Water fluoridation opposition

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Opposition to water fluoridation refers to activism against the fluoridation of public water supplies. The controversy occurs mainly in English-speaking countries, as Continental Europe does not practice water fluoridation, although some continental countries fluoridate salt.[1] Most of the health effects are associated with water fluoridation at levels above the optimal concentration of 0.7 – 1.2 mg/L (0.7 for hot climate, 1.2 in cool climates), but those organizations and individuals opposed raise concerns that the intake is not easily controlled, and that children, small individuals, and others may be more susceptible to health problems. Those opposed also argue that water fluoridation is ineffective,[2] may cause serious health problems,[3][4][5] and imposes ethical issues.[6] Opposition to fluoridation has existed since its initiation in the 1940s.[1] During the 1950s and 1960s, some opponents of water fluoridation also put forward conspiracy theories describing fluoridation as a communist plot to undermine public health.[7] Sociologists used to view opposition to water fluoridation as an example of misinformation. However, contemporary critiques of this position have pointed out that this position rests on an uncritical attitude toward scientific knowledge.

Contents

Ethics

Many who oppose water fluoridation consider it to be a form of compulsory mass medication. They argue that consent of all water consumers cannot be achieved, nor can water suppliers accurately control the exact levels of fluoride that individuals receive, nor monitor their response.[6] It is also argued that, because of the negative health effects of fluoride exposure, mandatory fluoridation of public water supplies is a breach of ethics and a human rights violation.

In the United Kingdom the Green Party refers to fluoride as a poison, claim that water fluoridation violates Article 35 of the European Charter of Fundamental Rights, is banned by the UK poisons act of 1972, violates Articles 3 and 8 of the Human Rights Act and raises issues under the United Nations Convention on the Rights of the Child.[8]

Water fluoridation has also been criticized by Cross and Carton for violating the Nuremberg Code and the Council of Europe's Biomedical Convention of 1999.[9] Dentistry professor David Locker and philosopher Howard Cohen argued that the moral status for advocating water fluoridation is "at best indeterminate" and could even be considered immoral because it infringes upon autonomy based on uncertain evidence, with possible negative effects.[10]

The precautionary principle

In an analysis published in the March 2006 issue of the Journal of Evidence Based Dental Practice, the authors examine the water fluoridation controversy in the context of the precautionary principle. The authors note that:

  • There are other ways of delivering fluoride besides the water supply;
  • Fluoride does not need to be swallowed to prevent tooth decay;
  • Tooth decay has dropped at the same rate in countries with, and without, water fluoridation;
  • People are now receiving fluoride from many other sources besides the water supply;
  • Studies indicate fluoride’s potential to cause a wide range of adverse, systemic effects;
  • Since fluoridation affects so many people, “one might accept a lower level of proof before taking preventive actions.”[11]

Potential health risks

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Health risks are generally associated with fluoride intake levels above the commonly recommended dosage, which is accomplished by fluoridating the water at 0.7 – 1.2 mg/L (0.7 for hot climates, 1.2 in cool climates). This entails a daily fluoride dose of between 1 – 3 mg/day, as men are recommended to drink 3 liters/day and women 2.2 liters/day.[12] In 1986 the United States Environmental Protection Agency (EPA) established a maximum contaminant level (MCL) for fluoride at a concentration of 4 milligrams per liter (mg/L), which is the legal limit of fluoride allowed in the water.[13] In 2006, the US National Research Council (NRC) reviewed the health risks associated with fluoride consumption[14] and unanimously concluded that the maximum contaminant level of 4 mg/L should be lowered. The EPA has yet to act on the NRC's recommendation.[15][16] The limit was previously 1.4 – 2.4 mg/L, but it was raised to 4 mg/L in 1985.[17]

Opposition groups express the greatest concern for vulnerable populations, and the National Research Council states that children have a higher daily average intake than adults per kg of bodyweight.[14]:23 Those who work outside, or have urine problems also will drink more water. Of the following health problems, only osteosarcoma, a rare bone disease affecting male children, is strictly associated with the recommended dosage of fluoride. The weight of the evidence does not support a relationship,[18] although a study described as the most rigorous yet by the Washington Post found a relationship among young male boys. The authors' adviser faced an investigation based on his dismissal of the results and an apparent conflict of interest.[19] An epidemiological connection between areas with high intake of silicofluorides and increased lead blood levels in children has been observed in areas fluoridated at the recommended dosage.[20][21] A 2007 update on this study confirmed the result and noted that silicofluorides, fluosilicic acid and sodium fluosilicate are used to fluoridate over 90% of US fluoridated municipal water supplies.[22]

Chemistry professor Paul Connett, the executive director of the Fluoride Action Network, points out that dosages cannot be controlled, so he believes that many of the health effects observed at levels above 1 mg/L are relevant for 1 mg/L. He highlights the issues raised by the 2006 report in the form uncertainties, data gaps, and a reduced margin of safety.[23] A panel member of the report, Kathleen M. Thiessen, writes that the report does seem relevant to the debate, and that the "margin of safety between 1 mg/L and 4 mg/L is very low" because of the uncontrolled nature of the dosage.[24] In her opinion fluoride intake should be minimized. Another panel member, Robert Isaacson, stated that "this report should be a wake-up call" and said that the possible effects on the endocrine gland and hormones are "something that I wouldn’t want to happen to me if I had any say in the matter."[25] John Dull, the chair of the panel, stated that "the thyroid changes worry me ... we’ve gone with the status quo regarding fluoride for many years—for too long, really—and now we need to take a fresh look ... I think that’s why fluoridation is still being challenged so many years after it began. In the face of ignorance, controversy is rampant".[3] Hardy Limeback, another panel member, stated "the evidence that fluoridation is more harmful than beneficial is now overwhelming and policy makers who avoid thoroughly reviewing recent data before introducing new fluoridation schemes do so at risk of future litigation".[26]

Excess fluoride consumption has been studied as a factor in the following:

  • A weakening of bones, leading to an increase in hip and wrist fracture.[4] The National Research Council found the overall evidence "suggestive but inadequate for drawing firm conclusions about the risk or safety of exposures at [2 mg/L]", but states that fractures do seem to increase as fluoride is increased from 1 mg/L to 4 mg/L, suggesting a "continuous exposure-effect" dose-response relationship at these levels.[14]:170
  • Adverse effects on the kidney. Within the optimal dose, no effects are expected, but chronic ingestion in excess of 12 mg/day are expected to cause adverse effects, and an intake that high is possible when fluoride levels are around 4 mg/L.[14]:281 Those with impaired kidney function are more susceptible to adverse effects.[14]:292
  • Little research has been done on possible liver damage, although some studies suggest negative effects at chronic ingestion of 23 mg/day.[14]:292
  • Chromosomal damage and interference with DNA repair.[14]:304 Overall, the literature from in vitro and rodent studies does not indicate genotoxicity, but the in vivo human studies are inconsistent.[14]:316
  • Four epidemiological studies have noted a correlation between increased fluoride and low IQ.[14]:205-223 The most rigorous of these compared an area with mean water concentration of 0.36 ± 0.15 mg/L (range 0.18-0.76 mg/L) to an area with 2.47 ± 0.79 mg/L (range 0.57-4.50 milligrams per liter [mg/L]). Most of these studies did not publish important details, making them difficult to evaluate. If these correlations are caused by fluoride, the mechanism is not known, but the National Research Council speculates that effects on the thyroid could lead to poor test results.[14]:208
  • Inhibition of melatonin production and promotion of precocious puberty in animal studies.[27] Fluoride may have an analogous inhibitory effect on human melatonin production, as fluoride accumulates readily in the human pineal gland, the brain organ responsible for melatonin synthesis.[28]

Fluorosis

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Dental fluorosis

For more details on this topic, see Dental fluorosis.
A severe case of fluorosis.
A severe case of fluorosis.

Dr. John Colquhoun[4], former Principal Dental Officer of Auckland, New Zealand, and Dr. Hardy Limeback,[2], Associate Professor and Head, Preventive Dentistry at the University of Toronto, were formerly in favor of fluoridation and both cite dental fluorosis as a major reason in their opposition to fluoridation. Dental fluorosis occurs because of the excessive intake of fluoride either through fluoride in the water supply, naturally occurring or added to it; or through other sources. The damage in tooth development occurs between the ages of 6 months to 5 years, from the overexposure to fluoride. In its severe form it is characterized by black and brown stains, as well as cracking and pitting of the teeth. [32][33][34][35]

The World Health Organization cautions that fluoride levels above 1.5 milligrams per liter leaves the risk for fluorosis.[36] To protect against this health organizations in some high fluoride areas endorse providing alternative water sources, or removing fluoride from the water.[37] 0.07 – 1.2 milligrams per liter of fluoride is considered to be the optimal level. A CDC evaluation concluded that prevalence of some level of fluorosis among children and adolescents in the United States had increased by from 22.8% in 1986 – 1987 to 32% in 1999 – 2002.[38]

Skeletal fluorosis

For more details on this topic, see Skeletal fluorosis.

Skeletal fluorosis is a bone disease exclusively caused by excessive consumption of fluoride. Development of skeletal fluorosis is directly related to the level and exposure of fluoride exposure, for example, water fluoridated at five parts per million (ppm) for ten years or more is needed to produce signs of osteosclerosis.[39] In advanced cases, skeletal fluorosis causes pain and damage to bones and joints. Advanced cases usually involve about ten times the normal amount of fluoride. [40]

Efficacy

The largest study of water fluoridation's efficacy, conducted by the National Institute of Dental Research, showed no statistically significant difference in tooth decay rates among children in fluoridated and non-fluoridated communities.[41] A review of the evidence from the University of York, published in 2000, examined 30 studies.[42] The researchers concluded that the quality of evidence in most studies was poor, also expressing concern over the "continuing misinterpretations of the evidence".[43] Many medical authorities argue that the effects of fluoridation on teeth are topical (brushed on) rather than systemic (swallowed). [44][45][46][47][48][49][50][51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67][68][69][70]

Statements against

Since 1985, the EPA headquarters' union has expressed concerns about fluoride. In 2005, eleven environmental protection agency EPA employee unions, representing over 7000 environmental and public health professionals of the Civil Service, called for a halt on drinking water fluoridation programs across the USA and asked EPA management to recognize fluoride as posing a serious risk of causing cancer in people. The unions acted on an apparent cover-up of evidence from Harvard School of Dental Medicine linking fluoridation with an elevated risk of osteosarcoma in boys, a rare but fatal bone cancer.[71]

In addition, over 1,730 health industry professionals, including one Nobel prize winner in medicine (Arvid Carlsson), doctors, dentists, scientists and researchers from a variety of disciplines are calling for an end to water fluoridation in an online petition to Congress.[72] The petition signers express concern for vulnerable groups like "small children, above average water drinkers, diabetics, and people with poor kidney function," who they believe may already be overdosing on fluoride.[72] Another concern that the petition signers share is, "The admission by federal agencies, in response to questions from a Congressional subcommittee in 1999-2000, that the industrial grade waste products used to fluoridate over 90% of America's drinking water supplies (fluorosilicate compounds) have never been subjected to toxicological testing nor received FDA approval for human ingestion."[72] The petition was sponsored by the Fluoride Action Network of Canton, New York, the most active anti-fluoridation organization in North America.citation needed

Their petition highlights eight recent events that they say mandates a moratorium on water fluoridation, including a 500-page review of fluoride’s toxicology that was published in 2006 by a distinguished panel appointed by the National Research Council of the National Academies.[73] While the NRC report did not specifically examine artificially fluoridated water, it concluded that the U.S. Environmental Protection Agency's safe drinking water standard of 4 parts per million (ppm) for fluoride is unsafe and should be lowered. Despite over 60 years of water fluoridation in the U.S, there are no double-blind studies which prove fluoride's effectiveness in tooth decay. The panel reviewed a large body of literature in which fluoride has a statistically significant association with a wide range of adverse effects.[74]

A separate petition that calls on the United States congress to halt the practice of fluoridation has received over 12,300 signatures. [75]

In his 2004 book The Fluoride Deception, author Christopher Bryson claims that "industrial interests, concerned about liabilities from fluoride pollution and health effects on workers, played a significant role in the early promotion of fluoridation."[76]

Dr. Hardy Limeback, BSc, PhD, DDS was one of the 12 scientists who served on the National Academy of Sciences panel that issued the aforementioned report, Fluoride in Drinking Water: A Scientific Review of the EPA's Standards. Dr. Limeback is an associate professor of dentistry and head of the preventive dentistry program at the University of Toronto. He detailed his concerns in an April 2000 letter titled, "Why I am now officially opposed to adding fluoride to drinking water".[2]

In a presentation to the California Assembly Committee of Environmental Safety and Toxic Materials, Dr. Richard Foulkes, B.A., M.D., former special consultant to the Minister of Health of British Columbia, revealed:

The [water fluoridation] studies that were presented to me were selected and showed only positive results. Studies that were in existence at that time that did not fit the concept that they were "selling," were either omitted or declared to be "bad science." The endorsements had been won by coercion and the self-interest of professional elites. Some of the basic "facts" presented to me were, I found out later, of dubious validity. We are brought up to respect these persons in whom we have placed our trust to safeguard the public interest. It is difficult for each of us to accept that these may be misplaced.[77]

On April 15, 2008, the United States National Kidney Foundation (NKF) updated their position on fluoridation for the first time since 1981.[78][79] Formerly a supporter of water fluoridation, the NKF now takes a neutral position on the practice.

The International Chiropractors Association opposes mass water fluoridation, considering it "possibly harmful and deprivation of the rights of citizens to be free from unwelcome mass medication."[80]

Use throughout the world

Main article: Water fluoridation#International status

Water fluoridation is used in the United States, United Kingdom, Canada, and Australia, among other countries. The following developed nations previously fluoridated their water, but stopped the practice, with the years when water fluoridation started and stopped in parentheses:

  • German Federal Republic (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) [81]

In 1986 the journal Nature reported, "Large temporal reductions in tooth decay, which cannot be attributed to fluoridation, have been observed in both unfluoridated and fluoridated areas of at least eight developed countries."[82]

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 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, and encourages removal of fluoride where fluoride content in water is too high. [83]

Conspiracy theories

Anti-public health flier issued in May 1955 by the Keep America Committee, alleging a conspiracy theory that water fluoridation is a communist plot.
Anti-public health flier issued in May 1955 by the Keep America Committee, alleging a conspiracy theory that water fluoridation is a communist plot.

Water fluoridation has frequently been the subject of conspiracy theories. During the "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. They also opposed other public health programs, notably mass vaccination and mental health services.[84] 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 inequalities in the social structure of the United States.[85]

Some took the view that fluoridation was only the first stage of a plan to control the American people: "Already there is serious talk of inserting birth control drugs in public water supplies, and growing whispers of a happier and more manageable society is so-called behavorial drugs are mass-applied." Fluoridation, it was claimed, was merely a stepping-stone on the way to implementing more ambitious programs. Others asserted the existence of a plot by communists and the United Nations to "deplete the brainpower and sap the strength of a generation of American children". Dr. Charles Bett, a prominent anti-fluoridationist, charged that fluoridation was "better THAN USING THE ATOM BOMB because the atom bomb has to be made, has to be transported to the place it is to be set off while POISONOUS FLUORINE has been placed right beside the water supplies by the Americans themselves ready to be dumped into the water mains whenever a Communist desires!" Similarly, a right-wing newsletter, the American Capsule News, claimed that "the Soviet General Staff is very happy about it. Anytime they get ready to strike, and their 5th column takes over, there are tons and tons of this poison "standing by" municipal and military water systems ready to be poured in within 15 minutes."[7]

This viewpoint led to major controversies over public health programs in the US, most notably in the case of the Alaska Mental Health Enabling Act controversy of 1956.[86] In the case of fluoridation, the controversy had a direct impact on local programs. During the 1950s and 1960s, referendums on introducing fluoridation were defeated in over a thousand Florida communities. Although the opposition was overcome in time, it was not until as late as the 1990s that fluoridated water was drunk by the majority of the population of the United States.[84]

The communist conspiracy argument declined in influence by the mid-1960s, becoming associated in the public mind with irrational fear and paranoia. It was lampooned in Stanley Kubrick's 1964 film Dr Strangelove, in which a character initiates a nuclear war in the hope of thwarting a communist plot to "sap and impurify" the "precious bodily fluids" of the American people with fluoridated water. Similar satires appeared in other movies, such as 1967's In Like Flint, in which a character's fear of fluoridation is used to indicate that he is insane. Even some anti-fluoridationists recognized the damage that the conspiracy theorists were causing; Dr. Frederick Exner, an anti-fluoridation campaigner in the early 1960s, told a conference: "most people are not prepared to believe that fluoridation is a communist plot, and if you say it is, you are successfully ridiculed by the promoters. It is being done, effectively, every day . . . some of the people on our side are the fluoridators' 'fifth column'."[7]

Court cases

United States

Fluoridation has been the subject of many court cases. Activists have sued municipalities, asserting that their rights to consent to medical treatment, privacy, and due process are infringed by mandatory water fluoridation.[9] Individuals have sued municipalities for a number of illnesses that they believe were caused by fluoridation of the city's water supply. So far, the majority of courts have held in favor of cities in such cases, finding no or only a tenuous connection between health problems and widespread water fluoridation.[87] To date, no federal appellate court or state court of last resort (i.e., state supreme court) has found water fluoridation to be unlawful.[88]

Early cases

A flurry of cases were heard in numerous state courts across the U.S. in the 1950s during the early years of water fluoridation. State courts consistently held in favor of allowing fluoridation to continue, analogizing fluoridation to mandatory vaccination and the use of other chemicals to clean the public water supply, both of which had a long-standing history of acceptance by courts.

In 1952, a Federal Regulation was adopted that stated in part, "The Federal Security Agency will regard water supplies containing fluorine, within the limitations recommended by the Public Health Service, as not actionable under the Federal Food, Drug, and Cosmetic Act."[89]

The Supreme Court of Oklahoma analogized water fluoridation to mandatory vaccination in a 1954 case.[90] The court noted, "we think the weight of well-reasoned modern precedent sustains the right of municipalities to adopt such reasonable and undiscriminating measures to improve their water supplies as are necessary to protect and improve the public health, even though no epidemic is imminent and no contagious disease or virus is directly involved . . . . To us it seems ridiculous and of no consequence in considering the public health phase of the case that the substance to be added to the water may be classed as a mineral rather than a drug, antiseptic or germ killer; just as it is of little, if any, consequence whether fluoridation accomplishes its beneficial result to the public health by killing germs in the water, or by hardening the teeth or building up immunity in them to the bacteria that causes caries or tooth decay. If the latter, there can be no distinction on principle between it and compulsory vaccination or inoculation, which, for many years, has been well-established as a valid exercise of police power."[90]

In the 1955 case Froncek v. City of Milwaukee, the Wisconsin Supreme Court affirmed the ruling of a circuit court which held that "the fluoridation is not the practice of medicine, dentistry, or pharmacy, by the City" and that "the legislation is a public health measure, bearing a real, substantial, and reasonable relation to the health of the city."[91]

The Supreme Court of Ohio, in 1955's Kraus v. City of Cleveland, said, "Plaintiff's argument that fluoridation constitutes mass medication, the unlawful practice of medicine and adulteration may be answered as a whole. Clearly, the addition of fluorides to the water supply does not violate such principles any more than the chlorination of water, which has been held valid many times."[92]

Fluoridation consensus

In 1973, as cases continued to be brought in state courts, a consensus developed that fluoridation, at least from a legal standpoint, was acceptable.[87] In 1973's Beck v. City Council of Beverly Hills, the California Court of Appeal, Second District, said, "Courts through the United States have uniformly held that fluoridation of water is a reasonable and proper exercise of the police power in the interest of public health. The matter is no longer an open question."[87]

Contemporary challenges

Advocates continue to make contemporary challenges to the spread of fluoridation. For instance, in 2002, the city of Watsonville, California chose to disregard a California law mandating fluoridation of water systems with 10,000 or more hookups, and the dispute between the city and the state ended up in court. The trial court and the intermediate appellate court ruled in favor of the state and its fluoridation mandate, and the Supreme Court of California declined to hear the case in February of 2006.[93] Since 2000, courts in Washington,[94] Maryland,[95] and Texas[96] have reached similar conclusions. Citizens for Safe Drinking Water is raising money to support a lawsuit in federal court seeking an injunction against public water districts' use of unapproved drugs in the drinking water supply in the United States.[97]

Republic of 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.[98] However, the court found that such a right to bodily integrity did exist, despite the fact that it was not explicitly mentioned in the Constitution of Ireland, thus establishing the doctrine of unenumerated rights in Irish constitutional law.

Further reading

  • (1992) Review Of Fluoride: Benefits And Risks. Report Of The Ad Hoc Subcommittee On Fluoride. Diane Pub Co. ISBN 0-7881-0729-1. 
  • Fawell, John Wesley (2006). Fluoride in drinking-water. Geneva: World Health Organization. ISBN 92-4-156319-2. 

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