TABLE OF CONTENTS

REPORTS OF THE STANDING COMMITTEES

AND OTHER COMMITTEES

As Considered by

The Council of the City of Toronto

on February 2, 3 and 4, 1999

BOARD OF HEALTH

REPORT No. 1

1By-law Respecting Animals

2Meeting Provincial Standards Across the City of or Selected Public Health Programs and Services

3Review of the Recommendations of the Report of the Task Force on Health and Work for the City of Toronto

City of Toronto

REPORT No. 1

OF THE BOARD OF HEALTH

(from its meeting on January 25, 1999,

submitted by Councillor John Filion, Chair)

As Considered by

The Council of the City of Toronto

on February 2, 3 and 4, 1999

1

By-law Respecting Animals

(City Council on February 2, 3 and 4, 1999, amended this Clause by:

(1)amending the draft By-law Respecting Animals appended to the report dated January 14, 1999, from the City Solicitor, by:

(a)deleting from Part I, headed "Interpretation", the definition of "at-large" and inserting in lieu thereof the following new definition:

" 'at-large' means being found on any other property than that of the owner of the animal, and not under the control of the owner, except where the owner of the property permits the animal to be on his or her property;";

(b)deleting from Part V, headed "Cats", all of Section 19 and inserting in lieu thereof the following new Section 19:

"19.The Medical Officer of Health may take possession of and impound any cat found at-large where,

(a)in the opinion of the Medical Officer of Health and the owner of the property the cat is deemed to be causing damage or creating a nuisance; or

(b)in the opinion of the Medical Officer of Health, the cat is in distress, injured and/or unidentifiable.";

(c)adding to Schedule A, entitled "Prohibited Animals", the following:

"Proboscidae (elephants)";

(d)deleting from Schedule B the words "CNE Grounds" and inserting in lieu thereof the words "Exhibition Place", to reflect the proper legal description of those lands; and

(2)adding thereto the following:

"It is further recommended that:

(a)the question of the prohibition of usual domesticated farm animals on lands not zoned 'Agricultural', be referred to the Commissioner of Urban Planning and Development Services, with a request that she, in consultation with the City Solicitor, submit a report to the Board of Health on the effect of subsection (3)(11) under Part II, headed 'Prohibited Animals', on the City's existing farms, and whether or not there should be a grandfathering clause for lands, regardless of their current zoning, that have historically been, and are currently being, used as active farms;

(b)the Medical Officer of Health be:

(i)given the discretion to waive the adoption fee for seniors if, after the required interview of a prospective pet owner, it is determined that it would be in the best interest of the prospective owner and the animal to allow the adoption;

(ii)encouraged to pursue remedies available under the Dog Owners Liability Act in cases where an attack or bite causes considerable harm to people or other animals;

(iii)requested to conduct a public education campaign on responsible pet ownership, including the recourse available under the Dog Owners Liability Act;

(iv)requested to submit a report to the Budget Committee, in time for City Council's consideration of the 1999 Operating Budget, on anticipated revenues and expenditures resulting from the By-law Respecting Animals;

(v)requested to submit a report to Council, through the Board of Health on:

(1)a process mechanism for increasing adoption rates of animals at all animal shelters; and

(2)the involvement of the private sector in the registration of animals; and

(c)the City Solicitor be requested to include a clause in the By-law that would provide an exemption for persons who:

(i)on the date of the passage of the by-law, were lawfully keeping animals listed in Schedule A, headed "Prohibited Animals", until such time as the animal has died or is otherwise disposed of; and

(ii)have registered the animals referred to in above in Part (c)(i), with the Medical Officer of Health by September 1, 1999;

(d)the issue of feral cats be referred to the Animal Services Advisory Committee for the development of appropriate by-laws, policies, and programs;

(e)the following motion be referred to the City Solicitor for a report thereon to the Board of Health, in consultation with the Medical Officer of Health:

'WHEREAS the animal control by-law prohibits large numbers of animals from being owned by one owner, whether they be dedicated amateurs and hobbyists who are contributing to the notion of these animals and their biology;

NOW THEREFORE BE IT RESOLVED THAT the City of Toronto adopt a permit system to allow the ownership of animals that would otherwise be prohibited subject to the payment of a permit fee sufficient to cover the costs of such a program, and verification by a qualified veterinarian licensed to practice in the Province of Ontario, that the individual applicant has the knowledge, resources and facilities to maintain such animals at no risk to the general public.'; and

(f)the following motions be referred to the Medical Officer of Health and the City Solicitor for consideration:

Moved by Councillor Brown:

'That the Clause be amended to provide that:

(1)the fees set out in Section 10 of Schedule C, and in Section 18 of Schedule D, come into effect on July 1, 1999, for any and all new registrations, or in the case of previously registered cats and dogs, on the expiry date of any existing licence and/or registration; and

(2)any licence or tag issued to any owner for a specific dog or cat cannot be transferred to another dog or cat.'; and

Moved by Councillor Mammoliti:

'It is further recommended that the North York Poop Patrol Program be reinstated and extended throughout the City of Toronto.' ")

The Board of Health recommends:

(1)the adoption of the By-law Respecting Animals appended to the following report (January 14, 1999) from the City Solicitor, subject to amending the by-law:

(i)by striking out the words "or euthanized" in sections 13(1) and 20(1);

(ii)to permit the foster programs under the supervision of an affiliate or branch of the Ontario Society for the Prevention of Cruelty to Animals to rehabilitate squirrels, noting for information that the keeping of songbirds is not restricted in the by-law; and

(iii)to enable the Medical Officer of Health to issue a muzzle order for a first dog bite on the owner's premises if in her opinion the bite is severe;

and that authority be granted to introduce the necessary Bill in Council in the form or substantially in the form of the by-law attached to this report, as amended;

(2)the adoption of the following set of principles regarding implementation of Part V of the By-law Respecting Animals:

(i)the primary intention of Part V of the by-law is to ensure that lost cats are reunited with their owner wherever possible, or else adopted out after a minimum five-day holding period;

(ii)that euthanasia will occur only after all reasonable attempts by staff have failed to secure a suitable home for the animal; and

(iii)euthanasia in any other circumstance will only occur for reasons of health, safety or the humane treatment of a sick or injured animal;

and that staff be directed to implement the by-law in accordance with these principles; and

(3)that revenue generated from cat registration fees be allocated to a special purpose account to assist with spay/neuter costs for animals adopted from municipal shelters:

Purpose:

To present the Board of Health with a harmonized animal control by-law.

Funding Sources, Financial Implications and Impact Statement:

None.

Recommendation:

That authority be granted to introduce the necessary Bill in Council in the form or substantially in the form of the by-law attached to this report.

Council Reference/Background/History:

The Board of Health at its meeting held December 1, 1998, had before it a report (October 29,1998) from the City Solicitor attached to which was a revised animal control by-law which reflected the recommendations made by the Animal Services Sub-Committee of the Board of Health. The Board made a number of recommendations at its December 1, 1998 meeting including the referral of all the material before the Board to its January 1999 meeting. The Board also requested the Medical Officer of Health, in consultation with the City Solicitor, to report on a revised by-law taking into account the concerns and suggestions of the deputants and people who had written to the Board, and any other recommended amendments deemed appropriate.

Comments and Conclusion:

Attached for consideration of the Board is a revised animal control by-law which reflects the directions of the Board of Health. The by-law has been prepared in consultation with the Medical Officer of Health.

Contact Name:

Jane Speakman, Solicitor, 392-1563.

--------

Authority:

Enacted by Council:

CITY OF TORONTO

Bill No.

BY-LAW No.

A By-law respecting animals.

WHEREAS section 210 of the Municipal Act authorizes a municipality to pass by-laws respecting animals and birds; and

WHEREAS section 220.1 of the Municipal Act authorizes a municipality to pass by-laws imposing fees or charges on any class of persons;

The Council of the City of Toronto HEREBY ENACTS as follows:

PART I

INTERPRETATION

1.In this by-law,

"animal" means all species of fauna excluding humans, fish and aquatic invertebrates;

"animal centre" means a facility operated by or for the City of Toronto for the keeping and disposition of stray and admitted animals;

"at large" means being found on any other property than that of the owner of the animal except where the owner of the property expressly permits the animal to be on his or her property;

"bite" means piercing or puncturing the skin as a result of contact with a dog's tooth or teeth;

"cat" means a feline of the species Felis catus;

"City" means City of Toronto;

"Council" means City of Toronto Council;

"dog" means a canine of the species Canis familiaris;

"dwelling unit" means one room or a group of rooms, occupied or capable of being occupied as the home or residence of one or more persons, and containing only one kitchen or other facility for the preparation of meals;

"ferret" means a ferret of the subspecies Mustela putorius furo;

"keep" means to have temporary or permanent control or possession of an animal and keeping has the same meaning;

"Medical Officer of Health" means the Medical Officer of Health for the City of Toronto Health Unit or any person acting under his or her authority;

"microchip" means an approved Canadian standard, encoded identification device implanted into an animal, which contains a unique code that permits or facilitates access to owner information, including the name and address of the owner, which is stored in a central database accessible to the Medical Officer of Health;

"muzzle" means a humane fastening or covering device of adequate strength over the mouth to prevent a dog from biting;

"owner" means a person or persons who possess, harbour, or have custody of an animal and where the owner is a minor, the person responsible for the custody of the minor;

"pigeon" means any of a widely distributed family of birds derived from self-sustaining captive populations of Columbidae;

"police work dog" means a dog trained for and actually engaged in law enforcement by any Federal, Provincial or Municipal government agency;

"protective care" means the temporary keeping of an animal to a maximum of five (5) days, as a result of an eviction, incarceration, medical or fire emergency or any other situation that the Medical Officer of Health deems appropriate;

"rabbit" means a European rabbit of the species Oryctolagus cuniculus.

PART II

PROHIBITED ANIMALS

2.(1)No person shall keep, either on a temporary or permanent basis, any prohibited animal in the City.

(2)For the purposes of subsection (1), prohibited animals are those classes of animals listed in Schedule A.

3.Section 2 does not apply to:

1.The premises of a City animal centre.

2.The premises of an affiliate or branch of the Ontario Society for the Prevention of Cruelty to Animals.

3.The premises of an accredited veterinary hospital under the care of a licensed veterinarian.

4.The premises of the Toronto Zoo.

5.The premises of facilities accredited by the Canadian Association of Zoos and Aquariums (CAZA).

6.The areas of the City in which professionally produced films are being made by film professionals and film production companies, and only temporarily during filming.

7.The areas of the City in which educational programs are being conducted with animals, if the animals are owned by institutions accredited by CAZA or the American Zoo and Aquarium Association and only while the educational programs are actually being conducted, provided that such programs be limited to a maximum of three days at any one location.

8.Premises registered as research facilities pursuant to the Animals for Research Act, R.S.O. 1990, c.A.22.

9.The premises of slaughterhouses licensed pursuant to the Meat Inspection Act, R.S.O. 1990, c.M.5.

10.The premises of the Toronto Police Department.

11.Domesticated Ungulates of the families Artiodactylus and Perissodactylus, Anseriformes, Galliformes and Struthioniformes:

(a)on lands owned and operated by the City listed in Schedule B; or

(b)on lands zoned agricultural.

12. The premises of the Toronto Wildlife Centre.

4.Subject to section 17, no person shall keep in any dwelling unit more than six (6) of any combination of dogs, cats, ferrets and rabbits except that any person who, on the date of the passage of this by-law, was lawfully keeping more than six (6) of any combination of dogs, cats, ferrets and rabbits may keep those dogs, cats, ferrets and rabbits until they have died or are otherwise disposed of.

PART III

CARE OF ANIMALS

5.Every person who keeps an animal within the City's boundaries shall provide the animal or cause it to be provided with adequate and appropriate care, food, water, shelter, exercise, attention and veterinary care as may be required to meet the need of the species.

6.If an animal is customarily kept out of doors, the person having the custody or control of the animal shall provide for its use at all times a structurally sufficient, weather-proofed and insulated enclosure of appropriate size and dimension.

7.(1)No person shall keep any animal in the City tethered on a chain, rope or similar restraining device of less than three (3) metres in length.

(2)Every person who has tethered an animal shall ensure, at all times, that the animal has unrestricted movement within the range of the tether, and that the animal cannot suffer injury resulting from the tethering.

8.(1)No person shall keep an animal within the City in an unsanitary condition.

(2)For the purposes of subsection (1), an animal is kept in an unsanitary condition where the keeping of the animal results in an accumulation of faecal matter, an odour, insect infestation or rodent attractants which endanger the health of any person or animal, or which disturbs or is likely to disturb the enjoyment, comfort or convenience of any person.

9.(1)Where an animal is sheltered at a City animal centre for protective care, a per diem sheltering fee shall be paid to the Medical Officer of Health in advance of redeeming the animal by the owner in the amount specified in Schedule C.

(2)Where an animal is not redeemed at the end of the protective care period, it shall be treated as an impounded animal.

PART IV

DOGS

10.Every owner of a dog shall,

(1)register the dog with the Medical Officer of Health and pay a tag and licence fee in the amount specified in Schedule C.

(2)until ceasing to be the owner of the dog, obtain a new tag and licence for the dog prior to the expiration of each licence issued for the dog which shall expire the following year on the anniversary date of its initial issuance.

(3)keep the tag securely fixed at all times on the dog for which the tag is issued.

(4)pay a tag replacement fee specified in Schedule C in the event the tag issued for the dog is lost.

11.(1)No owner of a dog shall cause or permit the dog to run at large in the City, except as permitted in those areas of City parks where dogs are permitted to run at large as designated by City by-law.

(2)For the purposes of this by-law, a dog shall be deemed to be running at large when found in any place other than the premises of the owner of the dog and not under the control of any person.

(3)No person shall keep a dog off the premises of the owner other than on a leash which shall not exceed two (2) metres in length except where consent is given by the person owning the property where the dog is found.

12.(1)Sections 10 and 11 do not apply to police work dogs.

(2)Subsection 10(1) does not apply to any owner of a dog that has a lifetime licence issued for the dog by the former City of North York, Scarborough or Toronto.

13.(1)Any dog running at large contrary to the provisions of this by-law may be seized and impounded, or euthanized by the Medical Officer of Health.

(2)Where, in the opinion of the Medical Officer of Health, a dog seized under subsection (1) is injured or ill and should be euthanized without delay for humane reasons or safety to persons, the dog may be euthanized by the Medical Officer of Health without permitting any person to reclaim the dog.

(3)Any dog seized by the Medical Officer of Health shall be impounded for a minimum period of five (5) days from the time of its impoundment, exclusive of the day on which the dog was impounded, and days on which the animal centre is closed, during which time the owner shall be entitled to redeem the dog.

(4)If a dog is not redeemed within the time period referred to in subsection (3), the dog shall become the property of the City and may,

(a)be adopted for a fee in the amount specified in Schedule C; or

(b)be euthanized by the Medical Officer of Health.

(5)Where a dog is seized and impounded by the Medical Officer of Health under subsection (1),

(a)a per diem impoundment fee shall be paid to the Medical Officer of Health in advance of redeeming the dog by the owner in the amount specified in Schedule C; and

(b)the owner shall ensure the dog is identified with a microchip.

(6)Where a dog seized and impounded by the Medical Officer of Health under subsection (1) is injured or ill and receives veterinary care necessary for the well-being of the dog, the Medical Officer of Health shall, in addition to any amount charged pursuant to subsection (5), be entitled to charge the person claiming the dog under this Part the cost of the veterinary care to the Medical Officer of Health.

14.(1)Where the Medical Officer of Health has reason to believe that a dog has bitten a person or domestic animal, the Medical Officer of Health shall,

(a)where the bite is the first bite on record with the City, and where the bite occurred on the owner's premises, serve the owner with a Notice of Caution;

(b)where the bite is a second or subsequent bite on record with the City, serve the owner with a Notice to Muzzle.

(2)Where the Medical Officer of Health has reason to believe that a dog has bitten a person or domestic animal in the City other than on the owner's premises, the Medical Officer of Health shall serve the owner with a Notice to Muzzle.

15.(1)An owner who is served with a Notice of Caution or a Notice to Muzzle is entitled to a hearing by the Medical Officer of Health who may confirm the Notice or exempt the owner from the muzzling requirements.

(2)To receive a hearing, the owner must mail or deliver to the Medical Officer of Health within thirty (30) days after a copy of the Notice of Caution or Notice to Muzzle is served on the owner, notice in writing requesting a hearing.

(3)Although a hearing may be requested, a Notice served pursuant to section 14 takes effect when it is served on the person to whom it is directed.

(4)Once a Notice to Muzzle has been issued and properly served upon the owner of the dog, no person shall permit the dog to be off the premises of the owner unless properly muzzled.

(5)For the purposes of subsection 15(4), where an owner of a dog has exclusive possession of part of a building or property, "premises" means that portion of the property of which the owner has exclusive possession.

(6)Once a Notice to Muzzle has been issued and properly served upon the owner of the dog, the owner of the dog shall ensure that the dog is identified with a microchip.

16.Every owner of a dog shall immediately remove excrement left by the dog on property anywhere within the City.

17.No person shall keep more than three (3) dogs in and about any dwelling unit within the City, except that any person who, on the date of the passage of this by-law was lawfully keeping more than three (3) dogs, may keep those dogs until they have died or are otherwise disposed of.

PART V

CATS

18.Every owner of a cat shall,

(1)register the cat with the Medical Officer of Health and pay a tag and registration fee in the amount specified in Schedule D except that no fees are payable where a cat has a lifetime identification tag issued by the former City of Etobicoke, North York, Scarborough or York or the former Borough of East York.

(2)until ceasing to be the owner of the cat, obtain a new tag for the cat prior to the expiration of the tag issued for the cat which shall expire the following year on the anniversary date of its initial issuance.

(3)keep the cat tag securely fixed at all times on the cat for which the tag is issued.

(4)pay a tag replacement fee specified in Schedule D in the event the tag issued for the cat is lost.

19.No owner of a cat shall cause or permit the cat to be at large in the City.

20.(1)The Medical Officer of Health may take possession of and impound, or euthanize any cat at large contrary to the provisions of this by-law.

(2)Where the Medical Officer of Health has taken possession of a cat under subsection (1) and is of the opinion that the cat is injured or ill and should be euthanized without delay for humane reasons or safety to persons, the cat may be euthanized by the Medical Officer of Health without permitting any person to reclaim the cat.

(3)Where the Medical Officer of Health has taken possession of a cat it shall be impounded for a minimum period of five (5) days from the time of its impoundment, exclusive of the day on which the cat was impounded, and days on which the animal centre is closed, during which time the owner shall be entitled to redeem the cat.

(4)If the cat is not redeemed within the time period referred to in subsection (3), the cat shall become the property of the City and may

(a)be adopted for a fee in the amount specified in Schedule D; or

(b)be euthanized by the Medical Officer of Health.

(5)Where the Medical Officer of Health has taken possession of a cat or has impounded it under subsection (1),

(a)a per diem impoundment fee shall be paid to the Medical Officer of Health, in advance of redeeming the cat by the owner in the amount specified in Schedule D; and

(b)the owner shall ensure the cat is identified with a microchip.

(6)Where the Medical Officer of Health has taken possession of a cat and has impounded it under subsection (1) and it is injured or ill and receives veterinary care necessary for the well-being of the cat, the Medical Officer of Health shall, in addition to any amount charged pursuant to subsection (5) be entitled to charge the person claiming the cat under this Part, the cost of the veterinary care to the Medical Officer of Health.

PART VI

SPAY/NEUTER CLINICS

21.(1)Clinics established for spaying or neutering dogs and cats in the former Cities of Etobicoke, North York and York are continued and referred to as City Spay/Neuter Clinics.

(2)City Spay/Neuter Clinics shall be operated under the control and supervision of the Medical Officer of Health.

(3)No dog or cat shall be spayed or neutered at a clinic unless:

(a)the dog or cat is owned by a resident of the City;

(b)the dog or cat is the property of the City; or

(c)the dog or cat has been adopted from a City animal centre.

22.(1)Where a dog or cat is spayed or neutered, a fee shall be paid to the Medical Officer of Health in advance of the spaying or neutering being performed in the amount specified in Schedule E.

(2)Despite subsection (1), an additional fee in the amount specified in Schedule E payable in advance of redeeming the cat or dog may be charged if the spay or neuter surgery was complicated by the physical condition, including pregnancy, of the dog or cat.

PART VII

PIGEONS

23.No person keeping pigeons shall permit the pigeons to stray, perch, roost or rest upon lands, premises or buildings of any person or upon any public place in the City, except on the property of the person keeping the pigeons.

PART VIII

FEES

24.Fees for additional services provided by the Medical Officer of Health are set out in Schedule F.

PART IX

SCHEDULES

25.Schedules A, B, C, D, E and F attached to this by-law shall form part of this by-law.

PART X

OFFENCES

26.Any person who contravenes any provision of this by-law is guilty of an offence.

PART XI

TRANSITION PROVISIONS

27.An Order or Notice to Muzzle issued under a by-law listed in subsection 28 (1) is continued and is deemed to be a Notice to Muzzle under subsections 14(1) and 14(2) of this by-law.

28.(1)The following are repealed:

1.Borough of East York By-law Number 88-97, being a by-law respecting the care and keeping of cats;

2.Borough of East York By-law Number 39-80, as amended, being a by-law to provide for the licensing of and other matters respecting dogs;

3.Borough of East York By-law Number 60-83, as amended, being a by-law to prohibit the keeping of certain animals and to regulate the keeping of certain other animals and birds within the Borough of East York;

4.Borough of East York By-law Number 30-89, as amended, being a by-law to prohibit the keeping of certain kinds of animals;

5.Borough of East York By-law Number 68-80, as amended, being a by-law to regulate the keeping of animals in the Borough of East York;

6.Borough of East York By-law Number 122-96, as amended, being a by-law to require the muzzling of a dog after it has bitten any person or domestic animal;

7.City of Etobicoke Municipal Code Chapter 95, Animals, as amended;

8.City of North York By-law Number 32819, being a by-law to regulate animals in the City of North York;

9.City of North York By-law Number 32823, being a by-law for the Muzzling of Dogs;

10.City of Scarborough By-law Number 17902, being a by-law to regulate the keeping of pigeons, as amended;

11.City of Scarborough By-law Number 22992, being a by-law to provide for the regulation and keeping of dogs and other animals or any class thereof within the municipality, as amended;

12.City of Scarborough By-law Number 23892, being a by-law to prohibit and regulate the keeping of certain kinds of animals within the municipality;

13.City of Toronto Municipal Code Chapter 133, Animals, as amended;

14.City of York Municipal Code Chapter 303, as amended, Animal Control;

15.City of York Municipal Code Chapter 305, as amended, Dog Excrement Removal;

16.City of York Municipal Code Chapter 317, as amended, Spaying-Neutering Clinic;

17.City of York By-law Number 1192-87, as amended, being a by-law to require that owners of dogs remove excrement left by their dogs in the City of York;

18.City of York By-law Number 2453-92, as amended, being a by-law to prohibit, restrict, regulate and license animals and birds; and

19.Borough of York By-law Number 2510-76, as amended, being a by-law to establish, maintain and operate a clinic for the spaying or neutering of domestic animals in the Borough of York.

(2)Where this by-law conflicts with any other by-laws respecting animals, this by-law prevails to the extent of the conflict.

29.This by-law comes into force on July 1, 1999.

ENACTED and PASSED this ______ day of ______________, A.D. 1999.

____________________________________________________________

MayorCity Clerk

Schedule A

Prohibited Animals

Mammals

Artiodactyla (such as cattle, goats, sheep, pigs)

Canidae (such as coyotes, wolves, foxes, hybrid wolf dogs) except dogs

Chiroptera (bats such as fruit bats, myotis, flying foxes)

Edentates (such as anteaters, sloths, armadillos)

Felidae (such as tigers, leopards, cougars) except cats

Hyaenidae (such as hyaenas)

Lagomorpha (such as hares, pikas) except rabbits

Marsupials (such as kangaroos, opossums, wallabies) except sugar gliders derived from

self-sustaining captive populations

Mustelidae (such as mink, skunks, weasels, otters, badgers) except ferrets

Non-Human Primates (such as chimpanzees, gorillas, monkeys, lemurs)

Perissodactyla (such as horses, donkeys, jackasses, mules)

Procyonidae (such as coatimundi, cacomistles)

Rodentia (such as porcupines, and prairie dogs) except rodents which do not exceed1,500 grams and are derived from self-sustaining captive populations

Ursidae (bears)

Viverridae (such as mongooses, civets, genets)

Birds

Anseriformes (such as ducks, geese, swans, screamers)

Galliformes (such as pheasants, grouse, guineafowls, turkeys)

Struthioniformes (flightless ratites such as ostriches, rheas, cassowaries, emus, kiwis)

Reptiles

Crocodylia (such as alligators, crocodiles, gavials)

All snakes which reach an adult length larger than 3 metres

All lizards which reach an adult length larger than 2 metres.

Other

All venomous and poisonous animals.

Schedule B

Milliken Park

Thompson Park

Sunnybrook Park

Riverdale Park

High Park

Black Creek Pioneer Village

CNE Grounds

Toronto Island Farm

Woodbine Racetrack

Schedule C

Section of By-lawPurposeFee

Section 9Protective Care

first 24 hours or part thereof$40.00

subsequent per diem rate -dogs$20.00

cats$10.00

Section 10Dog Licences

unaltered dog$ 35.00 (1 yr.)

$140.00 (5 yrs.)

dog identified with a microchip$25.00 (1 yr.)

$15.00 (1 yr.) if senior citizen

$75.00 (5 yrs.)

$50.00 (5 yrs.) if senior citizen

dog that is spayed or neutered $15.00 (1 yr.)

$50.00 (5 yrs.)

no fee if senior citizen

dog that is spayed or neuteredno fee

and identified with a microchip

personal assistance dogno fee if certificate is produced from The Canadian National Institute for the Blind or Hearing Ear Dogs of Canada or satisfactory equivalent

replacement licence tag$3.00

Section 13Impoundment Fee (Dogs)

first 24 hours or part thereof$40.00

subsequent per diem rate$20.00

Section 13Adoption Fee$125.00

Schedule D

Section of By-lawPurposeFee

Section 18Cat Registration

unaltered cat$ 35.00 (1 yr.)

$140.00 (5 yrs.)

cat identified with a microchip$25.00 (1 yr.)

$15.00 (1 yr.) if senior citizen

$75.00 (5 yrs.)

$50.00 (5 yrs.) if senior citizen

cat that is spayed or neutered$15.00 (1 yr.)

$50.00 (5 yrs.)

no fee if senior citizen

cat that is spayed or neuteredno fee

and identified with a microchip

replacement registration tag$3.00

Section 20Impoundment Fee (cats)

first 24 hours or part thereof$30.00

subsequent per diem rate$10.00

Adoption Fee$75.00

Schedule E

Section of By-lawPurposeFee

Section 22Spay/Neuter Surgery

Neutering a male dog$60.00

Spaying an immature female dog$90.00

less than one (1) year

Spaying a female dog $110.00

more than one (1) year

Neutering a male cat$40.00

Spaying a female cat$60.00

Additional fee if physical

complications$20.00

Sheltering fees at clinic (per diem)

dogs$20.00

cats$10.00

Schedule F

Section of By-law PurposeFee

Section 24 Surrender Fees (Owned Animal)

Dogs$ 35.00

Cats$ 20.00

Litters$ 20.00

Small animals$ 10.00

Cremation Fees

Small animals (<14kg)$ 75.00

Medium animals (14 to 27kg)$100.00

Large Animals (28 to 55kg)$125.00

Extra Large Animals (>55kg)$150.00

Adoption Fees

Birds

Budgie, Finch types$ 5.00

Cockateils, Love Bird types$ 20.00

Parrots

Small(<1 kg)$ 50.00

Large(>1kg)$100.00

Fish$ 5.00

Mammals (other than rodents)$ 40.00

Reptiles, Amphibians and

Invertebrates$ 20.00

Rodents$ 5.00

Other

Trap Rentals (Deposit)$100.00

Pick-up and Delivery Fees $ 20.00

Cat Boxes$ 5.00

The Board of Health submits, for the information of Council, the following report (January 15, 1999) from the Medical Officer of Health:

Purpose:

To provide supporting comments on the revisions to the By-law Respecting Animals, taking into account the concerns, suggestions and recommendations arising from the deputations, written comments, submissions from the Animal Services Advisory Sub-Committee, the Board of Health and staff.

Source of Funds:

Not applicable.

Recommendation:

It is recommended that the Board of Health receive this report for information (a companion report from the City Solicitor provides the detail of the By-law Respecting Animals).

Background:

The Board of Health at its meeting on December 1, 1998, had before it a report (November 27, 1998) from the Medical Officer of Health regarding the Revised By-law Respecting Animals and a report (October 29, 1998) from the City Solicitor respecting the Revised Animal Control By-law. The Board also had before it a number of reports and communications and heard deputations from a number of interested persons. The Board of Health took the following action with respect to the matters before it that are related to this report:

(1)referred all material before the Board of Health with the exception of those matters referred to in the following Recommendation No. (2), to the Board of Health for its January 1999 meeting, and requested the Medical Officer of Health, in consultation with the City Solicitor, to report thereon with a revised By-law taking into account the concerns and suggestions of the deputants and people who had written into the Board, and any other recommended amendments deemed appropriate;

(2)referred the recommendations of Community Councils with respect to the Uniform Policy for Leashed and Unleashed Dogs in City Parks, the establishment of leash-free zones in the City and the regulation of dog walkers, to the Economic Development Committee for consideration;

(3)requested the Medical Officer of Health to report to the Board of Health on:

(a)details on a public education campaign regarding spay/neuter clinics; and

(b)a clarification of the provisions of the By-law with respect to attendant working dogs (e.g., seeing-eye dogs); and

(4)referred the following motions placed by Councillor Prue to the Medical Officer of Health for consideration:

(a)an appeal process which would consider exemptions, in certain situations, for animals included on Schedule A; and

(b)that the exemption definition contained in the Birds order/family of Psittaciformes be revised to conform with the federal legislation as set out in Appendix I of the Convention on International Trade in Endangered Species (CITES) or the International Union for the Conservation of Nature (IUCN).

Comments:

The development of the By-law Respecting Animals was done within the scope of Toronto Animal Services' mission statement: "To promote and support a harmonious environment where humans and animals can coexist free from conditions that adversely affect their health and safety."

The following outlines the rationale of the revisions to the By-law Respecting Animals. Also incorporated is a response to the request for clarification of the provisions in the by-law with respect to attendant working dogs (e.g., seeing-eye dogs) and response to the motions placed by Councillor Prue. The report outlining the details on a public education campaign regarding spay/neuter clinics will be presented at a future Board of Health meeting. The list of comments is in order as presented in the by-law prepared by the City Solicitor.

(1)Part I, Interpretation:

The definition of "animal" has been narrowed to exclude fish and aquatic invertebrates from reference in this by-law. This means that the City will not regulate the keeping of fish and aquatic invertebrates, such as lobsters.

(2)Part II, Prohibited Animals:

In the previous draft of the by-law, there was a section that allowed Foster Programs under the supervision of an affiliate or branch of the Ontario Society for the Prevention of Cruelty to Animals to keep any animal on the prohibited list in a fostered situation outside of the premises of an OSPCA affiliate or branch. This section was deleted as there is a significant concern that the inclusion of this exemption would permit the keeping of animals that have been prohibited for reasons of health and safety. Such risks could include exposure to rabies vector animals and other zoonotic diseases. The City would also be limited in any action to remedy potential problems if this clause were to remain in the by-law.

(3)Part III, Care of Animals:

Section 7 (2), of the by-law has been amended to read: "Every person who has tethered an animal shall ensure, at all times, that the animal has unrestricted movement within the range of the tether, and that the animal cannot suffer injury resulting from such tethering."

It was recommended by the Animal Services Advisory Sub-Committee that the word "supervised" be included in this section. After further consideration, staff determined that the term "supervised" would be difficult to enforce, therefore, "supervised" was replaced with the phrase "at all times" as this covers a broader scope of control in preventing injury while the animal is tethered.

(4)Part IV, Dogs:

The Board of Health requested a clarification of the provisions of the by-law with respect to attendant working dogs (e.g. seeing-eye dogs). The fee schedule for licencing dogs permits free registration of personal assistance dogs upon proof that the dog is used for such purposes. The proof may be provided by way of certificate from the Canadian National Institute for the Blind or Hearing Ear Dogs of Canada, or any satisfactory equivalent proof.

In the previous draft by-law a provision was included that stated, "No person shall have more than three dogs under his or her control at any time while off the premises of the owner or owners of the dog or dogs." This provision has been deleted from the by-law. This issue has been referred to the Economic Development Committee for consideration in conjunction with the recommendations of Community Councils with respect to the Uniform Policy for Leashed and Unleashed Dogs in City Parks, the establishment of leash-free zones in the City and the regulation of dog walkers.

The reference in the previous draft by-law to the suggested fee guide of the Ontario Veterinary Medical Association has been removed as there may be situations where the City is restricted in recovering all costs incurred when providing veterinary care necessary for the well-being of the dog. This reference has also been deleted from the corresponding section of Part V, Cats.

(5)Part V, Cats:

The section regarding the impoundment of cats has been reworded by replacing the term "seized" with "take into possession." The wording was changed in response to concerns that the term seized had resulted in the misperception that the City would go about seizing cats at will. This replacement wording will allow the City to fulfill service expectations.

(6)Part VIII, Fees:

The current Animal Centres provide other services to animal owners such as adoption, euthanasia, and cremation. The fees for these services are set out in the referenced Schedule F of the by-law. The amounts were established by taking into account the fee schedules in the former municipalities and current costs to deliver the service.

(7)Schedule A: Prohibited Animals:

The list of Prohibited Animals has been significantly reduced to mainly cover animals which may be considered a health and/or safety risk to the community. To a lesser degree the list also includes those animals whose keeping in an urban setting may lead to significant nuisance problems, such as noise and/or odour for neighbouring residents.

Mammals - Four groups of mammals (including whales, seals, manatees and elephants) and references regarding mammals taken from the wild have been removed as there is existing legislation to deal with many of the concerns regarding these animals. The weight limit regarding Rodentia has been increased to ensure inclusion of all commonly kept rodents of self-sustaining captive populations, such as chinchillas.

The prohibited list contains a variety of farm animals due to health and safety concerns as well as nuisance problems. All pigs (including Vietnamese pot-bellied pigs) are prohibited in the by-law, which is consistent with the restrictions that existed in all of the former municipalities in Toronto. Vietnamese pot-bellied pigs can range in size from 35 lbs to over 200 lbs. An exemption based upon weight within a single species and animal breed would be difficult to enforce and does not deal with the other issues, such as potential nuisance problems, and therefore is not recommended.

Birds - Twenty-two groups of birds and references regarding birds taken from the wild have been removed as there is existing legislation to deal with many of the concerns regarding these animals. The order/family of Psittaciformes was one of the twenty-two groups that was deleted. The remaining three groups are considered a health and safety concern and/or present a significant nuisance.

Reptiles - Twelve references to reptile groups and references regarding reptiles taken from the wild have been removed as there is existing legislation to deal with many of the concerns regarding these animals. These groups have been replaced by the prohibition of all snakes which reach an adult length larger than three metres and all lizards which reach an adult length larger than two metres. Further health and safety concerns are addressed by the prohibition of venomous and poisonous animals.

Amphibians - All references have been deleted as any health and safety concerns are addressed by prohibiting venomous and poisonous animals. All references regarding amphibians taken from the wild have been removed as there is existing legislation to deal with many of the concerns regarding these animals.

Other - The only reference remaining under "Other" prohibits the keeping of poisonous and venomous animals.

Schedule A does not include an exemption provision on an appeal process as the Municipal Act does not provide for a public appeal process for prohibited animals as it does for the dog muzzle section. Even if the process was provided, it would be very difficult to establish criteria by which to grant exemptions given the variety of species specific needs to be considered and extra resources that would be required to provide for such appeals.

A grandfather clause has not been included because the animals now remaining on the prohibited list are there for reasons of health and safety and/or present a nuisance.

Conclusions:

This report provides supporting comments on the revisions to the By-law Respecting Animals, taking into account the concerns, suggestions and recommendations arising from the deputations, written comments, submissions from the Animal Services Advisory Subcommittee, the Board of Health and staff.

Contact Name:

Eletta Purdy, Manager, Toronto Animal Services, 394-8109.

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The Board of Health reports, for the information of Council, also having had before it during consideration of the foregoing matter the following communications, a copy of which has been forwarded to all Members of Council and which is on file in the office of the City Clerk:

-(December 1, 1998) from Ms. Wendy Korver, D.V.M., Bowmanville Veterinary Clinic;

-(November 30, 1998) from Mrs. Betty Walker;

-(December 2, 1998) from Mr. Michael Brassard;

-(December 1, 1998) from Ms. Nancy Mueller, Chair, Community Standards Subcommittee of Crime S.C.O.P.E. Etobicoke Office.

-(undated) from Ms. Kristen Boychuk, North York;

-(December 23, 1998) from Dale Gienow, President, Speaking of Wildlife Inc., Baltimore, Ontario;

-(January 12, 1999) from Mr. Christopher Pritchard, Chief Technician, Department of Otolaryngology, and Ms. Tracey Yvonne Young, Logistics Assistant, Communications Department, St. Michael's Hospital, Toronto;

-(January 18, 1999) from Mr. Vern Campbell, East York, Ontario;

-(January 19, 1999) from Mr. Rick Parker, Tottenham, Ontario;

-(undated) from Mr. Vernon Nixon, Toronto, Ontario;

-(January 22, 1999) from Mr. Christopher Holoboff, representing The Avicultural Advancement Council of Canada; Parrot Symposium of Canada; Budgerigar and Foreign Bird Society of Canada; and Parrot Association of Canada;

-(January 22, 1999) from Mr. John Nelson;

-(January 22, 1999) from Ms. Barby Hall;

-(January 22, 1999) from Dale and Jody Gienow, Speaking of Wildlife Inc.;

-(January 25, 1999) from Ms. Marlene Semple, Annex Animal Rescue;

-(January 22, 1999) from Ms. Daniela Quaglia, Public Affairs Advisor, Toronto Humane Society;

-(January 23, 1999) from Ms. Liz White, Director, Animal Alliance of Canada;

-(January 23, 1999) from H. Makarewicz;

-(January 24, 1999) from Ms. Holly Penfound, Director, Zoocheck Canada Inc., and Ms. Liz White, Director, Animal Alliance of Canada;

-(January 22, 1999) from Ms. Adelaide Bell;

-(January 25, 1999) from Ms. Anna Young;

-(January 25, 1999) from All Saints Church;

-(January 24, 1999) from Mr. Jeff Hathaway, and Ms. Jenny Pearce, Director, Canadian Exotic Animal Owners Association; and

-(January 25, 1999) from Merle Blain, President and Alternate Member, Etobicoke Humane Society.

(City Council on February 2, 3 and 4, 1999, had before it, during consideration of the foregoing Clause, the following communications, in support of the proposed changes to the by-law respecting animals:

(i)(January 14, 1999) from Dr. Sheila McDonald, President, Kelowna Branch, British Columbia Society for the Prevention of Cruelty to Animals;

(ii)(January 26, 1999) from Dr. P. Burgmann and Drs. Dawson, Regan, Parker and Lane, Animal Hospital of High Park;

(iii)(January 27, 1999) from Dr. W. Hugh Chisholm, Atlantic Cat Hospital Ltd.;

(iv)(January 27, 1999) from Ms. Connie Mahoney, Chairperson, Kelowna SPCA Performing Animals Committee;

(v)(January 29, 1999) from Ms. Shelagh MacDonald, Program Director, Canadian Federation of Humane Societies;

(vi)(January 30, 1999) from Mr. Clifford Warwick, Consulting Biologist;

(vii)(January 30, 1999) from Ms. Janine Denney-Lightfoot, Annex Cat Rescue;

(viii)(February 1, 1999) from Ms. Gail Zwioker, Secretary/Treasurer, Nova Scotia Humane Society;

(ix)(February 2, 1999) from Mr. Ian Campbell, Toronto; and

(x)(undated) from Ms. Margaret Both, Vice-President, Ontario Hepetological Society.)

(City Council also had before it, during consideration of the foregoing Clause, the following communications, in opposition to the proposed changes to the by-law respecting animals:

(i)(January 28, 1999) from Ms. Kathleen Callister;

(ii)(January 28, 1999) from Ms. Nancy Stannard;

(iii)January 28, 1999) from C. McIntosh;

(iv)(January 25, 1999) from Ms. Susan Kent Davidson;

(v)(January 27, 1999) from Ms. Susan Kent Davidson;

(vi)(January 31, 1999) from Mr. Mike Warren;

(vii)(January 24, 1999) from Ms. Linda Pitney;

(viii)(January 26, 1999) from Ms. Geraldine Robertson;

(ix)(January 25, 1999) from Ms. Mary Adachi; and

(x)(January 28, 1999) from Ms. Adelaide Bell, together with the signatures of 14 concerned citizens.

(xi)(January 30, 1999) from Ms. Gilda Dailey and Marisa Dailey;

(xii)(February 2, 1999) from Ms. Holly Penfound, Director, Zoocheck Canada Inc. and Ms. Lesli Bisgould, LL.B., Director, Zoocheck Canada Inc. on behalf of Ms. Liz White, Director, Animal Alliance of Canada;

(xiii)(February 2, 1999) from Ms. Nathalie Karvonen, Executive Director, Toronto Wildlife Centre;

(xiv)(February 3, 1999) from Dr. Sylvia Mittler, Toronto;

(xv)(February 2, 1999) from H. Makarewicz, enclosing a petition of 17 names; and

(xvi)(February 2, 1999) from Ms. Patricia Morton, Toronto.)

(Councillor Miller, at the meeting of City Council on February 2, 3 and 4, 1999, declared his interest in the foregoing Clause in that he has a financial interest in a company that does business with the Toronto Humane Society in this regard.)

2

Meeting Provincial Standards Across the City

for Selected Public Health Programs and Services

(City Council on February 2, 3 and 4, 1999, struck out and referred this Clause together with the following motion, to the Budget Committee for further consideration:

Moved by Councillor King:

"It is further recommended that the Medical Officer of Health, the Commissioner of Community and Neighbourhood Services, and the Chair of the Board of Health, be requested to meet with the Chief Medical Officer of Health to:

(1)review the new provincial standards for mandated public health programs, in particular Toronto's interpretation of the guidelines, to determine if the City's Department of Public Health will be meeting or exceeding the expectations of the Ministry of Health; and

(2)discuss funding issues;

and submit a joint report thereon to the next meeting of the Board of Health.")

The Board of Health recommends the adoption of Recommendations Nos. (5) and (6) embodied in the report dated January 18, 1999, from the Medical Officer of Health, viz:

"(5)the Board of Health recommend that Council urge the Ontario Ministry of Health and Health Canada to provide funding for methadone programs and services in Toronto that serve hard-to-reach and high-needs clients; and

(6) the Board of Health recommend to Council that the City's Methadone Works pilot program be ended on March 31, 1999, unless ongoing external funding is obtained to continue the program beyond that date."

The Board of Health reports, for the information of Council, having:

(1)approved in principle Options (a) of Recommendations Nos. (1), (2) and (4), with a request that the Medical Officer of Health submit a report to the Board at its next meeting, scheduled to be held on February 22, 1999, on additional cost implications for the selected options in the context of the 1999 budget submission for public health;

(2)recommended the adoption of Recommendation No. (3) to the Community and Neighbourhood Services Committee; and

(3)requested the Chair of the Board of Health, the Medical Officer of Health and the Commissioner of Community and Neighbourhood Services to review the Board of Health's position on service harmonization, and report back thereon to the Board at its next meeting.

The Board of Health submit the following report (January 18, 1999) from the Medical Officer of Health:

Purpose:

To inform the Board of Health of the costs of service options for meeting new provincial standards across the City in three program areas in 1999 and beyond.

Financial Implications:

Recognizing the City's budget constraints, a range of service level options is identified for each program (Table 1). These options correspond to a range of financial impacts (Table 2). No source of funds has been identified. The estimated costs for meeting the new standards in these three program areas cannot be achieved within the current budget without service impacts in other areas. These cost estimates are based on current program configurations. Further analysis and refinement of these estimates is continuing to ensure efficiency and cost-effectiveness in the delivery of these services.

Recommendations:

It is recommended that:

(1)the Board of Health select one of the following service level options for the Food Safety Program and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto, at an additional cost of $646,411.00 in 1999 (including a one-time cost of $61,000.00), and $1,756,234.00 in 2000 and subsequent years; or

(b)provision of the minimum service level mandated by the Province, at an additional cost of $406,630.00 in 1999 (including a one-time cost of $39,900.00), and $1,100,189.00 in 2000 and subsequent years;

(2)the Board of Health select one of the following service options for tuberculosis (TB) control and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto, at an additional cost of $726,159.00 in 1999 (including one-time costs of $100,000.00) and $1,878,478.00 in 2000 and subsequent years; or

(b)provision of the minimum service level mandated by the Province, at an additional cost of $567,572.00 in 1999 (including one-time costs of $87,000.00) and $1,441,715.00 in 2000 and subsequent years;

(3)the Board of Health request Council through the Community and Neighbourhood Services Committee to advocate with the Board of Health and local hospitals for provincial funding to provide appropriate accommodation for people without housing who have active TB, in order to reduce disease transmission and promote a stable environment which will assist them to regain their health;

(4)the Board of Health select one of the following service options for needle exchange for the purposes of HIV prevention and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto, at an additional cost of $227,878.00 in 1999 (including one-time costs of $41,000.00 in 1999) and $560,634.00 in 2000 and subsequent years plus one-time capital costs of $82,000.00 in 2000; or

(b)provision of the minimum service level mandated by the Province, at an additional cost of $180,565.00 in 1999 (including one-time costs of $41,000.00) and $418,696.00 in 2000 and subsequent years.

(5)the Board of Health recommend that Council urge the Ontario Ministry of Health and Health Canada to provide funding for methadone programs and services in Toronto that serve hard-to-reach and high-needs clients; and

(6) the Board of Health recommend to Council that the City's Methadone Works pilot program be ended on March 31, 1999, unless ongoing external funding is obtained to continue the program beyond that date.

Background:

As described in the March 1998 report to the Board of Health entitled "Investing in Public Health", the goals of Toronto Public Health are to make public health programs and services accessible across the city and responsive to diverse needs, to improve the equity of health outcomes and the overall health of the population, and to maximize efficiency in the delivery of public health services. That report also described the potential impact on current services and resources as a result of the new provincial standards outlined in the Mandatory Health Programs and Services Guidelines, which were received from the Province in early 1998.

In August 1998, a preliminary budget forecast was submitted to the Chief Administrative Officer regarding estimated costs to meet these new provincial standards in relation to the following mandatory programs: Food Safety, Tuberculosis Control, and the needle exchange component of the Sexually Transmitted Diseases (including HIV/AIDS) program.

On October 13, 1998, the Board of Health adopted a report entitled "Issues Related to the 1999 Budget Supplementary Report". That report outlined the key directions being proposed by the Medical Officer of Health regarding next year's budget, including these priorities for mandatory program harmonization in relation to the new standards.

Comments:

Legal Framework:

The fundamental role of the Toronto Board of Health is to promote and protect the health of the City's population. Health units across the province are regulated by provincial legislation. The Health Protection and Promotion Act, c.H. 7, R.S.O. 1990, the Regulations made pursuant to that Act, and the Mandatory Health Programs and Services Guidelines published by the Minister of Health, prescribe the duties and responsibilities of local health units. The Health Protection and Promotion Act states that every Board of Health shall comply with the mandatory guidelines. Should the Minister of Health determine that a health unit has failed to meet the prescribed standards, the Minister has broad powers to ensure the provision of these mandatory programs, the costs of which may be treated as a debt to the Province of Ontario by the obligated municipality in the health unit concerned. The Province also expects all boards of health to deliver additional programs and services in response to local needs and subject to municipal approval.

Framework for New Standards:

In 1997, the Province made a series of "Who Does What" decisions that re-aligned financing responsibilities between the Province and local municipalities, a process commonly referred to as downloading. Public Health had previously been cost-shared between the Province and the former six municipalities in Toronto on a 40:60 ratio, respectively. In addition, the Province paid 100 percent of the cost of certain programs that reflected provincial priorities. Most of these programs and services were downloaded to the local level effective January 1, 1998. The Province still pays 100 percent of the cost for a few programs and services, the details of which will be contained in the February report to the Board regarding the proposed 1999 Operating Budget.

The harmonization of public health programs is complicated by the Province's introduction of new program standards in parallel with both downloading and amalgamation. The Mandatory Health Program and Services Guidelines were first promulgated in 1984 and substantially revised in 1989, the version that was in effect in the year preceding amalgamation. These were again revised effective December 1997 (accompanying downloading amendments to the Health Protection and Promotion Act) to ensure that the duties and responsibilities of local boards were clearly spelled out, that the implementation of mandatory programs and services was amenable to monitoring and enforcement by the Ministry, and to ensure that local municipalities paid the expenses incurred by local boards of health in the performance of their duties.

Public Health staff from Toronto and across the province participated in the development of these new standards, although final decisions were subject to the approval of the Minister of Health and Cabinet. The criteria used by the Ministry to develop these standards included:

(a)consideration of the health needs across the province;

(b)the effectiveness of interventions to reduce these needs;

(c)whether it was appropriate for local boards of health to undertake this work; and

(d)whether local boards of health had the capacity to provide or ensure the provision of these programs and services.

Compared with the previous 1989 edition, the new standards are considerably more detailed and prescriptive, leaving little room for discretion in some cases. By contrast, the old guidelines left more opportunity for varying interpretations of the standard. This had resulted in varying levels of program implementation across the former six health units in Toronto. Even without new standards in place, this variation in service level would have had to be addressed by the current Board of Health. Staff are attempting to develop preliminary estimates of the costs for service harmonization had there been no new standards, as compared with the costs of complying with the new standards.

However, it must be noted that the Province gave explicit consideration to the scientific literature and best practices as of 1997, including new and emerging health issues that exist in Toronto and elsewhere. Therefore, the new standards reflect a level of programming that staff could have recommended as the optimal level even if the new standards had not been in place.

Policy Setting Process:

Pursuant to direction received from City Council in November, the Chief Administrative Officer is preparing a city-wide report on service level harmonization to the Strategic Policies and Priorities Committee, which will be referred for comments to local Community Councils and then to Standing Committees. This report will include information on the harmonization options contained in this report. It is generally recognized that harmonization will be a multi-year undertaking and that priorities will have to be established for the overall approach and sequencing of programs to be reviewed. Priorities for 1999 will include consideration of service levels for roads, sanitation, libraries and public health. As such, the Board's position on public health service level options should be conveyed to the Chief Administrative Officer as soon as possible. A detailed report on the public health component of the CAO's recommended operating budget will be presented to the Board of Health at its next meeting on February 22, 1999.

The options for service harmonization contained in this report are set out in relation to the City's health needs, evidence-based research, and the Board's legal duty to provide at least the minimum standard of provincially mandated programs. These options describe alternate levels of service which could be provided and which also comply with the prescribed standards under applicable legislation. The Board of Health (and, ultimately, City Council) has to make policy decisions, determined by financial, economic, social and political factors or constraints, as to which option is ultimately selected.

Once these programs have been harmonized, they will be monitored and evaluated to assess the impacts of the service level and funding decisions that have been made and the results will be reported to the Board.

Finally, it must be reiterated that the programs described in this report are the priorities for revision in 1999, not the full scope of public health programs requiring revision or enhancements to bring them into compliance with new provincial standards. As planning and amalgamation work proceeds, service level options for additional programs (e.g., in the Family Health and Lifestyles areas) will be brought forward for consideration in the Year 2000 budget cycle and beyond.

In addition to the programs dealt with in this report, options to harmonize selected local programs are described in companion reports appearing on this agenda including "Harmonization of Dental and Oral Health Services" and "Harmonization of Food Access Grants". Harmonization options for services for the homeless and options to harmonize ETS By-laws will be the subject of separate reports to the Board of Health at its February 22, 1999 meeting. Harmonization of the Animal Control By-law appears elsewhere on this agenda and harmonization options for Animal Services in general will be reported to the Board of Health later in the year for consideration in the 2000 budget cycle.

Description of Harmonization Options:

This report uses report-style appendices to explain the rationale for service harmonization in each area and to present two options for the Board's consideration.

Three of the 14 provincially mandated programs are prioritized for harmonization in 1999:

Food SafetyAppendix A

Tuberculosis ControlAppendix B

Needle Exchange Appendix C

For each program, Option A represents the optimal approach in health terms. This option is based on a combination of information on the City's health needs, evidence-based research, and the Ministry of Health's Mandatory Program and Services Guidelines, 1997. In each case, Option A is the one which as Medical Officer of Health I must endorse from a Public Health perspective.

These options are supported because they:

(1)meet legislated requirements;

(2)respond to changing and increasing local needs;

(3)use strategies considered to be "best practice" substantiated by research evidence;

(4)provide coverage that enables achievement of effective prevention in the target or risk groups; and

(5)achieve geographic equity in access to services according to the distribution of need.

Option B represents an alternative approach that is not optimal in health terms but provides some service delivery at lower cost when compared with Option A. For each mandatory program, Option B represents the minimum level of service required by the Ministry of Health. All boards of health in Ontario must provide or ensure the provision of at least this level of service.

Options A and B are also compared with the outcome of a policy decision not to increase program resources. In the case of mandatory programs, the current envelope of funds would be re-distributed to provide a consistent level of service relative to the distribution of health needs across the City, recognizing that this level will fall below the minimum requirement. Redeployment of existing resources to serve the entire City will result in service reductions in one or more regions, with the threshold for service being raised in order to address only those with the highest needs.

Conclusions:

Starting in the fall of 1997, Public Health has consistently indicated that additional resources will be required to harmonize services, to meet health needs in cost effective ways, and to achieve compliance with provincially legislated and regulated requirements. The program options put forward for harmonization in 1999 must be considered in light of available information on health needs, the effectiveness of preventive measures, and the future costs of preventable illness and death. The Board of Health (and, ultimately, City Council) has to make policy decisions, determined by financial, economic, social and political factors or constraints, as to which option is ultimately selected.

Contact Name:

Dr. Sheela Basrur, Medical Officer of Health, Tel: 392-7402; Fax: 392-0713, and

Connie Clement, Director, Public Health Planning and Policy, Tel: 392-7463; Fax: 392-0713

Table 1

Summary of Service Impact of Program Options

Insert map page - Table 2

Budget Impacts of Service Options

Appendix A

Food Safety Program

Purpose:

To inform the Board of Health about options for meeting provincial standards for food safety across the City.

Recommendation:

(1)It is recommended that the Board of Health select one of the following service level options for the Food Safety Program and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto, at an additional cost of $646,411.00 in 1999 (including a one-time cost of $61,000.00), and $1,756,234.00 in 2000 and subsequent years; or

(b)provision of the minimum service level mandated by the Province at an additional cost of $406,630.00 in 1999 (including a one-time cost of $39,900.00), and $1,100,189.00 in 2000 and subsequent years.

Background:

For the Food Safety Program, Mandatory Health Programs and Services have very specific program standards and requirements and therefore, there is little flexibility or discretion in terms of interpreting the minimum standards.

Need:

It is estimated that one in six or 1.5 million people in Ontario suffer from food-borne illnesses every year, at a medical cost alone of about half a billion dollars. The nature and scope of food-borne diseases are rapidly changing, resulting in greater public risk. Examples include:

(a)widespread food-borne outbreaks in industrialized countries from agents previously unrecognized as food-borne pathogens (e.g., E.coli O157:H7, Salmonella typhimurium DT104, Cyclospora);

(b)increasing prevalence and virulence of well recognized food-borne pathogens (e.g., Listeria monocytogenes is currently implicated in an outbreak involving 35 cases and 4 deaths across nine U.S. states);

(c)increasing number of previously unrecognized "hazardous" foods (e.g., outbreaks of E.coli caused by fresh-pressed apple cider, bean sprouts, and radish sprouts in North America and Japan);

(d)globalization of the food supply (e.g., three major Cyclospora outbreaks involving fresh Guatemalan raspberries between 1996-98 with over 300 cases reported in Toronto in spring 1998);

(e)new production technologies (e.g., aquaculture conditions suspected to be the source of the newly-identified Streptococcus iniae infection from Tilapia fish in Toronto 1995-96);

(f)increase in susceptible populations (e.g., the elderly constitute a growing percentage of the population, and are at higher risk of food-borne illness); and

(g)a general decline in safe food preparation skills in the home as a result of increasing reliance on convenience foods, take-out meals, and restaurant eating (31 percent of the food dollar in Canada is now spent out of the home).

Under-reporting of food-borne diseases is common. It is estimated that for every case of food-borne illness reported to a health agency, as many as 25 may go unreported. Consequently, the yearly average of 1,700 food-borne cases reported among residents of Toronto may actually represent up to 42,500 cases per year. Moreover, Toronto's non-resident population increases by several thousand daily; potentially hundreds of food-borne cases associated with food premises in Toronto may not be reflected in the Toronto totals, because the current surveillance system records cases based on city of residence rather than place of consumption. Even so, incidence rates of food-borne diseases in Toronto have consistently been 30 percent to 40 percent higher than the provincial rates throughout the 1990s.

Ontario surveillance data shows that most outbreaks of food-borne illness between 1993 and 1996 were associated with foods served in restaurants, catered events, and health care institutions, while "home" was the main source for single, sporadic cases. Toronto's 17,582 food premises employ over 40,000 food handlers, most of whom have no formal training in food safety.

Effective Prevention:

There is demonstrated evidence of the effectiveness of: (1) incorporating risk assessment and the Hazard Analysis Critical Control Point (HACCP) system into the conventional food premises inspection programs; (2) food handler training; and (3) community-based food safety programs. HACCP is a food quality assurance system addressing risk factors that are directly linked to food-borne illness (e.g., inadequate temperature control and cross-contamination). It is believed that HACCP provides greater assurance of food safety than any other preventive measure yet devised.

The provincial 1997 Mandatory Health Programs and Services Guidelines for Food Safety are consistent with this evidence and international standards. Minimum requirements require annual assessments of all food premises to determine their potential for causing food-borne illness. Based on this assessment, each premise is classified into one of three risk categories: high, medium or low. Mandated minimum inspection frequencies are three, two, and one per year for high, medium and low-risk premises, respectively. In addition, high-risk premises must receive at least one HACCP audit per year. The 1989 version of the Mandatory Programs and HACCP Protocol were not prescriptive with respect to minimum inspection frequencies as mandated in the 1997 version. This resulted in differences in scheduled inspection frequencies and HACCP audits between the former health units. Minimum inspection frequencies for many of the former health units were based on available public health inspector resources.

The revised Mandatory Programs also require all Boards of Health to: provide food safety information to consumers, non-profit community groups and schools; ensure the availability of certified food handler training; undertake food recalls; and respond to food-related complaints within 24 hours of notification.

Current Service Delivery Issues:

It would appear that none of the six former health units' current food safety programs fully meet the 1997 Mandatory Program requirements because the Guidelines establish more detailed requirements, in particular the minimum number of inspections based on risk category of food premises. There is also wide discrepancy among levels of services. In 1997, for example, inspection frequencies for high and medium risk services ranged from once a year or less in Toronto to four or more times a year in Etobicoke. Some offices conducted extensive HACCP audits, while others only conducted modified audits and some offices did not include HACCP audits as part of their inspections. There is also diversity in the type and amount of food handler training provided. Special events (e.g., Caribana, Molson-Indy, CNE) place a heavy demand on the Toronto office for approval and inspection. All six offices meet the Ministry's requirement for 24-hour response to any food-related complaints but are able to allocate only minimal resources for public education on food safety issues.

The number of food premises is expected to continue to rise. The concentration of ethnocultural foods in Toronto and increasing diversification of the food industry (e.g., doughnut shops operating as cafés selling sandwiches and soups; supermarkets offering "take-out" items) further increase the inspection workload.

Options for Harmonization:

Option A:Optimal Prevention:

With a food safety budget increase of 45 percent, Option A results in effective food safety programs throughout the City in compliance with minimum Mandatory Program requirements consisting of: inspection services, expanded community food safety initiatives, food handler training and certification programs, effective and efficient response to consumer complaints and enquiries; and an enhanced surveillance and monitoring system to identify and assess risks and prevent and control hazards that can lead to food-borne illness. Staffing levels will be adequate to meet the demands of special events and functions (food vendors at these events are not included in the total 17,582 premises). This level of service would ensure that each year all high risk premises are inspected three times (including one HACCP audit), all medium-risk premises two times and low-risk premises once.

The enhanced community food safety initiatives will include locally implementing public education campaigns such as "Fight BAC". This campaign launched by a unique national coalition of industry, government, environmental and consumer groups comes at a time when many Canadians have inadequate knowledge about basic food safety practices. Campaigns such as this will result in new partnerships with many food operators in a joint effort to reduce food-borne illness.

Expanding the partnership with the small business offices (such as present in Toronto) to the entire City will lead to increased opportunities to assist owners in safely designing and operating their new food business. Developing new and strengthening existing partnerships with community, cultural and business groups and associations will ensure equal access to food safety programs and services. An environmental epidemiologist dedicated to the Food Safety Program will permit detailed analysis of food-borne illness (i.e., sentinel physician reporting, analysis of hospital emergency room visits, etc.) to get a clear picture of food-borne illness in the City.

This will require additional public health staff such as health promotion specialists, an epidemiologist and environmental consultants outlined in the costs below. Approximately five staff currently provide this type of support to the Food Safety Program. These FTEs are not included as part of the existing 53.3 public health inspector FTEs in the Food Safety Program.

This option equalizes current programs and levels of service across the City, standardizing inspections and eliminating differences. Food premises in Etobicoke, York, East York and North York will see decreases from the number of inspections conducted in 1997 and inspections in Scarborough and Toronto will increase. The Toronto area, with approximately 45 percent of the food premises, will have the largest increase in number of inspections. Those with decreased numbers of inspections will benefit from the HACCP Protocol and increased implementation of non-inspection services as per the Mandatory Program requirements. Partnerships with the private sector and the community will be enhanced with the common goal of providing a safer food supply.

This additional cost of $1,756,234.00 annualized provides for an additional 20.7 public health inspectors, one manager, one epidemiologist, one health educator and two clerical support staff with implementation to begin in September 1999 ($585,411.00), a one-time cost of $61,000.00 in September 1999 and full implementation in 2000.

Option B:Minimum Mandatory Program Standards:

With a food safety budget increase of 28 percent, Option B results in effective food safety programs throughout the City in compliance with minimum Mandatory Program requirements consisting of: inspection services, community food safety initiatives, food handler training and certification programs, effective and efficient response to consumer complaints and enquiries; and a surveillance and monitoring system to identify and assess risks and prevent and control hazards that can lead to food-borne illness. Staffing levels will be adequate to meet the demands of special events and functions (food vendors at these events are not included in the total 17,582 premises). This level of service would ensure that each year all high risk premises are inspected three times (including one HACCP audit), all medium-risk premises two times and low-risk premises once.

This option equalizes current programs and levels of service across the City, standardizing inpsections and eliminating differences. Food premises in Etobicoke, York, East York and North York will see decreases from the number of inspections conducted in 1997 and inspections in Scarborough and Toronto will increase. The Toronto area, with approximately 45 percent of the food premises, will have the largest increase in number of inspections. Those with decreased numbers of inspections will benefit from the HACCP Protocol and increased implementation of non-inspection services as per the Mandatory Program requirements. Partnerships with the private sector and the community will be enhanced with the common goal of providing a safer food supply.

This additional cost of $1,100,189.00 annualized provides for an additional 14.7 public health inspectors and two clerical support staff with implementation to begin in September 1999 ($366,730.00) plus a one-time cost of $39,900.00 in September 1999, with full implementation in 2000. In my opinion, as Medical Officer of Health, the minimum mandatory requirements cannot be met without this additional staffing.

Implications of No Additional Funding:

If there is no increase in the current budget of $3,856,750.00, it is recommended that the level of service be standardized across Toronto. This would require a redistribution of existing staff resources based on need. A proportion of staff resources from all of the other offices would need to be reassigned to the Toronto office, which has 45 percent of the food premises, resulting in a significant reduction of the current service levels in the areas served by the other five offices.

This option will result in over 16,000 compliance inspections not being carried out and potentially hundreds of critical violations going unchecked, placing the Toronto community at greater risk for food-borne illness and disease.

This option provides a level of service where all high-risk premises would be inspected three times annually, 83 percent (7,113) of medium-risk premises would receive only one inspection per year and 17 percent (1,465) of the medium-risk and all 6,254 low-risk would not be inspected. The criteria for selecting those medium-risk premises that would not be inspected include the presence of internal responsibility systems, such as full implementation of HACCP, self-auditing of food preparation, food handler training/certification, etc.

In my opinion as Medical Officer of Health, the Toronto Board of Health would not be in compliance with the Mandatory Programs under this option.

This level of public health surveillance and monitoring of food premises may also result in a lower level of self-compliance by owners/operators of restaurants and other food premises. Reduced inspection levels in some areas may also result in an increased number of complaint investigations and reinspections to ensure critical hazards rectified, resulting in further inability to meet even the proposed inspection schedule.

Program Budget and Budget Options:

Conclusion:

A broad range of global and local factors is responsible for recent outbreaks, new food hazards and an increasing need for effective food safety programs world-wide and in Toronto. In response, industry and governments in Europe, North America (and Ontario) are implementing new standards based on evidence of effective interventions. These include: risk assessment and incorporating the Hazard Analysis Critical Control Point (HACCP) system into conventional food safety premises inspections programs; food handler training; and community-based safety programs. Effective food safety programs are essential to the health of the population and the ability of Toronto to maintain its reputation as a safe and healthy city for business, tourism and living. This report presents options for meeting provincial standards for effective food safety programs in Toronto. These options have different budget implications. The Board of Health (and ultimately City Council) has to make policy decisions, determined by health, financial, social and political factors and constraints as to which option is ultimately selected.

References:

Altekruse SF, Cohen ML, Swerdlow DL. Emerging Foodborne Diseases. Emerg Infect Dis 1997 Jul-Sep:3(3):285-93.4.

Campbell ME, Gardner CE, Dwyer JJ, et al. Effectiveness of Public Health Interventions in Food Safety: A Systematic Review. Canadian Journal of Public Health 1998;89(3):203-207.

FSnet Dec. 19, 1998 http://www.exnet.iastate.edu/Pages/families/fs/homepage.html.

Hauschild AHW, Bryan FL. Estimate of cases of food and waterborne illness in Canada and the United States. Journal of Food protection 1980; 43:4335-4440.

Institute of Medicine, National Research Council. Ensuring Safe Food: From Production to Consumption. Washington D.C. : National Academy Press, 1998; 51-59.

Meng J. Doyle MP. Emerging Issues in Microbiological Food Safety. Annu Rev Nutr 1997;17:255-75.

Ontario Ministry of Agriculture, Food and Rural Affairs (OMAFRA), 1994. Community Food Advisor Program Guidelines. OMAFRA, Toronto. Revised May 1994.

Ontario Ministry of Health. Public Health and Epidemiology Report Ontario (PHERO). 1998;9(5):109-112.

RDIS data 1995-1997, Toronto Public Health.

Rocourt J. Bille J. Foodborne Listeriosis World Health Stat Q 1997;50(1-2):67-73.

Silliker JH, Baird-Parker A, Bryan FL, et al. Report of the WGO/ICMSF Meeting on Hazard Analysis Critical Control Point System in Food Hygiene. World Health Organization, Geneva, Switzerland, 1982.

Sly T. Ryerson Polytechnic University, School of Occupational and Public Health. Personal Communication. December 20, 1998.

Toronto Board of Health. 1997. Is Food the Next Public Health Challenge? City Clerk, Toronto. September 5, 1997.

Toronto District Health Council. Toronto's Health System Report Card (Interim Report). November 1998 102-103.

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Appendix B

Tuberculosis Program

Purpose:

To inform the Board of Health about options for meeting provincial standards for tuberculosis control across the City.

Recommendations:

It is recommended that:

(1)the Board of Health select one of the following service options for tuberculosis (TB) control and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto at an additional cost of $726,159.00 in 1999 (including one-time costs of $100,000.00) and $1,878,478.00 in 2000 and subsequent years; or

(b)provision of the minimum service level mandated by the Province, at an additional cost of $567,572.00 in 1999, (including one-time costs of $87,000.00) and $1,441,715.00 in 2000 and subsequent years; and

(2)the Board of Health request Council through the Community and Neighbourhood Services Committee to advocate with the Board of Health and local hospitals for provincial funding to provide appropriate accommodation for people without housing who have active TB in order to reduce disease transmission and promote a stable environment which will assist them to regain their health.

Background:

For the TB control program, there is a provincial protocol under the Mandatory Health Program and Service Guidelines which has specific program standards and requirements. Therefore, there is little flexibility or discretion in terms of interpreting the minimum standards.

Need:

There are approximately 2000 new cases of tuberculosis reported in Canada each year, including 800 in Ontario. The City of Toronto has 450 - 500 cases of TB per year with an incidence rate three times the provincial rate. Three key factors have contributed to the increased prevalence of TB in Toronto:

(1)Toronto experiences high immigration from countries where TB is endemic (over 90 percent of the TB cases in Toronto occur in the foreign-born). TB rates in some major source countries are 30 - 40 times the Toronto rate and 30 percent of all immigrants to Canada settle in Toronto, a city which has 6 percent of the Canadian population.

(2)Socio-economic factors - numbers of unemployed, low-income singles and families with children, people who are homeless - are all above the provincial average; poverty and crowded conditions increase the risk of acquiring and spreading TB among vulnerable groups.

(3)Toronto's HIV infection/AIDS incidence rate is three times the provincial rate. Having HIV greatly increases the risk of developing TB and prolongs the TB treatment period when TB does occur.

Drug resistant tuberculosis is of great concern and has been linked to outbreaks in cities such as New York and San Francisco. In 1996, 16 percent of Toronto cases demonstrated resistance to one or more antibiotics (compared to 8.7 percent nationally); multi-drug resistant (MDR-TB) cases reached 2.6 percent in 1996 compared to less than 1 percent for Canada as a whole. Mortality in drug resistant cases ranges between 18 - 70 percent. Drug resistant strains result primarily from incomplete or improper treatment; a drug resistant TB case costs $230,400.00 (U.S.) to treat compared to $14,500.00 (U.S.) for a case of nonresistant TB. TB prevention directly lowers future public health costs, while also reducing expenditures in other sectors (e.g., acute care hospitals).

Conversely, failure to invest in TB prevention can lead to escalating disease rates and associated costs, as occurred in New York City where complacency about declining numbers of TB cases led to cut-backs in the TB program during the 1980's. Within a short period of time, TB rates tripled and drug resistance increased to 23 percent, with mortality in resistant cases reaching more than 80 percent. In response to this growing epidemic, the U.S. Center for Disease Control (CDC), expanded its budget to support TB programs from $25 million in 1991 to $104 million in 1993. With the additional funding, New York City embarked on a massive expansion of its Directly Observed Therapy (DOT) program, going from 137 persons on DOT in 1991 to 1282 DOT patients by 1993. That year the number of new TB cases fell for the first time in 15 years. This reversal was attributed to the expanded DOT program. In 1997, New York City had a population of 8.6 million and 1737 cases of TB, for an incidence rate of 21.6/100,000 population; it also required a $40 million TB program with over 500 staff. While it can be argued that the structure of the health care and social service systems are very different in the U.S., it is important to pay attention to the New York lesson and implement an effective TB program that will save lives and money in the long run.

TB is now regarded world-wide to be the leading cause of death among people who are HIV positive. In the City of Toronto in 1996, 4.2 percent of TB cases had HIV/AIDS listed as a risk factor, up from 3.7 percent for 1992-96. The mortality rate in persons who have TB and who are also HIV positive ranges between 20 percent to 35 percent, in part because TB accelerates the natural progression of HIV infection. Targeted programming and strategic interventions are required to prevent co-infection in Toronto.

Effective Prevention:

In 1993 the World Health Organization (WHO) declared TB a "global emergency". It recommended universal use of Directly Observed Therapy (DOT). DOT consists of closely supervised treatment by watching patients swallow their medication to make sure every dose is taken; it is the most effective way to cure TB as it ensures patients adhere to treatment. Non-adherence is difficult, if not impossible, to assess in advance and variables such as age, income, occupation, education do not reliably, consistently or accurately predict adherence to therapy. Incomplete treatment of TB is worse than no treatment at all because it leads to drug resistance. DOT is labour intensive but it works. The World Bank describes DOT as one of the most cost-effective health strategies.

The Canadian Expert Committee on Tuberculosis (ECOT), through the National Consensus Conference on Tuberculosis held in December 1997, made recommendations including:

(a)Directly Observed Therapy as the standard treatment;

(b)screening of high-risk groups for case finding and prophylaxis (e.g., drop-ins, homeless shelters, correctional facilities, alcohol and drug rehabilitation programs);

(c)improved communication and collaboration between AIDS and TB programs;

(d)case manager for each case of active TB (to monitor compliance, check drug toxicity monthly); and

(e)monitoring of clients on INH prophylaxis for toxicity.

The provincial Mandatory Health Programs and Services Guidelines (1997) state that the "Board of Health shall have in place an effective program for TB prevention and control which shall include case finding, case holding, treatment and follow-up". The minimum requirements outlined for TB prevention and control in Ontario, detailed in a provincial protocol, are consistent with the recommendations of the WHO, expert committees, and scientific research and experience concerning cost-effective TB prevention and control except in the case of DOT. The guidelines state that the Board of Health must "ensure that all persons with active tuberculosis complete the prescribed course of chemotherapy through the provision of DOT or another appropriate intervention." Other interventions are not described and to date no intervention has been shown to cure TB as cost-effectively as DOT. There may be strategies whereby DOT can be used in a modified manner but these have not been evaluated.

Current Service Issues:

There is considerable variation in the degree to which the new 1997 Mandatory Health Program and Services Guidelines are being met in the six former health units:

(a)Less than 20 percent of cases are followed with DOT (Toronto offers DOT to all cases, Etobicoke and North York offer DOT selectively; Scarborough, East York and City of York do not have DOT programs).

(b)Educational sessions and updates to physicians, other health care workers and high risk groups are provided only on as-time-permits basis (e.g., Toronto offers education to shelter and hostel staff; North York and Etobicoke offer education only upon request; and Scarborough cannot offer any educational sessions because of a lack of staff).

(c)Screening of high risk groups, other than contacts of active cases, is not available anywhere in the City.

(d)Monitoring of adherence to chemoprophylaxis is not available anywhere in the City.

(e)Monitoring of individuals on surveillance for inactive TB (Post Landing Surveillance of immigrants and refugees) varies from one contact only (Scarborough and City of York) to annual follow-up for five years (Toronto).

Options for Harmonizing the TB Program:

Option A:Optimal Prevention:

With the addition of 28 FTEs to the current 35.25 FTEs, Toronto will be able to provide DOT to all TB cases and select high risk contacts and provide TB education, including regular updates to physicians and other health care workers throughout the City. It will permit more careful monitoring of clients on chemoprophylaxis and screening of selected groups at high risk of developing TB (e.g., injection drug users, English as a Second Language [ESL] students, homeless and underhoused persons living in shelters). The increase will enable Toronto to meet the requirements set out in the Mandatory Health Programs and Services Guidelines. It also provides equal access across the city to the most cost-effective form of treatment for active tuberculosis and the best protection against increasing TB drug resistance and preventable TB mortality. While DOT currently is primarily provided by RPNs (six to seven community visits per day), a variety of other strategies are currently being explored to provide DOT in the most cost-effective way possible (persons coming to the health unit or community clinic, contracting out, using non-professional staff for low-risk cases).

The additional budget required is $1,878,478.00 (a 90 percent increase in the current budget of $2,100,000.00 for a total budget of $3,978,478.00) to begin implementation in September 1999 with an increase in operational costs of $626,159.00 in 1999 plus one-time computer costs of $100,000.00.

Option B:Minimum Mandatory Program Standards:

With limited expansion (budget increase of 69 percent and 19.75 staff), full DOT will be available to only 40 percent of TB cases. This will be a reduction in the DOT program in the Toronto district while it increases the services available in other parts of the City. All new cases will start on DOT for the first month until treatment is well established. During this period the client will be assessed for risk factors commonly associated with non-adherence (e.g., failure to keep appointments) and a decision regarding the necessary support he/she requires will be made. The DOT program will be restricted to select high risk cases (e.g., persons who have drug resistant TB, persons who are co-infected with HIV, children and teenagers, persons who are homeless or under-housed, persons with substance abuse problems and individuals who are experiencing adverse reactions to TB medication). In other cases, an enhanced follow-up program will be used as a strategy to ensure adherence to treatment. Persons deemed to be at low risk can be followed at progressively longer intervals (e.g., initially weekly then tapering to monthly).

This expansion of the DOT program in some parts of the City will ensure improvement in completion of treatment and decline in relapse rates. This option also establishes enhancement to educational outreach as required in the new Mandatory Health Programs and Services Guidelines. Education will be available to targeted high-risk groups (e.g., new immigrant and refugee centres) and annual updates will be provided to health professionals. In addition, contact follow-up of new cases will be expanded to meet the new requirements. Limited screening of high risk groups (e.g., homeless shelters, ESL classes) will be undertaken and monitoring of individuals on chemoprophylaxis will be enhanced to the minimum level specified in the guidelines. Direct contact with individuals on post landing surveillance for inactive TB will be initiated.

This option increases access to DOT from the current 20 percent of cases to about 40 percent of cases. While it is anticipated that this option would comply with the minimum requirements of the 1997 Mandatory Health Programs and Services Guidelines, it would be difficult to provide the majority of persons with active TB with the treatment that has been proven to be most cost-effective. This requires a budget increase of $1,441,715.00 with implementation to begin in September 1999 with a budget increase of $480,572.00 for operational costs in 1999 plus one-time costs of $87,000.00.

Implications of No Additional Funding:

With no budget increase, existing resources would be redistributed to reflect patterns of health needs across the City. As a result, TB services would be decreased in the districts of Toronto, Etobicoke and North York, with expansion in Scarborough, East York and the City of York. DOT would only be available on a selected basis to high-risk pulmonary cases who are deemed to be most likely to be non-adherent to treatment.

Since it has been established that health care providers are unable to predict adherence to and completion of TB treatment, the incidence of non-adherence, acquired drug-resistance and TB mortality would be expected to rise. This would particularly occur in the districts where DOT services are cut back. Educational outreach would be limited to select high-risk settings on an as-time-permits basis which may have a negative impact on timely case identification and contact follow-up.

In my opinion, as Medical Officer of Health, many of the provisions specified in the Mandatory Guidelines would not be met. The dollars not invested in prevention and follow-up will put pressure on future budget requirements to treat cases that could have been prevented. This prediction is based on the American experience where it has been estimated that the health system cost of treating a single outbreak of drug resistant TB approaches $1,000,000.00 (U.S).

Program Budget and Budget Options:

* The cost of drugs for TB treatment and chemoprophylaxis is paid by the Province.

Conclusion:

Tuberculosis is a global emergency, a major cause of death in many countries and a leading cause of death among people who are HIV positive. Toronto has high immigration from many countries where TB is endemic. Drug resistant forms of TB are increasing world-wide and in Toronto. Other conditions for increasing TB are homelessness, poverty, substance abuse, crowded living conditions, and HIV.

Evidence of the cost effectiveness of TB prevention and control interventions is mounting and clear about the importance of infrastructure to ensure early identification of cases, directly observed therapy, follow up of all contacts and education for high-risk populations and health care providers. Experience is also clear in demonstrating that the costs of failure to invest in prevention are many times higher when a TB crisis results.

This report presents options for meeting provincial standards including optimal level to effectively prevent and control TB and minimal level to meeting provincial standards. The Board of Health (and ultimately City Council) has to make policy decisions determined by financial, economic, social and political factors and constraints as to which option is ultimately selected.

References:

Bayer R, Wilkinson D. Directly Observed Therapy for Tuberculosis: History of An Idea. The Lancet, Vol. 345, June 17, 1995. Pp. 1545-1548.

Chaulk CP, and Kazandjian VA. Directly Observed Therapy for Treatment Completion of Pulmonary Tuberculosis. JAMA, March 25, 1998, Vol. 279, p. 944.

Faning EA. Globalization of Tuberculosis [editorial comment]. CMAJ 1998; 158: Pp 611-2.

Moore RD, Chaulk CP, Griffiths R, Cavalcante S and Chaisson RE. Cost-Effectiveness of Directly Observed Versus Self-Administered Therapy for Tuberculosis. Am J Respir Crit Care med, 1996; Vol. 154, Pp. 1013-1019.

Park MM, Davis AL, Schluger NW, Cohen H and Rom WN. Outcome of MDR-TB Patients 1983 - 1993. Am J Respir Crit Care Med, 1996; Vol. 153, Pp. 317-324.

Prevention and Treatment of Tuberculosis Among Patients Infected with Human Immunodeficiency Virus: Principles of Therapy and Revised Recommendations, Morbidity and Mortality Weekly Report, October 30, 1998, Vol. 47, p. 7.

Report of the National Consensus Conference on Tuberculosis, held in Toronto December 3-5, 1997. Pp. 8-13.

Reported Tuberculosis in the United States, 1997. U.S. Department of Health and Human Services, Public Health Services, Centres for Disease Control and Prevention, National Centre for HIV, STD and TB Prevention, Division of Tuberculosis Elimination. Pg. 43.

TB Programme. TB a global emergency: WHO report on the TB epidemic Geneva. Switzerland: World Health Organization 1993 (WHO/TB 1993-177).

Weis SE, Slocum PC, Blais FX, King B, Nunn M, Matney GB, Gomez E and Foresman BH. The Effect of Directly Observed Therapy on the Rates of Drug Resistance and Relapse in Tuberculosis. The New England Journal of Medicine, Vol. 330, April 28, 1994, Pp. 1179-1184.

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Appendix C

Needle Exchange Services

Purpose:

To inform the Board of Health about options for meeting provincial standards for needle exchange services for the purposes of HIV prevention across the City.

Recommendations:

It is recommended that:

(1)the Board of Health select one of the following service options for needle exchange for the purposes of HIV prevention and recommend the additional funding required within the 1999 budget approval process:

(a)provision of an optimal service level for the City of Toronto, at an additional cost of $227,878.00 in 1999 (including one-time costs of $41,000.00 in 1999) and $560,634.00 in 2000 and subsequent years plus one-time capital costs of $82,000.00 in 2000; or

(b)provision of the minimum service level mandated by the Province, at an additional cost of $180,565.00 in 1999 (including one-time costs of $41,000.00) and $418,696.00 in 2000 and subsequent years;

(2)that the Board of Health recommend that Council urge the Ontario Ministry of Health and Health Canada to provide funding for methadone programs and services in Toronto that serve hard-to-reach and high-needs clients; and

(3) that the Board of Health recommend to Council that the City's Methadone Works pilot program be ended on March 31, 1999, unless ongoing external funding is obtained to continue the program beyond that date.

Background:

Need:

Injection drug use is the fastest rising risk factor for HIV, representing a significant need and opportunity for effective prevention.

(1)The number of injection drugs users in Toronto is estimated at 15,000. The largest concentration of AIDS/HIV among Ontario injection drug users continues to be in Toronto (half of all cases) and all the six former municipalities are among the 10 health units with the highest AIDS rates.

(2)The current HIV seroprevalence rate among injection drug users in Toronto is 9.5 percent, showing a steady increase since 1991 when the rate was less than 5 percent. Although the rate in Toronto is increasing, it is low compared to Montreal (20 percent) and Vancouver (25 percent). Worldwide experience shows that once the HIV rate in a population reaches 10 percent, it can increase exponentially, making effective prevention programs in Toronto imperative.

(3)Conditions known to contribute to HIV transmission are increasing (e.g., lack of stable housing, transience, sharing needles, injecting cocaine). Anecdotal evidence indicates that crack injection is significant in Scarborough, East York, North York and Toronto.

(4)Street Youth are a growing risk group, with estimated HIV rates triple those of the general population; between 17 and 30 percent are estimated to be injection drug users and needle sharing is common.

(5)Research suggests that difficulty in obtaining sterile injecting equipment is the main reason that injection drug users share equipment.

(6)A recent scan to gather information about the need for increased services to injection drug users in Toronto revealed that all areas in the new City of Toronto are under-serviced, with the exception of the former City of Toronto.

Recognizing injection drug users as a priority group for AIDS prevention, the Ontario Ministry of Health recently created a mechanism to fund community outreach workers to work with injection drug users. Six workers will be hired in Toronto, with one position going to The Works (the former City of Toronto needle exchange program). The guidelines for this program clearly state that the workers must be "value added" and not duplicate or replace existing services and programs. The outreach workers are also expected to work towards reducing the isolation of injection drug users and should assist in reaching those presently not accessing services. There have already been preliminary discussions requesting supplies, training and support for the outreach workers in the Toronto area from The Works. It is therefore anticipated that this program will increase demand for needle exchange services and supplies in Toronto.

Effective Prevention:

The 1997 Provincial Mandatory Health Program and Services Guidelines state that "The Board of Health shall ensure that injection drug users can have access to sterile injection equipment by the provision of needle and syringe exchange programs as a harm reduction strategy to prevent the transmission of HIV, Hepatitis B, Hepatitis C and other blood-borne infections and associated diseases in areas where drug use is recognized as a problem in the community. The strategy shall also include counseling and education and referral to primary health services and addiction/ treatment services..."

The provision of sterile injection equipment is the most effective method for the prevention of HIV and other communicable diseases in injection drug users. A World Bank report found the former City of Toronto was one of five cities worldwide able to maintain a low HIV seroprevalance rate, primarily because the needle exchange programs started early and were multi-faceted. Research clearly demonstrates that a multi-faceted needle exchange service is a contributing factor to maintaining a low HIV rate. Multi-faceted needle exchange programs provide needles, condoms, instruction regarding safer drug use and safer sex, counselling regarding drug use, referrals to detox and drug treatment, assistance in accessing housing, food and clothing, testing for HIV, Hepatitis B and C, Hepatitis B vaccines, methadone and access to primary care and other health and social services.

Access to needle exchange services is enhanced through a combination of service sites.

(a) Mobile Service enables staff to reach a large geographic area, provide services to clients where they are and reach injection drug users who are concerned about anonymity.

(b) Fixed Site/Drop-in is a good venue for more in-depth service provision, including counselling, health testing (e.g., HIV and Hepatitis) and referrals to other services.

(c) Street Outreach introduces services to the target population in areas where there has not been service and educates injection drug users about the service and how to access it.

(d)Partnerships with community agencies enable provision of needle exchange for clients in an environment that they already trust and within which they feel comfortable.

Current Service Delivery Issues:

There is significant variation in the degree to which the 1997 Mandatory Health Program and Services Guidelines are being met in Toronto. The former City of Toronto appears to be the only district that meets the requirements. The former health units of Etobicoke and York offered a minimal level of service. Prior to amalgamation, the former North York was in the initial stages of developing a partnership with a community agency to provide basic needle exchange and condom distribution to injection drug users. The former municipalities of Scarborough and East York did not offer needle exchange services. Public Health staff in the Scarborough district are working closely with a community agency to expand other services for injection drug users.

The former City of Toronto funded a one-year methadone pilot project (called Methadone Works) in response to a recommendation arising from the Inquiry into Homelessness and Street Deaths (1996). Members of the Inquiry based this recommendation on research that clearly demonstrates a connection between drug use and homelessness. Methadone maintenance has also been shown to reduce the use of illicit drugs and criminal activity, improve mental and physical health and economic productivity, improve retention in addiction treatment, reduce needle sharing and reduce HIV rates and transmission. The results of an evaluation of the program are expected in April 1999. Preliminary results reveal that many clients of Methadone Works have been able to reduce needle use and therefore needle sharing, and have been able to secure more stable housing.

The Toronto district needle exchange program operates Methadone Works in partnership with Breakaway Youth and Family Services in Etobicoke. There has been a substantial increase in methadone availability in Toronto in the recent past, mainly through private physicians who do not have comprehensive support services readily available for patients. Research demonstrates that successful methadone programs have a high level of optional support services. Methadone Works offers intensive support services and counselling and is the only low threshold harm reduction methadone program of its kind in Toronto. This program was designed for clients of The Works (many of whom are homeless or underhoused and have a variety of other service needs) who require counselling and would probably not remain on methadone without intensive support. Priority is given to clients who are HIV positive or pregnant. Methadone Works is co-located with The Works in an effort to increase accessibility to methadone for current injection drug users who have a positive history with a program that is non-judgemental and non-threatening. Clients without OHIP are also seen and the costs of methadone and other drugs prescribed by the methadone physician are covered in the methadone budget.

Methadone Works started in November 1997 as a pilot project with one-year funding from the former City of Toronto. A one-time grant from the Substance Abuse Bureau of the Ministry of Health will continue funding of the program until March 31, 1999. An application for continued annualized funding has been submitted, but is not expected to be approved due to financial constraints. A further application has been submitted to the Substance Abuse Bureau of the Ministry of Health for an additional two months of funding to carry the program until the end of May 1999, but a response has not yet been received. Applications will also be made to Health Canada and other federal funding sources.

Options for Harmonizing the Needle Exchange Program:

Option A: Optimal Prevention:

In this option, services would be enhanced to the level in the former City of Toronto to extend multifaceted needle exchange services across the city. Overall staffing and services would be almost doubled. A total of 5.8 Counsellors, three vans and one Clerk would be added and the Peer Outreach budget would be enhanced. Currently, 16 partnerships with community agencies and pharmacies for the provision of needle exchange services are in place, and Option A would see the number of partnerships increased to 30.

This level of service would comply with the Mandatory Health Programs and Services Guidelines and would have the greatest chance of ensuring the prevention of HIV, Hepatitis B and C and other communicable diseases in the injection drug using population in Toronto. This option has the potential for exchanging the largest number of needles; the one-time purchase of new vans (with capital expense spread over 1999 and 2000) is critical to the best practice nature of this option in that the existing two vans account for a major portion of needles currently exchanged. Vans are equipped with a stationary table and chairs, storage, needle disposal container, and a cab so that people can stand in the van as well as receive counselling, referral or health testing.

A total of $560,634.00 would be added to the annual base budget, bringing the total budget for needle exchange services to $1,185,634.00. In addition, a total of $123,000.00 in capital costs would be required for the purchase of three vans. Implementation of the needle exchange component would begin in September of 1999.

Option B: Minimum Mandatory Program Standards:

Services would be enhanced to the level of service delivery in the former City of Toronto, with the exception of the mobile component which would only be partially enhanced. This option would add four Counsellors, one van, one Clerk and an enhanced Peer Component and community agency partnership program. The focus of service delivery would be street outreach and support for peers and community agencies. The primary goal in the first year would be client finding.

It is anticipated that Option B would comply with the 1997 Mandatory Guidelines, however, limited availability of the mobile component in larger, more dispersed regions of the City will decrease efficiency and increase staff travel time, potentially decreasing access to needle exchange services to the most isolated clients.

A total of $418,696.00 would be added to the base budget (making the total budget for needle exchange services $1,043,696.00). A total of $41,000.00 in capital costs would be spent in 1999 to purchase one additional van. Implementation of Option B would begin in September of 1999.

Implications of No Additional Funding:

If resources remain the same, services would be redistributed to serve pockets of highest need across the City. This would reduce services provided to current clients in order to provide access to new clients in underserviced areas. The program would provide an inadequate level of prevention and HIV rates in the injection drug using population would likely increase. In my opinion as Medical Officer of Health, this level of service would not be a reasonable interpretation of the provincial standards given the conditions that exist in the City of Toronto.

Methadone Program:

If a funding commitment for continuation of the methadone component of The Works is not obtained before March 1999, we will work with clients on a case-by-case basis to determine the most appropriate option for discharge and referral. A methadone program with a harm reduction approach, in partnership with The Works with its multifaceted counselling, and support services, is an important component of the continuum of services for injection drug users in Toronto. Alternative funding or alternative service partnerships will be needed to provide access to comparable services if Methadone Works is terminated. The provision of methadone is not required in the provincial mandatory guidelines.

Program Budget and Budget Options:

Conclusion:

Experience world-wide and in other Canadian cities suggests the consequences of failure to provide comprehensive HIV prevention and harm reduction strategies for injection drug users have high human, social and treatment costs. Consequences include a rapid rise in HIV rates in this population; increasing HIV among women who contract HIV through needle sharing and among children who contract AIDS through perinatal transmission; increased spread of other communicable diseases such as Hepatitis B and C and preventable treatment costs of over $100,000.00 per case.

This report describes needle exchange services which represent optimal and minimum potential for preventing the spread of HIV among injection drugs users, their partners and children. Both meet the provincial standards for the provisions of needle exchange as part of a harm reduction strategy including counselling, education and referral to health care and addiction treatment services. The Board of Health (and ultimately City Council) has to make policy decisions, determined by health, financial, social and political factors and constraints as to which option is ultimately selected.

References:

Cavalieri et al, Proposal to the AIDS Bureau, Ministry of Health, Province of Ontario, for the Deployment of Four Outreach Workers to Provide Prevention, Education and Support Services to the IDU Community in the City of Toronto (Excluding Scarborough and North York).

DesJarlais et al. International Epidemiology of HIV and AIDS Among Injection Drug Users. AIDS, 1992, Volume 6 pp.1053-1068.

Jones, T. Steven and David Vlahov, Use of Sterile Syringes and Aseptic Drug Preparation are Important Components of HIV Prevention Among Injection Drug Users, Journal of Acquired Immune Deficiency Syndromes and Human Retrovirology, 18(Suppl 1):S1-S5, 1998 Lippincott-Raven Publishers, Philadelphia.

Millson P., Myers T., Calzavera L., Major C., Fearon M., Wallace E., Rea E., Rankin J., Degani N., Chapman C., Rigby J. HIV Trends Among Injection Drug Users in Toronto, 1989-1997. Seventh Annual Canadian Conference on HIV/AIDS Research, Quebec City, May 1998. CanJ Infect Dis, 1998, 9, Suppl A, March/April, #276P.

Personal communication, 1998 Peer Program (The Works, Toronto Public Health).

Poulin, C. et al. The Epidemiology of Cocaine and Opiate Abuse in Urban Canada. Canadian Journal of Public Health. 1998. 89(4). 234-238.

Reed, S. et al, HIV Prevalence in Toronto Street Youth. Toronto Hospital For Sick Children. 1993.

Remis R. et al. Report on the HIV/AIDS Epidemic in Ontario. 1981 - 1996. Ministry of Health, 1998.

Research Group on Drug Use. Drug Use in Toronto, City of Toronto, 1998.

Roy, E. et al. Injection Drug Use Among Street Youth: A Dynamic Process. CJPH, July-Aug 1998 (239-240).

Schwartz RH. Syringe and Needle Exchange Programs: Part 1, Southern Medical Journal, 1993,86:318-22.

Swan, N., Research Demonstrates Long-Term Benefits of Methadone Treatment NIDA Notes, National Institute on Drug Abuse, November/December, 1994.

World Bank. Confronting AIDS Public Priorities in a Global Epidemic, A World Bank Policy Research Report, Oxford University Press, 1997.

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The Board of Health reports, for the information of Council, also having had before it during consideration of the foregoing matter the following communications:

(i)(January 22, 1999) from Ms. Anne Dubas, President, Canadian Union of Public Employees (CUPE) Local 79, urging Councillors to support the optimal approach to meeting provincial standards for food safety, tuberculosis control and needle exchange services; and

(ii)(January 21, 1999) from Ms. Rita Luty, Chair, Northern Health Area Community Health Board, advising that the Northern Health Area Community Health Board at its meeting held on January 21, 1999, adopted a motion in support of the selection of optimal service levels for the Food Safety Program, tuberculosis control and needle exchange for the purposes of HIV prevention, to be funded from new fiscal resources, and the pursuit of additional funding for methadone programs and services in Toronto.

Dr. Barbara Yaffe, Director, Communicable Disease Control, gave a presentation to the Board of Health on the foregoing report.

Mr. Dennis Casey, Vice-President, Canadian Union of Public Employees Local 79, appeared before the Board of Health in connection with the foregoing matter.

3

Review of the Recommendations of the

Report of the Task Force on Health and Work

for the City of Toronto

(City Council on February 2, 3 and 4, 1999, amended this Clause by:

(1)deleting the words "work with" in Recommendation No. (2) of the Board of Health, and inserting in lieu thereof the words "assist as required", so that such recommendation shall now read as follows:

"(2)the Board of Health request City Council to receive the Report and undertake a full review of and report on how the City of Toronto can implement key recommendations, in particular Recommendation No. (17); and further that Health Unit staff assist as required Human Resources to put together terms of reference for the review, the terms of reference to be based on the City of Toronto response outlined in this report;";

(2)deleting the words "on how the City might implement" from the preamble of Recommendation No. (4) of the Board of Health, and inserting in lieu thereof the words "on the implications of the new City implementing", so that such preamble shall now read as follows:

"(4)the Board of Health request that the Human Resources Division, in consultation with appropriate Health Unit staff, the City's bargaining units and any appropriate outside experts and organizations, prepare a comprehensive report on the implications of the new City implementing a four-day work week, and other shorter work time ideas, such report to include but not be limited to:"; and

(3)inserting the words "on the workplan to examine the above" after the words "submit a report", in Recommendation No. (6) of the Board of Health, so that such recommendation shall now read as follows:

"(6)the Executive Director of Human Resources and the Medical Officer of Health be requested to submit a report on the workplan to examine the above, to both the Board of Health and the Corporate Services Committee in May 1999.")

The Board of Health recommends the adoption of the recommendations embodied in the following report (January 15, 1999) from the Medical Officer of Health, amended to read as follows:

(1)the Board of Health and City Council recognize the critical link between employment and population health by supporting in principle the Report of the Task Force on Health and Work and its recommendations;

(2)the Board of Health request City Council to receive the Report and undertake a full review of and report on how the City of Toronto can implement key recommendations, in particular Recommendation No. (17); and further that Health Unit staff work with Human Resources to put together terms of reference for the review, the terms of reference to be based on the City of Toronto response outlined in this report;

(3)the Board of Health request City Council to ensure that these recommendations be considered in human resources policies as well as planning processes under development in the City of Toronto;

(4)the Board of Health request that the Human Resources Division, in consultation with appropriate Health Unit staff, the City's bargaining units and any appropriate outside experts and organizations, prepare a comprehensive report on how the City might implement a four-day work week, and other shorter work time ideas, such report to include but not be limited to:

(a)examining the use of overtime;

(b)implications for collective bargaining (some elements of which may need to be in camera);

(c)phase-in possibilities and opportunities;

(d)other municipal models within Canada and abroad; and

(e)areas where other levels of government need to become involved;

and further, that the Board of Health request Human Resources staff, working with appropriate partners within and outside the municipal corporation, to organize a series of public round tables, or other public events, that promotes a public discussion of shorter work time ideas;

(5)the Board of Health and City Council advocate to Human Resources Development Canada for the initiation and development of a voluntary collective benefits insurance fund for all Canadians in the non-standard and contingent workforce, with a further report on how this advocacy can be done; and

(6)the Executive Director of Human Resources and the Medical Officer of Health be requested to submit a report to both the Board of Health and the Corporate Services Committee in May 1999:

Purpose:

To report on the preliminary review of the recommendations of the Report of the Task Force on Health and Work.

Recommendations:

It is recommended that:

(1)the Board of Health recognize the critical link between employment and population health by supporting in principle the Report of the Task Force on Health and Work and its recommendations;

(2)the Board of Health request City Council to receive the Report and undertake a full review of and report on how the City of Toronto can implement key recommendations, in particular Recommendation No. (17);

(3)the Board of Health request City Council to ensure that these recommendations be considered in human resources policies as well as planning processes under development in the City of Toronto;

(4)the Board of Health request that, in investigating the feasibility of a four-day work week, the City of Toronto begin by monitoring overtime currently worked in the City; and

(5)the Board of Health and City Council advocate to Human Resources Development Canada for the initiation and development of a voluntary collective benefits insurance fund for all Canadians in the non-standard and contingent workforce.

Background:

The impact of conditions of employment on the overall health of the population has been documented for some time by a range of agencies and investigators. As conditions of work began to change rapidly in the 1990s, due to global economic trends affecting our domestic labour market, health impacts began to accelerate noticeably on individuals, families and communities. This impact on the health of Toronto residents was brought to the attention of the former Toronto Board of Health and was investigated by a Task Force formed specifically to make recommendations on the issue. The Report of the Task Force on Health and Work was adopted by the former City of Toronto Board of Health on September 9, 1997, and by the former City of Toronto Council on September 22 and 23, 1997 (see Appendix A for chronology).

The report was subsequently considered by the current Board of Health on April 21, 1998. The Board of Health deferred consideration of the report until the Medical Officer of Health could report on the outcome of a review by the Chief Administrative Officer and the Executive Director of Human Resources of the report's recommendations (see Appendix B for the recommendations of the Task Force on Health and Work). The following report is the result of that review. The Chief Administrative Officer and the Executive Director of Human Resources have participated in the development of this report and concur with its recommendations.

Comments:

In Canada, as in other parts of the world, lack of sustaining work remains a central determinant of the health of the population. In 1997, the National Forum on Health stated that "the most important yet the most difficult issue for the health of Canadians is the availability of jobs." One year later, the problem became acute in Ontario where, according to Statistics Canada, 14,000 jobs were lost in the month of June alone. In that month, Ontario experienced 40 percent of the total job losses in Canada, more than any other province. Many of these job losses have been sustained in the City of Toronto.

 The Task Force on Health and Work highlighted work-related stress as a key factor affecting the health of Toronto residents and uncovered the following causes:

(1)many Toronto residents have no income-generating work;

(2)other Toronto residents are employed at intermittent part-time or contract work at low wages and with no benefits;

(3)the Toronto residents that have full time employment are often working long hours under difficult conditions;

(4)streamlining, downsizing and other changes in the workplace have resulted in job loss for some workers and a constant level of insecurity for others;

(5)decreases in wages and benefits have occurred for many workers as a result of global competition and restructuring;

(6)deregulation and de-skilling of the labour market has meant less access to safe, fair and sustaining conditions of employment for many workers;

(7)changes in the labour market are having a particularly negative impact on women and youth;

(8)self employment, while providing some benefits to workers, can also result in low wages and no employment benefits; and

(9)changes in technology have eliminated many jobs and resulted in increased demands on workers to match the accelerated pace of business.

While the Task Force recognized that the findings of its investigation are in part due to changes taking place globally, its recommendations provide actions that the City of Toronto could take to improve work conditions for its own employees. These actions would build on a tradition of positive municipal employee relations within the former municipalities and of providing quality services to enhance health and employment in the larger community. These actions also offer an opportunity for the City of Toronto to set an example for other employment sectors by assuming a leadership role in healthy employment policies. Moreover, in the current climate of increasingly high employee stress levels, protecting the health of its own workforce is highly desirable if the City is to realize maximum employee productivity and retention. Key actions that could be taken by the City of Toronto (Recommendation No. (17) of the Report of the Task Force on Health and Work) and the preliminary response of the City to these recommendations follow:

The Report of the Task Force on Health and Work also makes recommendations to other levels of government and the private sector in order to ensure that the goal of sustainable work is acted on provincially and nationally (Recommendations Nos. (1) to (16)).

Conclusions:

The recommendations of the Task Force on Health and Work offer an opportunity for the City of Toronto to assume a leadership role in implementing practices within its own workforce that will improve the health of its employees at a time when employment-related stress is a local, national and global concern. Many of these practices were in place in the former municipalities that now constitute the new city and build on the best traditions of a safe and healthy workplace for all municipal employees. Moreover, by providing leadership on this issue, the City of Toronto will demonstrate to other levels of government and to other employment sectors the importance of dealing substantively with the health impacts of work-related stress.

Contact Name:

Liz Janzen, Regional Director, Toronto Office, Public Health

Tel: 392-7458; Fax: 392-0713

ljanzen@toronto.ca.

Valerie Hepburn, Health Education Consultant

Tel: 392-7451; Fax: 392-1483

vhepburn@toronto.ca

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Appendix A

Report of the Task Force on Health and Work

Chronology of Events

December 1994The Report of the Advisory Group on Working Time and the Distribution of Work, chaired by economist Arthur Donner, is released by Human Resources Development Canada.

April 1996The former City of Toronto Board of Health initiates an investigation into the health effects of changes in work experienced by Toronto residents .

June 1997The federal government releases a subsequent report, Collective Reflection on the Changing Workplace.

September 8, 1997Acting President of CUPE Local 79 supports the Report and encourages the Board of Health "...to ensure that its principles become an integral part of the new government's philosophy".

September 9, 1997Report of the Task Force on Health and Work presented to and adopted by the Board of Health of the former City of Toronto.

September 22-23, 1997Former Toronto City Council adopts the Report and recommends that it also be adopted by City Council and the Board of Health for the new City of Toronto.

City Council also refers the Report to the federal Minister of Health and Human Resources and the provincial Ministers of Labour and Finance, all of whom express interest in and/or support for the Report.

January 1998Public Health staff meet with federal Minister of Health Allan Rock to discuss Recommendation No. (15) of the Report, which is congruent with recommendations of two previous federal reports.

January 26, 1998Report of the Task Force on Health and Work is considered by the interim Board of Health for the new City of Toronto.

The interim Board of Health referred the report to the first meeting of the new Board of Health and requested a presentation on the Report's recommendations.

The interim Board of Health also requested that the report be forwarded to the Executive Director of Human Resources for consideration as part of the budgetary process with specific attention to Recommendations Nos. (15), (16) and (17).

In addition, the interim Board of Health requested that this report be forwarded to all bargaining units in the City of Toronto.

April 21, 1998Peter Tabuns, Chair of the Task Force on Health and Work, presents the Task Force's findings to the Board of Health.

The Board of Health defers consideration of the Report until the Medical Officer of Health reports on the outcome of a review of the Report's recommendations by the Chief Administrative Officer and the Executive Director of Human Resources.

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Appendix B

Conclusions and Recommendations

"What do we owe one another as members of the same society who no longer inhabit the same economy?"

(United State Secretary of Labor Robert Reich, 1992)

"All initiatives related to economic well-being, social justice and health are connected and need to be thought of and planned for in relation to each other."

(Corporate president at the business leaders' focus group of the Task Force on Health and Work)

The inquiry into the changing nature of work and its effect on the health of Toronto residents revealed widespread concern about negative changes in individual and community health as a result of the trends and themes discussed in this report.

Even while the inquiry was taking place, and particularly since it ended, these trends and themes have been reinforced. Internationally, the new Multilateral Agreement on Investment (MAI) threatens to eliminate the power of nation signatories to regulate or control foreign corporations, while giving foreign corporations the right to sue governments and strike down law which are not in their interest. At the same time, here in Ontario new legislation is poised to impact workers in the public and service sectors, while new and revised labour laws continue to accelerate the devolution of worker protection and eliminate basic rights. Such examples, among others discussed earlier in this report, indicate that decision makers are moving society increasingly and further along the road to ill health.

The Task Force on Health and Work recognizes that the trends and themes identified by the inquiry are part of a changing work culture that is worldwide in scope and will continue to evolve. While we cannot change this culture, we can influence its evolution and minimize the negative health impacts. Certainly it is in the interests of decision makers, whether in the public or private sectors, to do so. We believe that a health society - one that is just, productive and peaceful - is the best indicator of a healthy future.

This perception, reinforced by the values, principles and beliefs stated earlier in this report, are the basis for the following recommendations.

General Policy Considerations:

The Task Force on Health and Work recommends:

(1)(a)that governments at all levels, as well as domestic and transnational corporations, labour and the non-profit sector, understand that the changing nature of work, and the unemployment, under-employment and over-employment that accompany it, have an impact on global health, and seek innovative solutions through the global community as well as at home; and

(b)that governments, corporations, labour and the non-profit sector investigate health-enhancing solutions to the changing nature of work which are currently being modelled in Canada and the international community, and emulate their successes with their own workforce. For example, a recent plan for the British Columbia forest industry proposes to create 6,500 new jobs while moving to a shorter work week and eliminating overtime;

(2)that in the course of negotiating the Multilateral Agreement on Investment, governments, corporations and labour build in explicit means of optimizing the health of the workforce affected by the agreement, and that such considerations become a standard feature of future international trade missions and agreements; and

(3)that all public policies, including those at the municipal level, be subjected to a health impact analysis and adjusted accordingly in order to balance economic and population health priorities. This recommendation encompasses both government economic policies and policies originating from other ministries and departments, such as labour, community and social services, industry or finance, trade and commerce, development and planning.

Federal Government Policies:

The Task Force on Health and Work recommends:

(4)that the federal government, in recognition of the fact that the health of the population, the economy, and government depends on achieving the lowest possible unemployment rates,

(a)set yearly national employment targets, similar to inflation and deficit targets, as recommended by the Centre for Policy Research Networks, and provide incentives to corporations, unions, and other stakeholders to realize them; and

(b)establish these targets with the goal of making available meaningful employment at an adequate level of income to all men and women able to work; and

(5)that the federal government ensure that the Canada Labour Code provide minimum employment standards that include working conditions and pro-rated wages and benefits for non-standard workers such as part-time, self-employed, contract and home workers.

Provincial Government Policies:

The Task Force on Health and Work recommends that the provincial government:

(6)review and amend the Employment Standards Act with the goal of strengthening key determinants of healthy work, such as sustaining wages, healthy working conditions, and individual ability to organize work and control decision making;

(7)reject proposed changes to the Employment Standards Act that would increase the maximum work week from 48 to 50 hours and create a 'flexible' or floating minimum wage;

(8)(a)extend employment standards rights to the non-standard and contingent workforce so that self-employed, freelance, part-time, contract, outsourced and home workers are fully protected by the Employment Standards Act and entitled to wages, benefits and working conditions equal to full-time and standard workers; and

(b)review employment standards on an on-going basis to assure that workers' rights are protected in a changing work culture;

(9)develop a mechanism, such as a voluntary registry for non-standard workers, as a safeguard against unjust practices and working conditions;

(10)review proposals with respect to workers' compensation to assure maximum income protection and coverage for all Ontario workers injured on the job, including those suffering mental stress and chronic pain; and

(11)rigorously enforce the Occupational Health and Safety Act, recognizing that non-union workers are especially vulnerable to reprisals for pursuing their rights, and provide assistance through the Ministry of Labour to ensure that workers understand their rights and participate in decision making related to occupational health and safety in the workplace.

Measures of Health and Work:

The Task Force on Health and Work recommends:

(12)in order to begin to comprehend and address the health effects of the changing nature of work,

(a)that the federal government seek to understand the health of the economy not just in terms of the goods and services produced (GDP), but in terms of the numbers of sustaining jobs available and the quality of life of people living in the economy, and develop through Statistics Canada measures to achieve such understanding; and

(b)that the federal government develop and use a more accurate measure of unemployment that considers the participation rate and the employment/population ratio, counts under-employed workers and those who have given up their job search, and eliminates the substitution of part-time for full-time employment.

Public Health:

The Task Force on Health and Work recommends:

(13)that all agencies that deal in public health issues continue to raise the awareness of the public and decision makers in government, labour, the corporate and non-profit sectors regarding the importance of employment as a basic prerequisite to individual, community and social health and as a means of preventing illness; and

(14)that the government of Ontario mandate and resource health units across Ontario, in the context of health promotion and advocacy programs,

(a)to identify employment-related health issues among the population they serve; and

(b)to address the issues identified for the purpose of improving individual, community and social health.

Immediate Solutions:

The Task Force on Health and Work recommends:

(15)in order to increase employment and the quality of personal, family and community life in the short term,

(a)that employers and labour explore and/or expand innovative work arrangements that optimize health, including a reduction in standard work time, flexible hours of work, job sharing, phased-in retirement education and family leave; and

(b)that governments support such initiatives based on successful models of government support in other jurisdiction; for example, the Robien Law (1996) in France. Under this law employers commit to reducing work hours and increasing staff by at least 10 percent for a minimum of two years. In return the employer's payroll taxes are reduced for seven years by an amount dependent on the number of new jobs created. The reduction in payroll revenues is offset by savings in unemployment insurance and social assistance costs, and by revenues generated from a new tax-paying workforce that is consuming goods and services.

Education and Training:

The Task Force on Health and Work recommends:

(16)(a)that all levels of government enhance and co-ordinate their efforts to support a full range of relevant education and job training programs that promote employability skills in a changing job market, including literacy skills and English as a Second Language, entry level skills for young people, and comprehensive and current technological skills;

(b)that educational institutions, business, labour, government and the voluntary sector explore constructive and innovative partnership to maximize the ability of workers to find, maintain, enrich or change jobs; and

(c)that (a) and (b) above be supported by an enabling infrastructure of child care and education leave.

The New City of Toronto:

The Task Force on Health and Work recommends:

(17)that the new City of Toronto model leadership in enlightened government and healthy work in the following ways:

(a)by considering all new City policies in light of their impact on the health of workers living in the City or employed by the City;

(b)by adopting a fair wage policy so that the new City will use only those contractors that provide fair wages, benefits, working conditions and equality of opportunity to workers engaged under standards specified by the new City's fair wage office, and who agree to the monitoring and auditing of these standards by that office;

(c)by investigating the feasibility of establishing a voluntary collective benefits insurance plan for Toronto residents among the non-standard and contingent workforce as a means of centralizing contributions and payouts to individual workers;

(d)by playing an active role in supporting the health of workers in the context of a changing work culture by maintaining and extending the public programs, services and resources provided by Parks and Recreation, Public Libraries, Public Health, and the Workers' Information and Action Centre;

(e)by maintaining a public workforce of sufficient size and skills to provide excellence in the services required by a larger and more diverse population, recognizing that a public workforce is best suited to ensure access, equity, cultural sensitivity, and public accountability for those services;

(f)by maintaining good labour relations with and a healthy work environment for that workforce, in order to maximize high standards of community service delivery and capacity building;

(g)by supporting innovative approaches to work that improve productivity and enhance employment opportunities, including flex time, phased-in retirement and all forms of leave, as well as investigating the feasibility of a four-day work week; and

(h)by developing a charter for healthy work, in line with the principles and themes developed in this report, that would direct City policy and be used to influence other employers.

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Mr. Mark Hudson, representing the citizens' group "32 HOURS: Action for Full Employment", appeared before the Board of Health in connection with the foregoing matter, and submitted material with respect thereto.

Respectfully submitted,

JOHN FILION

Chair

Toronto, January 25, 1999

(Report No. 1 of The Board of Health, including additions thereto, was adopted, as amended, by City Council on February 2, 3 and 4, 1999.)