Chapter 4: The Chief Public Health Officer's report on the state of public health in Canada 2008 – Environment and housing
Social and Economic Factors that Influence Our Health and Contribute to Health Inequalities
Environment and housing
Where a person lives matters since both natural and built environments influence health. It creates the context for determinants of health such as income, employment, social networks and personal behaviours.
Although health related to the environment is primarily outside the scope of this report, the physical environment can also contribute to health inequalities (e.g. adequacy of housing, indoor air quality and water supply). Environmental challenges associated with changing conditions, particularly climate, are expected to place increased health burdens on society and the infrastructure now and towards the foreseeable future.
Outdoor air pollution causes health effects that include coughing, aggravation of asthma and other respiratory diseases, as well as the exacerbation of cardiovascular disease. This results in increases in emergency room visits, hospital admissions and premature death as air quality degrades. Research indicates even low concentrations of these pollutants can result in adverse health effects.251 An increase in air pollutants contributes to an increase in morbidity and premature mortality. Health Canada estimates that, in eight Canadian cities, air pollution is responsible for 5,900 excess deaths per year.252
Particulate matter and ozone are two key components of smog. In southern Ontario and southern Quebec, an indicator of exposure to ground-level ozone concentration has increased by about 17% and 15% respectively between 1990 and 2005, while there has been no discernible change in the indicator for particulate matter over the same time period. No trends were discernible for either pollutant in other parts of the country.251
For the majority of Canadians, water quality is considered to be safe, with 85% of Canadians receiving their water supply from treated municipal water works.253 Nevertheless, there are still challenges to be addressed, particularly in small and remote communities and on First Nations reserves.254
Building Healthier Urban Communities
The Vancouver Agreement
When a public health emergency was declared in Vancouver's Downtown Eastside neighbourhood, the governments of Canada, British Columbia and Vancouver came together to work toward an effective and sustainable solution. Crime, drug trafficking and drug use had contributed to epidemic rates of HIV infection and had created an unstable environment where residents felt threatened and defeated. Through a unique five-year tripartite initiative called the Vancouver Agreement, three levels of government were able to combine their services and expertise and work with residents, community groups and businesses toward the creation of a healthier community. Results have included: lower death rates due to alcohol and drug use (including overdoses), HIV-AIDS and suicide; greater access to health services through the opening of four new health clinics in the community, expanded addiction treatment services and an after-hours youth crisis response program; and initiatives that have made a difference to residents – from employment for street youth in the city's hotel industry to a mobile after-hours drop-in centre for sex workers who regularly face violence and abuse. The initial Agreement was created in 2000 and in 2005 it was renewed for an additional five-year period. It has been recognized through national and international awards and replicated by Western Economic Diversification Canada through similar arrangements in other western Canadian cities.255, 256, 257
The majority of Canadians (80%) live in urban areas.133 These built environments can influence physical and mental health through factors such as community design, adequate housing, access to safe water, good sanitation, safe neighbourhoods, and adequate access to education, recreational services, public transit and child care.7, 167, 261 In essence, the built structure provides the setting for many of the social determinants of health.216
In Canada, the built environment is undergoing significant change and one of the greatest challenges is urban sprawl. Urban growth now typically includes the creation of low-density, decentralized communities that include suburban residential, strip retail and employment development.
While city centres (cores or central business districts) have traditionally provided the greatest source of employment, reliance on suburban employment has now grown as the growth of cities has increased outward. For example, although, the number of jobs in Canada’s city centres has increased, the number of jobs in Canada’s suburbs has increased four times as much.258 Decentralized residential and employment areas have also led to the development of extensive road networks and greater reliance on vehicle commuting. The number of Canadians who drive to work increases with distance away from the city centre: at 5 kilometres from the centre, 58% of the population drive; and at 20 kilometres away, 80% drive.259 This increase in vehicle use and commuting has resulted in higher incidences of vehicular injury in suburban areas, as well as higher rates of heart and respiratory diseases and obesity, and elevated stress related to both commuting among congested traffic and increased noise levels.260, 261
Urban land uses can positively and negatively influence health behaviours. For example, ‘walkability’ measures the extent to which an urban environment supports residents moving between places using an active, safe and more environmentally friendly form of transit such as walking or biking. However, walkability is dependent on whether the community design includes recreational pathways and sidewalks, safe levels of lighting, and compatible land uses that ensure pleasant safe spaces for both recreational and transit activities.261 In more ‘walkable’ neighbourhoods, people tend to have increased physical activity levels which may lead to lower rates of obesity.262 Similarly, the built environment can influence access to affordable and nutritious foods. There is evidence that compared to higher-income neighbourhoods, low-income neighbourhoods often have limited grocery stores (particularly those selling fresh produce), offer nutritious foods at a higher cost and have a greater concentration of fast food services – all of which may contribute to poorer eating habits among residents.
The built environment can also provide opportunities for social interaction through an array of social networks and organizations. Generally, the larger the urban centre, the greater the number and complexity of social networks. Social engagement in the community builds trust, efficacy and a sense of belonging that is associated with improved mental and immunological health.117 Urban centres tend to be less culturally and socially homogeneous and have diverse populations. Within these cities, communities comprised of close networks of people of similar cultural and social perspectives offer the benefits of community such as social support.265 Research has shown, for example, that recent immigrants can better integrate into Canadian cities that have communities with strong social and cultural support networks.266
Although urban areas provide many opportunities for social contact with others, they can also create anonymity and isolation.265 Regardless of neighbourhood density, many urban dwellers say that they do not know their neighbours, a number of elderly residents live alone, and those who are not connected with the greater community can experience isolation.265, 267
Designing Healthy and Sustainable Cities
The Healthy Cities initiative is an internationally led approach to building a stronger movement for public health at the urban level. Applying public health criteria to choices made in communities about land use and urban design can improve the health of the communities' populations.268 Coinciding with a trend toward urbanization, the population in Canada and similarly developed countries is aging. To address the issues arising from these dual trends, the WHO launched an age-friendly cities project in 2005 with funding from the Government of Canada, the Government of British Columbia and Help the Aged UK.269 The project aims to encourage communities to create age-friendly physical and social urban environments that will better support older citizens in making choices that enhance their health and well-being and that will allow them to participate in their communities, contributing their skills, knowledge and experience.270 After consulting with older citizens and their caregivers/service providers in 33 cities representing 22 countries, the WHO created a "Global Age-Friendly Cities Guide" for any government, organization and/or individual interested in identifying and improving the age-friendly status of a city.269, 271 Groups in various countries, including Canada, are already developing networks through use of the Guide to support each other and share best practices.269 In September 2006, the Federal, Provincial and Territorial Ministers Responsible for Seniors endorsed participation in a second component of the project called the "Age-Friendly Rural and Remote Communities Initiative".272
Housing, or lack thereof, is a critical component of an individual’s environment. In Canada, 13.7% of Canadians report being unable to access acceptable housing. The term acceptable housing used here refers to housing that is affordable (costing less than 30% of before-tax income), does not require major repairs and is not overcrowded.273 The Canada Mortgage and Housing Corporation reports that ‘affordability’ is the least frequently met of these criteria for acceptability.274
Health outcomes related to housing are complex, as housing can directly and indirectly impact health. Inadequate housing may produce direct effects in extreme climates. Respiratory disease/poor lung function and allergies related to moulds from cold, damp or poorly ventilated houses may develop.278 Other health conditions can arise related to exposure to specific toxic substances like lead and asbestos from substandard plumbing and insulation, environmental tobacco smoke and residential radon from contaminated soil.279
Addressing Affordable Housing
Habitat for Humanity Canada
Habitat for Humanity Canada, a member of the Habitat for Humanity International, is a national, non-profit organization that works to break the cycle of poverty for low-income Canadian families by providing them with safe, affordable housing and promoting homeownership. Habitat homeowners work alongside volunteers to build the homes, which are funded through donations of money, supplies, land and labour from community partners that range from individuals to corporations.275 At completion, homes are sold to partner families at no profit. Mortgages are interest-free and capped at 30% of the homeowner's income, with all payments going to a revolving fund that finances the building of more houses.276 Since 1985, when the first group in Winkler, Manitoba began its work, Habitat for Humanity Canada has built more than 1,200 homes across the country through its 72 affiliates located in all 10 provinces and two of the three territories.275 Habitat homeowners are reported to benefit through improved finances, less reliance on social services and the chance to build equity in a home. About 40% of recipient parents report seeing an improvement in their children's school grades and 22% reported that it was attributable to their children being healthier and better able to concentrate since moving into Habitat housing. Over half of recipient parents reported seeing an improvement in their children's behaviour and 60% attributed this to their children being happier, more outgoing and feeling more confident.277
Overcrowding and poorly ventilated houses can also increase susceptibility to disease. The number of people per dwelling has been known to greatly impact the physical and mental health of inhabitants, including raising the risk of acquiring tuberculosis.278 This is especially true for many Canadian Aboriginal populations and for immigrants from some countries where older generations infected with tuberculosis in childhood may experience disease reactivation later in life that can infect others in the home.280 Both groups experience a higher rate of overcrowding than the general population and also account for the highest rates of new and relapsed cases of tuberculosis in Canada.209, 281 Among Aboriginal populations in 2006, rates of new and relapsed cases of tuberculosis were at 27.4 per 100,000 compared to only 5 per 100,000 in the overall population. Among immigrants, rates of new and relapsed tuberculosis cases were 14.8 per 100,000.209
Homelessness is also a health issue. It is difficult to measure how many people in Canada are homeless as homelessness is a continuum with a variety of short and long term experiences.282 The most recent number often cited – 150,000 people – is believed to be an underestimate.283 Some of these people become homeless as a result of inadequate income, living in a community with inadequate housing, or having a mental illness, which may hinder opportunities for employment and income.284 While homelessness can affect a broad range of people, approximately one third of the homeless are between the ages of 16 and 24 years.285 A third of street youth report trading sex for shelter, money and substances, particularly cigarettes (80% of street youth smoke daily) and have higher rates of STIs and blood-borne infections than youth in the general population. A lack of housing contributes to a vicious circle influencing eligibility for income supports, community benefits, voter registration and employment options that could bring about changes in living conditions. As well, about half of youth living on the street have been involved with the child welfare system at some point during their lifetime. An equal share were abused as children and left home as a result. Many street youth dropped out or were expelled from school. In 2003, for both male and female street youth, the main source of income was social welfare.286
Examples of Community Level Support for Children
Community Action Program for Children
The Community Action Program for Children (CAPC) provides long-term funding to community groups and coalitions offering programs to address the health and development of children (aged 0 to 6 years) who are living in conditions of risk (e.g. low income, single parents, newcomers to Canada).287 CAPC recognizes that communities have the ability to identify and respond to the needs of children and places a strong emphasis on partnerships and community capacity building. Approximately 450 CAPC projects operate in more than 3,000 communities throughout Canada and deliver approximately 1,800 programs that serve an estimated 110,000 participants (children and parents/caregivers) in a typical month.288 CAPC projects involve partnerships which may include health organizations, educational institutions, community associations, early childhood or family resource centres and child protection services.287 National and regional evaluations of CAPC have found numerous benefits for families participating in CAPC programs, including lower rates of maternal depression and sense of isolation, and less emotional and behavioural issues reported among children.289
Healthy Child Manitoba
In March 2000, the Manitoba government established Healthy Child Manitoba, a long-term, cross-departmental prevention strategy for putting children and families first.290, 291 The Healthy Child Committee, comprised of eight ministries, develops and leads child-centred public policy across government and ensures inter-departmental co-ordination with respect to programs and services for children, adolescents and families.290 A corresponding Deputy Ministers' committee and cross-departmental working groups, ensure that children's issues and well-being are a shared priority. Healthy Child Manitoba supports 26 province-wide parent-child coalitions to promote and support community-based programs that reflect each community's diversity and unique needs.292 Priorities include: prenatal benefits and community programs: FASD prevention and support; healthy schools; healthy adolescent development and the recent introduction, province-wide, of the Triple P Positive Parenting Program.291 Results from program specific evaluations have ranged from improved parenting skills and a better sense of community connectedness for families involved in home visiting programs, to an 80% enrolment rate in an alcohol and drug treatment program for participants in the Stop FAS mentoring program for women who have used alcohol or drugs during current or previous pregnancies.291, 293
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