Should fluoride be removed from Ireland’s water supply?

An edited version of this article was printed in Village Magazine, November 2014 

In October, Dublin City Councillors voted in favour of removing fluoride from public water supplies. The motion, which was passed by 22 votes, called for the removal of fluoride and to make it a crime for anyone that attempts to add it to water supplies. Dublin is not the first city to pass such a motion: in March, Cork City Council also passed a motion requesting the Government to end treating public water supply with fluoride. Christopher O’Sullivan, the Fianna Fáil councillor who tabled the motion, said he hoped its passing will produce a “domino effect” with other county councils. 

Anti-fluoride groups, who are actively campaigning to end water fluoridation in Ireland, will no doubt consider these events as significant victories. Many argue that fluoridation is known to cause many health problems, such as cardiovascular and neurological disease, type 1 diabetes, osteoporosis, skeletal fluorosis, chronic fatigue and depression. Others claim it causes Down syndrome, various cancers, Alzheimer’s, Sudden Infant Death Syndrome (SIDS), lower IQs in children, and various other conditions.  

Fluoride is added to water supplies since it is a very cost effective way of preventing tooth decay and enhancing dental health—something Ireland has been doing since 1964. Fluoride is known to strengthen teeth and reduce dental bills, as well as decreasing the chances of fillings, and extractions. In fact, the United States Centers for Disease Control and Prevention ranked fluoridation of drinking water to prevent dental caries as ninth in its public health achievements of the 20th century.

Opponents of water fluoridation don’t always dispute the dental benefits, but they nevertheless claim the adverse health risks should be sufficient to easily outweigh them. If the various risks associate with drinking water containing fluoride are valid, then it must be the case that opponents have a strong case in calling for its removal from water supplies. On the other hand, there doesn’t really seem to be much, if indeed any, evidence to support the claim that it is associated with any of the various harmful risks mentioned above.

In 2000, a review of 214 studies found that there was no clear evidence of adverse potential effects associated with water fluoridation. Although it must be said that the authors of the analysis pointed out that some of the studies were conducted in the 1940s and 50s and were of low to moderate quality. More recently, however, a report by Public Health England (March 2014) looked at rates of hip fractures, kidney stones, Down’s syndrome, cancer, and all-cause mortality and concluded that there wasn’t any evidence of harmful effects to health in fluoridated areas. In actual fact, there was some evidence to show that the rate of deaths from all recorded causes was marginally lower in fluoridated areas than non-fluoridated areas. 

Additionally, a major study from New Zealand, published in August, came to a similar verdict: the panel said it “is unanimous in its conclusion that there are no adverse effects of fluoride of any significance arising from fluoridation at the levels used in New Zealand.” Both of these recent studies also found evidence that fluoridation of the water improves the population’s dental health. On top of that, the respective Deans of Harvard Medical School, Harvard School of Dental Health, and Harvard School of Public Health all support water fluoridation “as an effective and safe public health measure for people of all ages.”

Anti-fluoride advocates, in response to this, might refer to cases of fluoride poisoning that occurred in the United States during the 1990s as a cause for concern. On that basis, though, it doesn’t necessarily follow that we ought to completely remove fluoride from water systems; instead setting a standard that requires regular tests to be carried out to ensure fluoride water levels are safe would seem like a more appropriate option. No doubt you can find many studies that show that significant health problems can materialise if concentrations of fluoride are high, but the World Health Organization recommends a guideline maximum fluoride value of 1.5 mg/litre, and the levels in Ireland has been set at between 0.6-0.8 mg/litre.

But since fluoride is likely to be dangerous in large quantities, wouldn’t completely avoiding it be the best option? Not necessarily, especially when we consider that nearly everything can be harmful at a high enough dose—water and vitamin C, for instance, can be lethal if you consume too much. In many cases, we usually don’t prohibit things just because they can be harmful if taken in large quantities.  

Opponents often say that several other developed countries no longer add fluoride to their water supplies. However in some countries, it is added to salt or other food products instead, or else because the drinking water is already naturally fluoridated to the recommended levels (as is the case in France and certain parts of the United States). Some countries also have different dental care strategies that do not require water or salt fluoridation. Unfortunately these are specific details anti-fluoride campaigners in Ireland don’t usually consider, or else fail to mention.      

It might be argued that even if fluoride isn’t harmful, authorities still don’t have the right to add it to our public water supplies. That is to say, it cannot be morally justified for the State, or any other organisation, to interfere in the lives of individuals against their will. This, of course, is part of a much broader and complex topic, which I won’t fully address here. Nevertheless, I will try to deal with a few points. Arguably, it is permissible for authorities to add fluoride to water, since it significantly enhances the quality of the population’s oral health (in particular, those who cannot afford regular dental visits). From a utilitarian point of view, the acquired benefits, all things considered, may well take precedence over some interference with individual choice.

Secondly, I would question the motivating force of someone who would campaign, as a matter of principal, against fluoridation on the basis of individual choice, particularly when we’ve good reason to believe the general quality of dental health would decline if that particular course of action was taken. Considering this point, there are a lot more worthwhile campaigns that one could devote their time and resources to. Anti-fluoride campaigners might say they are in favour of implementing other ways of managing dental care. This is a fair point, but they should be still reluctant to remove fluoride from water supplies before offering a viable, cost effective alternative. Finally, one could also make the case on this basis to remove chlorine (it can also be toxic!) from water supplies.  Chlorine, as we know, is often added to drinking water to kill certain bacteria and other microbes. All the same, I doubt many would consider removing chlorine from water supplies, on the basis that it interferes with individual choice.

Some people might be of the opinion that even if anti-fluoride campaigners convinced enough politicians, and that as a consequence it was actually removed from our water supplies, the outcome itself would be relatively innocuous.  Yet, even if we discount the oral health benefits that would be lost, I still think we should be concerned if it’s known that politicians are receiving public health advice from those who have hardly any reliable empirical data to support their claims. In the opening page of his book, Nonsense on Stilts: How to Tell Science from Bunk (2010), the scientist and philosopher Massimo Pigliucci says that “[a]ccepting pseudoscientific untruths, or conversely rejecting scientific truths, has consequences for all of us, psychological, financial, and in terms of quality of life.” 

The concern about tolerating relatively benign pseudoscientific facts, Pigliucci argues, is that it lowers one’s defences against the more harmful delusions that are based on the same kinds of confusions and fallacies. Obvious examples include those who claim vaccines cause autism, that theories of anthropogenic climate change are false, and that there’s no connection between HIV and AIDS. A more recent example are those who’ve decided to impose quarantines on health care workers coming back from West Africa where they may have cared for patients with Ebola, despite the fact this motivation is contrary to our scientific understanding. When views like these come to sway public-health policy, they cease to be innocuous.  

It’s important to note that we also shouldn’t rigidly adhere to a particular set of beliefs at all costs. But rather we should be open to the idea that empirical findings are often tentative and additional evidence may force us to re-evaluate our position. In other words, public health policy should strive to be in accordance with the best scientific evidence available. However, it certainly doesn’t follow from any of this that we should accept politicians and policy-makers who entertain or consider implementing ideas that are unaccompanied by significant evidence. Certainly, let’s be cautious about water fluoridation, but not have a political or emotional opposition to it.