§ 4.0 p.m.
§ Mr. Toby Jessel (Twickenham)
I am grateful for the opportunity to draw attention to the need to take action to promote dental health, which is in a very bad state at present. We are a nation with a high proportion of rotten teeth. The pattern is set in childhood. I am told that among five-year olds 70 per cent. require dental treatment. On average, they each have one decayed tooth and one already extracted. At 12 years old, 95 per cent. have some decay, and at 14 the figure is 97 per cent. Children with bad teeth become adults with bad teeth, or sometimes adults with no teeth at all.
Such figures, when turned into millions of people, are the measure of a massive quantity of pain, misery and suffering, of time wasted, of loss of work and of diet problems; for dental health affects general health. If anything can be done to cut down this largely unnecessary evil, surely the Government and Parliament have a duty to give a firm and clear lead.
Fortunately, something can be done. By putting a small amount of fluoride in water supplies, up to about one part per million—where it is not already present naturally up to that level—a great deal of dental decay can be prevented.
I should like to remind the House of the results—published last month—of fluoridation in Anglesey by quoting from the British Dental Journal of 4th March 1975: 1696In September 1974 a … study … was carried out on five-year-old and on 15-year-old Anglesey children who had throughout life received fluoridated drinking water. … Similiarly aged children from neighbouring Bangor and Caernarvon were examined for purposes of comparison. The average level of fluoride in the Anglesey drinking water has been taken to be 0.9 parts per milion and in the control community—Bangor—as 0.01 parts per million. Five-year-old Anglesey children had 38 per cent. fewer attacked teeth and 47 per cent. fewer attacked sites on teeth than had the control children.The report in another passage, says that 15-year old Anglesey children had 44 per cent. fewer decayed teeth and 82 per cent. fewer decayed front teeth. Interestingly, there were no differences in the amount of mottling.
These results bear out the colossal volume of evidence of the beneficial effects of fluoride in other places, both where it occurs naturally in the water supply and where it has been artificially and deliberately introduced.
In the face of such evidence of the contribution to human welfare and relief from suffering that such action can bring, surely any refusal or failure to act is just as big a decision as to take positive action. Those who agitate against this simple measure carry a heavy responsibility on their shoulders.
§ Mr. Andrew Bowden (Brighton, Kemptown)
My hon. Friends refers to there being a heavy responsibility on the shoulders of those who agitate against this measure. I have a list here of over 350 doctors, dentists, research chemists and other scientists who say,It is our opinion that published research work has shown clearly that the toxic effects of fluorides, even in trace quantities, are such that fluoridated drinking water may be harmful, or even dangerous, to many people, particularly in its long term effects, which have not been sufficiently investigated, and that it is therefore quite wrong to force everyone to consume artificially fluoridated water.
§ Mr. Jessel
The figure of 350 such people is not impressive when set against the totality of all doctors and dentists in this country who number about 30,000–100 times as many. The overwhelming majority of professional medical and dental opinion is in favour of fluoridation and accepts the evidence that it is beneficial to health and cannot be detrimental. However, I should be glad if 1697 the Minister of State would comment on the point made by my hon. Friend.
I sometimes wonder what is in the minds of this vociferous but small band of people who argue against a proposal which is intended to relieve pain and which is supported by such a very large proportion of the experts. I believe that they are well meaning, but, apart from what I regard as their scaremongering, their main argument is that to fluoridate water is an interference with individual freedom. They argue that because of that it is wrong in principle.
However, in saying that, they oversimplify. In this controversy there is not one principle but two. On the one hand, there is the principle of the relief of human suffering and pain and the improvement of health. On the other hand, there is the argument for individual freedom. These two principles happen to be in conflict with one another. So we must decide how much weight to give to each.
The potential relief of pain for millions of people is substantial. The intrusion upon freedom in those cases is very slight. As in the view of the overwhelming majority of responsible opinion it carries no disadvantage, common sense suggests that the aim to stop pain should prevail over the other principle in this instance.
I should like to ask the Minister of State to comment on some other aspects, now if there is time or otherwise in a consultative paper that he promised in reply to a Question that I put on 25th March.
First, is there any evidence that water fluoridation strengthens the bones of middle-aged and elderly people? Secondly, will the hon. Gentleman tell us something of the costs of water fluoridation up to one part per million? I have heard the figure of lop per head per year quoted compared with an average of £3 per head per year spent on dental treatment. These figures may be out of date. I should like to know what the current position is.
Does the hon. Gentleman agree that taxpayers' money is being wasted by not fluoridating water and that if fluoridation were to take place our limited dental manpower resources could be better applied?
1698 Thirdly—this is an associated question—when I put my Question about the Anglesey results on 25th March, my hon. Friend the Member for Wycombe (Sir J Hall) asked a supplementary about the alternatives to fluoridation and said that it would be wasteful to apply fluoridation to everybody. Will the Minister comment on the comparative costs of other ways of taking fluoride than through the water supply, such as by tablets, in school milk or by topical application? More important than the costs, will the Minister comment on the practical prospects for achieving a wide, if not universal, coverage by such other means?
Fourthly, will the Minister comment on the suggestion by opponents of fluoridation that it postpones but does not prevent decay?
Fifthly, and most importantly, will the Minister confirm that fluoridation does no harm to health? Some opponents of fluoridation put out what I believe to be scaremongering material. How confident can the public be that there is nothing to worry about?
Two weeks ago, I had a letter from a Twickenham constituent who apparently had believed the scares of which he had read, and he wrote to tell me of his fear that fluoride was—to quote his words "a poisonous pollution". I felt that I should tell him in reply that, if he really believed that, he should stop drinking our local water in Twickenham, which already has a natural supply of fluoride of one part per 5 million, and he should order a supply of beer from a different part of the country.
In conclusion, I refer to the scope for action by the new health authorities. In a Written Answer on 24th March to a Question from me, the Minister said:Under the National Health Service Reorganisation Act 1973 each health authority is fully responsible for deciding in respect of its own area whether it wishes fluoridation to be introduced and, if so, for approaching the appropriate regional water authority. My right hon. Friend the Secretary of State for the Environment would expect a regional water authority to give effect as soon as it reasonably could to a health authority's request for fluoridation, provided that this was acceptable to any other health authority whose area would receive supplies of the fluoridated water."—[Official Report, 24th March 1974; Vol. 889, c. 15–16.]1699 That reply makes clear that the new health authorities have a duty to decide, and that the water authorities are expected to comply. But where populations under different health authorities share a common water supply, how can the matter be resolved if the majority of health authorities want fluoridation against the wishes of a minority which do not wish it? Are the wishes of the minority to prevail? That, surely, would be an undemocratic loading of the dice against action being taken. In my experience, that actually happened on the old Metropolitan Water Board in London, of which I was a member and on which I first took an interest in this subject.
I do not believe that the Department of Health and Social Security has yet faced up to this problem and brought out a solution. But with the establishment of the new health and water authorities, the time has surely come to do so. I shall be glad to hear from the Minister how he sees this important aspect of the matter.
We now know how to relieve a great deal of dental pain and suffering at low cost. I doubt that there is any other measure which would reduce misery and pain so effectively and so cheaply. Sooner or later, I am sure, it will come about, and then people will ask why it was not done earlier. What is needed now is common sense and, above all, courage.
§ 4.13 p.m.
§ Mr. Andrew Bowden (Brighton, Kemptown) rose—
§ Mr. Deputy Speaker (Sir Myer Galpern)
I take it that the hon. Member for Kemptown has come to some arrangement for his intervention.
§ Mr. Deputy Speaker
Certainly, but has the hon. Gentleman arranged to leave the Minister sufficient time to reply?
§ Mr. Bowden
Yes, Mr. Deputy Speaker. I shall be very brief.
First, I thank my hon. Friend the Member for Twickenham (Mr. Jessel) for giving me two minutes—it may be even less than that—to say a few words on this subject. I speak as chairman of the 1700 all-party Anti-Fluoridation Group in the House, with 85 members.
Parliament has never specifically authorised or approved compulsory mass medication, and I believe that it would be utterly wrong to allow it to go ahead on any basis until the House has debated the matter in principle and decided to give its approval.
The fundamental issue at stake here is the right to accept or reject treatment, for if something is put into the water supply—whatever it may be, and for whatever reason—no element of choice is left, and the vast majority of our people have to take water from that supply. It is one of the great principles of freedom in this country that an individual or family shall have the right to decide what they eat and drink, and that parents shall be free to decide what their children take in the form of medication.
The supporters of fluoridation have not made out their case on medical grounds. There are serious differences of medical opinion not only in this country but throughout the world. It would, therefore, be utterly wrong to go ahead even on medical grounds until we were absolutely sure that there were no long-term harmful effects. But, on the moral issue alone, I believe it to be wrong to have any form of mass compulsory medication in this country.
§ 15 p.m.
§ The Minister of State, Department of Health and Social Security (Dr. David Owen)
It may help the House if I state from the start that fluoridation as a public health measure is supported by almost every reputable body in the whole area of public health. It is supported by the Central Health Services Council, the Standing Dental and Medical Advisory Committees, the British Medical Association, the British Dental Association, and the Royal Society of Health, and by unanimous resolution of the World Health Assembly. I do not believe that such organisations are likely to endorse a measure of unproven safety and efficacy and it is because I believe that it is of both proven safety and efficacy that I shall respond to the hon. Member for Twickenham (Mr. Jessel) in the spirit in which he raised the matter.
I am glad that the hon. Member for Brighton, Kemptown (Mr. Bowden) had 1701 the opportunity of intervening because it is right to reflect in a debate of this sort that there are differences of view. No one is suggesting compulsory mass medication. That would mean that the Government were saying that fluoridation of all water supplies should take place immediately. The hon. Member is right to say that that has never been adopted by this House, and were such a decision to be made by a Government it would rightly be debated in this House.
The first thing that needs to be stated about fluoride is that it occurs naturally in the water supply in many parts of the country anyway. I draw attention to the resolution of the World Health Organisation Expert Committee on Water Fluoridation which stated:The most convincing evidence of the safety of water fluoridation comes from the numerous population groups who have drunk naturally fluoridated water containing one part per million or more during their lifetimes. In these groups drinking has been, of course, uncontrolled and there have been well and ill babies as well as healthy young adults and frail elderly people. Medical practitioners and specialists in these areas have never detected and defined a systematic aberration in health of any kind related to the fluoride consumed.This is a most powerful statement.
There has been a lot of scientific controversy about fluoride. Arguments against the widely-established evidence of the safety of water fluoridation have, in general, been based I believe on unique conditions. I have studied this evidence as much as I have been able to study it, and in my judgment as a health Minister, over 20 years of careful and intensive epidemiological studies have demonstrated the safety of controlled-water fluoridation as consistently as its effectiveness in the prevention of dental decay.
I should like to turn to some of the points raised in the debate about both the powers and the costs and certain other aspects, but I shall deal also with the situation which exists at the moment. Fluoridation consists merely of the adjustment to the optimum level for dental protection—one part per million in temperate climates—of the fluoride content of those water supplies which are deficient in it naturally. Intensive investigations have shown that children brought up in areas with about one part of fluoride 1702 per million parts of water have on average about 50 per cent. less dental decay than children brought up in areas where there is only a trace of fluoride. Moreover, in areas with this level of fluoride there are many more children with teeth completely free of decay.
There have been extensive reports on fluoridation studies. Reports were published in 1962 and 1969 on the results achieved after five years and 11 years respectively. I will not go into that aspect now. Many of these facts and many of the different arguments and decisions about the matter will be presented when we deal with preventive health, as we promised, in the consultative document to be produced towards the end of this year. That will go much wider than just fluoridation.
There have been some remarkable investigations, and attention should be drawn to one of them which showed that the withdrawal of fluoridation led to a reversal of the benefits in the areas where there was shown to be a benefit. One of the study areas, Kilmarnock, where improvements in children's dental condition had been observed similar to those in some of the studies elsewhere, ceased to fluoridate its water supply in 1962. By 1968 caries experience in five-year-old children had increased, and was substantially the same as in the control town, Ayr. The only consistent change in Kilmarnock between the start of the study in 1956 and the end of fluoridation in 1962, and thereafter to 1968, was in the fluoride content of the water supply. That is probably one of the most interesting experiments where we have seen a reversal of the trend when fluoridation of the water ceased.
The Research Committee concluded after 11 years of the studies:The fluoridation of water supplies at the level of one part per million of fluoride is a highly effective way of reducing dental decay and is completely safe.I should like to deal with some other studies made since then. The study in Anglesey has been mentioned. Anglesey was one of the areas in the United Kingdom study, which for that purpose had been divided into fluoridated study and unfluoridated control areas until 1964. The recent paper by Professor Jackson and his colleagues described a study of caries experience in five-year-old and 15-year-old Anglesey children 1703 who throughout life had received fluoridated drinking water, and in children of similar age from Bangor and Caernarvon, which had negligible amounts of fluoride in their drinking water, and which had to be used as control areas because of the fluoridation of the whole of Anglesey. To avoid the possibility of bias, all children were taken to a single examination centre, where the dental examiners were kept unaware of the communities from which the children came. That study has shown convincingly the benefits of fluoridation.
The hon. Gentleman asked about the strengthening of bones and whether fluoridation had any other influences. The expert Research Committee noted, from published reports, thatThe influence of fluorides on the skeletal system has been the subject of much research and evidence is now emerging of a possible beneficial effect on the prevalence of osteoporosis in the elderly.However, the evidence is still somewhat tentative by comparison with the case for fluoridation to bring about an improvement in dental health. I do not want to make too much of it at this stage.
The hon. Gentleman also raised the question of cost. The report on "The Fluoridation Studies in the United Kingdom, and the Results Achieved after Eleven Years" indicated that the reductions in the number of decayed teeth which have occurred at Watford, a study area, since the water supply was fluoridated, represented over the whole of England and Wales a potential elimination of the need to fill each year more than 2½ million temporary teeth in children up to the age of seven and more than 1 million permanent teeth in children up to the age of 10. In time this will lead to both a higher standard of dental health and an improved dental service for the whole population. Against that background, it is right for the Department of Health and Social Security to invest in such worthwhile objectives.
As for specific costs, it is difficult to offer a precise figure, because of varying conditions in local areas. But it is probably reasonable to estimate that at present it should be a few pence per annum per head of the population over the whole country, a small amount when considered against the background of the benefits that fluoridation is known to bring.
1704 The hon. Gentleman also spoke of the comparative costs of alternative measures, such as tablets. I am carefully considering the matter, and hope to be able to deal with it in the consultative document. All the evidence is that such measures are less reliable and more costly as preventive measures covering the whole population. It is difficult to know their exact costs, but all the evidence indicates that fluoridation of water supplies is not only the most effective but the cheapest way.
The hon. Gentleman asked about our powers. The matter is complicated. Under section 2 (2)(e) of the National Health Service Act 1973 the appropriate Secretary of State has the duty to provide throughout England and Wales, to such extent as he considers necessary to meet all reasonable requirements, such facilities for the prevention of illness as are appropriate as part of the health service in place of arrangements of a kind which were provided by the former local health authorities under section 12 of the Health Services and Public Health Act 1968, which continued earlier provisions. The facilities covered by this provision include fluoridation as a public health measure for the prevention of dental decay.
In the National Health Service Functions (Directions to Authorities) Regulations 1974, Statutory Instrument 1974/24, the Secretary of State has directed that this duty should be exercised by regional health authorities, in England, and, on their behalf, by area health authorities. Where an area health authority decides to introduce fluoridation of water supplies in its own area it has to approach the appropriate regional water authority about the necessary arrangements.
The nine regional water authorities in England were set up under the Water Act 1973, which, like much of the National Health Service Reorganisation Act 1973, came into operation on 1st April 1974. The Government expect any water authority that receives a request from a health authority for fluoridation to give effect to it as soon as it reasonably can—it is a matter for my right hon. Friend the Secretary of State for the Environment—assuming that that is also acceptable to any other health authority whose area would receive supplies of fluoridated water.
1705 I recognise the importance of what the hon. Member has said about the overlapping of areas of water authorities and health authorities. It causes considerable problems. I should like to look into the problem of overlapping when there is a division of opinion between health authorities that take their water from the same water authority. It is not a matter of having a unanimous view. It simply has to be the view of the area authority, and the water authority should then undertake its responsibility. The cost, as with most public health measures, is borne by the area health authority, and I have already said that potentially there are considerable savings to be made.
The use of fluoride remains pre-eminent among the measures available for increasing resistance to dental decay. Experience over the many years has shown that the fluoridation of water supplies is by far the best and cheapest means of ensuring the adequate levels necessary to build up resistance to caries, although caries can never be excluded.
As the House knows, we have recently had evidence of the extent of dental decay in children, and I must confess that these figures are shattering. The extent of dental decay in children, as shown by the survey, is that two-thirds of the 13,000 children surveyed, aged between five and 15 years, required treatment for dental caries and about one-quarter of the five to eight-year-olds, and one in eight of the nine to 15 age group had five or more actively decaying teeth.
A similar survey among adults in 1968 showed that in England and Wales as a whole nearly 37 per cent. of those surveyed had lost all their natural teeth and in more than 50 per cent. of those total tooth loss had occurred since the National Health Service began.
Those are very depressing figures. They emphasise the need for dental health measures that, by protecting against dental decay in childhood, will provide sound, healthy, natural teeth, which, as I have explained, should last through much of adult life. It is certainly a mistake to think that fluoridation is something to be done only for children, as has sometimes been said.
1706 I need not remind the House of the benefit to general health that is obtained from having natural teeth, particularly in being able to take advantage of a more naturally nutritious diet. A great deal of cost would be saved to the country as well as a great deal of pain and misery. Dental trouble is also a frequent cause of people staying away from work.
Area health authorities have to look at all this as part of their overall responsibility for the health of the people. We are to publish a consultative document. The Royal College of Physicians is currently making a survey and I hope that it will allay some of the anxieties that the hon. Member has mentioned among a small number in the medical and other professions, and I hope that it will convince those few remaining doubters of the safety and efficacy of these measures.
It is up to the area health authorities to decide. Personally, I hope that they will decide on fluoridation. I believe in more democratic health authorities and I believe that they should reflect the views of their localities, but in my responsibility as a health Minister I shall do everything I can to encourage them to make this decision.
Compulsory mass medication is a quite separate issue, as the hon. Member said. It is a difficult subject on which the House and the Government any Government—will eventually have to decide. At present power resides with the regional health authorities. With the present massive expenditure on the treatment of dental decay in this country, any health authority should weigh the advantages carefully when considering the cost. My advice is that it is worth paying the cost because of the benefits to dental health.
But it is a choice for the authorities to make. They certainly have my support if they decide to fluoridate the water supply, and—
§ The Question having been proposed at Four o'clock and the debate having continued for half an hour, Mr. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at half-past Four o'clock.