I move that the Bill be now read a Second Time. This measure is intended to curb and reduce the incidence of a disease which not only causes suffering, but also, because of the damage which it does, may lead to grave disorders and prolonged ill-health. The disease in question is dental caries. It is one of the most prevalent and widespread disabling diseases in the world. And it is not restricted to any specific age, sex or economic status. Wheresoever dental surveys have been made, almost everyone has been found to have been affected by it. The extent to which it is prevalent among our people, and particularly our children, is appalling. Indeed it has been said that it has probably made more inroads among us than among any other people with a similar high standard of living. It is a disease for which so far no effective and complete cure has been found.
Scientific investigation into the incidence of dental caries in this country began when my colleague, Deputy Dr. Ryan, then Minister for Health, requested the Medical Research Council of Ireland to undertake a survey "to ascertain whether there were significant differences in dental condition amongst school children living in different areas of the country and whether such differences, if they existed, could be related to differences in the dietary intake of the children". The survey carried out in the latter part of 1952, was based on the Irish National Nutrition Survey which, following discussions that the then Minister for Local Government and Public Health, who happened to be myself, had initiated with the Medical Research Council in 1944, was eventually begun in 1946.
Incidentally the Report of the Nutrition Survey showed that the average daily calorie intake of our people was 3,105 for the years 1946-48, which was not only the highest in Western Europe but was practically on a par with the average daily intake of the people of the U.S.A. So far as the average standard of nutrition is concerned, our community continues to hold that high place to-day. The information obtained by the Nutrition Survey formed the essential basis of the survey into dental conditions, in relation to dietary habits. For, as the Report on the Dental Caries Survey points out, the Reports on the Nutrition Survery "gave a comprehensive picture of dietary habits in this country, and revealed differences in the levels of food intake between the various areas investigated".
The results of the Dental Caries Survey were rather surprising in some respects. First of all it revealed that it was not possible to associate the incidence of dental decay with the intake of certain foods in the different areas as ascertained by the National Nutrition Survey; and it also showed that the incidence of this decay among children was not significantly different as between one area and another. What it did confirm, beyond doubt, was the correctness of the opinion, held by all those who were competent to speak on the matter, that in this part of Ireland the incidence of dental caries among school children is very high; and that little is done—and, I would interpolate, in our present situation, with our present methods and resources in money and personnel, little can be done—to prevent the disease or arrest its progress among them.
We are not, I would assure the House, at all unique among communities in that respect. For instance, Professor P.J. Walsh, Director of the University of Otago Dental School and member of the Medical Research Council of New Zealand, giving evidence on this matter before a Commission of Inquiry in New Zealand, said at paragraph 51:
New Zealand teeth are decaying faster than the dental profession, even with the aid of the school dental nurses, can cope with them. At the present time we simply cannot recruit and train enough persons to deal with this one disease.
In substantiation of this view Dr. J. L. Warren, Professor of Conservative Dentistry in the same University made this telling statement at paragraph 52:
The present system of controlling dental caries in New Zealand is the placement of fillings in teeth as they decay. This system is wasteful. Firstly, in the absence of good hygiene or good diet, and they are both commonly absent, fillings do not in fact control the incidence of dental caries. The destruction of the teeth is progressive and complete despite fillings. Second, only 60 per cent. of the children and adolescents whose teeth are filled at the State's expense continue with treatment when the State relinquishes its responsibility, that is, after the 16th birthday.
In making our Dental Survey, the experts who conducted it concerned themselves with children in three age-groups. These groups were: (i) children aged between five and six years; (ii) children between the ages of seven and eight; and (iii) children who were between twelve and thirteen years old. In all, the teeth of some 2,000 in these age groups were examined in the Dublin County Borough and in various other towns and rural areas, more or less typical of each of the four provinces. A special examination was made of the teeth of children in the Congested Districts.
It will be seen that the survey was widespread and was, of course, carried out with meticulous care. Here is what it disclosed, and at this stage I would emphasise that I am concerned to give a broad picture of the conclusions to be drawn from the Survey. I shall not give statistics to the last decimal or to interpret them with the refinement of a statistician.
I shall begin with the children whose ages were between five and six years. In their case, and it will be recognised that they were little removed from babyhood, the number of decayed or missing teeth represented 35.7 per cent. of the total number of teeth which they had developed in their teething age. Based on the average for the whole group, the probabilities were that if the teeth of any child in it were examined, it would be likely that he would have had no more than two-thirds of his deciduous, or first teeth, in good and sound condition, a very large part, almost all in fact of the remaining one-third would be decayed, and a relatively very small portion would be altogether missing.
In the samples of children who were two years older and were between seven and eight years of age, the survey disclosed that, of the number of first teeth which they ought to have had, only 53 per cent. were sound; and of the balance 41 per cent. were decayed and almost 6 per cent. were missing. In the case of the permanent teeth which these children had developed, approximately 25 per cent. were already decayed or missing—even at that tender age.
In the case of children whose ages lay between twelve and thirteen some, as might have been expected, still had a few of their first teeth; but of those which might still have remained with them, less than 55 per cent. were there and sound; the rest were decayed or missing. As for the permanent teeth which they had developed, over 25 per cent. had already been attacked by decay or were missing. Significantly, even in the case of children in this oldest class, whose permanent teeth, once lost, would never be renewed, relatively few had received conservative treatment and had teeth which had been filled.
This is the position among the children of the State, as it was exposed to us by the survey. What the position is among our adolescent and in our adult population I must leave to your imagination, for we have no comparable research to guide us in respect of them. But the following extract from page 18 of the Report of the New Zealand Commission on the Fluoridation of Public Water Supplies is surely significant:—
"The incidence of dental decay in males (aged 17 to 23 years) who are performing their compulsory military training has been studied in surveys conducted under the direction of Colonel Fuller. He has a unique opportunity for observing the effects of previous treatment, and the results of the first survey are given in Table 5. More recent results of combined clinical and X-ray examinations showed that about 99 per cent. of the recruits had experienced dental decay and that on the average a recruit had 22 decayed, missing, and filled teeth. Of these 5 were missing, 6 had been filled, and 11 were decayed and needed filling or extraction. The number of untreated teeth in these totals must be regarded as a particularly unfortunate fact. The mouths of seven to ten per cent. of these recruits were in such a state that it would have been necessary to extract all the remaining teeth before the men would have been fit for service overseas. In one group of 597 recruits 18 per cent. were already wearing some form of denture and 11 per cent. required the fitting of some form of denture."
In the light of this experience, I feel that it is not unlikely that among our adolescents and adults the ravages of dental decay are even more deplorable and more widespread than among our children.
This, in brief outline is the problem with which I, as Minister for Health, am bound by the responsibilities of my office to deal. The task is not made easier by the fact that dental caries is so common that the vast majority of people look upon it as a commonplace disease, a disease that attacks everyone and from which everyone must suffer as a matter of course. In its carly stages, when only a few teeth are attacked by it, what its ultimate consequences may be are seldom fully realised—certainly not by the child and adolescent on whom it makes its first onslaught. Very many such, infortunately, are careful to conceal the suffering which it inflicts upon them, preferring to grin and bear it rather than submit themselves to remedical treatment. And yet, however common and commonplace it may be, dental caries, when one considers its nature and characteristic consequences, is a horrible affliction. The disease is erosive in its operations, so that it eats into and rots away essential bodily structures. The New Zealand Commission of Inquiry, describing its ravages, tells us that:—
Dental decay is the invasion and destruction of teeth by microorganisms. Since the infection may spread to the tooth socket and jaw bones, to the soft tissues of the face and neck, and even further afield, dental decay is the cause of other kinds of ill health in certain cases.
If other disease were to produce the same effects, if on the same wide scale it were to attack and erode our bones, or our limbs, or any bodily tissue, as dental caries does our teeth, would we not strive to make ourselves immune from it, and would we not use all the knowledge that intensive scientific research has made available to us to do so? Of course we would. To make the children of the nation in great part immune from the disease, to increase their resistance to it, not only in childhood but in adolescence, and perhaps even in adult life, is the aim of this Bill. I suggest that on humanitarian grounds alone what is proposed by it should be tried. If fluoridation is as effective here as it has been elsewhere, our children will be much less prone to toothache and all its torments; and adolescents and adults will benefit too, even though not to the same marked degree.
There is another good reason why everything possible should be done to lessen the incidence of dental caries among us. Apart from the pain and suffering which it involves, the disease is well-known to be the cause, or, if not the sole cause, a contributory cause of illnesses and physical disorders which in many cases result in prolonged and disabling ill-health. Dental decay, therefore, is not only a virulent source of suffering and mental strain; it is often the root cause of economic hardship and financial loss.
The problem then arises as to how the disease is to be dealt with. When we come to consider that question, the first fact we must grasp is that, to the extent to which it has progressed in any individual who has shed all his deciduous or first teeth, dental caries is incurable. By the skill of the dentist the decay which the disease causes may be arrested, its ravages may be repaired; but the process of decay can never be reversed and a tooth extracted is gone for ever. Since, therefore, there is no radical cure for dental caries, we must act firmly on the principle that prevention is better than cure.
When, however, we come to consider individual or personal prophylactic measures, we are immediately up against the difficulty that they all call for qualities of perseverance and discipline in a high degree, certainly to a degree that is seldom found among those who suffer the first onset of dental decay, and is hardly less rare among their elders. We may instruct our children in the principles of oral hygiene; we may admonish them to brush their teeth regularly; to live wholesomely, abstaining from sweets and jams and confections and all the things that childern love; but all this, from a child's point of view, is a counsel of perfection, a counsel which ninety-nine children out of a hundred will not heed.
In the evidence which he gave to the New Zealand Commission, Dr. B.J. Bibby, the Director of the Division of Dental Hygiene in the New Zealand Department of Health had this to say on that point:
I am sure it is widely known that dental decay can be reduced by attention to oral hygiene and less frequent consumption of carbohydrate and sugary foods, but against this knowledge are set the accepted social customs and the dietary habits of the nation—difficult to change even over a long-term period.
The young child in the home may be taught to observe all the tenets of good oral hygiene and his diet may be easily controlled, but once his social contacts and experience widen outside the home it is difficult for him to flout the social and dietary habits of his companions.
And if some children do what they are bidden and follow our injunctions meticulously and docilely, what have we secured? Not a widespread measure of natural protection against the disease, not an increased degree of natural resistance to it for the generality of children, just a diminished risk in the case of the relatively few individuals who exercise continuously this strong discipline over themselves.
Prophylaxis on this limited scale will not yield any significant success in combating the disease. To be even partially effective to any significant extent, the prophylactic measures must provide the children with a high degree of built-in immunity, an immunity which is built-in into their teeth from their earliest years, something which is acquired by them whether or not they follow a strict régime in diet and oral hygiene. Over the past forty years research into the problem of finding a prophylactic against dental caries has been intensively pursued in many countries. All the results indicate that, if piped public water supplies are available to a community, it is possible and easily practicable to build up in young children a high degree of immunity from it. This can be done here, as it has been done elsewhere, to a considerable degree by a relatively slight adjustment in the fluoride content of our drinking waters.
Fluoride as a trace element occurs naturally, not only in drinking waters but in the majority of foods, in vegetables, meats, cereals, fruit, fish and, notably, in tea. It is a normal constituent of bones and teeth. Clearly then unless ingested in excessive quantities it is not deleterious to health. Indeed no diet adequate for maintaining normal health is wholly free from the mineral. On the other hand, painstaking investigations, pursued over forty years, do indicate that, where standards of living are high, a deficiency, an infinitesimal deficiency, of it in the water used for drinking is associated with a heavy incidence of dental caries. I am not saying that a fluoride-deficiency is the cause of this condition, but it would appear that an adequate intake of fluoride has a strongly inhibiting effect on its development. Conversely, an inadequate intake heavily increases vulnerability to the disease; which would appear to explain its widespread prevalence among our people.
In 1948, in the course of an investigation, sponsored by the Medical Research Council of Ireland and conducted by an eminent chemist, it was found that out of 42 of our drinking water sources examined, 32 had less fluoride than one part per ten millions. In none of the remaining 10 cases did the fluoride content exceed three parts per ten millions. Even this maximum is considerably below what is regarded as the optimum fluoride content necessary for promoting resistance to dental decay. Against these findings we must place the fact that as the Report of the Medical Research Council of Ireland on its dental caries survey indicated, the incidence of dental caries in this country is probably amongst the highest in the world.
There are many authorities, impeccable and unquestionable authorities, to support the conclusions that to enable the teeth of the growing generation to withstand the onset of dental caries, under modern civilised living conditions, a certain minute quantity, 1 p.p.m., of fluoride must be ingested by the children with the ordinary day to day intake of water; and that where the fluoride content of the natural water sources falls below this minimum it is most desirable, even one may say imperative, to increase this to the required degree. First among these authorities, I naturally place the Fluorine Consultative Council which my predecessor as Minister for Health, Deputy T.F. O'Higgins, appointed in January, 1957. I would like at this point to record my appreciation of the concise and comprehensive study of the problem which this body carried out. In May, 1958, the Council reported to me in the following terms:—
Having considered all the information available on the relationship between fluorine and dental decay, the Council is satisfied that an increased intake of fluorine will reduce the incidence of dental caries and that it is desirable to provide for such an increased intake. The Council is further satisfied that the increased intake of fluorine can best be provided by the fluoridation of public water supplies to the level of 1.0 part per million F. In so recommending the Council is aware that not quite 50 per cent. of the community would thereby benefit at present even if all public piped water supplies in the country were fluoridated but the percentage will increase according as public piped water supplies are extended.
In 1957 the World Health Organisation set up a committee of experts to study the question of water fluoridation. In 1958 the Report of this Committee was published. It opened with the following statement:—
Water fluoridation as a public health measure to aid in the control of dental caries is receiving worldwide attention. Many government officials, public health administrators and others have asked for guidance in the form of an authoritative report presenting the subject in a way which will serve as a useful guide when water fluoridation projects are considered.
Having examined the problem in all its aspects the Report summarises the views of the Expert Committee in the following findings:—
1. Dental caries is one of the most prevalent and widespread diseases.
2. There is no hope of controlling the disease by present treatment methods alone.
3. Among the numerous preventive methods, the fluoridation of drinking water supplies is the most promising.
4. The effectiveness, safety, and practicability of fluoridation as a caries-preventive measure has been established.
5. 1 p.p.m. fluoride has been shown to give maximum benefits; first, by epidemiological studies where fluoride occurs naturally in the water, and secondly, where fluoride has been added at optimum concentrations through mechanical means.
6. Hundreds of controlled fluoridation programmes are now in operation in many countries. Some have been in progress for the past 12 years, so that conclusions are based on experience. No other public health procedure, during the initial stages of its application, has had such a background in time or extent.
13. Growth and development, somatic and psychic, are normal in children drinking water containing 1 part per million fluoride.
17. No other vehicles or techniques for the prophylactic application of fluorides can at present replace the fluoridation of drinking water as a public health measure. Where water fluoridation cannot be used, research into other vehicles and improved methods of local fluoride application should, however, be encouraged.
In July, 1955, the British Minister of Health issued a statement entitled "The Fluoridation of Water and the Prevention of Dental Decay." After a reasoned examination of the matter the statement concludes:—
"To summarise: the Government has every reason to believe that fluoridation is of great benefit in the preservation of the teeth of children, and ultimately also of adults, against dental decay and that it reduces dental decay in children by about 60 per cent. There is no evidence that the consumption of water fluoridated to a level of about 1 part per million has any harmful effects on those who drink it."
In November, 1956, the Government of New Zealand appointed a Commission "to inquire into the desirabilty or otherwise of the fluoridation of public water supplies." The Commission reported in July, 1957. I have placed a copy of its Report in the Library and I would strongly recommend all members of the Oireachtas to study it. I am sure that those who do will agree with me that it is a fully detailed account of a comprehensive and searching investigation into all aspects of the subject. The Report in its 154 pages, supplemented by numerous appendices, and fully documented, examines with painstaking and objective care not only the merits of the proposal but every objection which has been raised against it. Following Part I, which is introductory, the Commission in Part II of the Report examines the problem of dental health and proceeds to declare:
"We regard the following matters as established:
(1) Virtually every child born in New Zealand experiences dental decay and in consequence an unduly high proportion of the population over the age of 21 years uses some form of denture.
(2) Sustained efforts over many years by both the Department of Health and the dental profession to introduce improved dietary habits have been ineffective. At the present time there is no hope of any programme of dental health education achieving a significant beneficial effect.
(3) The filling of teeth is not a preventive measure but a means of treating decay.
(4) The problem of controlling the rate of dental decay by treatment is beyond the resources of the dental services in this country.
(5) The incidence of dental decay in New Zealand is so widespread and severe that it constitutes a major problem in public health and is a matter for grave concern.
Those words might quite readily apply to the conditions in this country.
In Part III the Commission having considered the effect of "fluoride in relation to dental health", reports:
We regard the following matters as established:
(1) Fluoride is a natural component of all teeth and by hardening their mineral structure it makes them more resistant to dissolution by acids.
(3) In New Zealand the fluoride content of potable waters is considerably below 1 part per million.
—as it is in fact in this country.
(4) In areas where there is fluoride in drinking waters at optimum concentrations, whether naturally present or artificially added, the prevalence of dental decay in children is at least 50 per cent lower than in areas where the fluoride content is 0.2 parts per million or less. In the higher fluoride areas about one-third of all children escape dental decay entirely and the beneficial effects continue into adult life.
(5) There is no evidence that the consumption of fluoridated water would do harm to the pulp of the teeth or to the tissues which surround and support them.
(6) The regular ingestion of a substantial excess of fluoride (more than 1.9 parts per million) in the drinking water may cause dental fluorosis. This is only one type of mottled enamel. Other enamel defects unrelated to fluoride are common. Enamel defects can develop only during the years of childhood.
(7) When the drinking water contains 1 part per million fluoride, or slightly more, the incidence of dental fluorosis has no significance.
(8) As the result of painstaking and thorough scientific observations conducted over a period of at least 40 years, there is a rational basis for the proposal to add fluoride to public water supplies in which this trace element may be deficient.
The Commission in Part IV went on "to consider whether there can be any possible objections to fluoridation on other grounds", and, after a careful analysis of the evidence and the authorities submitted to it for and against fluoridation, summarises its findings on "the behaviour of fluoride in the human body" as follows:—
"In summary, our conclusions in regard to be toxicity of fluoride are:—
(1) Fluoride is beneficial in proper doses and the optimum level in drinking water can be established with certainty.
(2) In common with all foods including pure water, it can become harmful in substantial overdoses.
(3) Acute or violent reaction could be produced only by such huge overdoses that the possibility becomes irrelevant in relation to the fluoridation of water.
(4) In the proposal to fluoridate water, there is no risk of chronic fluoride poisoning.
(5) The suggestion that fluoride is an enzyme poison has no relevance to fluoridated water.
(6) The implication contained in certain anti-fluoridation literature that fluoridation involves the use of a substance with properties similar to certain deadly organic compounds of fluorine, is absurd and entirely misleading."
From this the Commission in Part V proceeds to examine the complaint that fluoride is harmful to health. As a result it reports:
"After full consideration of all the evidence we are satisfied that fluoridated water does not cause or aggravate any of the following disorders:—
(1) Disorders of the brain and nervous system, disorders of the special senses, and disorders of the mind.
(2) Disorders of the heart and blood vessels.
(3) Disorders of the kidney and urinary tract.
(4) Cancer.
(5) Diabetes or disorders of the Thyroid gland.
(6) Disorders of the gastrointestinal tract and the liver.
(7) Disorders of pregnancy and labour or developmental defects in children.
(8) Disorders of bones, joint, and the bone marrow.
(9) Irritation of the eyes or irritation of mucous membranes.
In part VI of the Report the Commission then analyses the case against fluoridation on medical grounds, and on that point gives its views as follows:
"We regard the following matters as established:—
(1) The process of fluoridation does not add a substance that is foreign to the water, but merely brings about a slight change in the concentration of the fluoride already present naturally in that water.
(2) No diet is devoid of fluoride and water is the normal vehicle for conveying this substance to the body.
(3) Fluoride is a normal constituent of bones and teeth.
(4) Fluoride is a nutrient and is beneficial in proper amounts. In common with many other foodstuffs it has adverse effects on the body when ingested in excess.
(5) In the proposal to fluoridate public water supplies there is no risk of excessive ingestion; there is no risk of chronic fluoride poisoning; and the possibility of acute poisoning can be disregarded entirely. Suggestions to the contrary in some anti-fluoridation propaganda are misleading and absurd.
(6) No harmful effects on health will follow the fluoridation of water supplies whether in respect of the complaints specifically made before us or otherwise."
Having examined several other aspects of the matter, in accordance with its terms of reference, the Commission, in Part XII of its Report, publishes certain Specific Findings. These Findings are expressed in the form of query and answer; and I quote those which are immediately relevant, as follows:—
"(1) Whether benefits to dental health may reasonably be expected in New Zealand from the addition of fluoride to public water supplies, having regard to the results of the fluoridation of water supplies in other countries:
CONCLUSION: Yes.
(2) Whether any disadvantages may result from the addition of fluoride to waters naturally containing less than one part of fluoride per million:
CONCLUSION: No.
(4) Whether there are any practicable methods of adjusting the daily intake of fluoride other than by addition to the water consumed.
CONCLUSION:
(i) There is no practicable method of adjusting the intake of fluoride other than by addition of that substance to public water supplies.
(ii) No alternative suggested would be effective as a public health measure.
Finally the Commission (p. 154) sums up its findings in a General Conclusion as follows:—
"Introduced in accordance with the principles outlined in paragraph 548 we are satisfied that widespread use should be made of the fluoridation process for the purpose of achieving an urgently needed improvement in the present serious state of dental health in New Zealand."
Some weeks ago in a letter to the newspapers, opposing the fluoridation of public water supplies, a correspondent suggested that the Royal Medical Board of Sweden had condemned this procedure. In view of the high authority which was thus flagrantly misrepresented, it is advisable to deal with that allegation now.
The question with which the present Bill is concerned, caries prevention through fluoridation, may be said to have come under critical and scientific examination in Sweden in 1952. In that year a committee of experts was appointed by the Royal Medical Board of Sweden to investigate the use of fluorides as a means of preventing dental decay. On completion of the Committee's enquiries the Board submitted a report to the Government in February, 1955, declaring that the addition of fluorides to drinking water would be a measure of great potential value in the prevention of the widespread disease of dental caries. In view, however, of the fact that the scientific advisers expressed some doubt as to the harmlessness of fluoride, even at the low concentration recommended, the Board considered it advisable to await the outcome of further research before recommending that fluoridation should be more generally used in combating dental caries.
Following this cautious decision, the question was subsequently examined on two further occasions, and arising out of them, the Royal Medical Board on April 12, 1958, reported to the king of Sweden that:—
"In the opinion of the board the inquiry carried out has shown that fluoridation of public water supplies does not involve any demonstrable health hazards even on prolonged consumption of the water. Being convinced that fluoridation of drinking water is an effective means of preventing caries in children and young persons, the Board maintains that communities which desire to start fluoridation of their domestic water supplies should be authorised to do so under the necessary technical control.
In this connection the Board wishes to point out that both the World Health Organisation and the American Medical Association recently, after special expert inquiries, have unreservedly recommended fluordiation of drinking water as an effective and safe means of preventing dental caries.
The Board is fully aware of the fact that, in point of principle, objections may be raised against fluoridation of drinking water on the grounds that the citizens would be compelled to consume fluoridated water, and that a movement of opposition against fluoridation exists in the United States and to some extent in Sweeden as well. The "Interim Committee for Personal Integrity" in Goteberg, for instance, has appealed to the Board for measures against fluoridation of drinking water. The Board cannot find, however, that these objections carry sufficient weight to be allowed to obstruct an important public health measure. The incidence of dental caries in Sweden, has reached such proportions that all available means for its combat have to be utilised. Fluoridation of drinking water is one of the methods that should be employed."
As a footnote to the foregoing, the following extract from a preceding page (13) of the Report is a conclusive comment on the suggestion that there are available to us other ways of compensating for the fluoride deficiency in our drinking waters:—
"The committee consider—also unanimously—that at present they cannot recommend a generalized administration of prophylactic does of fluoride with vehicles other than water. On prescription by a physician or a dentist fluoride as tablets may be given in individual cases. Clinical experiments with administration of fluoride in flour, common salt or milk should not be started until further experience has been gained concerning the dosage and the effect of fluoride in these vehicles."
Since it was in the United States that the suggestion was first made that the onset of dental caries could be inhibited, or at least considerably retarded by the addition of fluoride to drinking water, it is not surprising that fluoridation is in widespread use there. According to the latest figures available to me, more than 44 million people in the U.S.A. now drink fluoridated water. Seven million of these live in areas where, without any artificial addition, the water sources carry concentrations of the mineral of not less than 0.7 p.p.m. But close on 37 million live in areas where the water is mechanically fluoridated, as is proposed in this Bill. In fact about two-thirds of American cities with populations of 500,000 and upwards, together with one-third of those residing in towns within the population limits of 10,000 to 500,000, have fluoridated water. This is not surprising, since a great number of responsible scientific bodies in that country have sponsored and recommended fluoridation. Among such bodies are the American Medical Association, the American Dental Association, the National Research Council, the College of American Pathologists, and the Commission on Chronic Illness.
The actual experience of the beneficial results of fluoridation in the United States, even when operated on such a vast scale in so many diverse communities, has led in due course to the employment of the process by responsible health authorities in many other countries. Controlled fluoridation programmes are now in operation in Australia, Belgium, Brazil, Canada, Chile, Colombia, E1 Salvador, Federal Republic of Germany, Great Britain, Japan, Malaya, Netherlands, New Zealand, Panama Canal Zone, Sweden, Venezuela. Approved plans for the first fluoridation projects in Norway and Switzerland are in the process of being implemented. The Expert Committee of the World Health Organisation comments that this reflects "the world-wide extent of endorsements by responsible health officials and their advisory councils."
It will be clear from all this that the overwhelming consensus of informed scientific, medical and dental opinion is convinced that the fluoridation of public water supplies, to the extent of one part in a million, would be from the point of view of public health a highly beneficial measure. This is admitted even in a document submitted to me on behalf of the recently formed Pure Water Association—which the House may know opposes fluoridation. Incidentally pure water is not to be found anywhere in nature. This document states: “It would be idle to deny that good grounds exist for believing that the presence of fluorine in the diet tends, in some ways as yet unexplained, to render the teeth of young children resistant to decay.”
Notwithstanding this universally admitted fact there are some who question the efficacy of fluoridation as a protective measure and argue against it; just as there are some individuals who even to-day would contend that the earth is flat. From the medical, dental and scientific points of view all such opponents are non-suited. They cannot adduce one tittle of substantial evidence to disprove the conclusions that, in a concentration which does not exceed 1 part per million of natural drinking water, fluoride tends to build up a great measure of resistance to dental caries in the majority of children and adolescents drinking such water and that ingested in this infinitesimal proportion it does not impair either the dental health or the general health of the community. All the weight of experience, research and carefully controlled trials is to the contrary. There is only one ground on which, without reference to established facts, opponents of fluoridation can challenge the right of the community to safeguard itself against a diseased condition, which is not only widespread and very distressing, but is also a source of considerable economic loss to the community and of ill-health to individual citizens. The fluoridation of public water supplies constitutes, some of those who oppose it allege, a grievous infringement of the rights of the individual. If this allegation were well-founded that would be a grievous matter indeed.
But does the fluoridation of public water supplies in fact violate individual rights? It is highly germane to the argument to point out that the public water supplies do not belong to the individual; they belong to the community. Such rights as the individual may possess or enjoy in them, arises from his membership of the community with which his lot is joined. As an individual he has no right of veto over the decisions of the community, though of course he has the right to dissent from them. Where these decisions are made for the common good by the appropriate authority, he must abide by them for so long as he may wish to enjoy the advantages which membership of the community gives to him. Therefore, if there be good grounds for deciding that the public water supplies must contain a prescribed trace of a mineral nutrient which all experience tends to prove is essential for the greater protection of the general body of citizens against a particular dental disease and which is not harmful to health no individual is justified in opposing the prescription merely because he personally does not like it. He cannot expect to enjoy the advantages of the communal supply and at the same time retain the right to deny to the community the benefits of dental prophylaxis.
Moreover the individual living in a community has his duty to all his fellows. He cannot deny them the right to protect themselves against disease. And where that disease is so widespread that it constitutes a grave menance to the general health of the community he must, in charity and as a matter of social obligation, at least acquiesce in the steps which the community takes to protect itself against it. Provided always, of course, that nothing is asked of him which would violate his physical or psychic integrity by mutilating or destroying his members, or impairing his intellect or faculties, thus interfering with his personality in its particular and characteristic function. The addition to public water supplies of an infinitesimal trace of fluoride to reinforce the fluoride which is already there, does none of these things, and, therefore, cannot be objected to on ethical grounds. It is true that some who oppose fluoridation say that the process raises certain ethical considerations. But at no time have those who argue thus cited or quoted any authoritative objection based upon ethical principles. If then those who are entitled to speak and act for the community and have a responsibility for its well-being, seeking the greatest protection of the dental health of children decide that public water supplies will be fluoridated to the optimum level, the decision cannot be regarded as a real infringement of the rights of the individual and should be accepted in the general interests of all.
Some say they object to fluoridation because it is a measure of mass-medication. That is a striking phrase, and no doubt has been coined for its great propaganda value, but it has no relevance and no application in this context. Flourine is not a medicine. A medicine is something which is used to cure a disease. Fluorine salt will not cure dental decay; but if ingested in infinitesimal quantities as part of the day to day diet it will tend in a large measure to prevent its onset. As the Report of the New Zealand Commission so cogently stresses, the plain fact is that fluoride is a nutrient which is beneficial in proper amounts. It is doubtful if a human being can live healthily without it. Indeed it has been said that if anyone were so foolish as to try to do so he would be restricted to a diet of cabbage, beets and cauliflower, cooked in distilled water. Here in Ireland it might not be necessary for him in some places to distil the water. But leaving that aside, the diet does not appeal to me, nor I am sure to any one else, as nourishing, satisfying and appetising. Fluorine not being a medicine there can be no suggestion of mass-medication in the fluoridation of water, any more than there is mass-medication in the chlorination of water which is a common practice in this country.
Finally it is nonsense to say that fluoride could be made as generally and conveniently available as a prophylactic through any other vehicle than water. It is the unanimous opinion of all authorities who have fully considered the question that for effective and general prophylaxis there is in the present state of our knowledge no alternative to the fluoridation of the public water supply. On that point let me recapitulate what the authorities have said:—
The Expert Committee on Water Fluoridation appointed by the World Health Organisation stated:
No other vehicles or techniques for the prophylactic application of fluoride can at present replace the fluoridation of drinking water as a public health measure.
Our own Fluorine Consultative Council said:
The Council is further satisfied that the increased intake of fluorine can best be provided by the fluoridation of public water supplies to the level of 1 part per million F.
The New Zealand Commission of Inquiry on the Fluoridation of Public Water Supplies reported:
There is no practicable method of adjusting the intake of fluoride other than by addition of that substance to public water supplies. No alternative suggested would be effective as a public health measure.
In the Report of the Royal Swedish Medical Board it was stated:
The committee consider—also unanimously—that at present they cannot recommend a generalised administration of prophylactic does of fluoride with vehicles other than water.
For all these reasons I trust that the House will see its way to give the Bill a Second Reading.
I will now refer to the main provisions of the Bill. Section 2 lays a general duty on health authorities to arrange for fluoridation of public water supplies. Power is being taken to fix a time limit for the performance of this obligation in any particular case. I do not envisage that this power will often require to be used as I am convinced that health authorities will be as appreciative as I am and as I trust the House will be of the benefits to be derived from this measure.
The House will observe in particular that Section 2 imposes a statutory limit on the amount of fluorine which may be added to water. This provides assurance that the limit of one part per million, which has authoritative backing as to its usefulness and efficacy, can never be exceeded without the authority of the Oireachtas being first obtained.
The purpose of Section 3 is to designate which health authority is to fluoridate each water supply and in particular to deal with areas in which a public water supply serves the functional area of two or more such authorities. The simple expedient of assigning the duty to one authority in such cases is adopted. Section 5 provides for the apportionment of expenditure in such cases between the health authorities concerned. The basis of apportionment will be the amount of water consumed.
Sanitary authorities, as the House knows, are the bodies at present vested with the statutory responsibilities in regard to the actual supply of water to the public. It is proposed, therefore, in Section 4 to make provision for the performance of the work by those bodies as agents for health authorities in relation to fluoridation. This arrangement, it will be admitted, is the obvious one. The section provides for the recoupment by the appropriate health authority to the sanitary authority of such expenses as the latter body may incur.
Section 6 will enable the Minister for Health to require the making of estimates of the incidence of dental caries. In this connection the House will recall that the Fluorine Consultative Council recommended that before any public water supply is fluoridated steps should be taken to assess the incidence of dental caries in children, and it is my intention to utilise this section, in so far as may be necessary for this purpose, having regard to available information.
It is intended that half of the current expenditure of the health authorities under this Bill will be recouped to them from the Health Services Grant. To provide for this it will be necessary to recognise fluoridation as a health service for the purpose of the Health Services (Financial Provisions) Act, 1947. Under that Act as it stands, however, the recognition of a new health service can only be made effective from the beginning of a local financial year. Thus, fluoridation could not be recognised for the purpose of the Health Services Grant until 1st April, 1961, at the earliest and any local expenditure on it before that date would fall entirely on the rates. To get over this difficulty, an amendment of the 1947 Act is proposed by Section 7 of the Bill whereby the recognition of fluoridation for the purposes of the Grant can be made effective at any time.
Section 8 contains the usual provision for the laying of Regulations under the Bill before the Houses of the Oireachtas. Section 9 deals with the short title and collective citation of the Bill.
I trust the House will see its way to give me the Second Reading.
