In the background, I have been working very hard on a video in my free time that will go live tomorrow, which I hope will be of interest to my viewers. I’m a little disappointed in the quality of the audio in some sections, but I will work on this with future videos.
Anyway, as happens, I tend to refer to the science literature and in doing so, I came across Awofeso (2012) Ethics of Artificial Water Fluoridation in Australia. Public Health Ethics. 5 (2): 161-172. (doi: 10.1093/phe/phs016).
While I will not go through the entire article – many points made in it are discussed in the video – there are a couple points I would like to raise that hit me in the face not unlike “Pythonesque fish slap” when I read it.
“Epidemiological trends do not fully support effectiveness of artificial water fluoridation in both caries prevention and reducing relatively high rates of dental caries among vulnerable populations. A recent report by the Australian Institute of Health and Welfare revealed that Australian children from the poorest areas have about 70 per cent more dental decay compared with children from the highest socioeconomic groups. For example, in Western Australia, where over 90 per cent of water supplies are fluoridated, dental decay was 22 per cent higher in poorer cohorts compared with richer socioeconomic populations. This report also noted that caries prevalence varied from 29.3 per cent in the Australian Capital Territory to 49.7 per cent in the Northern Territory, average national prevalence of 38 per cent. (Australian Institute of Health and Welfare, 2011a). This compares with a national average of 40 per cent caries prevalence in the 1970s (Wilson, 2004). Thus, there is little epidemiological evidence to suggest that widespread adoption of water fluoridation has translated into substantial reduction in caries prevalence in Australia.”
The author makes a number of inappropriate claims from comparisons being made. To make sense of the potential influences of water fluoridation on different socio-economic groups, the comparison must be made between similar groups of different fluoridation cover rather than between socio-economic groups within the one cover region.
For instance, you would standardise income across your research area (what you can buy for a dollar does change across Australia) and then cluster your groups by this standard income. You would then look at a given standardised income group across different communities where the difference is the amount of access to fluoridated water.
Stating that WA has 90% fluoridated water cover and that lower socio-economic groups has higher rates of tooth decay ONLY concludes that there are social and economic factors as to why poorer people have more tooth decay and cannot state whether or not rates of tooth decay in more vulnerable groups has or has not been improved by access to fluoridated water at all.
Furthermore, comparing ACT to NT is just as misleading. Firstly, the Qld state government have this nice graphic, showing that 70% of people in the NT have access to Fluoride, while 100% of people in ACT do. The ACT is a very small and highly urbanised state, while the NT is huge and has many people living in remote communities with little access to everything from fresh fruit and vegetables to quality doctors and educators.
Taking a quick look at the ABS census data, whatever measure you care to use, NT rates lower than ACT for income as well (not standardised). Again both access to fluoridated water and socio-economic factors are likely involved and no meaningful conclusions on the effectiveness of water fluoridation can be drawn.
A clear case of “apples and oranges” is developed to wrongly suppose that fluoridation is ineffective, which is then used like a domino to support other claims (such as, cost – clearly, if it is ineffective the cost is too great).
On cost, the author writes;
“[T]he assumptions underlying the cost-effectiveness calculations were not stated. It is debatable that $1 invested in water fluoridation translates to $30 saved in dental treatment, because not all those affected by dental caries will lose days off work or seek treatment. Also, it is not mentioned if the cost of fluorosis treatment (lifetime treatment costs of $100,000) is included in the cost-effectiveness calculations (Clinch, 2008).”
Again, many sleights of hand are being used.
First, the argument can easily be turned on fluorosis treatment; not everyone whom develops fluorosis will seek treatment.
The rates of fluorosis in fluoridated regions of Australia are relatively low when compared with rates of tooth decay in areas without fluoridated water supply (eg 56% of children between 5-12 years of age have experienced caries in NSW, Child Dental Health Survey 2007, Phelan et al (2009), where fluorosis levels are never claimed to be as high anywhere in Australia), so it is understandable that costs in relation to fluorosis are subjective and unlikely to be comparable to costs resulting from dental caries.
Water fluoridation has time and time again, proven to be safe, cost effective and effective to reduce the rate of tooth caries (also demonstrated in the NSW survey).
As a final point, the author discusses ethics drawing back to the question of “autonomy.”
This is the refuge of the fool, akin to the pathetic whining we heard in relation to phasing out old technology light globes; “they’re telling us even what type of light globe we can use.”
It is a philosophical question that indeed deserves debate, but only in relation to meaningful subjects. Stressing over light bulbs and 1ppm levels of fluoride in ones drinking water are not subjects worth such debate.
There are many limitations to what the individual can actually do in practice. We do not even have legal responsibility over our own life; we can be kept alive against our will. On the question on the amount of power an individual can own and yield, we limit this to guns of varying level and more often they are not carried into public places.
The standing scientific literature on the subject of water fluoridation demonstrates that, if it is applied within the World Health Organisation guidelines, it is effective and safe. It is also cheap. With that in mind, knowing that teeth everywhere are surprisingly alike, what ethical grounds remain for an individual to complain, “it’s against my freedom to be provide cost effective dental decay protection by the government! Who the hell are they to extend my life and the quality of my teeth?”
I will go into more detail in the following video and have done so in my form articles on the subject.
Awofeso (2012) has produced a terrible report, full of obvious biases and misleading comparisons to drawn unsubstantiated claims contrary to more than 40 years of real world evidence across Australia. I would have hoped that the review panel of Public Health Ethics should have heard numerous alarm bells ringing from such blatantly wrong and misleading word play. Clearly, in this example, they did their journal no favours.