‘Water Fluoridation’. If you are a councillor in Hamilton (or in fact a councillor in any local authority) these are words to strike fear into your heart. The expensive debacle over the decision to stop and then restart fluoridating community water supplies in the Hamilton region highlights a major problem with HOW we decide whether a community water supply should be fluoridated. This decision should not lie with local authorities, it should lie with central government.
The current system is broken – remember Hamilton?[box]
The Hamilton Water Fluoridation Debacle
In 2013, two years after a local referendum was returned in favour of local water fluoridation, the Hamilton council passed a vote to stop fluoridating the community water supply. This result came after presentations to the fluoridation tribunal from interested parties, alongside lobbying of individual council members (the standard process used across the country). There was such a backlash about this decision in the electorate that a second referendum was called to ask Hamilton locals if wanted their water fluoridated. A massive seventy percent of those who voted in the referendum were in favour of continued community water fluoridation, and so 2 months after it was stopped fluoridation was restarted.[/box]
The Hamilton experience shows us is that the current system, which delegates responsibility of community water fluoridation to local councils, leads to chaos and unrepresentative and unscientific decision making. All of which is expensive for rate and tax payers in the short and long term.[box]
The Tribunal Based System for Deciding Community Water Fluoridation
The current tribunal based system involves interested parties (usually the anti-fluoridation lobby and pro fluoride DHBs) making a submission (in person or written) to a dedicated local council subcommittee. There may be public meetings held during the process. Submissions are analysed and recommendations made (by those within council), the council subcommittee will then vote. No formal training is given to the council to help them understand what high quality scientific research looks like, no neutral project leader trained in science methodology is there to guide the group on how to interpret evidence, no systematic (non-biased) appraisal of the evidence is undertaken by the group. Importantly, these are all key components to a high quality health related decision making process. Rather it is a ‘he said she said’ scenario. Individual members of the committee may be lobbied outside of the process. Why does this matter? Because humans are notoriously bad at making impartial decisions based on evidence if they have a pre-existing position (and most of us do). We seek instead the data that supports our current thinking. It is called ‘confirmatory bias’. Add to this a non-representative non-expert panel, a lack of understanding of scientific methods, no access to neutral expertise, and you have a process that is alarmingly open to bias and fails to meet the most basic principles of evidenced-based decision making.[/box]
In our last blog we argued that expanding fluoridation of community water will ensure the poorest kids and adults in this country have an equal chance of avoiding decayed and rotten teeth. Currently, only half the population lives in an area with fluoridated drinking water. In some cases this is due to the high cost of fluoride to smaller councils, and sometimes there are technical difficulties in fluoridating non-reticulated supplies.
However, some well populated and well-resourced areas including Christchurch (which has a rate of tooth decay in children nearly double that of fluoridated areas), New Plymouth, and Tauranga have chosen not to have fluoridated community water because they believe the risks to be greater than the benefits. This is a shameful decision as it unfairly impacts those that need fluoridated water the most; the poor, the silent, the excluded, kids in our society. Those that can afford better dental care (the small, vocal anti-fluoride lobby) are denying those that cannot afford it the right to better oral health. Decisions in these regions are based not on fairness or the majority of people’s views, but rather on the spinning of bad science by an irrational and proactive minority.
Neither cost nor interest group lobbying should be a barrier to fluoridation, a fairer and more transparent system is needed and this is why central government needs to step up and take responsibility for community water fluoridation.
Decisions about fluoridation should not rest with local councils
Fluoridation can be a very difficult issue for local councils. Some smaller Councils can’t afford to fluoridate water. This is despite fluoridation often being cost effective for the taxpayer, thanks to the health benefits that come with it. Other Councils face intense political pressure on the issue, thanks to a vocal minority.
Local Government NZ has itself advocated for central government to take the lead role on fluoridation. A select committee on child health also recommended a shift of responsibility to the Ministry of Health and Local District Health boards (DHBs).
Central government should step up to help improve coverage rates
Decisions about such a significant public health intervention should reside with central government, informed by their expert health advisers (The Ministry of Health).
Why should central government have the lead role? Because water fluoridation is one of the best and most effective ways we can ensure that all children in NZ have an equal opportunity to not suffer the pain and on-going disability of decayed and rotten teeth. This is a national health issue, with significant costs and benefits at a national level (yes that is right we all pay when kids get rotten teeth). But to date politicians have shirked their responsibilities on this.
Dr Rob Beaglehole (The New Zealand Dental Association Spokesperson on this issue) points out that with central government leading on water fluoridation we could do a whole lot more to ensure more kids in need have access to fluoridated water.
“Central government could fully cover the cost of community water fluoridation in smaller areas” (removing the cost barrier to some smaller councils). They could legislate to require community water fluoridation.
Local people can still have a say if central government takes responsibility
It has been argued in the UK that local level decision making for fluoridation is more democratic. To ensure democracy is observed we can involve District Health Boards and use appropriate methods to monitor local area public support. For example, Dr Rob Beaglehole suggests that well-designed independent surveys run by Statistics New Zealand (which ensure representation from across the community) could be run at the local level to check that the majority of people do wish to have fluoridated water. “Any such survey could follow a period of community consultation run by the relevant DHB (with appropriate information campaigns). This process would be superior to having referenda which sometimes engage only a minority of voters”
Citizen Juries are another option Dr Beaglehole suggests. They have the benefit of being representative and receive carefully balanced information. Citizen Juries would ensure a democratic process is used and could determine if communities wish to opt out of any national fluoridation policy.
It would be cheaper for central government to take responsibility
The current tribunal based system used to decide community water fluoridation costs a lot. Due to the vocal misinformation of anti-fluoride campaigners, health officials (from DHBs and the Ministry of Health) have to spend time and money countering the anti-fluoridation campaigns in every local area. In addition, the Ministry of Health pays for a group called the National Fluoride Information Service “…. to provide independent scientific information and technical advice on water fluoridation in New Zealand to DHBs (District Health Boards), TLAs (Territorial Local Authorities) and the Ministry ‘’. In effect we are paying twice for the scientific advice on this issue (which as we discussed in the last blog is already very clear). Then there are situations like the Hamilton local referendum have to be paid for, alongside costs of stopping and restarting fluoridation.
It’s a waste of money, a complete mess.
Anti-Fluoride people can just opt out
With a national level policy for fluoridating water in place those who don’t wish to drink fluoridated water can just enact their personal choice and opt out. Get a specific filtration system that removes the fluoride, or just buy the stuff in bottles (compared to the costs of poor oral health for kids who don’t get the benefits of fluoride this is peanuts).
Kids who already get a rotten deal should not get rotten teeth too because of the concerns of a few uninformed but vocal middle-class worried well. The government needs to stop avoiding its responsibilities here and put in place a fairer and more effective system for deciding and implementing community water fluoridation. The current system is costing us all heavily.