The Community and Neighbourhood Services Committee further reports, for the information of Council, having requested:

At this inaugural meeting of the City's Community and Neighbourhood Services Committee, I want to advise members of some early actions I intend to take in my role as Children's Advocate and invite their interest and support. To assist in shaping the City's Agenda for Children and developing a Children's Strategy for the new City, I will be writing to members of Council to survey their interest in serving on the Children's Action Committee. The Children's Action Committee will report through this Committee to Council. For those who are interested, I will also be hosting an orientation service tour of the variety of children's programs currently in operation followed by a discussion of the issues and initiatives to be included on the Children's Action Plan.

To assist the Children's Action Committee in the development of the Children's Agenda, the Children's Strategy and the Children's Action Plan, I will also be assembling a small reference group of community leaders knowledgeable about the needs of children and how they can best be met. Together, we will further develop the proposal for a Toronto Civic Commission on Children and Youth and bring forward for your review recommendations concerning its mandate, leadership and structure as well as a proposed strategy and schedule for its implementation. Where appropriate, presentations will also be made to the Review Committee chaired by Councillor Miller, which will be considering recommendations made by the Toronto Transition Team.

With respect to timing, I hope to present the proposed approach for the development of the Children's Strategy for the new City at the next meeting of this Committee to allow its early consideration by City Council. The workplan of the Children's Action Committee should be available for your review by March. Recommendations regarding a Toronto Civic Commission on Children and Youth will be developed and presented by April.

I look forward to working with you and members of the Community and Neighbourhood Services Committee on all matters affecting the needs of children and families within the City of Toronto.

Summary of the Recommendations of the

Metro Task Force on Services to Young Children and Families

embodied in AThe First Duty@.

A Children's Strategy:

Recommendation 1:

The Council of the new City of Toronto should formally adopt a Children's Strategy that explicitly embodies these principles:

Recommendation 2:

The Council of the new City of Toronto and the Transition Team responsible for setting up the new administration should organize civic operating structures in a way that is consistent with the principles of the Children's Strategy. To provide better service to children and families, the new organizational structures should enable and ensure a high level of co-ordination between those responsible for delivering child care, public health, recreation, housing and police services. A single structure should be established that would be responsible for both implementing the Strategy and for managing the delivery of all services to young children under six, including child care and public health.

Children's Advocate:

Recommendation 3:

The Council of the new City of Toronto should appoint a Children's Advocate to ensure that the principles of the Children's Strategy are being upheld. The Advocate would monitor the policies and activities of the civic government, consult with service providers, volunteers, consumers, clients, advocacy groups and other members of the community, and consider suggestions and complaints from the public regarding the city's success in implementing the Children's Strategy. The Advocate would report annually to Council on the progress of implementation.

Recommendation 4:

The Children's Advocate should convene a Children's Services Forum to establish greater co-operation and co-ordination among children's services providers. Participants in the forum should include representatives of the municipal government (including child care, recreation and public health services), as well as the education, children's mental health and child protection sectors. The forum should meet regularly to consider such issues as information sharing, shared accommodation, joint capital projects, joint purchasing arrangements, rationalization of data management procedures, collaborative research projects and other joint initiatives that would encourage more co-ordinated delivery of services to children and families. The forum would be a framework within which inter-sectoral working groups could be established to deal with specific issues.

Community Mobilization:

Recommendation 5:

As part of the Children's Strategy, governments and school boards in the Metropolitan Toronto area should create a major community-wide public information initiative to build understanding and support for the needs of young children and the benefits of early investment in them.

Recommendation 6:

Businesses and business organizations, and community organizations and unions in Metropolitan Toronto must play an expanded leadership role in a community mobilization in support of children.

Monitoring Progress:

Metro Report Card on Children:

Recommendation 7:

To measure progress in implementing the Children's Strategy, the municipal government should continue to produce the Metro Report Card on Children. The Children's Advocate should assume responsibility for public release and dissemination of the report card.

Recommendation 8:

In order to produce a more comprehensive and useful report card on the situation of children, the various children's service sectors must co-operate in the development of additional indicators of children's health and well-being.

Recommendation 9:

Goals and targets linked to indicators of health and well-being must be developed to measure progress in improving the situation of children. The Provincial and Municipal Governments and school boards should formally adopt these goals and implement policies that serve to achieve them.

Data Collection and Sharing:

Recommendation 10:

Agencies must adopt the policy of freely sharing data with each other in a manner that does not compromise the privacy and confidentiality of clients. To more easily share data, agencies must work together to harmonize their data collection procedures and technologies.

Improving Services to Children and Families:

Culturally Appropriate Service:

Recommendation 11:

Children's service providers must put a high priority on anti-racist strategies and cultural sensitivity in the design and delivery of programs and in the hiring and training of staff. Placements and other decisions affecting children must be handled in a culturally appropriate manner.

Healthy Starts:

Recommendation 12:

In order to decrease the incidence of low birthweight babies and to maximize infant health, information programs on prenatal and postnatal nutrition and the avoidance of health hazards must be readily available to all expectant mothers.

Recommendation 13:

Public health authorities should establish a comprehensive home-visiting program to identify children at risk and refer their families to appropriate services and community support systems. This system of prevention and early intervention must be guided by an understanding of the benefits of co-operative service delivery.

Supporting the Role of the Family:

Recommendation 14:

All levels of government must recognize how critically important it is that young children receive nurturing and stimulating care and that they adopt social and tax policies which offer parents a wider range of options.

Recommendation 15:

The Provincial Government should mandate that schools, in collaboration with school advisory councils and parents, should strengthen curriculum units on life skills, nutrition, responsible sexual behaviour, parenting skills and addiction avoidance to assist young people in making informed choices about parenthood and developing appropriate life skills.

Child Care:

Recommendation 16:

Federal, Provincial and Municipal Governments must make a renewed commitment to formal, accessible high-quality child care. This commitment should recognize that in most instances care for young children is most appropriately provided by trained professional staff working under Provincial standards that are vigilantly monitored by licensing authorities.

Recommendation 17:

By the year 2000 the Provincial and Municipal Governments should have in place a plan to provide a full range of quality child care services to meet the needs of all families in the Metropolitan Toronto community.

Recommendation 18:

The Provincial and Municipal Governments must recognize that, while short-term informal care arrangements are sometimes necessary to help clients exit social assistance, these arrangements are transitional and intended to provide care only until the client can access the formal child care system.

Recommendation 19:

The Provincial and Municipal Governments must reaffirm their commitment to a stable child care system in Metropolitan Toronto, planned and managed in such a way as to ensure equity of access for families in all parts of the Metro area. To ensure a full mix of care options for parents, such a system must continue to include both centre- and home-based options provided directly by the municipality or purchased from community operators.

Recommendation 20:

Both Provincial and Municipal Governments must recognize the social value of the work performed by child care employees and adopt policies that will gradually improve compensation for employees of both the commercial and the non-profit sectors.

Recommendation 21:

Governments must commit the resources necessary to increase the number of child care spaces available for infants and toddlers.

Recommendation 22:

Municipal governments and child care providers must work together to develop more flexible access to child care services.

Recommendation 23:

Private and public sector employers must work together with employee groups to develop more comprehensive child care arrangements that are suitable for varying parental timetables.

Recommendation 24:

The needs of parents must be reflected in employee benefit packages, allowing parents to take leave when a child is sick, to accompany a child to medical appointments or to attend meetings at school.

School Readiness:

Recommendation 25:

The Provincial Government must recognize that junior kindergarten is an important part of the developmental and learning continuum, and reinstate it as a mandatory program.

Recommendation 26:

The Provincial Government and school boards should develop an early childhood education program that would build on the strengths of the child care and school systems, and would ensure that children enter the primary grades ready to learn.

Health and Nutrition:

Recommendation 27:

Municipal and Provincial Governments must make the commitment to adequately fund quality nutrition programs wherever they are needed in Metropolitan Toronto, and to provide necessary support to ensure these programs can continue to serve children.

Recommendation 28:

The Provincial and Municipal Governments must work together to expand community health promotion and monitoring services for young children and families.

School-age Child Care:

Recommendation 29:

The Provincial and Municipal Governments and the school boards must co-operate to develop a new model for school-age child care. The starting point for discussion of a new model should be the framework described in the proposal on pilot projects, submitted by the Task Force to the Provincial Government in June 1996.

Child Protection:

Recommendation 30:

The child welfare, education, health, children's mental health, and child care sectors should develop joint program initiatives to identify children at risk and to prevent child abuse.

Sharing Facilities:

Recommendation 31:

The Provincial Government should revise its current policy and provide capital funding for the construction and renovation of child care centres in school facilities.

Recommendation 32:

Schools, community centres or other public facilities should be used as the hub for the delivery of children's services in communities.

Recommendation 33:

New schools and community centres should be planned as multi-use facilities that accommodate a full range of children's services.

The First Steps:

Recommendation 34:

Existing municipal councils and school boards should endorse the recommendations of the Task Force with a strong statement on the value of investing in young children and forward them to the municipal Transition Team and the Education Improvement Commission, as well as the new Council and school boards.

Recommendation 35:

Early in their term, the new Council and school boards should adopt the Children's Strategy and develop an implementation plan that describes the details of action, outlines the implementation process and specifies time frames and budgets.@

City Council, at its regular meeting on September 22 and 23, 1997, gave consideration to Clause 8 contained in Report No. 9 of the Board of Health, titled AChild Poverty - A Public Health Perspective.@

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

(Clause 8 embodied in Report No. 9 of The Board of Health)

Child Poverty - A Public Health Perspective

The Board of Health advises that it has taken the following action and recommends Council=s endorsement:

(1) requested the Minister of Health to reallocate at least $13 million of the savings from Metro hospital restructuring to support community-based public health programs, raising funding from 1.7 percent to 2 percent of current Metro health spending to combat the serious long-term health impacts of child poverty;

(2) forwarded the report (September 3, 1997) from the Medical Officer of Health to the Toronto Transition Team, the Board of Health for the new City of Toronto and the new City of Toronto Council with a request that it be reviewed in conjunction with the First Duty report; and to the Boards of Education in Metropolitan Toronto for their information;

(3) forwarded the report (September 3, 1997) from the Medical Officer of Health to the other Boards of Health in Metro Toronto requesting that they direct the Medical Officers of Health to work together to identify public health services and programs to be offered throughout the new City of Toronto which will reach low income children and families;

(4) requested the Medical Officer of Health for the new City of Toronto to report to the Board of Health and new City of Toronto Council by March, 1998 outlining a public health service strategy, and the costs of that strategy, to combat child poverty for the new City, including the best ways to co-ordinate with other municipal services and community agencies;

(5) forwarded the report (September 3, 1997) from the Medical Officer of Health to the Federal Minister for Human Resource Development, who is Co-chair of the Ministerial Council on Social Policy Development and to the Minister of Health Canada; and

(6) endorsed the following recommendations contained in the communication (September 8, 1997) from the Toronto Board of Education:

The Medical Officer of Health made a presentation to the Board.

The Board of Health submits the report (September 3, 1997) from the Medical Officer of Health:

Origin: Medical Officer of Health, September 3, 1997 (p:\1997\ug\cms\hld\hl970071.hld)

Recommendations:

(1) That the Board of Health request that the Minister of Health reallocate $13 million of the savings from Metro hospital restructuring to support community-based public health programs, raising funding from 1.7 percent to 2 percent of current Metro health spending to combat the serious long-term health impacts of child poverty.

(2) That this report be sent to the Toronto Transition Team, the Board of Health for the new City of Toronto and the new City of Toronto Council with a request that it be reviewed in conjunction with the First Duty report.

(3) That the Board of Health send this report to the other Boards of Health in Metro Toronto requesting that they direct the Medical Officers of Health to work together to identify public health services and programs to be offered throughout the new City of Toronto which will reach low income children and families.

(4) That the Medical Officer of Health for the new City of Toronto report to the Board of Health and new City of Toronto Council by March, 1998 outlining a public health service strategy to combat child poverty for the new City, including the best ways to co-ordinate with other municipal services and community agencies.

(5) That the Board of Health send this report to the Federal Minister for Human Resource Development, who is Co-chair of the Ministerial Council on Social Policy Development, and to the Minister of Health Canada.

Background:

While the issue of child poverty is not new in Canada, its incidence continues to grow. Recent reports have highlighted the extent of the problem in Metro. AThe First Duty,@ a report of the Metro Task Force on Services to Young Children and Families, outlined the growing nature of the problem and made a number of recommendations for better service co-ordination and support which the Board of Health endorsed at its July 2, 1997, meeting. Subsequently, the United Way released a report, entitled AMetro Toronto: A Community at Risk,@ which also documents the growing trend toward more low income families and greater income polarization. Public health, with its emphasis on the basic determinants of health (income, education, housing, food, etc.) and its community-based approach, has a vital role to play in supporting children and families in need.

The purpose of this report is twofold:

- to detail the type and range of services provided by public health in the City of Toronto which support children and families in the community who are on low incomes; and

- to propose a process for consolidating and enhancing the role of public health in the megacity in terms of ameliorating the impact of poverty on children and their families.

In this discussion the focus is on young children from 0 to 10 years of age, not youth.

Comments:

AHow swiftly moved the finger of poverty, soiling and contaminating@. (Such a Long Journey by Rohinton Mistry.)

Section 1: Dimensions of the Problem:

(1.1) Canada

Child poverty, as the phrase implies, is rooted largely in the distribution of income and wealth which leaves many families without adequate income. Inadequate income reduces opportunities for health and increases exposure to conditions that adversely affect children from before birth through every stage of their life. While public services can do much to ameliorate the effects of low income, their impact can be much greater if families and communities are not in economic deprivation. Poor health outcomes are one of the most costly consequences of socio-economic inequality.

Compared to other industrialized countries, Canada has a high level of children living in poverty. Canada and Australia have the second highest proportion of children in poverty after the U.S. (UNICEF, 1996). Forty-five percent of lone parent families in Canada have incomes below Statistics Canada's Low Income Cut-off Point compared to 10 percent in Sweden and the Netherlands (Statistics Canada, 1992). Statistics Canada also reports that of those who relied on government transfer payments, the majority of both lone parent and two parent families have low incomes. In 1990, over one million children were growing up in families with low incomes.

Certain groups are more likely to have the problem of low/inadequate income:

A major reason for the growth of the problem is a reduction in government funding of basic family support services: child care, welfare, family benefits, child support, etc., as well as a decline in jobs and overall income levels. As a result, the gap between the poor and non-poor is widening and the depth of poverty is worsening (Little, 1996 and 1997). Relative living standards have been shown to be more closely related to negative health outcomes (i.e., mortality) than absolute income (Wilkinson, 1997). In turn, income disparities can lead to residential segregation, isolation, loss of social cohesion and erosion of public institutions and standards (Kawachi, 1997).

An effective way to ameliorate poverty is through a social safety net: government tax and income transfer policies. In some countries these policies have been very effective; for example, the UK and Ireland would have poverty rates of 30 percent but for such policies which have reduced the rate to 10 percent and 11 percent respectively. Both the US and France have poverty rates of around 25 percent before taxes and transfers, but France has reduced its rate to 7 percent whereas the US remains at 22 percent (UNICEF, 1996).

How does Canada fare with its policies? Compared to many other industrialized countries with a similar per capita level of GNP, Canada still has a higher level of child poverty after taxes and transfers: Australia is the same while only the US has higher levels (see Table No. 1).

In Canada, provincial welfare levels vary but all fall below the poverty line: from 46 to 72 percent of a poverty line income in 1994 and only 24 to 38 percent of average provincial income. Social assistance levels are higher in Europe: in the Netherlands a lone mother receives about 75 percent of a production worker's net average wage; in Sweden 109 percent. Other supports to child care, such as income for mothers to stay at home etc., are also available (Canadian Council on Social Development, 1996).

(1.2) Metropolitan Toronto and the City:

Child poverty is primarily an urban problem. Because 82 percent of children in Canada live in cities, national and provincial trends and policies have their biggest impacts on the urban areas. In Metropolitan Toronto and the City of Toronto, which have been hard hit by the recession of the 1990s, the situation is worsening as the data below indicate:

- According to a recent report by Metro=s Community Services Department, 36 percent or 89,000 children under 11 years old are living below the poverty line. A similar proportion holds for the City with the number being 35,000. Child poverty estimates for Metro and the City of Toronto are as much as seven times greater than neighbouring municipalities in the GTA.

- If children of the working poor are included, the proportion could be as high as 40 percent.

- Metro serves approximately 60 percent of all Ontario homeless people, of whom half (1,828) of those served nightly in shelters are families. About 30,000 people use Metro hostels for emergency shelter each year.

- Between 1990 and 1993 a total of 158,478 jobs were lost in Metro. The City lost over 81,000 jobs or half of all jobs lost in Metro. Unemployment rates have dropped since the early 1990s when the recession was at its peak but the unemployment rate remains over 10 percent higher in Metro than the provincial average.

- Low birthweight rate for Metro rose to over 7 percent in 1993 and 1994. The rate for the Province was 6.2 percent in 1993 and 6.6 percent in 1994, and for Canada 5.5 percent. Metro accounted for 48 percent of the provincial increase in the number of babies with a low birthweight between 1991 and 1994.

- The birth rate among adolescents (15 to 19 years old) is stable at about 24 births per 1,000 and about 4 percent of all births in the City. This is higher than the Metro and Ontario rates which are 21 and 23 respectively. In 1995, 362 babies were born to women under age 19 in Toronto. Many of these women are likely to be poor and 58 percent were single.

- Ethnoracial diversity is increasing. Metropolitan Toronto has 53 percent of the non-European ethnoracial population in Ontario and most of these ethnoracial communities have average incomes that are 50-70 percent of the Metro average.

- A 1994 study showed young families (with a head under 35) in Metro were worse off than older or previous generations in terms of income, temporary jobs, unemployment, part-time work and social assistance. Specifically, while two-thirds of those under 25 years old were employed in 1989, only one-half were in 1993 and the number who could only find part-time work doubled.

- Between 1985 and 1990, family poverty increased 16 percent in the City which was 76 percent higher than the provincial increase.

- In Metro, children in families receiving social assistance increased from 70,000 (16.8 percent) in 1990 to 127,037 (29.3 percent) in 1995.

- Over 27,000 Toronto children lived in households on social assistance in 1995. The proportion of people on social assistance increased in all City neighbourhoods between 1990 and 1995. Ninety-five percent of children under six in families on social assistance were affected by the 21.6 percent cut to welfare payments in October 1995. As a result, more than two-thirds of families with children have to use money for food and other basic needs to pay for housing.

- Hostel use by mother-led families increased by 53 percent from 1994 to 1995, and homeless families who were clients of Metro Children's Aid doubled.

- Children are the fastest rising groups of hostel/shelter users increasing from 3,991 in 1991 to 5,584 in 1995.

- In 17 out of 45 neighbourhoods in the City, one-third to three-quarters of children live in families on social assistance.

- The median incomes of lone parent families dropped 19 percent between 1990 and 1993.

- In Toronto, only 15 percent of all potentially eligible children are receiving subsidized care in 1993. Families who qualify for subsidized care have a waiting period of more than 18 months and in June 1997 there were 3,508 children in the city on the waiting list.

- Pre-school children are the most over-represented in food bank using families. Children under five are 25 percent of all children in the GTA, but 31 percent of the children supported by the Daily Bread Food Bank. A recent study found that almost one child in 20 in any given month lives in a family needing food bank help (Daily Bread Food Bank, 1996).

- The latest survey of food bank users in the GTA found that two out of five of the children of parents using the food bank went hungry occasionally, largely because the reduced cuts to social assistance means that more single mothers pay a higher proportion of their income for rents. The situation was similar for couples with children: the proportion of couples unable to cover their rents from the shelter allowance increased from 23 percent in 1995 to 78 percent in 1996. Consequently, almost 20 percent of children in these families occasionally went hungry, almost 10 percent once a week (Daily Bread Food Bank, 1996).

- Hundreds of social service agency programs have been cut and others severely reduced as provincial funding has been drastically reduced. Many of these programs serve low income families and children (Metro Social Services, 1996).

(1.3) Conclusion:

At a time when the economy is picking up and forecasts are for future strong growth, it is easy to miss the hardship and deepening crisis that is happening for a substantial number of families in Metro. The data cited above presents a picture of an increasingly polarized society in which those at the lowest end of the income scale are less and less able to provide their children with the basic care and support necessary for healthy development. At the same time, the services which can provide the essential underpinnings to keep these families going are being gradually eroded. If left unchecked, the current trends will have severe consequences.

Section 2: Poverty: Why is it a Public Health Concern?

The roots of public health lie in developing measures to deal with the effects of poverty and inadequate income. In 1918, Dr. Charles Hastings, who was later to become the Medical Officer of Health in Toronto, placed health and adequate income squarely in the same camp as other essential rights:

A major focus for public health interventions is in the area of child health and, given that low income is a barrier to good health for children, child poverty, especially in the context of child development, is a fundamental issue for public health. This was recognized by the public health nurses in the early 1900s who, then as now, saw that citizens could not adopt modern health practices because they were poor, and joined forces with the network of charitable organizations in the community (MacDougall, 1990).

A recent Ontario study found a significant correlation between low income (especially under $10,000.00 income) and psychosocial morbidity (defined as psychiatric disorders, poor school performance and social impairment). The authors conclude that Apoverty, particularly for the very young, is a strong independent predictor of poor psychosocial health@ (Lipman et al, 1994).

Other studies (National Forum on Health, 1996) have found a similar link. Inequity, marginalization and powerlessness which accompany poverty add to the distress of low income families, creating an environment that disadvantages their children. The outcomes for children of a life in poverty include higher rates of conduct disorders, school problems, emotional disorders, chronic diseases and hyperactivity among poor as compared to non-poor children. In both Britain and the US, the statistical links between increasing relative deprivation and growing psychosocial problems (crime, drug use and suicide) among young people has been demonstrated in a number of studies (Roberts, 1997).

Studies of income distribution, infant mortality and public policy show a strong relationship between income inequality and the rate of infant mortality (Sullivan, 1996) as well as low birthweight which predisposes children to neonatal mortality as well as infant and childhood morbidity. Compared with children from rich neighbourhoods, children in communities in economic hardship and with high housing costs more likely have low birthweight (Roberts, 1997).

Incidence of injuries, which are the leading cause of death for children over one year of age, is higher among families with low socio-economic status (Morrongiello, B., 1996).

Poor nutrition in early childhood can continue to hinder intellectual performance into adulthood. Households with low incomes are much less likely to consume foods rich in protective nutrients (like fruits and vegetables) and more likely to eat sweet and salty foods. As a result, children suffer from more dental caries, recurrent infections and anaemia (James, 1997). Even for children living in poor social and economic circumstances, having adequate nutrition during infancy and later can lessen the cognitive deficits created by poverty (Brown & Pollitt, 1996).

Children who have lived in poverty a long time are at a developmental disadvantage which reduces their life chances considerably (Campaign 2000, 1996). Child welfare research has found that the stress of poverty results in higher incidence of child neglect and abuse among poor families (op. cit.). Shout Clinic in Toronto for homeless youth reported an increase in visits from single mothers and their children under two from 66 in 1994 to 508 in 1996 (Shout Clinic, 1997).

Studies have found that unfavourable socio-economic conditions in childhood predispose to increased risk of coronary heart disease in adulthood due to poor fetal development and childhood growth (Smith, 1997).

Many homeless people have had violent, abusive experiences in childhood which has led to emotional disorders, suicide attempts and chronic medical problems (Babiuk, 1996). As homelessness is becoming more common for families due to economic factors, more and more children are exposed to dangerous and uncertain circumstances which will have lasting consequences. Of particular concern are health problems, hunger, poor nutrition developmental delays, anxiety, depression, behavioural problems and educational underachievement (Rafferty, 1991).

Children living in poverty may be at greater risk to exposure to environmental contaminants in air, soil, drinking water, and food and have higher rates of morbidity. While some possible linkages between environmental contaminants and children=s health have been identified, including respiratory, reproductive, neuro-developmental, immunological, hormonal and cancer outcomes, the nature and magnitude of exposures of children living in poverty to these contaminants are less well understood. Much of the research has focussed on children living in inner-city areas of the United States and it is not known to what extent their findings would apply to children living in poverty in Canada.

Public Health studies in South Riverdale, an economically disadvantaged neighbourhood of Toronto with adjoining industrial areas, documented significantly higher blood lead levels in children as young as two years old, versus children in comparison neighbourhoods. Research in the United States indicates that the prevalence of elevated blood lead levels remains highest among inner-city, underprivileged children living in deteriorating pre-1970's housing containing lead-painted surfaces (US Department of Health and Human Services, 1997). Lead poisoning in children has been associated with a range of potential adverse health impacts, including IQ deficiencies, reading and learning disabilities, and impaired hearing, reduced attention spans, hyperactivity, and antisocial behaviour.

Recent studies have shown that the following interventions can reduce inequalities in health for children and their families (Smith, 1997):

- targeting effective healthcare promotion and services at those groups with the greatest health needs;

- providing social, financial, and psychological support during pregnancy and childbirth;

- providing smoking cessation programes to pregnant women;

- providing folic acid supplements before and around the time of conception;

- providing personal support for breast feeding;

- providing free school milk;

- targeting effective interventions to reduce accidents of children who live in low-income communities;

- providing sex education and available, accessible, and acceptable services to reduce teenage pregnancy; and

- improving oral hygiene, reducing sugar intake, and promoting use of fluoride among people in deprived communities.

These are basic public health interventions, most of which can be provided through the existing community health system.

In summary, income inequality places children at risk for a lifetime of health problems. It is now a basic tenet of public health that the key to the health of the population lies in providing a range of socio-economic interventions and supports in the social and physical environment beyond the traditional health care system. The role of public health practitioners and agencies is to ensure that all vital elements are in place, including the basic prerequisites for health and lack of discrimination and racism, for all members of society.

Section 3: Public Health Responds:

While strategies that permit families to have a reasonable income (through government transfers, full employment policies, etc.) are the critical factor in alleviating poverty, family and community support initiatives are also vital. For example, it has been shown that non-economic factors, such as low maternal education, family dysfunction and social isolation, also have negative outcomes for children (Lipman, 1994). Also, controlled studies have shown that a well-designed home visiting program for mothers of newborns can reduce child abuse by 75 percent (Steinhauer, 1996) and comprehensive interventions which include health services, such as the Head Start program in the US, prepares children for school and enhances physical health and well-being through public health interventions such as nutrition, public health nursing and dental (Zigler, 1993).

Public health professionals play a unique role in dealing with the breadth of needs in families which try to cope with and/or overcome major problems related to low socio-economic status. In Toronto, this is the area where considerable public health service lies. Although there is overlap among current programs, there are six main areas where staff are working on this issue:

(3.1) Providing the Basics:

All children need to grow up in a safe, clean environment in secure, stress-free families with access to food, housing and education. Much of the work of the Department of Public Health is directed to ensuring a basic level of health service to all members of the community. Initiatives which provide general health services also reach children in need, such as the following:

- communicable disease control, especially through immunization of school and daycare children;

- environmental health protection through food safety, monitoring of water quality for drinking water, pools and beaches, inspections and enforcement of environmental safety regulations, and public education to minimize exposures to contaminants in air, soil, drinking water, and food;

- food handling and infection control education to staff in schools and daycares;

- food quality workshops for daycare personnel given by a community nutritionist and environmental health officer;

- breastfeeding promotion and corporate breastfeeding policy; mother to mother breastfeeding support groups;

- work directly with local hospitals to provide 24-hour home follow-up to new mothers who are experiencing shorter hospital stays.

- preconception and prenatal education and health promotion;

- food coupons and food to ensure adequate nutrition for mothers in the prenatal programs;

- programs to prevent teen births which often result in children living in poverty, specifically, school-based education and clinics, and access to supportive, confidential medical services and counselling;

- provision of dental screening, treatment and education for children and mothers with high need but low income through nine clinics located throughout the City;

- promotion of fruits and vegetables in community programs, such as markets, school meals, and parenting programs;

- parenting programs to enhance the capacity of families to foster the development of their children, including visiting child drop-in programs, working with schools and agencies to provide community resources, provision of snacks, babysitting and TTC tickets at high risk parenting programs;

- youth employment through special programs, such as the Peer Sex Education Program;

- co-ordination of school food programs in partnership with boards of education to provide nutritious meals/snacks to school children. Department of Public Health co-chairs the School Food Program Committees for both public and separate schools, assists with menu planning, provides food handler training, conducts facility inspections and participates in program reviews;

- administration of $1.9 million of the Food Access Grants from City Council which have expanded school food programs, increased food skills education and alternative food distribution systems and the formation of community networks which are increasing food access in their neighbourhoods. In addition, five community groups are running community economic development projects and a commercial Incubator Kitchen has been established;

- support to community, school and rooftop garden projects which provide additional food to families and information on home preserving;

- community development which helps groups and agencies to get funding, eliminate systemic barriers to healthy development and develop appropriate programs for disadvantaged groups; and

- community economic development to provide skills on food preparation and business development.

(3.2) Ensuring Healthy Growth and Development:

A great deal of the work of public health is in the area of prevention: providing education on ways to lay a solid foundation for future good health. Much of this work focuses on children either directly or through parents and caregivers.

For instance, the first three years are critical in ensuring that children have a good start to their lives. Recent research shows that brain development, which determines overall development, in the early years is extensive and highly vulnerable to environmental influences (Carnegie Task Force on Meeting the Needs of Young Children, 1994). Children who are resilient (able to adapt in the face of severe stress) are able to survive and succeed even in the face of adversity (Steinhauer, 1996). Many public health interventions are directed to addressing issues that arise in the early years; specifically:

- prenatal and postnatal programs directed to improve mother=s nutrition, reduce smoking and alcohol drug use during pregnancy and to improve social support and a successful role transition to parenthood;

- postnatal programs which help mothers cope with stress and promote attachment (e.g., infant parenting, breastfeeding, home visits, response to early discharge);

- nutrition promotion with parents and in schools to assist with making healthful food choices;

- mental health promotion through stress management, conflict resolution, violence prevention, abuse disclosure workshops to parents and staff of community agencies and information on accessing community resources;

- parenting groups (including raising sexually healthy children). In 1995, about 20 percent of first time mothers were reached;

- injury prevention initiatives;

- education programs aimed at reducing substance use;

- skills for Food Shopping is a community presentation for new immigrants to assist them make wise food choices in a new setting. AWhat Should My Children Eat to Be Healthy?@ is a slide presentation for youth by community groups following training by Department of Public Health nutritionists; and

- programs to prevent teen pregnancies and births.

(3.3) Intervening for High Risk Groups:

Low income families can be strengthened through targeted interventions that focus on building capacity in key areas, such as parenting, accessing the health system, developing employment skills and so forth. Over the years, the Department has developed a range of programs in this vein.

- Home visiting for high risk families on a range of issues from helping new mothers adjust, stress management, breastfeeding etc. Nurses, lay visitors and others provide support for parents facing barriers to good parenting outcomes. The Ministries of Community and Social Services and Health have recently allocated $762,150.00 to the City of Toronto and a total of $10 million to Ontario Health Units to provide assessment, referral and home-visiting to expectant parents and young children. These monies will enhance current services to high risk families.

- Parents for Better Beginnings, a primary prevention research demonstration project involving numerous organizations in Regent Park and Moss Park areas combining infant home visiting, parent relief with community development and integration of services.

- Growing Together provides home visiting by public health nurses and other services to high-risk multicultural families with young children living in a dense apartment complex in downtown Toronto.

- Cooking Healthy Together is a nutrition education program for community groups that provides hands-on experience in cooking, menu planning and safe food handling.

- Healthiest Babies Possible supports mothers at risk for having low birthweight babies by providing milk supplements, nutrition and lifestyle behaviour counselling by Department of Public Health dietitians and health education and counselling by PHNs.

- The Parkdale Parents= Primary Prevention Project is a community collaborative in Parkdale that provides a variety of supports, including nutritional supplements, pre and postnatal counselling and supports, information sessions, parent relief with community development and co-operation among local services, arts and crafts as well as community economic development for women, etc.

- Parents Helping Parents is a peer support program in which trained lay home visitors, with nursing support, provide support and assistance to high risk, mothers from eight ethnoracial communities to improve their parenting skills and enhance the mental and social development of their babies and toddlers.

- Prenatal classes to pregnant teens, single mothers, specific ethnic groups and newcomers to Canada to improve birth outcomes and parenting skills.

- Nobody's Perfect is a parenting program for young, single, low income, isolated mothers of children under six with limited formal education. It assists parents to develop the knowledge skills, self-confidence and social support essential to child rearing.

- Mental health education (stress management, violence prevention, etc.) for parents and children, as well as crisis intervention.

- Perinatal nutrition and support programs. In 1995 more than 200 pregnant women and their families were served weekly by six prenatal food supplementation programs.

- Breaking the Cycle and the Family Reconnection Centre assist women who are pregnant or parenting a child under six years of age deal with problems of substance abuse and recovery along with enhancing their parenting capacity.

- Ready or Not parenting program is a series of six-eight sessions directed to parents of pre-teens who may have difficulty accessing other programs related to social isolation, literacy and income. The program is designed to increase parent-child communication and provide information regarding prevention of substance abuse by their children. Training of community and parent facilitators have been culturally specific for three communities and parent booklets have been translated and culturally adapted in Portuguese.

- As members of the Family Sub-Committee of the Mayor=s Task Force on Drugs, public health staff have been involved in the planning, development, implementation and evaluation of the City of Toronto One-On-One Mentoring program, which was piloted in two schools during the 1996-1997 academic year. Volunteers were recruited through two Divisions of the Corporation to provide time with an individual child on a regular basis in a school setting. The pilot will be expanded this year.

- Community Kitchens are group education programs targeted to low income people, including single mothers with children, and assist with menu planning, food preparation and nutrition knowledge.

- Support to the underhoused and homeless.

(3.4) Advocating for Socio-economic Policies Supportive of Children=s Health:

With the goal of achieving greater health equity, public health professionals have long recognized the importance of reducing income disparities. The Department and Board of Health have urged Federal and Provincial governments to enact policies which provide adequate income support for vulnerable populations and maintain the social safety net. As well, Department of Public Health supports many networks and coalitions working towards this end.

In particular, staff:

Recognizing the need for co-ordination among social and health services to fully address community needs, public health has put considerable effort into building networks, coalitions and partnerships in all aspects of its work from policy formation to program delivery. Some specific examples:

A key component in dealing with the problem of child poverty is identifying its depth, nature and location so that specific measures can be taken to deal with it. The Department has been monitoring changes in income levels and health status outcomes for a number of years and using this information for program planning. Specific work in this area includes:

At the moment there are a number of factors in the overall environment in which public health is operating which present challenges to our efforts to deal with this problem. They are described here and addressed with solutions in the Recommendations Section.

While the programs and initiatives listed in this report are available in City of Toronto, they are not necessarily provided throughout Metro, even though there are comparable serious needs across the megacity. Services such as those offered by public health in Toronto should be equalized across the new Toronto so that all citizens in need are served.

Conclusions:

In many ways it is difficult to reconcile the image of Toronto as portrayed in international studies as one of the best cities in the world in which to live with the image of a city with growing poverty as shown in this report. Yet both pictures are true. The question is, which image should prevail? If asked, most Torontonians would reject the model of big cities south of the border with their decaying urban cores where the homeless and members of the drug subculture live in the abandoned buildings, where the disadvantaged have access to fewer supermarkets and other amenities and where there is what is called Athe urban health penalty@ (Andrulis, 1997). But unless positive measures are taken, this could be our fate. The signs are already there.

One necessary step is to maintain the services we know can make a difference, especially those that are preventive and community-based. In the long-run, they are more cost-effective than treatment or rehabilitation. Recently, the Minister of Health Jim Wilson stated AHealth-care restructuring is not about saving money. Every penny found in getting rid of waste, duplication and unnecessary administration will be invested in expanded and improved services... There will be no cuts in services. In fact, the government will expand services....we need to develop a truly seamless system where every penny is spent on providing services like....health promotion, prevention programs and public health.@ (Wilson, 1997). In the face of drastic cuts to welfare and provincial downloading of health and social program funding to municipalities, this is good news indeed.

Presently, only $87 million is spent on public health services in Canada=s largest city which is only 1.7 percent of the total health spending in Metropolitan Toronto and which does not even meet current needs. By restructuring hospitals in Metropolitan Toronto the Ministry of Health says it will save $470 million annually. An addition of $13 million from these savings directed to public health would allow more services for disadvantaged children and their families. This would amount to less than 3 percent of the savings from restructuring and bring the public health budget up to only 2 percent of total health spending in Metro.

Public health is in a unique position to assist in the fight against child and family poverty: the nature of their mandate and ways of working has long put them in the forefront of preventing and ameliorating the effects of poverty. The specific features of public health that make it a key player in this area are:

If the new City Council chooses to make child poverty a priority, a number of steps should be taken early in 1998; namely:

The Community and Neighbourhood Services Committee reports, for the information of Council, also having had before it during consideration of the foregoing matter a communication (November 27, 1997) from the Senior Political Advisor for The Honourable Arthur C. Eggleton forwarding a copy of the response received from The Honourable Pierre Pettigrew, Federal Minister of Human Resources Development, regarding AThe First Duty,@ Final Report of the Metro Task Force on Services to Young Children and Families.

(A copy of each of the list of references embodied in the aforementioned report and the additional material attached to the report was forwarded to all Members of Council with the agenda of the Community and Neighbourhood Services Committee for its meeting on January 15, 1998, and a copy thereof is on file in the office of the City Clerk.)