service and salaried service providers. TPH must start delivering this program by September 1, 2010. 

Background Information
HL33.6 - Toronto Public Health 2010 Budget Adjustments for Low Income Dental Program - Staff Report
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33010.pdf)

Communications
(June 29, 2010) Letter from Deb Matthews, Minister of Health and Long-Term Care (HL.New.HL33.6.1)
(http://www.toronto.ca/legdocs/mmis/2010/hl/comm/communicationfile-17828.pdf)

Speakers

Michael Brothers, Toronto Chapter Council of Canadians

Motions
Motion to Adopt Item (Carried)

6a Toronto Public Health 2010 Budget Adjustments for Low Income Dental Program
Origin
(August 9, 2010) Letter from Board of Health Budget Sub-Committee
Summary

The Board of Health Budget Sub-Committee on August 9, 2010, considered a report (July 29, 2010) from the Medical Officer of Health, addressed to the Board of Health and the Budget Committee, entitled “Toronto Public Health 2010 Budget Adjustments for Low Income Dental Program”, and forwarded its recommendation to the Board of Health.

Background Information
HL33.6a - Toronto Public Health 2010 Budget Adjustments for Low Income Dental Program - Letter from the Board of Health Budget Sub-Committee
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33060.pdf)


HL33.7

ACTION

Adopted 

 

Ward: All 

Creation of ChemTRAC Toxics Reduction Grants Program through Live Green Toronto

Committee Decision

The Board of Health recommended that City Council adopt the following recommendations contained in Executive Committee Item EX46.64 entitled "Creation of ChemTRAC Toxics Reduction Grants Program Through Live Green Toronto":

 

1.         City Council grant authority to the Toronto Environment Office to administer the toxics reduction grants under the Live Green Community Investment Program, on an annual basis beginning in 2010, and to make any necessary adjustments to the Live Green Community Investment Program in order to accommodate the addition of the toxics reduction grants.

 

2.         City Council delegate authority to the Director, Toronto Environment Office, and the Medical Officer of Health, to award funds, totalling $50,000 in 2010, for the toxics reduction grants under the Live Green Community Investment Program.

 

3.         City Council direct the Medical Officer of Health in collaboration with the Director, Toronto Environment Office, to report annually to the Board of Health on the grants program and any proposed changes deemed necessary.

Origin
(July 29, 2010) Report from Medical Officer of Health and the Director, Toronto Environment Office, addressed to the Budget Committee and the Board of Health
Summary

Toronto’s new ChemTRAC program is designed to protect public health and stimulate the greening of local businesses by tracking and reducing toxic chemicals found in the local environment. The program includes the Environmental Reporting and Disclosure Bylaw (Municipal Code Chapter 423), which came into force January 1, 2010. Toronto Public Health coordinates ChemTRAC in partnership with the Toronto Environment Office, Economic Development and Culture, Toronto Water and other city divisions.

 

ChemTRAC is a key part of City Council’s efforts to improve environmental sustainability within the corporation and among its residents, businesses and community organizations. It adds support for toxics reduction to the suite of City environmental programs such as those encouraging water conservation, energy efficiency and greenhouse gas reduction.  This program will identify new opportunities for many Toronto businesses, especially small and medium-sized enterprises, to reduce or find safer alternatives for toxic chemicals that enter our local environment from their operations.

 

Toronto Public Health seeks to partner with the Toronto Environment Office to establish a grants program that would offer a total of $50,000 in toxics reduction grants through the “Live Green Community Investment Program,” on an annual basis beginning in 2010. The grants would be directed to eligible business associations, non-profit organizations and labour groups to provide training, education, pilot programs and community partnerships to promote reduction of toxic chemicals, particularly those listed under the Environmental Reporting and Disclosure Bylaw. Toronto Environment Office would administer the grants program through the Live Green Community Investment Program, which offers an established infrastructure to enable Toronto Public Health to commence offering grants as early as Fall 2010. This report requests that City Council grant authority to the Toronto Environment Office to administer these toxics reduction grants in collaboration with Toronto Public Health. The Director of the Toronto Environment Office concurs with the recommendations in this report.

Background Information
HL33.7 - Creation of ChemTRAC Toxic Reduction Grants Program through Live Green Toronto - Staff Report
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33011.pdf)

Motions
Motion to Adopt Item (Carried)

7a Creation of ChemTRAC Toxics Reduction Grants Program through Live Green Toronto
Origin
(August 9, 2010) Letter from Board of Health Budget Sub-Committee
Summary

The Board of Health Budget Sub-Committee on August 9, 2010, considered a report (July 29, 2010) from the Medical Officer of Health, addressed to the Board of Health and the Budget Committee, entitled “Creation of ChemTRAC Toxics Reduction Grants Program through Live Green Toronto”, and forwarded its recommendation to the Board of Health.

Background Information
HL33.7a - Creation of ChemTRAC Toxics Reduction Grants Program through Live Green Toronto - Letter from the Board of Health Budget Sub-Committee
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33062.pdf)


HL33.8

ACTION

Adopted 

 

Ward: All 

Toronto Public Health 2010 Operating Budget Adjustment for Youth Engagement

Committee Decision

The Board of Health recommended that City Council adopt the following recommendation contained in Executive Committee Item EX46.62 entitled "Toronto Public Health 2010 Operating Budget Adjustment for Youth Engagement":

 

1.         City Council increase the Toronto Public Health 2010 Operating Budget by $289,973 gross and $0.0 net, and two temporary positions, to reflect confirmed one-time funding from the Ministry of Health Promotion for the Smoke-free Ontario Youth Engagement Strategy.

Origin
(July 27, 2010) Report from Medical Officer of Health addressed to the Budget Committee and the Board of Health
Summary

The purpose of this report is to seek approval for a one-time budget increase of $289,973.00 gross and $0.00 net, and an increase of two temporary positions in the Toronto Public Health (TPH) staff complement, fully funded by the Ministry of Health Promotion for the Smoke-free Ontario Youth Engagement Strategy.

Background Information
HL33.8 - Toronto Public Health 2010 Operating Budget Adjustment for Youth Engagement - Staff Report
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33012.pdf)

Motions
Motion to Adopt Item (Carried)

8a Toronto Public Health 2010 Operating Budget Adjustments for Youth Engagement
Origin
(August 9, 2010) Letter from Board of Health Budget Sub-Committee
Summary

The Board of Health Budget Sub-Committee on August 9, 2010, considered a report (July 27, 2010) from the Medical Officer of Health, addressed to the Board of Health and the Budget Committee, entitled “Toronto Public Health 2010 Operating Budget Adjustment for Youth Engagement”, and forwarded its recommendation to the Board of Health.

Background Information
HL33.8a - Toronto Public Health 2010 Operating Budget Adjustment for Youth Engagement - Letter from the Board of Health Budget Sub-Committee
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33063.pdf)


HL33.9

Information

Received 

 

 

Scarborough Local Health Committee Minutes

Committee Decision

The Board of Health received Item HL33.9 for information.

Summary

Minutes of the Scarborough Local Health Committee meeting held on May 31, 2010.

Background Information
HL33.9 - Scarborough Local Health Committee Minutes - May 31, 2010
(http://www.toronto.ca/legdocs/mmis/2010/hl/bgrd/backgroundfile-33013.pdf)

Motions
Motion to Receive Item moved by Valerie Sterling (Carried)
That the item be received for information.

Procedural Motions
Motion to Adopt Minutes moved by Fiona Nelson (Carried)

That the Minutes of the meeting of the Board of Health held on June 28, 2010, be confirmed.

 

 

Friday, August 20, 2010
Councillor John Filion, Chair, Board of Health
Meeting Sessions
Session Date Session Type Start Time End Time Public or Closed Session
2010-08-20 Afternoon 1:10 PM 2:15 PM Public
Attendance
Members were present for some or all of the time period indicated.
Date and Time Quorum Members
2010-08-20
1:10 PM - 2:15 PM
(Public Session)
Present Present: Bravo, Castro, Chari, Cho, Davis, Filion (Chair), Lee, Nelson, O'Brien, Perks, Sterling, Wong
Not Present: Fletcher