I wish to promote an open discussion with the Democrats for Social Credit about their anti-fluoridation policy so have sent them this Open Letter. If they are open to a good-faith discussion I am happy to provide space on this blog for an exchange of views on their policy.
Dear David Tranter,
Democrats for Social Credit
You wrote an open letter to the Minister of Health critiquing the government’s policy on community water fluoridation (CWF) and posing some questions about dental health programmes, documented evidence relating to CWF and human rights aspects you consider relevant.
Here I take issue with some of your claims – particularly about dental health in Denmark and the scientific evidence supporting CWF. I believe the evidence does not support the anti-fluoridation policy of your party and your party should reconsider that policy.
If you believe my arguments here are mistaken or otherwise wish to defend the current anti-fluoride policy of your party I am open to a good-faith exchange of opinions and offer you the right of reply and the opportunity for a further discussion on this blog.
Natural fluoridation in Denmark
You point to the good dental health in Denmark and assert “they have never fluoridated their water.” This is true – but you ignore the fact that much of the Danish population benefits from natural levels of fluoride in their drinking water.
Unlike New Zealand parts of Denmark have drinking water fluoride concentrations similar to the optimum concentrations recommended for CWF. Map 1 from Kirkeskov et al., (2010) shows the distribution of different drinking water fluoride concentration ranges. Map 2 shows the population distribution. We can see a significant fraction of the Danish population does have access to drinking water containing fluoride.
Map 1: Distribution of natural drinking water fluoride concentrations in Denmark. The town of Nexo is on the Baltic island of Bornholm – shown in the top left-hand rectangle.
Map 2: Population distribution in Denmark.
These natural levels of drinking water fluoride are beneficial to oral health in Denmark. Here is some data from Kirkeskov et al., (2010) illustrating this. The following graph compares the dental decay (numbers with more than 2 decayed, missing or filled teeth surfaces – dmfs) at various drinking water fluoride concentrations for 5 year-olds born in 1989 and 1999.
As we can see, the extent of decay declines with fluoride concentration.
There is a similar pattern for 15-year-olds born in 1979 and 1989. This figure shows the relative numbers with more than 2 decayed missing or filled teeth surfaces, DMFS, for 15-year-olds.
And the same pattern for 15-year-olds with more than 6 decayed, missing or filled tooth surfaces.
Danish dental health programmes
You refer to a “Nexux” programme and argue that this could be an alternative to CWF in New Zealand.
I think you are referring to the programme run in Nexo – a town on the east coast of the Baltic island of Bornholm, Denmark. It is a successful local dental health programme, but only one of several in Denmark. Nexo was in an area of very low socio-economic status and introduced a dental programme at the end of 1987 aimed at improving the dental health fo children. Ekstrand & Christiansen, (2005) give this description of the programme:
“Since 1992, the program has been offered to children from the age of 8 months. It is based on three closely interrelated principles applied according to the individual child’s needs: (1) education of parents, children and adolescents in understanding dental caries as a localized disease, (2) intensive training in home-based plaque control and (3) early professional, non-operative intervention, including professional plaque removal, local application of 2% NaF and application of sealants. In the period when the children have erupting permanent first or second molars, the parents and children are instructed in using a tooth brushing technique specially designed for erupting molar teeth.”
As you can see it is a rather intensive programme and is not a Denmark-wide programme. It has been successful in Nexo, where 15-year-olds had DMFS (decayed, missing and filled tooth surfaces) values in 1986 (before introduction of the programme) slightly higher than the Danish average. The equivalent values of DMFS for Nexo were the third lowest for all municipalities in 1993 and the lowest in 1999 (Ekstrand & Christiansen, 2005).
Elements of the Nexo programme will be used in other parts of Denmark, and in other countries. Especially where school-based programmes exist.
Incidentally, Map 1 indicates the concentration of natural fluoride in the drinking water on the island where Nexo is situated is similar to that recommended for community water fluoridation. Ekstrand et al., (2005) reports that the fluoride concentration in the Nexo drinking water is 0.8 mg/L.
Nexo is a complement to, not a substitute for, CWF
Each country and region adopt health programmes appropriate to their circumstance. In New Zealand, we have programmes which include some aspect of the Nexo programme or similar programmes like the ChildSmile programme in Scotland (see ChildSmile dental health – its pros and cons and ChildSmile – a complement, not an alternative, to fluoridation). For example the use of fluoride varnish treatments, especially in non-fluoridated areas.
New Zealand can learn from the experience of other countries and in practice, we may introduce some aspects of other programmes. But blanket transfer of full programmes is rare.
The important aspect, though, is none of these programmes is considered an alternative to fluoridation. They are considered as complementary to CWF, and not substitutes for CWF. The Danish Dental Association has supported fluoridation for areas of low natural fluoride concentrations. Similarly, the British Dental Association in Scotland supports both ChildSmile and CWF and has publicly called for communities to move towards introducing water fluoridation.
In fact, we can consider that the programme used in Nexo (where the drinking water contains fluoride at 0.8 mg/L) actually complements the effect of natural community water fluoridation.
You ask the Minister:
“Why do you ignore all the documented evidence against fluoridation instead of applying positive dental health policies such as the Denmark example?”
The “Denmark example” is dealt with above and it is not what you suggest. Similarly, I suggest the “documented evidence” you refer to really doesn’t give the viable argument “against fluoridation” you imply.
Unfortunately, you do not present any of this “documented evidence” for discussion. Perhaps, if you respond positively to my suggestion of a right of reply and an ongoing discussion, you can give this evidence.
You refer to the “H&D Commissioner’s Code of Rights” asserting that:
“no-one can be medicated without giving their informed consent” and “people have the right to give – or refuse – their INFORMED consent when fluoridation is applied to public water supplies?”
Well, I am all for people being properly informed and providing consent to the treatments used for their water supply. I see this as a democratic issue and I support democracy.
But you destroy your argument by suggesting fluoridation is a “medication” when it clearly is not – either legally or rationally. The legal argument was surely settled by the High Court decision in 2014 (see Corporate backers of anti-fluoride movement lose in NZ High Court) where Justice Rodney Hansen concluded:
“ In my view, fluoridation cannot be relevantly distinguished from the addition of chlorine or any other substance for the purpose of disinfecting drinking water, a process which itself may lead to the addition of contaminants as the water standards themselves assume. Both processes involve adding a chemical compound to the water. Both are undertaken for the prevention of disease. It is not material that one works by adding something to the water while the other achieves its purpose by taking unwanted organisms out.
 The addition of iodine to salt, folic acid to bread and the pasteurisation of milk are, in my view, equivalent interventions made to achieve public health benefits by means which could not be achieved nearly as effectively by medicating the populace individually. . . . All are intended to improve the health of the populace. But they do not, in my view, constitute medical treatment for the purpose of s 11″ [the relevant section of the NZBORA].”
Is scientific knowledge really “one-sided” propaganda
You also weaken your argument by claiming:
“the one-sided propaganda used to support fluoridation is not informing people”
Describing objective scientific research and findings as “one-sided” simply displays your own bias – and willingness to discredit or ignore the science. Again, you do not give specific examples of the science you consider “one-sided propaganda” – hopefully, you will do so if you take up my offer of a right of reply and a continued discussion.
“when fluoridation is forced upon people it is nothing less than mass medication concerning which people have no opportunity to give – or refuse – their consent.”
The common anti-fluoride claim that people are having fluoridated water forced upon them always raises the picture in my mind of a person being held down and water being forced down their throat as in force-feeding.
Of course, that is ridiculous – for a number of reasons.
- In New Zealand, there has usually been a democratic public consultation of some sort before the introduction of CWF – or even after its introduction. Local bodies have surveyed residents or used referenda. They have also used a consultation procedure relying on submissions from the public.The opportunity “to give – or refuse – their consent” has in most cases been far greater than for most decisions made by our representatives in this democracy of ours. Some voters find it annoying when asked for such consent (preferring their representatives decide) but I firmly believe it important to include the public in controversial decisions – even where the controversy results from scaremongering rather than facts (as it does with CWF).
- There are alternatives for the minority. This means that democratic decisions made by a community can actually be a win-win situation. The majority get the social policy they want and have voted for. the minority have access to alternatives. In fact, most anti-fluoride activists already use alternatives – they filter their tap water or source a different supply. Some cities already provide “fluoride-free” water sources to help this. Sometimes I think the real motivation of these ideologically driven activists is to deny this social health policy to others rather than any real concern they have for their own access to water.
- Some activists will acknowledge there is no evidence of any harmful side effects from CWF but invoke a “precautionary principle” to argue against it. They should be mollified by the fact that CWF is one of the most extensively researched topics. In a sense, we must thank the ideologically and commercially motivated anti-fluoride campaigners for this. Their activity is rarely successful in preventing CWF or fooling most of the public. But it does mean that researcher keep an eye on the arguments and are continually checking them out.
David, I believe you are mistaken, or misinformed, about the dental health programmes in Denmark. You ignore completely the availability of effective natural levels of fluoride in much of Denmark’s drinking water and seem unaware of the nature of the Nexo programme or its limited area of operation.
Expert opinion considers programmes like Nexo and the Scottish ChildSmile are effective complements to CWF – not substitutes for, or alternatives to, CWF. I support our health officials considering use of similar programmes in New Zealand but it is misleading for the Democrats for Social Credit to advocate for such programmes simply as a way of preventing or opposing CWF – which is an effective, beneficial and safe social health measure.
I appreciate you may not accept my arguments or the facts I have presented here. If that is the case I urge you to accept my offer of a right of reply and ongoing good-faith discussion and am happy to help this by making space available on this blog.
I look forward to your response.
Ekstrand, K. R., & Christiansen, M. E. C. (2005). Outcomes of a non-operative caries treatment programme for children and adolescents. Caries Research, 39(6), 455–467.
Kirkeskov, L., Kristiansen, E., Bøggild, H., Von Platen-Hallermund, F., Sckerl, H., Carlsen, A., … Poulsen, S. (2010). The association between fluoride in drinking water and dental caries in Danish children. Linking data from health registers, environmental registers and administrative registers. Community Dentistry and Oral Epidemiology, 38(3), 206–212.