Download Water Fluoridation - Ministry of Health

Water Fluoridation
Dr Stephen G Palmer
Medical Officer of Health
May 2010
Medical Officer of Health
• Special relationship with the Council
• Doctor practicing in:
– public health
– Epidemiology
– Health risk assessment &
risk management
• Independent statutory officer
• Kapiti’s Medical Officer of Health
Original map by Dr. John Snow showing the clusters
of cholera cases in the London epidemic of 1854
Provide advice – Not advocate
• Interpret the scientific literature:
– Especially epidemiological studies
– Studies that show benefits of fluoride
– Studies that may show risks of fluoride
• What will happen if fluoridation is removed:
– Drop in oral health status
– Those that will be most affected
– Benefits if any
• Tactics used by the opponents to fluoride to:
– Deny the benefits of fluoride
– Fear monger
Waipukurau health impact assessment (HIA) of
removing fluoridation - October 2009
• By Hawkes Bay Medical Officers of Health (x3)
• This HIA is:
– Relevant to Kapiti (but 10x magnitude)
– Mostly based on systematic reviews
– Most up-to-date quality scientific information
available
– Very conservative
– Unbiased
Findings – Effect of removing fluoridation on health
• Health losses:
• Health gains:
– Caries up 15%
– nil
– Decayed, missing or filled teeth
per person up to between
0.6 –2.25
– Greater impact on children from:
• Lower income households
• Maori and Pacific households
– This is Least Case Scenario
We expect the same for Kapiti
Did consider possible health gains
•
•
•
•
Dental fluorosis (aesthetic)
Skeletal fluorosis
Osteosarcoma
Other health conditions
• But NO HEALTH LOSSES OR HEALTH GAINS
Osteosarcoma
• Very rare:
– boys aged:
• 10-14 year olds = 1.14 cases per year for NZ
• 15-19 year olds = 2.36 cases per year for NZ
– Waipukurau:
• 1 case in 893 years for 10-14 year old boys
• 1 case in 411 years for 10-14 year old boys
• If there is a link?
– Small clusters in fluoridated areas
– Medical Officers of Health would be investigating these clusters
Based on this evidence my advice is that by removing water
fluoridation the community will receive no health gain at the
expense of harm being done to oral health.
• This is the best advice I can provide on the impact of
removing water fluoridation.
• This advice is unlikely to change in the future.
• Further research will firm up the weight of evidence
supporting this advice.
– Eg Peter Dennison – Martin Lee study
The Process
• No invitations
• Annual Plan process – fast tracking
• Consultation?
• Impartiality?
• Ministry of Health viewed as heavy weights
Advice on – “Fluoridation – Fragmented Facts”
• My advice would have been not to use this report.
• Also my advice is that it would be very challenging to
prepare a “pros” and “cons” report as the “cons” that are put
forward do not stand up to close scrutiny.
• If asked I would have provided technical support to officers
preparing an advisory report.
Advice on tactics used by opponents to Fluoride
Denying the benefits of water fluoridation
Selective reporting of studies
Downplaying or ignoring the evidence
Selective reporting of results
Using ecological comparisons
Fear mongering
Misrepresentation of the truth
Enforced medication
The big lie
Bamboozling with science
Half-truths
Moving the goalposts
Innuendo
Paranoia, conspiracy theories and
extremism
Follow the leader
Incomplete list
DENYING THE BENEFITS OF WATER FLUORIDATION
Selective reporting results and
Downplaying or ignoring evidence
From FANNZ submission to GWRC
PR Newswire September 29 2009
JADA Study Proves Fluoridation is Money down the Drain
•
The Association Between Enamel Fluorosis and Dental Caries in
U.S. Schoolchildren - Hiroko Iida and Jayanth V. Kumar
– “Permanent maxillary right first molars with fluorosis consistently had
lower levels of caries experience than did normal molars.”
– “The results highlight the need for those considering policies regarding
reduction in fluoride exposure to take into consideration the cariespreventive benefits associated with milder forms of enamel fluorosis.”
FEAR MONGERING
Misrepresentation of the truth and
The big lie
• Infant formula made up with fluoridated water:
– ADA’s advice always about very mild fluorosis:
• Which is not a health issue
– Opponents to fluoride:
•
•
•
•
Link it to moderate and severe fluorosis
Link it to local children with teeth defects that are not linked to fluoride
So seeds of doubt in parents of infants
Infer “we are poisoning our babies”
• This is extreme misrepresentation and distortion of the truth:
– This is telling a big lie
– On a par with MMR vaccine causing autism
• FSANZ concludes the upper limit needs to revised upward
FEAR MONGERING
Mass Medication
• Fluoride is a medicine:
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–
–
–
Medical ethics – freedom of choice
Linked to being poisoned
Emotional argument
Often picked up on and used by local government officials who are
responsible for decision making
• Fluoride is already in the water:
– It is a matter of augmenting it to an optimal level
– Similar to iodine in table salt or chlorine in drinking water
• Population preventive strategy:
– Those that are least able to make a choice gain the most benefit
– Those that are best able to make a choice can opt out
Freedom of Choice – Medical Ethics
• Risk of harm:
–
–
–
–
Diagnostic investigations, treatments or doing nothing
All associated with risk of harm to the patient
Higher risk – greater focus on informed choice
Eg. Coronary artery angiography
• Very invasive procedure
• One in one thousand chance of death
• Signed informed consent
• Fluoridation:
– Risk of harm is negligible
– Very effective
– Population preventive strategy best method to reach all children and
adults regardless of household income and ethnic group
– There is still freedom choice
Tactics used by opponents to Fluoride
• My advice:
– The tactics used by opponents to fluoride focus on:
• Denying the benefits of water fluoridation
• Fear mongering
– The tactics can very effective and convincing:
• Especially the recent videos
– It is important that councillors guard against being influenced by
these tactics
CDC
• Fluoridation is one of the 10 great public health
achievements of the 20th century
– “water fluoridation remains the most equitable and cost effective
method of delivering fluoride to all members of most communities,
regardless of age, educational attainment, or income level”.
• It is SAFE and Effective