Opposition to water fluoridation

Opposition to the addition of fluoride to drinking water arises from political, ethical, economic, and health considerations. International and national agencies and dental associations across the world support the safety and effectiveness of water fluoridation. In contrast, opponents view it as an infringement of individual rights, if not an outright violation of medical ethics, on the basis that individuals have no choice in the water that they drink, unless they drink more expensive bottled water. A small minority of scientists have challenged the medical consensus, variously claiming that water fluoridation has no or little cariostatic benefits, may cause serious health problems, is not effective enough to justify the costs, and is pharmacologically obsolete.

Opposition to fluoridation has existed since its initiation in the 1940s. In recent years, water fluoridation has become a prevalent health and political issue in many countries, resulting in some countries and communities discontinuing its use while it has expanded in others. which include researchers, dental and medical professionals, alternative medical practitioners, health food enthusiasts, a few religious groups (mostly Christian Scientists in the U.S.), and occasionally consumer groups and environmentalists. Organized political opposition has come from libertarians, the John Birch Society, the Ku Klux Klan, Robert F. Kennedy Jr., and the Green Party of the United States.

Proponents of fluoridation have been criticized for overstating the benefits, while opponents have been criticized for understating them and for overstating the risks. Researchers who oppose the practice state this as well. According to a 2013 Congressional Research Service report on fluoride in drinking water, these gaps in the fluoridation scientific literature fuel the controversy. As of 2012, about 435 million people worldwide received water fluoridated at the recommended level, of whom 57 million (13%) received naturally fluoridated water and 377 million (87%) received artificially fluoridated water.

Medical consensus

National and international health agencies and dental associations throughout the world have endorsed water fluoridation as safe and effective. The views on the most effective method for community prevention of tooth decay are mixed. The Australian government states that water fluoridation is the most effective means of achieving fluoride exposure that is community-wide. while the European Commission finds no advantage to water fluoridation compared with topical use. and the national dental associations of Australia, Canada, and the U.S. The American Dental Association calls water fluoridation "one of the safest and most beneficial, cost-effective public health measures for preventing, controlling, and in some cases reversing, tooth decay."

In the English speaking nations—the United States, Canada, UK, Australia and New Zealand, all of which practice water fluoridation—many medical associations and authorities have published position statements and endorsed water fluoridation. The U.S. Surgeon General, the American Public Health Association, the Royal Commission on the National Health Service, Australian Medical Association, New Zealand Medical Association, and Health Canada support fluoridation, citing a number of international scientific reviews that indicate "there is no link between any adverse health effects and exposure to fluoride in drinking water at levels that are below the maximum acceptable concentration of 1.5 mg/L." The Centers for Disease Control and Prevention listed water fluoridation as one of the ten great public health achievements of the 20th century in the U.S., along with vaccination, family planning, recognition of the dangers of smoking, and other achievements. The World Health Organization, looking at global public health, identifies fluoride as one of a few chemicals for which the contribution from drinking-water to overall intake is an important factor in preventing disease. This is because there is clear evidence that optimal concentrations of fluoride provide protection against cavities, both in children and in adults.

There is a minor scientific view against water fluoridation. The scientists or doctors who oppose water fluoridation argue that it has no or little cariostatic benefits, may cause serious health problems, is not effective enough to justify the costs, and is pharmacologically obsolete.

Safety

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Fluoride can be present naturally in water at concentrations well above recommended levels, which can have several long-term adverse effects, including severe dental fluorosis, skeletal fluorosis, and weakened bones. In 1984 the World Health Organization recommended a guideline maximum fluoride value of 1.5 mg/L as a level at which fluorosis should be minimal, reaffirming it in 2006.

Fluoridation has little effect on risk of bone fracture (broken bones); it may result in slightly lower fracture risk than either excessively high levels of fluoridation or no fluoridation. There is no clear association between fluoridation and cancer or deaths due to cancer, both for cancer in general and specifically for bone cancer and osteosarcoma.

In rare cases improper implementation of water fluoridation can result in overfluoridation that causes outbreaks of acute fluoride poisoning, with symptoms that include nausea, vomiting, and diarrhea. Three such outbreaks were reported in the U.S. between 1991 and 1998, caused by fluoride concentrations as high as 220 mg/L; in the 1992 Alaska outbreak, 262 people became ill and one person died. In 2010, approximately 60 gallons of fluoride were released into the water supply in Asheboro, North Carolina, in 90 minutes—an amount that was intended to be released in a 24-hour period.

Like other common water additives such as chlorine, hydrofluosilicic acid and sodium silicofluoride decrease pH and cause a small increase of corrosivity, but this problem is easily addressed by increasing the pH. Trace levels of arsenic and lead may be present in fluoride compounds added to water; however, concentrations are below measurement limits.

Efficacy

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Reviews have shown that water fluoridation reduces cavities in children. A conclusion for the efficacy in adults is less clear with some reviews finding benefit and others not.

A 2000 UK systematic review (York) found that water fluoridation was associated with a decreased proportion of children with cavities of 15% and with a decrease in decayed, missing, and filled primary teeth (average decreases was 2.25 teeth). The review found that the evidence was of moderate quality: few studies attempted to reduce observer bias, control for confounding factors, report variance measures, or use appropriate analysis. Although no major differences between natural and artificial fluoridation were apparent, the evidence was inadequate for a conclusion about any differences. A 2015 Cochrane review also found benefit in children. A 2011 European Commission review concluded that water fluoridation has no known advantage over topical prevention (e.g. through fluoride toothpaste). It also found that water fluoridation has limited benefit for adults, because the continued administration of systemic fluoride after the permanent teeth have erupted has questionable efficacy in preventing tooth decay. The effectiveness of water fluoridation can vary according to circumstances such as whether preventive dental care is free to all children.

Ethics

Water fluoridation pits the common good against individual rights. Some say the common good overrides individual rights, and equate it to vaccination and food fortification. In her book 50 Health Scares That Fizzled, Joan Callahan writes that, "For lower-income people with no insurance, fluoridated water (like enriched flour and fortified milk) looks more like a free preventative health measure that a few elitists are trying to take away."

Those who emphasize individual or local choice, may view fluoridation as a violation of ethical or legal rules that prohibit medical treatment without medical supervision or informed consent or that prohibit administration of unlicensed medical substances, view it as "mass medication", or may even characterize it as a violation of the Nuremberg Code and the Council of Europe's Biomedical Convention of 1999. Others have opposed it on the grounds of potential financial conflicts of interest driven by the chemical industry.

A 2007 Nuffield Council on Bioethics report reached a conclusion mainly on three points, stating that :

The balance of benefit to risk ratio – is unclear due to the lack of good evidence for or against water fluoridation.
Alternatives to the practice exist – topical fluoride therapy (toothbrushing, etc.)
The role of consent – it gets priority when there are potential harms.

The report therefore concluded that local and regional democratic procedures are the most appropriate way to decide whether to fluoridate.

Opposition groups and campaigns

The controversy is propelled by a significant public opposition supported by a minority of professionals,

Public opinion

Many people do not know that fluoridation is meant to prevent tooth decay, or that natural or bottled water can contain fluoride. As fluoridation does not appear to be an important issue for the general public in the U.S., the debate may reflect an argument between two relatively small lobbies for and against fluoridation.

A study of focus groups from 16 European countries in 2003 found that fluoridation was opposed by a majority of focus group members in most of the countries, including France, Germany, and the UK. A survey in Sheffield, UK, performed in 1999 found that while a 62% majority favored water fluoridation in the city, the 31% who were opposed expressed their preference with greater intensity than supporters. Every year in the U.S., pro- and anti-fluoridationists face off in referendums or other public decision-making processes: in most of them, fluoridation is rejected.

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A 2012 study found that 25 countries have artificial water fluoridation to varying degrees, with 11 of them delivering fluoridated water to more than 50% of their population. It found that a further 28 countries have water that is naturally fluoridated, though in many of them the fluoride concentration is above the maximum recommended level. About 435 million people worldwide received water fluoridated at the recommended level,

Despite support by public health organizations and dental authorities, the practice is controversial as a public health measure; some countries and communities have discontinued it, while others have expanded it. Neither side of the dispute appears to be weakening or willing to concede. The following nations previously fluoridated their water, but stopped the practice, with the years when water fluoridation started and stopped in parentheses:

Federal Republic of Germany (1952–1971)
Sweden (1952–1971)
Netherlands (1953–1976)
Czechoslovakia (1955–1990)
German Democratic Republic (1959–1990)
Soviet Union (1960–1990)
Finland (1959–1993)
Japan (1952–1972)
Israel (1981–2014, 2016–) *Mandatory by law since 2002.

Water had been fluoridated in Israel in all major cities since 1981. This was stopped by the Minister of Health in 2014 which was met with backlash. The subsequent Minister of Health in 2016 ordered the reintroduction of fluoride to Israel's public drinking water. Due to budgetary constraints, it has never taken effect. Dental health professionals and scholarly journals have noted the steep rise in tooth decay, especially in children due to the removal of fluoride in tap water in Israel.

In the United Kingdom a strategic health authority can direct a water company to fluoridate the water supply in an area if it is technically possible. The strategic health authority must consult with the local community and businesses in the affected area. The water company will act as a contractor in any new schemes and cannot refuse to fluoridate the supply. In areas with complex water sources, water fluoridation is more difficult and more costly. Alternative fluoridation methods have been proposed, and implemented in some parts of the world. The World Health Organization (WHO) is currently assessing the effects of fluoridated toothpaste, milk fluoridation and salt fluoridation in Africa, Asia, and Europe. The WHO supports fluoridation of water in some areas. In some other countries, sodium fluoride is added to table salt.

History

Fluoridation began during a time of great optimism and faith in science and experts (the 1950s and 1960s); even then, the public frequently objected. Opponents drew on distrust of experts and unease about medicine and science. Controversies include disputes over fluoridation's benefits and the strength of the evidence basis for these benefits, the difficulty of identifying harms, legal issues over whether water fluoride is a medicine, and the ethics of mass intervention. Rio Vista, the first city in California to fluoridate its water in 1951, voted to remove their fluoridation equipment in 1956. New Zealand was the second country to fluoridate, and similar controversies arose there. Fears about fluoride were likely exacerbated by the reputation of fluoride compounds as insect poisons and by early literature which tended to use terms such as "toxic" and "low grade chronic fluoride poisoning" to describe mottling from consumption of 6 mg/L of fluoride prior to tooth eruption, a level of consumption not expected to occur under controlled fluoridation. When voted upon, the outcomes tend to be negative, and thus fluoridation has had a history of gaining through administrative orders in North America.

thumb|alt=Black-and-white political cartoon of a leering skull menacing a doll-holding little girl whose back is supported by an arm tagged "UNINFORMED PUBLIC". Nearby bones hold three large balls labeled "FLUORIDATED WATER", "POLIO MONKEY SERUMS", and "MENTAL HYGIENE etc." The cartoon is entitled "At the Sign of THE UNHOLY THREE", signed "B. SMART", and captioned "Are you willing to PUT IN PAWN to the UNHOLY THREE all of the material, mental, and spiritual resources of this GREAT REPUBLIC?"|Illustration in [[:File:Unholy three.png|a 1955 flier by the Keep America Committee, alleging that fluoridation was a Communist plot]]

Outside North America, water fluoridation was adopted in some European countries, but in the late 1970s and early 1980s, Denmark and Sweden banned fluoridation when government panels found insufficient evidence of safety, and the Netherlands banned water fluoridation when "a group of medical practitioners presented evidence" that it caused negative effects in a percentage of the population.

Communist conspiracy theory (1940s–1960s)

Water fluoridation has frequently been the subject of conspiracy theories. During the "Second Red Scare" in the United States during the late 1940s and 1950s, and to a lesser extent in the 1960s, activists on the far right of American politics routinely asserted that fluoridation was part of a far-reaching plot to impose a socialist or communist regime. These opponents believed it was "another aspect of President Truman's drive to socialize medicine." They also opposed other public health programs, notably mass vaccination and mental health services. Their views were influenced by opposition to a number of major social and political changes that had happened in recent years: the growth of internationalism, particularly the UN and its programs; the introduction of social welfare provisions, particularly the various programs established by the New Deal; and government efforts to reduce perceived inequalities in the social structure of the United States.

Others asserted the existence of "a Communist plot to deplete the brainpower and sap the strength of a generation of American children".

2006 US NRC report

U.S. opponents of fluoridation were heartened by a 2006 National Research Council report about hazards of water naturally fluoridated to high levels;

Court cases

Ireland

In Ryan v. Attorney General (1965), the Supreme Court of Ireland held that water fluoridation did not infringe the plaintiff's right to bodily integrity. The court found that such a right to bodily integrity did exist, even though it was not explicitly mentioned in the Constitution of Ireland, thus establishing the doctrine of unenumerated rights in Irish constitutional law.

Netherlands

Water was fluoridated in large parts of the Netherlands from 1960 to 1973, at which point the Supreme Court of the Netherlands declared fluoridation of drinking water unauthorized. The Dutch Court decided that authorities had no legal basis for adding chemicals to drinking water if they did not also improve safety. It was also stated as support that consumers cannot choose a different tap water provider. Drinking water has not been fluoridated in any part of the Netherlands since 1973.

United States

Fluoridation has been the subject of many court cases wherein activists have sued municipalities, asserting that their rights to consent to medical treatment and due process are infringed by mandatory water fluoridation. To date, no federal appellate court or state court of last resort (i.e., state supreme court) has found water fluoridation to be unlawful.

In September 2024, in Food and Water Watch et al. v. United States Environmental Protection Agency, U.S. Federal Judge Edward Chen ruled that water fluoridation posed an, "unreasonable risk of reduced IQ in children…a risk sufficient to require the EPA to engage with a regulatory response…One thing the EPA cannot do, however, in the face of this Court's finding, is to ignore that risk."

References

External links

– description of the history and controversy of fluoridated drinking water