The purpose of this Bill is to oblige health authorities to fluoridate public piped water supplies to a level not exceeding one part of fluorine per one million parts of water in order to reduce the prevalence of dental decay —or dental caries—among us. The need to take prophylactic measures against this condition has been pressed year after year by dental surgeons and school medical officers who have drawn attention to the ravages of the disease among school children. And the Dental Caries Survey carried out under the auspices of the Medical Research Council of Ireland in 1952 indicated that the vast majority of children throughout the country suffer from this condition.
A copy of the report of the survey is in the Library. The survey was carried out at the request of my colleague, the Minister for Finance who was then Minister for Health, in order "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." For the purpose of their work, the surveyors divided the children into three age groups: five to six, seven to eight and 12 to 13 years old. In all, the teeth of over 2,000 children were examined in Dublin city and in a number of towns and rural areas which were taken as being more or less typical of each of the four provinces.
Apart from the depressing facts which it disclosed of the prevalence of dental caries among our children, the Survey furnished information on two questions of great social importance. It showed, first of all, 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 of 1946; and it also showed that its incidence among children did not significantly differ between the different areas covered.
As to its main purpose the Survey revealed that in the group of children between five and six years old only 4.3 per cent. were entirely free from dental decay, while 68.2 per cent. had five or more deciduous, or first teeth, either decayed, missing or filled. The number of decayed or missing deciduous teeth even at this tender age, represented 36 per cent. of the total number of teeth developed so far. In fact, an average child at this stage of life had only about two-thirds of his or her deciduous teeth unaffected by caries. Even the state of their permanent teeth was not good; for almost 18 per cent. of them were already decayed.
As regards children in the next age group—seven to eight years—it was found that only 1.4 per cent. were entirely free from dental decay in their deciduous and permanent teeth; and 41 per cent. of the deciduous teeth were decayed and 6 per cent missing. Of the permanent teeth which had erupted at that age, about 25 per cent. were already decayed or missing.
Only 0.9 per cent. of children in the age group 12 to 13 years had teeth entirely free from dental decay, and only 1.2 per cent were entirely free from dental decay in their permanent teeth. Of the deciduous teeth which might still have been extant at this age, less than 55 per cent. were sound and the remainder were decayed or missing. As regards their permanent teeth, over 25 per cent. had already been affected by dental decay or were missing and this as early as 12 or 13 years old. Now, I would like to stress the findings among this group, the oldest of the children examined, as they show the position among those who are approaching the end of their primary school career. Only 0.9 per cent., I repeat, were entirely free from dental decay; only 1.2 per cent. were free from dental decay in their permanent teeth; and 25 per cent. of all the permanent teeth examined were either decayed or missing.
I think the Seanad will agree that the survey exposed a situation which was deplorable indeed. Unfortunately, however, there is no reason for thinking that the position today is any better; it is quite likely to be worse, and as for adolescents and young adults, it is to be expected that among them the position is worse than among school children.
Though the incidence of dental decay in this country is very high, very high indeed, the available statistics show that the condition is a universally serious problem in all advanced western nations. For example, a recent dental survey from Scotland reveals that despite the free dental services available to all children under the national health service there, the condition of children's teeth has worsened in recent years. A typical Scottish child of five years old is said to have about seven of his 20 teeth either decayed, filled or already extracted.
In New Zealand, 99 per cent of recruits aged 17 to 23 years performing their compulsory military training a few years ago had experienced dental decay and, on average, each recruit had 22 decayed, missing or filled teeth.
On this point, the report of the Expert Committee on Water Fluoridation of the World Health Organisation has this to say:
Dental caries is one of the most prevalent and widespread diseases in the world. It is not restricted to any specific age, sex, or economic status, nor is it peculiar to any country or race. In countries where dental surveys have been carried out, it has been found that almost the entire population is affected by dental caries and its consequences. It has been found, too, that dental caries starts soon after the eruption of the deciduous teeth. Numerous studies have been made on the prevalence of caries among children in many countries, and it has been shown repeatedly that the average child reaching school age has many carious teeth. The consequences of the disease can be particularly serious both in childhood and adolescence. The carious lesions increase progressively in size, frequently leading to considerable suffering and eventual loss of teeth. The consequent reduction of function may affect nutrition in the growing child. Impaired mastication is the direct cause of digestive disorders, and secondary infection from a septic mouth may have far-reaching effects on general health. Not least among the unfortunate consequences of the loss of teeth caused by dental caries are traumatic occlusion, which can induce severe parodontal disease, and the serious psychological and social effect of facial disfigurement. Throughout the world, dental decay represents an economic drain upon both health services and individuals. It would be extremely difficult to assess the amount of efforts spent over many years in various countries to attempt to relieve this disease.
And these views have been echoed recently nearer home. Addressing the annual dinner of the Irish Dental Association last week, the outgoing President, Mr. D. Gogarty, said:—
The number of man hours actually lost to industry in this country through dental reasons is extraordinarily high. Proportionally, it is higher than in England although we cannot afford it to the same extent. But what is even more difficult to assess is the vast number of potential man hours lost through inefficient application of skills, which inefficiency is in turn due to a state of poor dental health.
There is absolutely no doubt that a man bedevilled with aches and pains in his teeth cannot work efficiently. There is no doubt that a man whose abscessed roots are oozing purulent matter constantly into his alimentary system cannot operate at peak efficiency. And there is further no doubt that these circumstances apply more in Ireland than in many other countries.
Some critics of the proposal in this Bill have argued that the problem should be tackled by expanding the facilities for treating the disease. I do not dispute that an expansion of treatment facilities is desirable, but it must be recognised that there are definite limitations in regard to the availability of dental personnel which, of course, seriously circumscribe our potentialities in the field of treatment. The Expert Committee of the World Health Organisation, which I have mentioned, had this to say on that point:—"Early detection and treatment of dental caries is effective in controlling the disease and its results"; but then they go on to add "Even in those countries with the highest ratio of dentists to population, however, no more than one-third of the needs of the people in this respect are being met."
The number of dentists in this country (about 620) is, proportionate to population, about one-third of the number in countries like Sweden and U.S.A. We would, therefore, it seems, have to increase the number of dentists here nine-fold to be able to tackle the problem adequately on a treatment basis. With the financial and educational resources at our disposal now and for a long time to come, this is obviously out of the question. All this apart, I believe, and as I am sure the Seanad will share the view, that prevention is better than treatment, particularly when treatment will not reverse the process of decay. And as to prevention, even its critics concede that fluoridation is a most effective means of preventing caries. They could not in honesty do otherwise, since several independent and reliable surveys extending over periods of years, have shown this quite conclusively.
No responsible person now contests the fact that water containing about one part of fluorine per million parts of water, if ingested from infancy and throughout childhood, inhibits dental decay among children by up to 65 per cent. Thus the prevalence of dental caries among children reared in a community served by public water supplies containing fluoride at the level I have indicated may be as much as 65 per cent. less than in communities served with water supplies containing no fluoride or, as is the case generally in this country, only insignificant traces of the mineral.
Controlled fluoridation studies have also shown that no ill effect of any kind is caused by water fluoridated as proposed in this Bill. An example of such a study is that which was made at Newburgh, New York, in which the adjacent town of Kingston was used as a control. The water in Kingston was not fluoridated; but the water in Newburgh was. Comprehensive medical examinations were made of the children in both towns. These clinical examinations included medical history, a general physical examination, measurements of weight, height, and circumference of the head and chest; vision; examination of the ear, nose and throat; measurement of hearing; and an assessment of physical development at successive examinations. X-ray examinations were carried out of the right wrist, both knees, and the bone density. In the final examination the lumbar spine was X-rayed. Originally 500 children in each city were selected and these were added to in later years. The total number of children examined in Newburgh was 817 and in Kingston 711. The medical examinations mentioned were carried out each year on each of the selected children. As a result of this very thorough study—and I think it will be admitted that it was a very thorough study—it was stated that "no difference of medical significance could be found between the two groups of children".
A report was published about a year or so ago on the results of fourteen years' experience of artificial fluoridation at Brantford, Ontario. It showed, in detail, the beneficial effects of fluoridated water on children's teeth in the age groups nine to eleven and twelve to fourteen years. They were quite remarkable. Having reviewed them the report went on to say: "No untoward effects which might be attributable to the presence of fluoride in the water supply have ever been reported by the medical profession in either Brantford or Stratford". Stratford, Ontario, is remarkable for the fact that it is a town with a naturally fluoridated water supply of 1.6 parts per million of fluorine. We can see from the results of this study that no ill effects of any kind, which might be attributable to fluoridated water, have ever been reported either in Brantford, during fourteen years of artificial fluoridation, or in Stratford, Ontario, where nature has endowed the water with 1.6 parts per million of fluorine.
In fact the truly significant fact that emerges from the welter of controversy is that the harmlessness of fluoridated water on the general health of people has been endorsed by the very many most reputable and authoritative bodies who have studied this subject in recent years. These include our own Fluorine Consultative Council; the Expert Committee of the World Health Organisation to whose report I have already referred; the British Medical Research Council; the New Zealand Commission on Water Fluoridation; the Royal Swedish Medical Board, and various other organisations such as the American Medical Association, the Canadian Medical and Dental Associations, and the Public Health Committee of the British Medical Association.
The opponents of fluoridation seek to convey the impression that medical opinion is seriously divided on the question of whether fluoridation involves a danger to health. It may be that some few medical men oppose it, but, against these, the remarkable thing is that so many authoritative medical organisations have unequivocably endorsed the safety and efficacy of fluoridation as a measure for the prevention of dental decay.
My predecessor in office, Deputy T. F. O'Higgins, appointed the Fluorine Consultative Council to which I have referred in January 1957, to consider "whether with a view to reducing the incidence of dental caries, it is desirable to provide for an increased intake of fluorine, and, if the Council considers it so desirable, to advise as to the best method of securing such an increased intake and as to any safeguards and precautions necessary." This Council comprised 17 persons, specially selected for their ability to assess the different aspects of this matter. In May, 1958, the Council furnished its report to me. In it the Council unanimously recommended—and I stress the word `unanimously'—the fluoridation of public water supplies to the level of one part per million of fluorine in the following terms:
38. Having considered all the information available to it 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.
39. Before any public water supply is fluoridated the Council considers that steps should be taken to assess the incidence of dental caries in children resident in the area served by that water supply. The Council also considers that subsequent to fluoridation adequate steps should be taken to permit a proper evaluation of the results.
40. In so far as the engineering aspects of fluoridation of public water supplies are concerned, the Council sees no particular difficulty in the procedure as the methods employed in the addition of fluoride to a water supply are similar to those in common use for the addition of other chemicals to water. The methods used in the protection of public waterworks workers handling fluoride salts are similar to those used in the handling of other chemicals which may have harmful effects and do not need special description here.
41. The Council is in doubt as to whether local authorities have the necessary statutory authority to add fluoride to public water supplies. It recommends the introduction of any legislation which may be necessary to enable local authorities to discharge this function.
This Bill is being brought in to give effect to the recommendation contained in paragraph 41 of the Council's report which I have just read. Its purpose is to clear up the doubt which was thought to exist as to whether public local authorities have the necessary statutory authority to add fluoride to public water supplies.
The Council devoted a considerable part of its report to examining the possible ill effects of fluoridated water, under the headings of acute poisoning, growth retardation, changes in bones, effect on kidneys, etc., and came to the conclusion that no ill effects on health were to be feared from the drinking of water containing one part per million of fluorine.
In paragraph 27 of its report, the Council say "Fluorides in water at a level of 1.0 p.p.m. have no effect upon the taste, odour, colour or acceptability of water for domestic use. No adverse effects on industrial, agricultural, horticultural or other similar processes due to the use of fluoridated water have been substantiated."
Some few years ago the World Health Organisation set up an expert committee to consider this question of water fluoridation and, having examined water fluoridation from the safety aspect under various headings, said: "All these findings fit together in a consonant whole that constitutes a great guarantee of safety—a body of evidence without precedence in public health procedures."
The British Medical Research Council called together a conference of experts in 1956 as a result of which the following statement was issued:
"The experts agreed in general with the conclusions of the United Kingdom Mission (which examined fluoridation in North America in 1953) to the effect that, despite considerable interest and research there is no definite evidence that the continued consumption of fluorides in water at a level of about one part per million in drinking water is in any way harmful to health, and they consider that if any untoward effect is revealed by future research this is most unlikely to be serious."
The Royal Swedish Medical Board, in recommending water fluoridation in 1958, commented: "In the opinion of the Board the enquiry carried out has shown that fluoridation of public water supplies does not involve any demonstrable health hazards even on prolonged consumption of the water."
The New Zealand Commission of Enquiry said: "No harmful effects on health will follow the fluoridation of water supplies whether in respect of the complaints specifically made before us or otherwise." They further said: "In the proposal to fluoridate water there is no risk of chronic fluoride poisoning."
Bearing in mind these definite and categorical statements, what must be accepted is that the alleged ill effects of fluoridation have been considered by the various bodies which studied this subject and these bodies have endorsed the safety of the practice. Apart from the studies already mentioned by me, the studies included the health of adults in areas with naturally fluoridated water supplies at levels even much greater than one part per million.
Perhaps the best known such study was that of the health of groups of adults, selected at random, living in the small towns of Bartlett and Cameron, in Texas, U.S.A. In 1943, over 100 persons who had been living for at least 15 years in Bartlett, where the natural concentration of fluorine in the water supply was no less than 8 parts per million, and a similar number of adults who had been living for the same period in Cameron, where the water contained 0.4 parts per million, were submitted to medical, dental, X-ray and laboratory examinations. The clinical investigations included a search for evidence of arthritis, raised blood pressure, stones in the urinary and bile tracts, goitre, abnormalities of the heart and blood vessels, etc. Laboratory studies included examinations of the blood and urine. These medical examinations were repeated ten years later in 1953 on the same individuals and, apart from mottled teeth among the Bartlett residents, the result of these examinations was that no clinically significant physiological or functional effects resulting from prolonged ingestion of water containing excessive fluoride were found.
Another way of checking on the harmlessness of fluoridated water was to compare various mortality statistics for 32 American cities which used naturally fluoridated water containing more than 0.7 parts per million fluorine with 32 other neighbouring cities using water with 0.25 or less parts per million of fluorine. These comparisons revealed no significant differences. Furthermore, in Britain, where fluoride is found naturally present in some water supplies, up to a level of four or more parts per million, the British Ministery of Health stated in 1956 that a comparison of vital statistics, including several different causes of death, in high-fluoride and low-fluoride areas revealed no differences "which could be interpreted as indicating any harmful effect on health, nor even a slight pointer to the need for any further studies to demonstrate this."
We in this country are fortunate in that we have come to consider fluoridation at a time when the process has already been the subject of extensive and exhaustive study and practical application over many years. At present over 37 million people in the United States of America drink mechanically fluoridated water, while another 7 million people there live in areas where the water supplies naturally contain 0.7 or more parts per million of fluoride. Over 1 million people in different provinces of Canada are also supplied with mechanically fluoridated water. Three towns in Britain—Anglesey in North Wales, Kilmarnock in Scotland, and Watford in England—have been fluoridated since 1955 or 1956 and certain towns in the following countries have had their water supplies fluoridated in recent years: Australia, Belgium, Brazil, Chile, Colombia, E1 Salvador, West Germany, Japan, Malay, Netherlands, New Zealand, Panama Canal Zone, Sweden, Switzerland and Venezuela.
In considering this question, it is essential to remember that fluorine is a natural mineral element and is found, in chemical combination as fluoride, naturally present as a trace element in the majority of foods—in vegetables, meat, cereals, fruit, fish and tea. So widespread are fluorides that it is prac tically impossible to select a diet which does not contain some trace of them They occur naturally, to a greater or lesser extent, in many water supplies, though in this country, so far as our evidence goes, only in infinitesimal proportions. Indeed an analysis of the fluoride content of forty-two drinking waters in different parts of Ireland, carried out in 1948 by Dr. J. A. Drumm, showed that only ten of them contained fluorides of between 0.1 and 0.3 parts per million. The remainder, including the Dublin water supplies, contained less than 0.1 parts per million. The addition of fluoride to water supplies is, therefore, not the addition of a substance that is completely foreign to water but a supplementing of the amount of fluoride which we already obtain in our daily diet, either in food or water. It is important to bear this point in mind when considering some of the objections raised against fluoridation.
One of the main grounds on which objection is taken to the fluoridation of public water supplies is that it is unethical and, for that reason, objectionable in principle.
Here is what the Fluorine Consultative Council in paragraph 37 of its report had to say on that point:
The Council received representations to the effect that fluoridation of public water was unethical. The main grounds for objection were that it was mass medication, an usurpation of parental rights by the public authorities and an interference by the public authority with the integrity of the human body. These objections were carefully considered and advice was sought and received. The Council is satisfied that there is no ethical objection to the fluoridation of public water supplies within the margin of safety recommended in this report.
That is a concise and very clear statement. You will note that the Council say they sought and received advice on the alleged ethical objections and were satisfied that there is no ethical objection to the fluoridation of water supplies within the margin of safety recommended, that is, at a level of 1 part per million.
Two members of the Council signed the Report subject to the deletion of that paragraph but this, I understand, was not because they believed there were ethical objections but because they felt that the Terms of Reference given to the Council did not permit it to concern itself with this aspect of the problem.
Fluoridation is said to be objectionable because it is "mass medication". This is the usual slogan used by anti-fluoridationists wherever this proposal arises. But is fluoridation mass medication in the proper sense of the term? As already made clear, fluoride is ingested in minute quantities as part of our normal daily diet. Fluoride is not a drug or medicine, but a nutrient. It benefits the bones and teeth and is, in fact, a normal constituent of bones and teeth. The addition of fluoride to water supplies will supplement, only supplement, our normal intake of this element. This, I submit is not medication; the fluoride in fact does not cure any ailment or a defect. It is simply a means of making people's teeth stronger and more resistant to the agents of decay.
It has been argued that whereas it may be desirable to provide for the fluoridation of public water supplies the actual implementation of the process should be left to each local authority to decide. There are very strong and cogent reasons why this matter should be decided by the Oireachtas and not left for determination by each local authority. Firstly, as was demonstrated by the Dental Caries Survey of 1952, there is no significant difference in the incidence of caries between different parts of the country and the need to bring the fluorine content of public water supplies up to the optimum level of 1 part per million exists in all areas. Secondly, if we were to leave this matter for decision by local authorities, it would mean that the very large body of local representatives concerned would have to make the attempt to familiarise themselves with the complex, technical, details of the issues involved. If they failed to spend the time and effort in studying this matter they would inevitably be deterred from taking the action which the situation so urgently demands by the misleading propaganda of opponents of fluoridation.
There are over 80 sanitary authorities—that is, water supply authorities —in this country, including the four county boroughs, the county councils, seven boroughs and 49 urban district councils. Only a little over 1½ million people are supplied with public piped water supplies and of these about half are served by the Dublin Corporation. Moreover several of these sanitary authorities avail of a common water supply. Thus in the Dublin area the Dublin Corporation water supply covers not only the city area but much of Dublin County and parts of Counties Wicklow and Kildare. It will be readily seen, therefore, that if it were to be left to each sanitary authority, or even to each county council or city corporation, to accept or reject fluoridation, serious difficulties might arise in practice.
This is a small country, with a homogeneous population, and members of the Oireachtas are in close and constant touch with local affairs. Many indeed are members of local authorities. I submit it would be an absurd waste of time to have repeated, perhaps at every local level, the prolonged debate which has already taken place in the Dáil on this measure.
For these reasons, I feel it is reasonable and logical for the question of the fluoridation of piped water supplies to be decided by the Oireachtas.
Even when the Bill is enacted the Oireachtas will have an opportunity, if a member should so desire, of discussing in detail the application of the measure. It will be noted that the Bill provides that before regulations are made under it surveys of the incidence of dental caries in the areas to be fluoridated shall be carried out and that the fluorine content of the public water supplies in those areas shall be determined. Reports of both these investigations must be laid before each House of the Oireachtas, as must also the regulations when made. Members of either House will then be in possession of all the facts to enable them to debate usefully any provision of the regulations which in their opinion calls for discussion.
Finally, I come to the question of cost. In paragraph 31 of their report, the fluorine Consultative Council said that the cost would vary with the size of the community and pointed out that in the fluoridation areas in Britain the cost, including allowances for capital costs, varies from about 3½d. to 7½d. per head of the population per year. A recent report about the cost of fluoridation in Watford, England, said that the all-in cost, including materials, maintenance and depreciation of plant, is working out at 4½d. per head per year. It is estimated that the annual cost of fluoridation for our country as a whole will be of the order of £30,000. Half of this cost will rank for recoupment from the Health Services grant. The capital cost of the equipment and its installation has been estimated at £100,000 for the entire country.
I will now refer briefly to the different sections of the Bill. Section 2 imposes a duty on health authorities to arrange for the fluoridation of public piped water supplies in accordance with regulations to be made by the Minister for Health. Subsection (2) of the Section empowers the Minister to fix a time limit for the carrying out of this function. It will hardly be necessary to avail of this power but it needs to be incorporated to provide against unreasonable delay in any area. Subsection (3) which provides for the regulations referred to, also stipulates specifically that the maximum amount of fluorine that may be added to public water supplies is one part by weight of fluorine per million parts of water, which is the level authoritatively endorsed from the points of view of efficacy and safety.
Subsections (4), (5) and (6) provide for the carrying out of surveys of the incidence of dental caries among school children in the areas to be fluoridated and surveys of the fluorine content, or other constituents, of public water supplies in those areas, reports of which are to be laid before each House of the Oireachtas.
Under Section 3 is to be determined the health authority which shall arrange for the fluoridation of a public water supply. Where a particular supply serves the population in the area of two or more health authorities the responsibility as between these authorities for arranging for fluoridation will be determined by the Minister.
Section 4 will enable the Minister to impose a duty on sanitary authorities, who are the statutory bodies responsible for supplying water to the public, to act as agents for the health authorities in the fluoridation of the public water supplies. The expenses incurred by the sanitary authorities will be met by the appropriate health authority.
Section 5 provides, where two or more health authorities are concerned, for the apportionment of expenses between them on the basis of the amount of water supplied to each.
Section 6 imposes a general duty on the Minister for Health to arrange from time to time for such surveys as appear to him to be desirable to be made as respects the health, or any particular aspects of the health, of persons, or classes of persons, in the fluoridated areas. This section was inserted to meet some views expressed in Dáil Éireann. The report of any such survey, which may be carried out through local health authorities or some other organisation or body, must be presented to each House of the Oireachtas.
Section 7 provides for the carrying out by health authorities of surveys of dental caries in their functional areas whenever required to do so by the Minister. Such surveys would among other things be of great value in demonstrating as time goes on the beneficial effects of fluoridation.
Section 8 refers to the Health Services (Financial Provisions) Act, 1947. It is intended that half the current expenditure of health authorities on fluoridation will be recouped to them from the Health Services grant as from the date on which such expenditure is incurred. The necessity for the section arose from the fact that under the 1947 Act as it stood the recognition of a new health service could only have been made effective from the beginning of the financial year following the introduction of the service. The new section will enable the recognition of fluoridation expenses for the purposes of the Health Services grant to be made effective at any time.
Section 9 contains the usual provision for the laying of regulations made under the Bill before each House of the Oireachtas.
