1 Tuberculosis (TB) and Immigrants/Refugees: Implications for Toronto Public Health's TB Control Program
2 Air Quality: Canada-Wide Standards for Particulate Matter and Ground Level Ozone
3 Combat Shooting as a Demonstration Sport at the 2004 Olympic Games
(City Council on September 28 and 29, 1999, adopted this Clause, without amendment.)
The Board of Health recommends the adoption of the report dated September 21, 1999, from the Medical Officer of Health.
The Board of Health reports, for the information of Council, having requested the Chair of the Board of Health, Councillor Joan King and the Medical Officer of Health to meet with the Federal Minister of Citizenship and Immigration to convey the Board's request for federal funding to address Tuberculosis among immigrants and refugees, with particular reference to recent influxes of refugee claimants from TB endemic countries, and to report back to the Board thereon.
The Board of Health submits the following report (September 21, 1999) from the Medical Officer of Health:
Purpose:
To inform the Board of Health about the TB control issues regarding immigrants and refugees in Toronto, with particular reference to the recent influx of Tibetan refugee claimants.
Financial Implications:
The 1998 base budget for the TB Control Program was $2,100,000.00. In March 1999, City Council approved a budget increase in order to harmonize the program throughout the City. The annualized increase will be $1,163,700.00 which will bring the total TB Control budget to $3,263,700.00 for 2000 and beyond.
TB Control is a mandatory public health program, cost-shared between the provincial and municipal governments in Ontario.
The high prevalence of TB among a recently arrived refugee group requires an intensive public health response. The TB Control Program cannot institute adequate control measures within the currently approved budget. Federal funding in the amount of $200,740.00 per year (for two years) to fund an additional four FTEs should be pursued to address the current refugee influx.
Recommendations:
It is recommended that:
(1) the City of Toronto immediately pursue federal funding for Toronto Public Health to expand the capacity of the TB Control Program to provide outreach and post-landing medical surveillance for refugee influxes from TB endemic countries;
(2) the City of Toronto urge Citizenship and Immigration Canada (CIC) to strengthen its post-landing surveillance mechanism to identify TB and other health issues (as appropriate) in refugee/immigrant groups, in consultation with Toronto Public Health and other key stakeholders. Specifically, the 60-day interval for medical examination of refugees must be shortened, and compliance monitored and enforced;
(3) the City of Toronto request Citizenship and Immigration Canada and Health Canada to expand current research to determine the optimal process for the medical follow-up of immigrants and refugees from TB-endemic areas and recommend and fund a national program to accomplish this, in consultation with Toronto Public Health and other key stakeholders;
(4) the City of Toronto urge the Province of Ontario to fully cost-share the harmonized base budget of Toronto Public Health's TB Control Program; and
(5) this report be forwarded for information to the Community Services Committee and the Toronto Advisory Committee on Immigrant and Refugee Issues.
Background:
Recent media coverage has highlighted TB among Tibetan refugee claimants in Toronto. The arrival of this high-risk group has prompted Toronto Public Health (TPH) to examine the broader issues of TB epidemiology among refugee communities in Toronto, including immigration health screening policy, post-landing medical surveillance and funding for public health TB services to immigrants and refugees (particularly where there is a rapid influx such as the Tibetan and Kosovar communities).
The prevention and control of TB requires coordinated action by all levels of government. The federal government (Citizenship and Immigration Canada) sets immigration health screening policy and funds medical services for incoming refugee claimants. The provincial government funds TB care, including provision of free TB drugs and cost-sharing of public health services. At the local level, Public Health Units ensure that people with active TB get the treatment they need, people in contact with active cases receive medical follow-up and transmission to others is prevented.
Toronto City Council approved an expansion of the TB Control Program to address the minimum provincial Mandatory Guidelines across the city as of September 1999. This expansion is currently being implemented.
Comments:
The City of Toronto is the key destination for immigrants and refugees coming to Canada. At the 1996 census, approximately 48 percent of Toronto's population was made up of immigrants and refugees. Over 49 percent of refugee claimants in 1998 entered Canada through the Toronto Region (about 10,000 people). It is therefore the municipality most affected by immigration and settlement policy and funding, which is primarily the responsibility of the federal government. Immigration patterns have changed considerably. In the early 1960's and 70's, newcomers to Canada came primarily from Western Europe, while today immigrants and refugees come to Canada primarily from Asia, Africa and Latin America, many of which are TB-endemic areas.
TB in the Tibetan Refugee Group:
Between December 1998 and July 1999, about 150 Tibetan refugee claimants arrived in Toronto from the United States. In August 1999, approximately another 180 arrived. Most of these new arrivals were born in the Tibetan refugee camps of northern India and Nepal - countries with high TB incidence rates.
There have been eight cases of TB reported among Tibetan refugees in Toronto since January 1999. Five of these were cases of multi-drug resistant TB (MDR-TB). Recognizing that this is based on limited data, it is clear that this group is experiencing a very high incidence of TB, (estimated to be 3,000 per 100,000 as compared to the Toronto rate of 20 per 100,000, and the Canadian rate of seven per 100,000).
TB is a Global Issue:
TB is a global health issue. The World Health Organization estimates that one third of the world's population is infected with latent (inactive) TB. In 1997, eight million new cases of TB disease developed. The Far East and Southeast Asia, the Indian Subcontinent, Sub-Saharan Africa, Eastern Europe, the former Soviet Union, the Caribbean, Central America and much of South America are all considered TB endemic areas. TB disease is also associated with poor socioeconomic conditions, poverty, crowding, lack of public health infrastructure, malnutrition and stress.
TB in Toronto:
There are 450-500 new cases of TB reported in Toronto each year, which is 25 percent of the TB in all of Canada. Ninety percent of these cases occur in people who were born in countries where TB is endemic. While immigrants and refugees are most at risk of developing active TB within the first five years of arrival, many cases have been in Canada for much longer. Individuals generally experience rates of TB which reflect those in their country of origin; their children have intermediate rates of TB, possibly due to household transmission (i.e. higher than other Canadian-born individuals). Other groups at high risk for TB locally include the homeless/under housed, the immuno- compromised and Aboriginal Canadians.
Based on laboratory testing, 15-20 percent of TB cases in Toronto are resistant to at least one antibiotic, compared to 11.8 percent of Canadian isolates in 1998. Approximately three percent of cases are MDR-TB, i.e. resistant to both Isoniazid and Rifampin, the major drugs used to treat TB. This is almost triple the rate of Canadian MDR-TB (1.2 percent in 1998). Drug resistant TB is much more difficult to treat. The antibiotics which are required are not as effective and therefore treatment is prolonged (18-24 months) as compared to 6 months for fully drug sensitive TB; also side-effects are more common and the cost of the medication is significantly higher. In addition, contacts of resistant cases must be followed intensively (directly observed prophylaxis is recommended) to ensure that future cases are prevented and outbreaks are avoided. These measures have huge resource implications for public health.
Immigration Medical Screening:
Immigration medical screening has two purposes: to protect the public health of Canadians by excluding individuals with an immediate contagious disease risk at the time of entry to Canada, and to exclude people with a medical condition which would impose an undue burden on Canada's medical or social system. Refugees do not have to meet the undue burden requirement. Visitors intending to stay in Canada for less than six months are not required to have a medical examination of any kind.
People who apply for immigration to Canada are required to undergo a medical examination in their country of origin within the year prior to arrival. For everyone over 11 years of age this includes a chest x-ray. Those found to have active TB are not permitted to enter Canada until they have been fully treated. Those with a history of treated TB, or signs of inactive TB, are allowed to enter the country provided they agree to medical surveillance.
Refugees who apply from outside Canada follow similar procedures but can complete treatment within Canada. Those who apply for refugee status within Canada or at the border, must file their claim within 30 days of arrival and are required to have their immigration medical within 60 days of submitting their claim. However, in practice this is often longer since there are currently no enforcement mechanisms or penalties for delay. Thus, individuals who have active TB may be in Canada for a considerable length of time before diagnosis. Given the transient and overcrowded settings in which newcomers must often live, this presents a significant risk of transmission to others in the community.
Health Canada began a reassessment of immigration health screening policy several years ago; however it has yet to produce its report and recommendations. Experience elsewhere may provide policy alternatives to the current Canadian situation.
Post-Landing Surveillance for TB:
Those individuals who are identified at increased risk of developing active TB based on their immigration medical are placed under medical surveillance. Immigration officials inform the Ontario Ministry of Health of such individuals and the Ministry then notifies the local health unit. However, a recent analysis found that post-landing surveillance detected only 10 percent of cases. This is because the current procedures for follow-up are unclear and inconsistently applied and there are issues regarding data-sharing between jurisdictions. In general, the health unit sends a letter to the individual's last known address reminding them to see a physician. Approximately 50 percent of referrals to Toronto Public Health for this purpose are locatable.
An in-depth study is currently being planned to determine how effective the current criteria for post-landing surveillance are in predicting future disease; results are not expected for several years.
TB Control Initiatives re Tibetan Refugees:
Toronto Public Health identified an unusually high rate of TB and MDR-TB among Tibetan refugee claimants in June 1999. At that time, staff notified provincial and federal authorities and began to work on strengthening prevention and early detection activities. All reported cases of TB in Tibetan refugee claimants have received priority for public health investigation and follow-up. Referral links have been established with respirologists familiar with drug-resistant TB and directly observed therapy (DOT) has been put in place for these individuals. To date, there have been no concerns whatsoever about compliance with treatment and Toronto Public Health is working in close collaboration with the Tibetan community.
As an interim measure to assist in early detection of TB, starting in August, 1999, Toronto Public Health provided TB screening for over 60 individuals; 18 percent have a history of active TB and 92 percent of those tested were skin-test positive and have been referred for further assessment. Notably, 100 percent of those screened have returned for follow-up.
Public Health worked in collaboration with the Tibetan community to identify issues and develop strategies for education and outreach. The Tibetan community has assisted with translation of resources and outreach. Community members also identified access to affordable housing and settlement services as urgent issues. Staff from the City's Shelter, Housing and Support Division, and Access and Equity Centre are also working with the community.
In late August, a system to fast-track TB assessments for incoming Tibetan refugees was developed in collaboration with Health Canada, Citizenship and Immigration Canada (CIC), the Ontario Ministry of Health (Public Health Branch), the Niagara Public Health Department and three local hospitals (St. Michael's Hospital, The University Health Network and West Park Hospital). Immediate medical screening of Tibetan refugees at the border was implemented on September 7, 1999. In addition, CIC is in the process of requesting recent Tibetan refugee claimants who have not yet had their immigration medical, to do so immediately.
TB and Immigrants/Refugees:
The recent Tibetan refugee claimants are only one example of newcomers with high rates of TB. Immigration patterns show that Toronto will continue to be a major destination for immigrants/refugees entering Canada, and that the majority will originate from TB-endemic countries.
The success of local TB control efforts is thus largely dependent on effective and timely surveillance, as well as follow-up mechanisms to identify new groups and cases and local capacity for community outreach. This requires staff who can speak the relevant languages and understand the cultural issues pertaining to that community. Strong linkages with other health and social services are also critical. TB care must be integrated with access to medical care as well as adequate housing, food, education and other basic determinants of health.
Federal policies regarding immigration in general and immigrant health screening in particular, have a considerable and disproportionate impact on Toronto's TB control program. Medical services for refugees are covered for a period of two years under the Interim Federal Health (IFH) program; health coverage is provided for refugee claimants once their claim is registered (up to six weeks). However, there is currently no designated federal funding for TB outreach, treatment or follow-up of immigrants and refugees by public health units.
The current cost of Toronto's TB Control Program is $3.2 million. It is estimated that the cost of providing TB service for immigrants and refugees ranges from $1.6 million to $2.9 million annually. An infected adult has a 10 percent chance of developing TB disease throughout their lifetime; thus, the public health efforts required for TB control will continue for many decades.
A number of intensified public health activities are required over the next decade to mitigate the increased risk of developing TB, in particular MDR-TB. These should include outreach and education, promotion of prophylaxis, provision of directly observed therapy and prophylactic therapy and close coordination with the rest of the health care system to ensure intensive medical follow-up. The resources to adequately address the public health concerns arising from communities, at very high risk of TB and MDR-TB, are currently not available. This would require at a minimum, four FTE's for two years: 1.5 Public Health Nurse, 1.5 Registered Practical Nurses and one Community Outreach Worker.
TB cases arising from the influx of such refugees will require close monitoring through directly observed therapy (DOT) for a minimum of six months. Those with MDR-TB will require DOT for 18-24 months; three times longer than a drug-sensitive case. Contacts of MDR-TB patients who develop TB infection may require directly observed prophylactic therapy (DOPT) to prevent their infection from progressing to active disease. This is particularly important for children and individuals who are immuno-compromised who are more likely to develop severe disease very rapidly. In addition, an infection rate of over 90 percent requires rigorous post-landing surveillance at two-three interventions per person. The resources to carry out the above measures were not anticipated at the time the harmonization request was put forward.
As more refugees from this or other high risk groups come to Toronto, it is essential that Toronto Public Health's TB control program be adequately resourced to protect our community. Preventing even one outbreak of MDR-TB will more than pay for the additional resources requested at this time.
At this point Toronto Public Health receives no federal funding for TB. Other jurisdictions do receive direct financial support from the federal level of government. For example, the TB program in New York City receives 60 percent of its funding from the federal government. In part this reflects the different organization of health and social services in the United States. However, it recognizes both the national interest in TB services, particularly related to immigration, and the unique situation of New York City. Like Toronto, New York is a major destination for immigrants and refugees, and has the largest TB caseload in the country. New York's TB problem became extremely severe, with outbreaks of MDR-TB, before the infusion of federal funds. Toronto needs this kind of federal support now in order to prevent a similar resurgence of TB and outbreaks of MDR-TB here.
Municipal Services to Immigrants and Refugees:
In a February 1999 report, "The Need for Federal Funding Assistance for Municipal Services to Immigrants and Refugees", the Commissioner of Community and Neighbourhood Services estimated that the City of Toronto provides social assistance, emergency shelter and public health services for immigrants and refugees at an approximate net cost of $30 million per year. As a key destination for newcomers to Canada, it is critical that the City of Toronto continue to provide supports and services to this population. The issue is not whether these services should be provided, but which level of government has access to adequate resources to appropriately fund these services to best meet newcomer needs and those of the host communities.
The City of Toronto has endorsed the recommendations pertaining to municipalities of the Legislative Review Advisory Group established in 1996 by the federal government to review legislation relating to immigration and the protection of refugees. Of particular interest is the recommendation that the federal government reimburse municipalities for the costs associated with providing social assistance, emergency shelter and other services. The Association of Municipalities of Ontario is also in support of the City of Toronto's request for Federal support for Toronto Public Health's TB Control Program (see attached). Unfortunately, no progress has been made on this issue to date.
Conclusions:
Toronto prides itself on being an international city. As such, however, we experience three times the national rate of TB. The World Health Organization has declared TB a global health emergency. The recent influx of Tibetan refugee claimants who have a high rate of TB and MDR-TB serves to highlight the need for a strong infrastructure to prevent and control TB. This requires changes to the federal policies regarding immigrant and refugee health screening.
In addition, despite expansion of Toronto's TB Control Program to meet the minimum provincial mandatory requirements, Toronto Public Health does not have adequate resources to prevent and control TB in the city's high-risk groups particularly for intensive influxes of refugees from TB-endemic areas. Federal funding for TB work related to all high-risk immigrants and refugees is critical.
Contact Name:
Dr. Barbara Yaffe
Director, Communicable Disease Control and Associate Medical Officer of Health
Tel.: 392-7405/Fax: 392-0713
I am writing to support the City of Toronto's request for the urgent need to devote more resources to combat the rate of Tuberculosis disease in Toronto.
The City of Toronto faces approximately 500 cases per year which result in about 20 preventable deaths. Toronto's Tuberculosis threat is augmented by the increasing number of immigrants moving to Toronto which could be carrying the disease.
AMO supports the City of Toronto's request that the federal government play a larger role in addressing Tuberculosis disease.
Dr. Barbara Yaffe, Director, Communicable Disease Control and Associate Medical Officer of Health, gave a presentation to the Board of Health in connection with the foregoing matter.
(City Council on September 28 and 29, 1999, adopted this Clause, without amendment.)
The Board of Health reports having adopted the report (August 27, 1999) from the Medical Officer of Health, subject to amending Recommendation No. (1)(e) by adding thereto the words "making the Greater Toronto Area a priority", so that such recommendation reads as follows:
"(e) facilitate the establishment of dedicated funding, legislation and policy to develop, improve and expand an integrated public transit system(s) within the Windsor-Toronto-Quebec corridor, making the Greater Toronto Area a priority";
and recommends that Council endorse the action taken by the Board of Health.
The Board of Health further reports, for the information of Council, having requested the Greater Toronto Services Board to forward to the Board of Health any relevant studies with respect to the number of vehicles per day on the roads in the Greater Toronto Area, for the purposes of policy advocacy.
The Board of Health submits the following report (August 27, 1999) from the Medical Officer of Health:
Purpose:
To provide comments to the Canadian Council of Ministers of the Environment and the Canada-Wide Standards Development Committee for Particulate Matter and Ozone on the proposed standards.
Recommendations:
It is recommended that:
(1) the Board of Health request the Canadian Council of Ministers of the Environment to adopt the following:
(a) establish Canada-wide standards for particulate matter (PM) and ozone as recommended by Toronto Public Health:
(i) PM10: 50 µg/m3 by 2010, 40 µg/m3 by 2015 (24 h averaging);
(ii) PM2.5: 25 µg/m3 by 2010, 20 µg/m3 by 2015 (24 h averaging);
(iii) Ozone: 82 ppb by 2010, 70 ppb by 2015 (1 h maximum);
(iv) Ozone: 68 ppb by 2010, 60 ppb by 2015 (1h, 4th highest);
(v) Ozone: 60 ppb by 2010, 50 ppb by 2015 (8 h equivalent, 4th highest);
(vi) Achievement measures:
PM: 98th percentile, averaged over three consecutive years; and
Ozone: 4th highest value, averaged over three consecutive years,
and develop mechanisms to ensure that actual emission and ambient level reductions are demonstrated by 2005;
(b) facilitate immediate implementation of the preliminary actions identified by each jurisdiction to achieve the standards;
(c) continue to invite and fund a representative group of public health professionals and health organizations to participate in consultation/workshop(s) in future Canada-wide standard setting exercises;
(d) request the Canadian Public Health Association to facilitate further consultation/workshop(s) on socioeconomic analysis relating to particulate matter and ozone; and
(e) facilitate the establishment of dedicated funding, legislation and policy to develop, improve and expand an integrated public transit system(s) within the Windsor-Toronto-Quebec corridor;
(2) the Board of Health forward this report to the Ministers of the Environment, Transportation, and Energy, Science and Technology in Ontario, to encourage these ministries to implement the preliminary actions identified for Ontario and to report publicly on their progress;
(3) the Board of Health forward this report for information to the Federation of Canadian Municipalities, the Association of Municipalities of Ontario, and the Greater Toronto Area Services Board;
(4) the Board of Health forward this report to other municipalities in Ontario with a population greater than 50,000 and request that they endorse these recommendations; and
(5) Board of Health recommend that City Council endorse this report and recommendations.
Background:
The Canadian Council of Ministers of the Environment (CCME) is an intergovernmental council consisting of 13 ministers of the environment for the federal, provincial and territorial governments in Canada. The purpose of the Council is to establish a forum for discussion and joint action on environmental issues of national, international and global concern. On January 29, 1998, the CCME (with the exception of Quebec) signed an accord designed to harmonize environmental programs and policies. The Canada-wide Accord on Environmental Harmonization defines the common vision, objectives and principles that will govern the partnership between jurisdictions to achieve the highest level of environmental quality for all Canadians.
Canada-wide standards for particulate matter (PM) and ground level ozone (ozone) are being developed under the Canada-wide Environmental Standards Sub-Agreement under the Canada-wide Accord on Environmental Harmonization. This sub-agreement provides a framework to address key environmental protection and health risk reduction issues that require common standards across the country. The CCME has established a process for developing Canada-wide standards (CWS) for a number of substances of national interest. Each signatory jurisdiction is responsible for implementing the CWSs. Public input is a key feature in the development process. Common principles will be used to develop the standards, although the way in which each standard will be developed and the opportunities for public participation, is determined on a case-specific basis.
The Canada-Wide Standards Development Committee for Particulate Matter and Ozone, consisting of representatives from federal/provincial/territorial governments, was formed to oversee the standard setting process for Particulate Matter (PM) and ozone. After examining the analyses of various expert reports and background information, the Development Committee has put forward a paper, titled "Discussion Paper on Particulate Matter (PM) and Ozone Canada-Wide Standard Scenarios for Consultation", in May 1999 for stakeholder consultation. The discussion paper presents a variety of specific "scenarios" on PM and ozone CWSs for possible adoption in Canada at this time. The Development Committee will consider stakeholders' views in preparing its recommendations for consideration by CCME in the fall of 1999. Toronto Public Health participated in the stakeholder consultation workshop and submitted comments directly to the Development Committee in June 1999 (available upon request).
Comments:
PM and ground level ozone (ozone) are two important constituents of smog. Smog alerts issued when the Ontario Ministry of the Environment calls an Air Quality Advisory are often due to elevated levels of ozone and/or PM and are typically regional in nature, encompassing the Windsor-Toronto-Quebec corridor. PM and ozone cause adverse respiratory effects in humans. The severity of the effects depends on the level of exposure of individuals. Increases in premature death rates, hospital admissions and emergency room visits have been shown to be associated with elevated PM and ozone levels.
As part of the continuing effort to improve air quality for Toronto residents, Toronto Public Health has been actively involved in the development process of CWSs for PM and ozone. Toronto Public Health has reviewed the scientific assessment document for ozone, and was sponsored to attend the National Multi-Stakeholder Consultation Workshop on the Development of Canada-Wide Standards for PM and Ozone in May 1999, in Calgary.
Canada-wide standards include a numerical limit (e.g., ambient, discharge and/or product standard), a commitment and timetable for attainment, a list of preliminary actions to attain the standard, and a framework for reporting to the public. For PM and ozone, the CWSs define the maximum levels allowed for these chemicals in the ambient outdoor air. Although CWSs by themselves are not legal instruments, governments may choose to use both legal and non-legal instruments in implementing the standards.
PM and ozone are known to pose significant threat to human health with no apparent threshold (i.e., the level below which no adverse health effects occur) for their effects. Since effects are observed at current ambient air levels, it is important to take actions to reduce the ambient air levels and develop health protective CWSs.
Canada-wide standards are based on the current state of health and environmental knowledge and are intended to be achievable targets. Other aspects such as social and economic impacts, and technical feasibility also are considered in the process. Toronto Public Health has made several recommendations to the Development Committee after considering the various scenarios proposed by the Development Committee as well as the background information, including a health impact assessment, a social, economic and technical feasibility analysis.
Recommendation for Numerical Limits:
Toronto Public Health's recommendation for PM and ozone standards is presented in Table 1. These numbers are to be adopted according to the implementation schedule identified. These recommendations are consistent with the position developed and presented by the Health Caucus at the May 1999 Consultation Workshop in Calgary. While the initial targets are being set for 2010, in order for progress to be achieved, plans must be developed and implemented much sooner. Toronto Public Health strongly urges that interim targets be set such that actual emission and ambient level reductions (curve bending) are demonstrated by the year 2005.
Table 1 Toronto Public Health Recommendations for Canada-wide Standards for Particulate Matter and Ozone
| Target Year | 2010 | 2015 |
| PM10 (24 h averaging)a | 50 µg/m3 | 40 µg/m3 |
| PM2.5 (24 h averaging)a | 25 µg/m3 | 20 µg/m3 |
| Ozone | ||
| 1 h, maximum | 82 ppb (current NAAQOc) | 70 ppb |
| 1 h, 4th highestb | 68 ppb | 60 ppb |
| 8 h equivalent, 4th highestb | 60 ppb | 50 ppb |
aachievement statistics: 98th percentile annually, averaged over 3 years
bfor achievement statistics: 4th highest annually, averaged over 3 years
cNAAQO - National Ambient Air Quality Objective
Although the numbers proposed for ozone and PM do not vary substantially from existing National Ambient Air Quality Objectives, Canada's air quality will improve because CWSs include actions which jurisdictions have committed to implement in order to achieve the standards, which has not been the case in the past. It is these actions that will lower the ambient levels of PM and ozone leading to better air quality.
Toronto Public Health ideally would like to see standards adopted that are closer to the lowest health effect levels of 25 µg/m3 (24-hour averaging) for PM10, 10 µg/m3 (24-hour averaging) for PM2.5 and 25 ppb (maximum 1-hour) for ozone. However, Toronto Public Health recognizes that these numbers are not achievable at this time due to the cost-prohibitive nature of currently available emission control technologies and a high background ozone level in the region. Therefore, the levels recommended should be seen only as the first step in an ongoing process to strengthen the standards towards the no-effects and/or background levels. Because of the considerable uncertainty concerning achievability of more stringent standards, the standard adopted should be reviewed periodically, e.g., every three to five years, leading up to and beyond the current target dates.
Health-Based Goals:
While a number of wide-ranging measures are needed to solve air quality problems, vehicle emissions are a major source for ambient PM and ozone. It is unlikely that substantial decreases in PM and ozone ambient levels can be achieved without reducing traffic density on the roads. Therefore, improvement of air quality will also require behavioural shifts, such as less reliance on personal vehicles and increased usage of public transit. The public may perceive that there are no health effects at air levels below the recommended air standards. Hence, Toronto Public Health recommends that the lowest health effect levels be adopted as health-based goals used to better inform and educate the public. These health-based goals can serve as tools to guide individuals in making personal decisions to avoid adverse health effects and to minimize personal contribution to poor air quality.
Action Plan:
The CWSs include a list of preliminary actions to attain the standard. It was recommended during the Calgary meeting that each jurisdiction should use a multi-stakeholder process to identify actions that need to be implemented so that the CWSs can be achieved by the target dates. While the full implementation plan should be identified by June 2000, a list of preliminary actions has to be ready for consideration by CCME in the fall of 1999. Toronto Public Health supports this recommendation and urges all jurisdictions to immediately implement the preliminary actions they have identified, and to report on their progress at regular intervals (e.g., every year) according to the reporting protocol developed for PM and ozone. These reports must be made public, allowing the public to monitor how well the Ministers of the Environment are meeting their commitment.
In order that the ultimate goal of reducing the ambient levels of PM and ozone towards the lowest health effects levels can be achieved, Toronto Public Health supports setting up a research program as part of the Canada-wide standards action plan. This program should focus on developing pollution prevention strategies, alternative industrial processes and more efficient emission reduction technologies. This research program will pave the way for making tougher Canada-wide standards achievable in the future.
The Windsor-Toronto-Montreal corridor has been identified as the region in Canada that will have significant difficulty achieving the eight-hour ozone standard of 60 ppb by 2010. Toronto Public Health recommends that the federal and provincial governments target this region with the necessary support to achieve these levels. For example, the federal and provincial governments, facilitated through the CCME, can develop legislative and policy actions that would encourage municipal and regional governments to develop long-term transportation plans that result in reduced vehicle emissions. To establish a dedicated fund to develop an efficient public transit system(s) within the Windsor-Toronto-Montreal corridor can be one of the first such actions. The provincial government can also establish air emission caps for the electrical sectors, which would substantially reduce air emissions from coal-fired plants producing electricity for Canadian consumers. Taking action to reduce self-generated emissions in the region will lend support for a stronger negotiating position with the United States on transboundary transport of air pollutants.
Conclusions:
Increased premature death, hospital admission and emergency room visits have been shown to be associated with elevated PM and ozone levels. It is imperative that PM and ozone air standards that are protective of human health are developed and implemented. Canada-wide standard development is one process by which standards are developed. Toronto Public Health has a keen interest in the development process because Toronto is in a region with high PM and ozone ambient levels associated with demonstrated adverse heath effects. Because of the size of the impacted population, Toronto Public Health participates in this and other federal/provincial process(es) to advocate for health-protective standards and a course of action to improve air quality in Toronto.
Contact Names:
Connie Clement
Director, Public Health Planning and Policy
Toronto Public Health
Tel: 392-7463/Fax: 392-0713
Angela Li-Muller, Ph.D.
Research Consultant
Health Promotion and Environmental Protection
Toronto Public Health
Tel: (416) 392-6788/Fax: (416) 392-7418
References:
(1) Canada-Wide Standards Development Committee for PM and Ozone, 1999. Discussion Paper on Particulate Matter (PM) and Ozone. Canada-Wide Standard Scenarios for Consultations. May, 1999. pp. 40 + appendices.
(2) CEPA Federal/Provincial Working Group on Air Quality Objectives and Guidelines, 1999. Ground-level Ozone Science Assessment Document. Consultation Draft. A Report by the Federal-Provincial Working Group on Air Quality Guidelines and Objectives. March, 1999.
(3) A Federal/Provincial Working Group on Air Quality Objectives and Guidelines, 1997. National Ambient Air Quality Objectives for Particulate Matter. Part 1. Science Assessment Document. A Report by the Federal/Provincial Working Group on Air Quality Guidelines and Objectives. October, 1997.
(City Council on September 28 and 29, 1999, adopted this Clause, without amendment.)
The Board of Health reports having adopted the following motion, and recommends that Council endorse the action taken by the Board:
WHEREAS several of the former Boards of Health passed resolutions in support of gun control legislation; and
WHEREAS the International Olympic Committee's goals include "the education value of good example and respect for universal fundamental ethnical principles" and "encouraging the establishment of a peaceful society, concerned with the preservation of human dignity"; and
WHEREAS the gun lobby's interest is to oppose gun control by promoting combat shooting as a 'sport'; and
WHEREAS the links between combat shooting and real violence have been demonstrated in places like Jonesboro, Arkansas where 11-year-old Andrew Golden, one of the shooters in the school massacre, had learned combat shooting from his father;
THEREFORE BE IT RESOLVED THAT the Board of Health indicate to the Canadian Olympic Committee, the Toronto Bid Committee and the International Olympic Committee in the strongest possible terms its opposition to permitting combat (or Practical) shooting as a demonstration sport for the 2004 Olympics or any future Olympics; and
BE IT FURTHER RESOLVED THAT this motion be forward to Toronto City Council and local Ontario Boards of Health for further endorsement; and
BE IT FURTHER RESOLVED THAT the Board of Health, in consultation with the Coalition for Gun Control and other appropriate groups, direct staff to review its current activities with respect to gun violence and to develop strategies for further action.
The Board of Health reports, for the information of Council, having had before it a communication (July 28, 1999) from Councillor Joe Mihevc, York Eglinton, forwarding a press release respecting Combat Shooting as a Demonstration Sport at the 2004 Olympic Games and thereafter; and advising of his intention to move that the Board of Health voice its opposition to the sport of Combat Shooting and that the appropriate organizations be so notified; and having also had before it additional documentation submitted by Councillor Mihevc.
Ms. Wendy Cukier, Chair, Canadian Coalition on Gun Control, appeared before the Board of Health in connection with the foregoing matter.
(A copy of each of the submissions referred to in the foregoing Clause has been forwarded to all Members of Council, and a copy thereof is on file in the office of the City Clerk.)
Respectfully submitted,
JOHN FILION
Chair
Toronto, September 21, 1999
(Report No. 7 of The Board of Health was adopted, without amendment, by City Council on September 28 and 29, 1999.)