§ Order for Second Reading read.7.46 pm
§ The Minister for Health (Mr. Kenneth Clarke)
I beg to move, That the Bill be now read a Second time.
The Bill is seen by the Government as a valuable measure of preventive medicine of some significance for the dental health of many children in this country. On the other hand, the Bill does not break any dramatic new ground. It clarifies the law to enable the existing practice to continue in some parts of England and the former practice to be resumed in Scotland. I refer to the practice whereby fluoride is added to the water in some parts of the country at local option. The practice has proved valuable in reducing the amount of dental decay among children.
I propose, first, to explain why we need to introduce such a Bill when there has been a long-standing policy on fluoride in this country and, until recently, in Scotland. Secondly, I propose to deal with the health and safety issues connected with water fluoridation. In view of some controversy in medical and scientific circles, the concern about some of these matters is understandable. Finally, I shall refer briefly to individual liberty and the role of the Government. I know that many hon. Members, including some of my hon. Friends, are concerned about those matters.
The need for the Bill arises from Lord Jauncey's judgment, in the Strathclyde fluoridation court case, delivered on 29 June 1983. Hon. Members may recall that the case was brought by a Mrs. McColl, a lady living in Glasgow, who sought to prevent Strathclyde regional council from carrying out its intention progressively to fluoridate the water supplies for which, as the statutory water authority, it was responsible. The case lasted for over 200 days, and its length made Scottish legal history. Much of the public hearing was devoted to discussion of the safety of water fluoridation, and a large number of expert witnesses were called, including almost ail the leading anti-fluoridationists.
It is my intention to cover safety issues in more detail later in my speech, but Lord Jauncey's finding on the safety issue was:there is no evidence to suggest that fluoride at the proposed level would have an adverse effect upon health".Having heard a great mass of evidence and the most sustained arguments before an objective arbiter— a judge in a court of law—that there have ever been in this country, Lord Jauncey rejected all the petitioner's contentions that fluoridation was hazardous and confirmed that the fluoridation of water supplies would be likely to reduce considerably the incidence of caries— dental decay—in Strathclyde.
Lord Jauncey accepted, however, that fluoridation was legally ultra vires in Scotland, because it went beyond the legal powers of Strathclyde regional council under Scottish water legislation. The case turned on the question whether the duty of the council to provide "wholesome water" provided the legal power for fluoridation. Lord Jauncey accepted that fluoridated water was wholesome in the sense thatit is neither contaminated nor in any other way dangerous to health",but concluded that fluoridation was legally ultra vires in the narrower sense that it 75did not facilitate the supply of wholesome water, nor was it incidental to it".
§ Mr. Keith Best (Ynys Môn)
Is it not a fact that Lord Jauncey in his judgment said that, when used for the purpose of preventing tooth decay, the addition of fluoride to the water represented a medicinal product? As such, would my right hon. and learned Friend agree that it would come within the Medicines Act?
§ Mr. Clarke
I do not recall that passage in Lord Jauncey's judgment. I have quoted his conclusions on the safety issue and the legal issue whether the existing statutory powers of the regional council cover the addition of fluoride. At the moment, fluoride is not regarded as a medicinal product by the licensing authority. Fluoride is a mineral that, when added to water, has these particular consequences; and it is a wholly separate issue as to whether it is a medicinal product and requires licensing under the Medicines Act. I shall pursue the point further if my hon. Friend wishes, but, on the strength of the evidence that I shall be citing in the course of my speech and of the body of evidence looked at by Lord Jauncey, there would not be any difficulty in obtaining a licence if it were established that fluoride is a medicine and requires a licence.
Following Lord Jauncey's opinion, the Government took immediate action to comply, and fluoridation ceased in Scotland. Fluoridation has, however, continued elsewhere in the United Kingdom, as Lord Jauncey's judgment is not binding outside Scotland. Although the Water Acts, as they apply in England and Wales, are similarly worded to the Scottish Acts, it does not follow that Lord Jauncey's view would necessarily be upheld by the courts south of the border. Unfortunately, doubt is now established because of the Scottish judgment.
The Government announced on 6 December 1983 that it was our intention, when the parliamentary timetable permitted, to bring forward legislation which could clarify the power of water authorities in Scotland to add fluoride to the water supply on the recommendation of the appropriate health boards. Since there was doubt over the legal powers of water authorities elsewhere in the United Kingdom to fluoridate, we announced that we also proposed that the legislation should cover all statutory water undertakers in England and Wales and that corresponding legislation should be enacted for Northern Ireland. That is still our intention, and the Bill reflects this.
I shall now address the basic question of the need and the case for water fluoridation as a measure of preventive medicine, which I began by describing. I hope that the House will be prepared to accept that dental decay constitutes a serious health problem which needs to be addressed. Although there has been a welcome reduction in dental decay over the past 10 years, it remains a significant and costly form of disease, which is particularly subject to regional variation. To illustrate this I shall quote from the 1983 child dental health survey, which showed that, for example, among 13-year-olds, 64 per cent. of children from Northern Ireland had active decay of the permanent dentition, 51 per cent. from Scotland, 40 per cent. from Wales and 31 per cent. from England.
Water fluoridation is not, of course, the only means of reducing dental decay, but it does have particular 76 advantages over other methods, which I shall briefly explain. Improvements in dental health can undoubtedly be brought about by improvements in diet and oral hygiene, and it is our policy as a Government to encourage dental health education through the Health Education Council and the community dental services. At the same time, we have to recognise that there are limits to what can be achieved by this method alone. For this reason, we believe that it is important to encourage other forms of preventive dental treatment involving the use of fluoride supplements. There are a number of means of providing fluoride supplementation, such as toothpaste, tablets and what is called topical application directly on to the tooth. These are certainly valuable methods of preventing tooth decay, and much of the recent general reduction in dental decay is thought to be related to the use of fluoridated toothpaste.
Fluoride tablets and topical application of fluoride are of value, particularly in those areas where fluoride is not added to water, but they are a relatively expensive means of reducing dental decay. The use of fluoride tablets also requires the following of a regular regime, and experience has shown that that is not always easy for parents to maintain. Topical fluoride requires administration by trained staff. All the other methods—better diet, oral hygiene and tablets—are followed by only a certain proportion of the population, and by no means all.
Water flurodiation has advantages over all these methods in that it is highly cost-effective, does not require the use of trained personnel or conscious effort by the recipient and confers a benefit on the whole of a given community.
§ Dr. M. S. Miller (East Kilbride)
I am in favour of what the right hon. and learned Gentleman is saying about the advantages of fluoride added to water. However, to complete the record, will he also mention the fact that fluoride can be and is being added to milk by an organisation run by a philanthropist in the south of England? That shows that there is another way to introduce fluoride into the system, although it is not as good a method as fluoride in the water.
§ Mr. Clarke
I am grateful to the hon. Gentleman for adding that example of another way in which fluoride can be given in the appropiate quantities to those who want it. I am glad that he agrees with me that all these specific methods do not reach all the population, and water fluoridation has advantages over all of them and is much more comprehensive in its effects.
I am aware that doubts have been raised in some quarters as to the effectiveness of water fluoridation. Lord Jauncey, in the Strathclyde case, considered the main studies that had been carried out on the effectiveness of fluoridation and concluded that, whatever inperfections individual studies might have,the message is nevertheless loud and clear from many different parts of the world. Water fluoridated to one part per million substantially reduces the incidence of caries. With evidence such as this available it is not surprising that the majority of the dental profession in the United Kingdom favours the fluoridation of water supplies".
Lord Jauncey also considered and rejected the theories that fluoridation only delays the incidence of caries and can lead to the delayed eruption of teeth.
In this country, that evidence about the effectiveness and safety of fluoride has been followed for years in some areas. About 5 million people, including my family, drink 77 water where the fluoride content has been artificially increased to the optimum recommended level of one part per million. Successive surveys have shown that dental decay levels among children who have had lifelong exposure to fluoridation are consistently lower than among children in comparable non-fluoridation areas. There is ample evidence that the fluoridation of water results in a markedly greater reduction in dental decay than simply the use of fluoridated toothpaste or other dental health measures.
The House may be interested to know, to add to my point about the experience that we now have, that fluoridation is carried out in more han 40 countries in five continents, and that more than 200 million people worldwide receive artificially fluoridated water.
§ Mrs. Jill Knight (Birmingham, Edgbaston)
Am I right in assuming that the water that my right hon. and learned Friend spoke of his family drinking is in the Birmingham area? Is he aware that the Birmingham dental hospital has no cases of caries among children and that when students are required to look at caries in children, as a result of the fluoridation programme, children from outside the Birmingham area have to be brought in.
§ Mr. Clarke
I am grateful to my hon. Friend for that information. Comparisons of the incidence of dental caries among children in my hon. Friend's part of the country— Birmingham— and in other comparable areas have shown that the incidence of dental caries is lower among children in Birmingham. There might be some reaction in Birmingham if people were told that fluoridation had to be withdrawn from the water because the House had failed to pass the necessary legislation. I accept, as I am sure my hon. Friend does, that it is not sufficient simply to prove that fluoridation reduces dental decay for it to be accepted as a public health measure.
All those who advocate the adding of fluoride to water are just as concerned as the opponents about public safety, and safety always has been, and will remain, a primary concern. During the 1970s the safety of fluoridation was reviewed repeatedly by national and international bodies, such as the World Health Organisation, the Canadian Public Health Association, the United States National Academy of Sciences, the Australian Health and Medical Research Council, and in this country by the Royal College of Physicians. All those bodies concluded in published reports that fluoridation represents a safe means of reducing dental decay.
Therefore, I hope that the House will forgive me if I do not today go through all the arguments that have been made about all the ailments which at some time or another have been attributed to fluoride, and seek to set out the scientific case that has refuted those claims. Fluoride has been blamed for the increased incidence of many ailments, ranging from cot deaths to AIDS. The House will perhaps understand how curious some of the more fringe claims have been when I say that the evidence on AIDS appeared to derive solely from the fact that water in San Francisco has fluoride added to it as a dental measure. It now appears that other causes exist for AIDS being prevalent in that city.
However, I accept that serious people have challenged the use of fluoride. Where detailed, assessable evidence is put forward that fluoridation is unsafe, it is extremely important that the Government and my Department should 78 examine carefully all the evidence and make known their conclusions. For that reason, I wish to address tonight in more detail some of the more serious problems that have been raised, especially the allegations that have been made for some years that fluoridation can cause cancer in man, together with recent reports from a laboratory in Japan concerning short-term tests of fluoride for mutagenicity.
§ Mr. Donald Stewart (Western Isles)
Is the Minister aware that, even if one accepted that fluoride is entirely safe, some of us would still be opposed to it on the principle that we cannot accept compulsory medication?
§ Mr. Clarke
I shall deal with that point at the end of my speech. There are doubts— it would clarify the debate if we narrowed the issue to that— about the effectiveness of fluoride, but the scientific case is overwhelmingly against them. Some silly claims, and some serious ones, have been made about the safety of fluoride. It is important to set out all the evidence to reassure the public that the overwhelming balance of evidence is that fluoride is safe. Then we are left with the serious issue which I know worries the right hon. Gentleman and some others, and which I hope to address at the end of my speech. I must first try to dispose of the safety arguments.
To take first the alleged link with cancer, the principal evidence for such a link has been presented by two American scientists, Dr. Burk and Dr. Yiamouyiannis, who since 1975 have claimed repeatedly that cancer mortality in the United States has increased as a result of fluoridation. Their claim is based on statistical comparisons of cancer death rates in fluoridated and non-fluoridated cities. The data in support of the allegation have been considered by other scientists here and elsewhere and have by no means received general credence, with many criticisms being levelled at the methodology employed by those two doctors.
My hon. Friend the Member for Reading, East (Sir G. Vaughan), when he was Minister for Health, established an expert committee, initially under the chairmanship of Professor Alderson, and subsequently Professor Knox, with the terms of reference:to reappraise the published and otherwise available data and conclusions on cancer incidence and mortality amongst populations whose drinking water is either artificially fluoridated or contains high levels of fluoride from natural sources.The report of that committee was published today, and copies are available in the House. After detailed consideration of the many studies covering large populations, which are considered in the report, including those of Burk and Yiamouyiannis, the committee concluded:We have found nothing in any of the major classes of epidemiological evidence which could lead us to conclude that either fluoride occurring naturally in water, or fluoride added to water supplies, is capable of inducing cancer, or of increasing the mortality from cancer. This statement applies both to cancer as a whole and to cancer at a large number of specific sites. In this we concur with the great majority of scientific investigation and commentators in this field. The only contrary conclusions are in our view attributable to errors in data, errors in analytical technique, and errors in scientific logic.
The committee went further— hon. Members can study the report to see that these are not selective quotations—and stated:The evidence permits us to comment positively on the safety of fluoridated water in this respect.The Knox inquiry was conducted entirely independently of the Strathclyde case, which by coincidence held its 200 79 days of hearings during the time when the Knox committee was carrying out its review of the epidemiological evidence.
Lord Jauncey came to similar conclusions after hearing all the evidence, including Drs. Burk and Yiamouiannis for the anti-fluoridationists, and he concluded:The fluoride/cancer argument, if I may call it so for brevity, has been shown to be based to a substantial extent on unsound principles and to have virtually ignored what may be described as the scientifically accepted facts of life about cancer and mortality.
I hope that that deals with the serious concerns raised by many campaigners about cancer. Some people will still not be satisfied, be we cannot subject it to more exhaustive scientific and judicial review than that to which it has been subjected during the past two or three years. The so-called experts who have tried to establish a link between cancer and fluoride have been forcefully rejected by scientists and those who have heard the evidence.
§ Mr. Ivan Lawrence (Burton)
Were thorough studies carried out on thalidomide before it was put on the market as being utterly safe?
§ Mr. Clarke
Not on this scale. A problem with thalidomide was that the most exhaustive tests were carried out, but, as is always the case with a new drug, and as we discovered in a few other cases, it is only when it is used extensively in the population that one has the final and most crucial test, when one can sometimes discover unexpected side effects. I do not wish to speak too authoritatively about thalidomide off the cuff, but with hindsight it is possible to say that not enough testing was done on expectant mothers. I hope that that failing will not be repeated.
The Knox report, which considered the epidemiological evidence, was based on a massive amount of data. In such studies, the more people who have taken a substance and the longer the period during which they have been taking it, the stronger one's conclusions can be. As I said, 5 million people have taken fluoride through the water supply in Britain for many years. The figure internationally is about 200 million. Fluoride is not a rare substance. It has been added to water for years and many studies on it have been published. A review of all that evidence enabled the expert committee to come to strong conclusions. In this case, we are on strong ground compared with the usual introduction of drugs.
§ Mr. Richard Alexander (Newark)
I have followed my right hon. and learned Friend's argument closely, and I am trying to support him. He said that in some cases, such as thalidomide, there might be unfortunate side effects. The report from which he has given us evidence dealt with an investigation into cancer. Did it also consider unexpected or unfortunate side effects?
§ Mr. Clarke
Yes; but cancer is the only one that has run for a long time. We considered cancer especially because the allegations about it have been more persistent. As I said, I could rehearse all the evidence about all the side effects, diseases or poisoning that have been claimed as deriving from fluoride. Lord Jauncey heard exhaustive evidence about many of those and came to his conclusions upon them. I said that I would not review them all, but it would be fair to the anti-fluoride case to say that the 80 allegations about cancer have been the most persistent. That is why my hon. Friend the Member for Reading, East asked the committee to consider cancer.
§ Mr. Laurie Pavitt (Brent, South)
I confirm the Minister's recollection of the thalidomide case. The Medicines Act 1971 was passed after it was realised that there had not been sufficient evidence about thalidomide and that it had been launched too quickly. Evidence presented to the investigation in Germany revealed that that had happened worldwide.
§ Mr. Clarke
I am grateful to the hon. Gentleman. His recollection is the same as mine, and I am sure that he is correct. We have vastly more evidence on and experience of fluoride. There are parts of the world, a few in this country and a number in the United States, where the natural incidence of fluoride is higher than the addition proposed in this country. There is no paucity of evidence. The mass of evidence enables experts to come to the conclusions that I have outlined.
I can demonstrate how exhaustive we have been, and will continue to be, in looking at various matters by dealing with the suggestion that fluoridation gives rise to a mutagenic hazard—the ability to alter human cells in ways that might be relevant to cancer and hereditary effects.
Lord Jauncey considered that issue during the Strathclyde case and, after receiving the available evidence, concluded:fluoride in the quantities likely to be ingested by humans from fluoridated drinking water has been positively shown not to be mutagenic".Since the Strathclyde case, a reputable Japanese scientist has published several papers demonstrating mutagenesis under laboratory conditions from very high concentrations of fluoride applied directly to cells. It is important to remember about that study, about which I am sure some of my hon. Friends who follow these matters closely have heard, that the authors of the work did not claim that it proved that fluoride would give rise to a mutagenic hazard at the much lower concentration of 1 mg per litre, which is standard to all British fluoridation schemes.
Nevertheless, we set in hand a programme of studies intended to replicate the Japanese work and assess its relevance to fluoridation. The research has been planned and carried out on the recommendations of our Department's committee on mutagenicity of chemicals in food, consumer products and in the environment. We continually take the best advice that we can obtain on laboratory research here and abroad and keep ourselves up to date. It is important for everyone to understand that research work is always going on somewhere on many health products.
§ Mr. Neil Hamilton (Tatton)
I am sure that my right hon. and learned Friend agrees that all that those reports can show is that, in the present state of scientific knowledge, fluoride in the quantities that are proposed to be added to drinking water does not constitute a health hazard.
However, can my right hon. and learned Friend explain what appears to be an inconsistency in Government policy? In most cases, chemicals, if ingested in particular quantities, can be toxic. In the past year or so, we have devoted considerable time to considering the effects of the ingestion of lead from exhaust emissions from cars, and 81 so on. In that case, the Government have adopted a different test. They have said that although there is not a shred of evidence that existing levels of lead in the atmosphere arising from exhaust emissions constitute a health hazard, those who favour keeping the existing law have to prove positively that it cannot constitute a health hazard. Of course, it is inherently impossible to prove such a negative, but I wonder why the Government do not adopt the same principle on fluoridation which, in particular concentrations, can also constitute a health hazard.
§ Mr. Clarke
I hope that my hon. Friend will forgive me if I do not get drawn too far into a discussion of lead in the atmosphere. However, I do not accept his description of where we are. There was no positive evidence to establish that lead in the atmosphere had damaged the health of children, but there was an area of doubt and of scientific contention. No one said that it could be proved that existing levels of lead in the atmosphere were safe. Therefore, it was decided to err on the side of prudence and to reduce the level of lead in the air. Certainly, no one claimed that lead was doing any good to anybody.
In so far as one can establish a case to demonstrate the safety of fluoridation, the epidemiological evidence has done so. There have been exhaustive studies by many people over many years and they have not been able to demonstrate any corrolation between the addition of fluoride or the natural incidence of fluoride and any particular condition. Unless one demands an absurd level of proof, one cannot go much further in demonstrating safety. The case for fluoride is not on all fours with the lead problem.
I thought that my hon. Friend the Member for Tatton (Mr. Hamilton) was about to concede that the health hazard argument is not valid in the fluoride debate. That is all that I am seeking to establish. I volunteer information on the latest studies to show how quickly we follow them up with our own research to check whenever doubts are raised.
We have advice from the Department's independent, expert scientific advisers from all relevant fields on all aspects of the evidence about the addition of fluoride to the drinking water of whole communities to achieve a concentration of 1 mg per litre. They have considered all the available evidence on the biological effects of fluoride in short-term tests, including the mutagenicity evidence from Japan and the United Kingdom, and animal carcinogenicity tests, as well as the direct and extensive studies of human populations reviewed in the Knox report.
All our scientific advisers, whom we use on a wide range of matters within the Department, conclude that there is no evidence leading to an expectation of hazard through the induction of heritable abnormalities, and no reliable evidence of any hazard to man in respect of cancer.
I sense that most of the hon. Members who have intervened either agree with me on the safety point or are not pressing it too strongly. I conclude my remarks about the safety of fluoridation with reassurances about safety in relation to cancer and mutagenic effects. I hope that those assurances demonstrate that the Government, the Department and our advisers keep under review all the evidence relevant to the safety of fluoridation. That is not 82 unique in this country; international health bodies do the same, as do the Governments of countries where fluoride is added to the water supply of major cities.
The passage of the Bill will not reduce our commitment to keep up to date on research and to take seriously any new doubts expressed about fluoridation. We will continue to draw on outside professional expertise, but the evidence is more overwhelmingly in favour of the safety of fluoride in water in the concentrations that we suggest than it is of the safety of many other things that are willingly accepted as part of health care of all kinds in this country.
I hope that most hon. Members will now be prepared to accept that fluoridation represents a safe and effective means of reducing dental decay. There remain, however, the objections—raised by the right hon. Member fix the Western Isles (Mr. Stewart)—of those who believe that, irrespective of the safety of fluoridation and its benefits, it constitutes an infringement of individual liberty and should never be carried out. [HON. MEMBERS: "Hear, hear."] I am always glad that one gets a resounding cheer of support when one mentions liberty.
§ Mr. Clarke
I hope that no one will launch an attack on liberty in urging the case for the Bill. Contrary to the partisan remarks of my hon. Friend the Member for Ynys Mon (Mr. Best), with which I might sometimes agree in other contexts, I think that, by and large, we are all in favour of liberty. However, one can take libertarian arguments to an almost absurd degree and it does not always strengthen them.
§ Mr. Clarke
May I begin before I give way? I hope that I do not have to stress my own commitment to liberty. It is not a challenge to the principle of individual liberty to say that in making judgments about cases, it is relevant to look at the degree to which one is infringing individual liberty. It sounds a dangerous argument, but it is not. The principle is not necessarily undermined by our looking at the degree to which individual liberty is affronted.
If anyone suggested the introduction of imprisonment without trial, the vast majority of hon. Members would probably be only too ready to go to the barricades to defend our present system with vigour. But we are talking about a circumstance in which people will find that harmless quantities of a harmless product are, unknown to them, being added to their drinking water, with no harm to them, but with considerable benefits to their children and many other people.
§ Mr. Clarke
That does not dispose of the individual liberty argument, but I must put those libertarian arguments into perspective before my hon. Friends leap to the barricades. When I have put them into perspective, I shall give way.
Let us consider what the threat to individual liberty is if we put into drinking water harmless quantities of this effective product in reducing dental decay. Hon. Members should consider the extent to which we all consume fluoride in other forms and the extent to which it already occurs naturally. First, I must point out that fluoride is present in most items of the diet, notably in tea. Indeed, heavy tea drinkers living in a fluoridated area will 83 consume more fluoride from tea than from consumption of fluoridated water. It is therefore somewhat ironic that Mrs. McColl was shown celebrating her victory after the Strathclyde judgment by drinking a "fluoride-free cup of tea". There is no such thing.
Thus, I hope that I have put the issue into perspective. I have already pointed out that in many parts of the world people consume fluoride in their diets in far larger quantities than is proposed for our water supply. The exercise of individual freedom by those members of the community who feel so sensitive about our water supplies has an impact on the individual freedom of other members of the community. My hon. Friend the Member for Birmingham, Edgbaston (Mrs. Knight) mentioned Birmingham. But the individual freedom of some people in Birmingham to refuse to allow fluoride to be put into the water is probably an infringement of the individual freedom of other inhabitants of Birmingham, who think that it will do them and their families good if fluoride is put into it—[Interruption.]
§ Mr. Wigley
I have followed the Minister's argument in balancing the interests of one group against those of another. I accept that those groups may have different opinions and different opinions also from those of the right hon. and learned Gentleman. After all, none of us has a monopoly of wisdom, and hindsight may teach us severe lessons. But will he not at least concede that at the very minimum there should be a democratic decision, area by area, as the measure can be implemented area by area? When fluoride was introduced in some areas many years ago, it was introduced by elected local authorities. Since health authorities are non-elected, I believe that there should be local referendums so that people can decide for themselves on the very basis outlined by the right hon. and learned Gentleman.
§ Mr. Clarke
I think that it should be a local decision and that is what we propose. A referendum on fluoride might not give rise to the consuming interest in the issue that is apparent in today's debate. However, I quite accept that it is a personal judgment. Indeed, the Government have accepted that by the way in which they have presented the Bill. Nevertheless, before we get a passionate argument about personal freedom, it is only fair to put the issue into perspective. Some of us believe that the benefits that the measure contains in terms of preventive health care are important. It is not a terrible affront to the freedom of an Englishman, a Scotsman, an Irishman or a Welshman to say, "You will have in your water some harmless substance of which you are not aware, which benefits the teeth of your family and of others."
§ Mr. Clarke
I shall answer the hon. Member for Caernarfon (Mr. Wigley), because he has touched on a very valid point, given the public sensitivities on this issue, which will no doubt be warmly expressed this evening. We believe, as he does, that it is right to continue to allow decisions to be taken locally after consultation of local opinion by the responsible local health and water authorities. That has been the policy of successive 84 Administrations for nearly 30 years. Much though we no doubt all look forward to an animated debate this evening on personal freedom, the Bill does not break any dramatic new ground. It restates the policy of successive Governments for the past 30 years.
Responsibility for preventive health measures has been vested by Parliament in the Secretary of State and through him in health authorities or, in Scotland, health boards.
§ Mr. Terence Higgins (Worthing)
I welcome my right hon. and learned Friend's statement about a decision being taken on a local basis, presumably to reflect the differences either in local variations of fluoride or in local opinion. But does he really think that health or water authorities are the appropriate bodies to judge local opinion?
§ Mr. Clarke
There are genuine local variations in, for example, the incidence of natural fluoride in the water. There are also sometimes practical problems in adding fluoride to the water in some localities. Thus, there are those reasons for local decisions. The health authorities are charged with a wide range of responsibilities for local health and are, therefore, the bodies most competent to determine the health needs of the local population. We charge them with doing that over a wide range of extremely serious issues. Similarly, the water authorities are obviously charged with the responsibility for dealing with the water. If we added to the number of local bodies to be involved in all of those things, no decision would be taken on anything. We are placing the local decision in the hands of those bodies that take dramatically more important decisions in their respective fields for their localities.
§ Mr. Clarke
I should like to explain the local position with care so that everyone understands it. At present it is for the health authorities to decide, having consulted local opinion, whether to apply for water fluoridation, and then to negotiate with the water authorities over the detailed contractual arrangements. Financial responsibility rests with the health authorities, and the water authorities act as agents for them under the terms laid down in the contract.
I emphasise that it is our intention in the Bill to leave those basic arrangements undisturbed. The Government thought about the issue, and we took a positive decision that we were not going to change our policy, the policy of previous Governments, or the practice of previous years. We are leaving the present basic arrangements undisturbed. The result is that the House may be assured that enactment of the Bill will not force any health or water authority to undertake fluoridation against its wishes. We rule out a national policy of compulsory fluoridation, which people will no doubt urge upon us. The Government thought about that and rejected it, because of the strong feelings that have been expressed.
The Bill does not reflect the beginning of any major campaign to put authorities under pressure to fluoridate, where they or their populations are unwilling to do so. Again, I think that it is important to get these main issues of principle into perspective. The Bill is simply a measure to restore in Scotland and to confirm elsewhere the powers to make local choices about fluoridation that had been assumed to exist for more than a quarter of a century. In 85 future, those decisions will reflect—as they have done over the past 25 years—the undoubted effectiveness of water fluoridation in promoting dental health, and the different circumstances and views of various localities.
Enactment of the Bill will simply mean that those authorities in England and Wales that have chosen to have schemes will not have to abandon them because of continued uncertainty about the law. Water fluoridation has been implemented on the whole rather slowly in Britain over the past 25 to 30 years, to the frustration of some of its enthusiasts. Enactment of the Bill will not necessarily change the pace at which it occurs, but it will confirm and clarify the basis on which individual authorities can look at the issues concerned and make their own choices. We are simply resolving a legal doubt which should not cloud the issue. In summary, we are alive to the case for fluoridation in dental health promotion and to local sensitivities. We do not see ourselves as breaking dramatic new ground.
§ Mr. Jim Craigen (Glasgow, Maryhill)
I think that we are all in favour of reducing the incidence of dental decay. If the Government brought forward legislation to reduce the sugar content in many of our foodstuffs and soft drinks, would not that have a significant effect in reducing the incidence of caries?
§ Mr. Clarke
I agree with both those propositions. We engage in campaigns of health education through the Health Education Council and others, pointing out the effects of sugar on dental decay and inviting people to adjust their diets. But for the reasons which I gave earlier, fluoride in the water goes way beyond that. The two are not mutually exclusive. However much one may try, through health education, to advise people about reducing the amount of sugar in their diet, one will not reach more than a certain proportion of the population. Placing fluoride in the water has proved to be more effective.
§ Mr. Clarke
I should like to answer one hon. Member at a time.
The hon. Member for Glasgow, Maryhill (Mr. Craigen) began by saying that he shared the view, which I am sure we all share, that we should reduce the incidence of dental decay. But if the Bill fails, it will not be open in any locality for local people and their authorities to decide that they want to introduce what has been proved to be the most effective single measure for reducing the incidence of dental decay in this country. If hon. Members vote against the Bill, they may have profound reasons—and some of my hon. Friends obviously think that they have—for doing so. However, they must not run away from the fact that in voting against it they will be rendering illegal a safe measure for reducing the incidence of dental decay which has proved to be extremely effective.
I have explained the Government's position. We have taken a cautious step. We should not have taken any new step had it not been for the recent judgment. Without that we should not have altered previous law or practice. Faced with the Strathclyde judgment, the Government had three choices. The first was to leave the law in England, Wales and Northern Ireland in the uncertain state that would result from Government inaction. The second was to introduce a different law relating to pressure or 86 compulsion to spread fluoridation. The third was to restore the law to what it had always been assumed to be. By doing that we restore the power of the local decision, which has been assumed to exist for over a quarter of a century, so that localities which want fluoride can continue to have it. We chose the last course, which is sensible and reasonable. I hope that the House will give effect to it and give the Bill a Second Reading.
§ Mr. Michael Meacher (Oldham, West)
The Minister began by saying that this was a modest Bill. He will be the first to agree that modesty is no guide to hon. Members being readily able to accept a measure. Some people may have thought that health and the National Health Service were simple matters. Frankly, although we are for it, fluoridation follows hard on the heels of Warnock, surrogacy and experimentation on embryos and hon. Members are disabused. We recognise the element of genuine and sincere controversy. Strong views are taken about some aspects of the proposals and so we recommend a free vote on the Bill.
That does not mean that the majority of us have serious doubts about the beneficial health consequences of fluoridation. In many parts of the world it has been shown that the incidence of dental caries varies inversely with the fluoride in drinking water. The higher the level, in water, the lower the level of caries in the community.
The Bill proposes fluoride at the level of one part per million—the optimum level. Since only 500,000 people here drink water containing natural fluoride at that level, the potential exists for a substantial gain in reducing dental caries throughout the country. Only 10 per cent of people here drink water artificially fluoridated to that level.
Such a gain would not be trivial and it should not be underestimated. Caries is common and unspectacular, but it should never be regarded as inevitable and it is certainly not trivial. The 1983 child dental survey shows that by the age of 15 years, on average six of the 28 permanent teeth of children are either decayed, missing or filled. Caries is the principal reason for dental extraction. It is a disturbing comment on the nation's health that a recent survey found that about one third of a sample of people over the age of 16 in England and Wales had had all their teeth extracted.
The economic cost to the nation must not be ignored. Dental caries is one of the most costly diseases. The treatment requires expenditure by the National Health Service of over £200 million each year in England alone. That is a substantial sum. It is also estimated to be responsible for the loss of over 2 million working days a year. Its prevention or reduction in terms of the individual's health and to the nation as a whole is a prize worth striving for. That is generally agreed.
§ Mr. Nicholas Fairbairn (Perth and Kinross)
Expenditure of £200 million is dramatic. What proportion would be affected by fluoridation, since it affects only children up to the age of 12 years?
§ Mr. Meacher
Fluoride affects young children, so the impact on adults will not be felt immediately. However in the long and medium terms the effect will be dramatic. As the Minister said, this is by far the most cost-effective means of reducing caries in the community in the medium term. Fluoridation is justified for the reasons that I have given. It is the most economical means of reducing dental caries.
87 It is sometimes said that fluoridation is unnecessary because equally effective means of attaining the same result are available. Caries would decline if people reduced their intake of sugar and refined carbohydrates. I agree that we need more aggressive campaigns to achieve that. Such campaigns are not alternatives, but additional. I doubt whether they will achieve the desired result on the scale required.
§ Mr. Craigen
The problem is double-edged, because it is not a question of people regulating their own diets. People have no choice about the amount of sugar in soft drinks, for instance. The sugar content is often higher than it has to be.
§ Mr. Meacher
That is true. There should be more parental control to discourage children from eating too much sugar and sweets, and the food industry should be more strictly regulated. Consumers should be given more information about the ill consequences of food which they buy. That could have a considerable effect, but it does not detract from the argument for fluoridation.
§ Dr. M. S. Miller
Does my hon. Friend accept that there is doubt about sugar being the cause of dental caries? I do not speak on behalf of the sugar lobby, but my hon. Friend might be surprised at the so-called "evidence" that sugar does not have the effect which many believe it does have on teeth?
§ Mr. Meacher
My hon. Friend the Member for East Kilbride (Dr. Miller) speaks with greater medical knowledge than I. I have been led to believe that sugar is one of the main causes of dental caries. If I am wrong, I stand corrected. That does not detract from the central force of the argument about the effectiveness of fluoridation.
As the Minister said, the most health-conscious people are most affected by such campaigns. The great advantage of fluoridation is that it benefits most the poorest and the ill-informed— those who are not reached by other initiatives, however desirable in principle they may be. For instance, motivation by parents is needed to ensure that children receive the proper dose of fluoridation tablets over the years. Topical applications are time-consuming and have only limited effect.
It is fair to say that this must surely be one of the most exhaustively researched public health measures of all time and from all the evidence it is reasonable to conclude that fluoridation is by far the most cost-effective means of reducing dental caries in children.
Out of the abundance of evidence I cite only two examples. Birmingham began its fluoridation scheme in 1964. At the start of the scheme, five-year-olds in the Northfields suburb were found to have much the same level of tooth decay as in neighbouring Dudley, which did not fluoridate. Within only six years the Northfield rate had been halved, while the Dudley rate remained much the same.
Secondly, research has shown that five-year-olds living in fluoridated Bromsgrove have three times the chance of never having tooth decay compared with children of the same age in non-fluoridated Hereford, not far away. Conversely, it was also found that a child in Hereford had 13 times more chance of having at least 10 or more teeth 88 decayed, missing or filled. One could give many other examples, but those are telling. There is much more evidence, both nationally, as the Minister said, and internationally and such evidence seems to me at least to be conclusive.
Nor is the benefit of fluoride, as the hon. and learned Member for Perth and Kinross (Mr. Fairbairn) seemed to suggest, entirely confined to childhood. For instance, in naturally fluoridated Hartlepool, probably the area with the highest natural fluoride rate in Britain, it has been found that there is significantly less caries than in York, not far away, which has a much lower fluoride level. That improvement is found not only at the age of five, but also at the age of 15 and for adults over 45.
However, I recognise—it would be difficult not to do so after listening to the Minister's reception—that the main objections to the Bill are not generally directed at the medical evidence but at wider considerations. Perhaps the most prominent argument is that, even if fluoridation is beneficial and safe, it still encroaches on individual liberty. The response earlier makes that clear.
That would be a lot more plausible if those who made that objection did not also accept the regular addition of several other substances to drinking water such as copper sulphate, aluminium, calcium and chlorine.
§ Mr. Meacher
Indeed. That has a different effect but it is equally beneficial, desirable and harmless. If 40 chemicals are put into drinking water, the addition of one further does not seem to be a cause of such tremendous controversy. Lord Avebury, a well-known and notable advocate of many civil liberties causes, has said:What is at stake is not the erosion of liberty but … 'the erosion of millions of teeth and the resultant suffering and misery of thousands of children, which fluoridation would go far to prevent'.
Another major complaint is that fluoridation represents a form of mass medication. Frankly, it does not. One cannot emphasise too strongly that fluoride is a natural constituent of water supplies. It occurs in Britain in natural form in concentrations of up to 5.8 mg per litre—nearly six times the level proposed under the Bill.
The adjustment of the quantity to an optimum level cannot be compared with the addition to the water supply of a substance not found there ordinarily. Equally, the phrase "mass medication"—the term most often used by opponents— seems to me at least both emotive and inaccurate as it is not a means of curing disease. I will say no more than that. I should have thought that a substance which had the effect of maintaining medical or dental health is more in the nature of a food or a nutriment than a medicine. It is a public health measure not unlike the adding of iodine to salt, calcium, iron and vitamin B to flour, and vitamin D to margarine.
For those reasons, I take the view that the so-called ethical objections to fluoridation do not stand up to scrutiny. I know that that is not a view shared by everyone and I respect the force of their argument and the way in which some people regard that as decisive. But I do not think that that is a view that is widely held in the population.
Nor do the claims that there are damaging medical side effects, including the cancer scare, which the Minister has gone to some lengths to dispel, hold water, although that is perhaps not the appropriate analogy. I am very much a 89 layman in such matters, as most hon. Members are, but I am impressed by the fact that Royal College of Physicians made a special study of all the available data in the mid-1970s and it concluded that there was no scientific or statistical basis for allegations of morbidity caused by fluoridation. A large list of conditions was discussed in depth. I know that there have been later studies, as the Minister mentioned.
I am also impressed by the fact that that view has been corrobated over and over again in similar studies by the British Medical Association, the British Dental Association, the Royal College of Surgeons of England, the Royal College of General Practitioners, the Royal Commission on the National Health Service, the British Paediatric Association and the Health Education Council. I could mention many others and they are all, by any standards, distinguished bodies in Britain.
I should be the first to recognise that those with an Athenasian inner certainty of their correctness in the face of the virtual unaminity of view of all the established bodies in Britain will not be persuaded. But in my view at least the medical evidence is overwhelmingly conclusive. Indeed, it is far more extensive than is strictly needed in order to warrant action now being taken on a wider scale to harness the preventive health potential of fluoridation.
The Royal Commission on the NHS went rather further and said:We are certain that it is entirely wrong to deprive the most vulnerable section of the population of such an important public health measure for the sake of the views of a small minority of adults.In other words, how can one justify not giving the child who lives in Wolverhampton or Salford the same protection against tooth decay as the child who lives in Birmingham or Watford already enjoys?
§ Mr. Best
May I accept, ex hypothesi, that the addition of fluoride to the water is not mass medication but preventive medicine? The hon. Gentleman's faith in the medical profession is touching, but will he say which other substance of preventive medicine is administered by doctors not knowing the number or identity of the recipients or the total quantity to be ingested?
§ Mr. Meacher
There are many. Salt is one. I am trying to think of the answer. It is only fair to say that one needs notice of such questions. It certainly can be answered and I should be glad to write to the hon. Member after the debate. But even if there were no immediate comparison to be made with any other product it would not prevent the application of fluoride up to a given optimum level if it has beneficial results. We do not need a precedent. We can take a view on the merits in their own right and that is what we should do.
§ Mrs. Edwina Currie (Derbyshire, South)
Is it not a matter of fact that we, by regulation, add vitamins to flour, and that one of the proposals for eradicating rickets among Asian families is to add vitamin D to chapati flour? Are those not examples in exactly the terms suggested?
§ Mr. Meacher
There is indeed, the important precedent of the bread and flour regulations. Iron and vitamin B are added to flour.
I do not wish to rest entirely on the view of doctors, although they have some right to special expertise in this area. The view is also held by over two in every three 90 persons in the country. A National Opinion Polls nationwide survey in 1980 found that 67 per cent. of the people interviewed thought that fluoride should be added to water if doing so could reduce tooth decay. Only 16 per cent. opposed adding it. In other words, four times as many support fluoridation as are against it.
Hon. Members will be the first to say that we do not make policy on the basis of the vagaries of opinion polls, and I accept that—they in no way indicate rightness or otherwise on this issue—but the results of that poll showed decisively that what is now proposed by the Government commands widespread public support. Significantly, for the purposes of the Bill, this general view, so widely shared by doctors and the population at large, was also accepted by Lord Jauncey in his Strathclyde judgement in June of last year, as the Minister said.
The judge unequivocally repudiated the medical evidence against fluoridation. He categorically asserted that it was safe and effective— on the basis of a 120,000-word judgment and the examination, which had taken more than a year, and which had been one of the most thorough and comprehensive examinations of the evidence— and ruled only on a technicality that Strathclyde was acting ultra vires in adding fluoride because fluoridation had begun to be administered in Britain only in the 1950s, and it was therefore unlikely to be covered by the duty under the Scottish Water Act 1946 to provide wholesome water. The judge stated:An individual's right to choose how to care for his own body should only be encroached upon by statutory provisions in clear and unambiguous language.I agree, but that is a legal comment, not a moral judgment. It is in keeping with his overall legal judgment—namely, that the law needs to be clarified if fluorides are to be added to drinking water—and I think it is fair to say that that is essentially why the Bill has been introduced tonight.
It is because I believe that the evidence is clear and conclusive that fluoride in water, either naturally or added at one part per million, substantially reduces dental caries throughout life; that water with this concentration of fluoride in a temperate climate is safe, irrespective of the hardness of the water; and that fluoridation is much more cost-effective than any of its alternative topical applications, that I support this measure, clarifying the rights of water authorities by empowering them to add fluoride up to a given optimum level at the request of health authorities. It is the least response that this House can justify.
I hope, therefore, that this modest Bill, which offers a substantial potential advance in the nation's health, will be carried overwhelmingly tonight.
§ Mr. Nicholas Fairbairn (Perth and Kinross)
It is strange indeed for me to listen in this House to the hon. Member for Oldham, West (Mr. Meacher) and the Minister taking the view that the judgment of an upper-class Right-wing Scottish judge should be the basis for legislation. Indeed, it is even more astonishing that any decision of a Scottish court should be regarded as the basis for shaking the foundations of English arrogance and altering the natural belief of the English in their statutory powers.
§ Mr. Fairbairn
Go and take some bromide.
I do not declare an interest but, because the Minister suggested—it was an unfortunate suggestion—that those who oppose fluoridation may do so for flippant, absurd, transient or fantasised reasons, I should perhaps tell the House that before I did moral philosophy I did medicine and that after I did moral philosophy I did law. I believe that fluoridation fails massively on all three principles.
If Lord Jauncey is to be quoted—fancy having a Scottish judge quoted in support of any constitutional change—let us remember that he said:To use the water supply for mass medication"—the hon. Member for Oldham, West said that it was not medication; I refer him to page 367 of Lord Jauncey's judgment—is without precedent or legal authority and is illegal.Tonight the Government are seeking to make what is illegal legal—[Interruption.] It is illegal in Scotland. It is not because they believe that it is illegal in England and Wales but because they fear it may be illegal.
Fluoride is a potent catalase poison which is cumulative. Only one third of fluoride which is ingested is egested and, depending on the pH or acidity or alkalinity of the body substances, the amount excreted is vastly altered. Indeed, in acidotic conditions, the amount which is not excreted and is accumulated is vastly enlarged.
Nobody on any side of the argument denies that it is toxic. Indeed, in the United States pharmacopoeia, it is linked and bracketed with arsenic, lead and cyanide as a poison. There are innumerable papers on the adverse effects at the volume proposed of one part per million, although in clause 1(5) the concentration is to be contained at that level onlyso far as is reasonably practicable.As I say, there are innumerable papers by the most distinguished scientists, many of them Nobel prize winners, on the toxic effects of fluoride, and I will give a few examples, although it is not on the medical and scientific matter that I rest my case. Indeed, if there were no medical and scientific case against it, I should still oppose it totally.
In India, Srikanha and Susheela have identified the characteristics of skeletal fluorosis such as calcification of the ligaments, joints and deformation of the bones and so on in many states where the level of fluoride is less than one part per million in the water. Of course, one of the variables is what else is in the water. In this country, there happen to be in most parts of the country where there is fluoride to that level large deposits of calcium and other minerals which are beneficial for the teeth and which to some extent lack fluoride.
In Turkey, the Hacettepe university has undertaken enormous research into the fact that fluoride at that level delays and prevents the healing and fracture of bones. In Sweden, at the Karolinska institute, it has been demonstrated that less than the level of 1 ppm of fluoride in the blood causes a surge of fluoride retention in many subjects. In 1976, Albert Schatz related the incidence of fluoride to the infant death rate in Chile. In Grand Rapids, where they had fluoridation, dental fluorosis, or discolouring and mottling Of the teeth, occurred in 19 per cent. of the white population and 39 per cent. of the black population, which relates to the other ingested compounds. There are many variables.
In West Hartlepool, which the hon. Member for Oldham, West quoted with such approbation, there is a 92 natural proportion of 1.5 parts of fluoride per million in the water. There is mottling of the teeth of 85 per cent. of the population and mottling or dental fluorosis to the distress point of 25 per cent. of the population. In osteoarthritis, the microcrystals of apatite are promoted and aggravated by fluoride. Even Dr. Donald Taves, who is such a promoter of the concept of fluoride, acknowledges its major effects on kidney malfunction. In general it affects hormones and thyrotoxine, locks up calcium, affects bone structure and affects the heart. It eventually causes a brittleness in the teeth which is far more expensive in the adult than any benefit that there may be in the delay of caries in a few children.
There are variables. There are some who are exquisitely sensitive to fluoride and show all the symptoms of nausea, diarrhoea, ulceration, internal skin lesions, fatigue and pruritis. If the hon. Member for Oldham, West is concerned about health, he should listen to arguments that suggest that members of the public may be put at risk.
There is the concept of variable thirst. There are conditions such as diabetes myelitis, diabetes incipitus, in which there will be different drinking patterns. One of the characteristics of fluoride toxication is increased thirst. This means that the variables result in different doses for different people and in different patients having different reactions to those doses.
In his judgment, Lord Jauncey said that it was not proved that fluoride was harmful, but he said that he could not exclude that it caused cancer. He held that it would cause dental fluorosis in some children. I do not take the view that judges are the best arbiters of scientific evidence in cases where for about 200 days and more some of the most experienced and dedicated men, unmotivated by any interest or prejudice, take opposite scientific views on the effect of fluoride. That, to me, leaves the case thoroughly not proven.
And all for what—so that we may reduce by 50 per cent. tooth decay, or delay it, in some children under 12 years of age. That is contradicted entirely by John Colquhoun, the retired chief dental officer of New Zealand. He stated last year that fluoridation had no effect on caries in children. In Birmingham, where there is fluoridation, there were 30 fillings per 100 teeth in 1964 and 40 per 100 in 1976, and an increase in milk teeth of 100 per cent.
Tooth decay is caused by many reasons, such as chemically adulterated food. As the hon. Member for Glasgow, Maryhill (Mr. Craigen) has said, it is caused by false chemical additives, be they sugar or otherwise. It is caused by neglect of the teeth or by excessive sweet eating.
Tooth decay, whatever its discomfort, is no worse than alopecia. It is no worse than athlete's foot. It is a nuisance, but it is never fatal. I know of no hon. Member, whether he has his own teeth, false teeth, filled or missing teeth who is thereby at any disadvantage.
§ Mr. Fairbairn
No; I shall not give way. I was relieved to discover that my hon. Friend was in favour of fluoridation because that confirmed my conviction against it. [HON. MEMBERS: "Give way".]
§ Mrs. Currie
Is my hon. and learned Friend seriously saying that no one has ever died under general anaesthetic for dental treatment? If he says that, my hon. Friends who live in or who represent Birmingham can correct him immediately.
§ Mr. Fairbairn
I am sure that many people suffering from piles, myopia or other ailments have died under anaesthetic, but that has nothing to do with tooth decay. It is to do with bad anaesthetics. If that is the basis of my hon. Friend's argument, I can say only that I hope she will take a general anaesthetic frequently. It is not for those who are against fluoridation to prove our case—great though the evidence is from most distinguished scientists. It is for the Government to prove their case. They must prove their case not on the balance of probabilities or possibilities or beyond reasonable doubt, but beyond all doubt, because so many distinguished scientists cannot be wrong.
I base my argument not on science but on principle. If the case for fluoride were proved, I would still object to it on principle. As Lord Jauncey said,To use the water supply for mass medication is without precedent or legal authority, and is illegal.As the Under-Secretary of State for Health and Social Security— my hon. Friend the Member for Oxford, West and Abingdon (Mr. Patten)— said, when the Government were introducing a plan to advise people what to eat:Our job is to do no more than inform the public about the consequences of their actions for their health. Of course it is for individuals themselves to decide what to eat"—I assume that he also meant what the individual decides to drink—and w hat risks to run.We have a Conservative Government trying to legalise compulsory force-feeding—in other words, to legalise assault. I doubt that that action would stand up in the European Court of Human Rights. Never has any remedial or preventive measure been made legitimate, far less compulsory, except in the interest of the person concerned. Force-feeding of the insane is exceptional, but all medical treatment of the sane requires the consent of the patient or, if he is comatose, of those who are able to give that consent. No patient in this country has ever been treated without consent. This measure suggests that every citizen should be compelled to be medicated—not for his own benefit but for the possible benefit of some other citizens who form a minute proportion of the population.
Vaccination is in the interests of the person who is vaccinated. Seat belts are in the interests of the person who drives. No measure of compulsion forces a person to undergo any measure that benefits someone else, and certainly no medicinal measure does so. The legislation proposes that we should all be compelled to ingest a substance—whether it is harmless does not matter—so that some people may obtain benefit for a complaint which is never fatal and which is, at most, irritating.
The medical profession recently predicted that 1.25 million homosexuals will die of AIDS by the end of the century. If the medical profession discovered a water-soluble substance which could render that disease not fatal—caries is merely an irritant—is it to be suggested that it should be added to our drinking water? If a vaccine were to be found which reduced the affects of schizophrenia, 94 should we all drink it? If the world population or rape crises were considered to be equally critical, should something be added to the water to alleviate those threats?
There are four substances in the atomic scale of elements which attract a common club—the halogens. They are fluorine, chlorine, iodine and bromide. Iodine appears in traces in water. It is harmless and tasteless.
§ Mr. Fairbairn
Salt is not a halogen, and it is not an element either.
Chlorine is added so that every member of the public can drink the water provided in safety. It is now proposed that fluorine should be added so that some people will benefit. Hon. Members who were in the Army will remember that the fourth halogen, bromide, was added to tea, called No. 9, to reduce the sex urge.
§ Mr. Fairbairn
In the Army one could choose not to drink tea, but one cannot not drink water because of this legislation. It is important to remember that because fluorine is tasteless, citizens have no way of telling whether it has been added, and the Bill has no method of preventing the dosage ingested from causing fluorosis.
I cannot but be amazed that the Government, who are dedicated to freedom and hostile to totalitarianism—[Interruption.] The fact that the hon. Member for Oldham, West supports the measure suggests that it is totalitarian,—who are suspicious of bureaucracy and hateful of tyranny and assault should be the author of a proposition to compel the public to swallow something which will be of no benefit to the vast majority of those who swallow it and may do great harm. A Government who object to local authority expenditure are compelling local authorities to add to that expenditure. The measure is contrary to the simple freedom of being allowed to drink potable water and of not being compelled to swallow anything which has no possible purpose for oneself.
The Minister said that we were not breaking new ground. We are breaking new ground in principle in saying that everyone must ingest what might be good for a few people, and that everyone must undergo medication for the sake of a minute proportion of the population.
If the measure passes tonight it will be because the payroll vote is as unfree to vote against it as we shall be unfree to drink water which is free of a substance which will do none of us good and may do all of us harm. It is not a matter of scientific argument; it is a matter of great principle. The Bill breaches a principle of freedom which has never been breached in this country before.
§ Mr. J. Enoch Powell (South Down)
It has been a profoundly evocative and moving experience for me to attend the introduction of the Bill in the House tonight as the second motion on the Order Paper on a rather dull day. Perhaps the House will bear with me for a few minutes to permit me to put on the record the reasons why that is particularly so.
It came to pass many years ago that the scribes in the Ministry of Health gathered together. They came to me and said, "O Minister, behold, it is the season of private Members' Bills. Go, therefore, to hon. Members who have been successful in the ballot and persuade them to 95 introduce a Bill to legalise fluoridation of the water supply, for there is an exceedingly learned Attorney-General who has given his opinion that such a procedure requires statutory authority." I answered, "Not so, for if there should arise contention or tumult in that House, then the Bill may not pass, and the last state will be worse than the first. Wait, therefore, and possess yourselves in patience." They waited and they possessed themselves in patience. And it came to pass, after many days, that that Attorney-General went elsewhere and was succeeded by another Attorney-General.
Then I called to me the scribes from the Ministry of Health and said, "Go now to the new Attorney-General and consult him on the question whether it be required that there be statutory authority for fluoridation of water supplies and omit not to tell him the opinion of his predecessor, for I have observed that the men of the law, the more eminent they are, the more they do rejoice in disagreeing with each other." So the scribes went and asked as they were bidden and, behold, the second Attorney-General gave an opinion which was adverse to the opinion of the first Attorney-General. And they came and told it to me. I said, "Take up your pens and write quickly unto all the health authorities that are in the kingdom, and tell them that if they consider it to be in the interests of health in their respective areas, they may enter into agreements with the water authorities to fluoridate the water supplies."
I do not repent of that episode in my ministerial past. On the contrary, I am convinced that the decision that Ministers have had to take since the judgment in a Scottish court has been rightly taken by them, as the procedure brought into action some 25 years ago in the manner which I have described was also justified on grounds which a layman might rationally establish.
First, there is overwhelming evidence that the presence of fluoride in drinking water avoids a great mass of dental caries in young persons. It does not avoid dental caries in all persons, but it is beyond doubt demonstrated to be beneficial to all persons in their younger years in respect of their dental health. It is also, in my view, overwhelmingly and crushingly demonstrated that the presence of fluoride in water— indeed in proportions considerably higher than are proposed to be artificially produced—has no morbid consequences whatsoever.
I found most impressive, in arriving at that conclusion, the fact that in very substantial areas here in this country fluoride up to six times the proportion of one part per million has been drunk for generation after generation without it having proved possible to indicate any disadvantage in terms of health or any special or unusual morbidity amongst the populations which had drunk that water. I must admit that I found that demonstration even more impressive than the mass statistical experiment which has been carried out, of course more massively than ever in the past 25 years, in the artificial fluoridation of the water supply.
§ Dr. M. S. Miller
To do justice to the views of the hon. and learned Member for Perth and Kinross (Mr. Fairbairn), does the right hon. Gentleman agree that there is one side effect—
§ Mr. Powell
I am much obliged to the hon. Gentleman for crossing that "t". However, the massive extent of fluoridation that has taken place makes the fact that there is no demonstrated correlation of morbidity with fluoridation so impressive as to be virtually irresistible.
I am brought, therefore, as was the Minister, in conclusion to the proposition that fluoridation of the water supply is compulsory medication of the population. I must confess that I have been unable, despite the term having apparently been used by a learned judge, to understand how the term "medication" can in any proper sense be applied in this context. There is, of course, no choice which any one of us exercises over the public water supply in the areas where we live. In the areas where fluoride is present naturally, there is no choice available to any member of the population as to the fluoride which he ingests from the water supply. It is in the very nature of a public supply that there cannot be personal choice, except by extreme contrivance. That applies, for example, to all measures such as those related to the purity of the air, the removal of noxious fumes and so on, that are adopted in the cause of public health. They are measures of which the consequences, by their very nature, and by the very nature of the vector medium, are bound to apply to all members of the community.
Fluoride is not a substance introduced into water to produce a specific medical effect upon certain individuals. It is not, as I understand it, medication in any natural sense. It is rather—I think that the word was used by the hon. Member for Oldham, West (Mr. Meacher)—a rectification of the content of the water supply, so that all areas can enjoy the same advantages as are enjoyed automatically in those areas where fluoride is present naturally in the water. I must therefore tell the House I have had to conclude that I, at any rate, can find no moral or libertarian reason why the advantages to be obtained from a water supply with a one part per million element of fluoride should not be made available to the people of this country at the discretion of the democratically elected local health authorities.
§ Sir John Page (Harrow, West)
Never before have I had the opportunity to follow the most famous prophet of Westminster. Being neither scribe nor Pharisee, I may not do justice to the speech of the right hon. Member for South Down (Mr. Powell), although I think that on the whole the Pharisees have acquired a reputation that they did not really deserve. Of the many speeches that the right hon. Gentleman has made, I think that I enjoyed his contribution today the most.
It is not always my role in the House to pour oil on wholesome but troubled waters, but today I shall seek to be moderate, modest and uncontroversial. First, I declare an interest as a director of a water company. My short argument will be devoted exclusively to the technical and administrative aspects of the Bill. I shall make no argument for or against fluoridation. I wish to remain entirely neutral on that, although I intend to vote for the Bill as it goes some way to clarify the legal uncertainties which currently face the water supply industry, as my right hon. and learned Friend the Minister for Health so honourably admitted in his speech.
For slightly more than 25 years, according to the right hon. Member for South Down, water authorities have added fluoride to water supplies at the request of health 97 authorities and under the umbrella of an indemnity provided initially by the Ministry of Health, and that rather loose arrangement has continued to this day. The Bill goes some way towards formalising the existing scheme.
Three aspects of the Bill—one major and two minor—are causing considerable worry and the industry will be most disappointed that my right hon. and learned Friend's speech today ignored the serious arguments and representations that it has put to him.
§ Mr. Kenneth Clarke
It may have been drowned in the excitement caused by one aspect of my speech, but I certainly tried to answer the representations made by the industry— albeit en passant, as they were essentially technical matters. For instance, I explicitly stated that health authorities would meet all the costs. That was included in my speech as the result of the water authorities' representations. I hope, therefore, that my hon. Friend will not take the view that the Government have ignored the arguments put by the water authorities.
§ Sir John Page
I am grateful to my right hon. and learned Friend. I listened to his speech with great dedication, but I must have missed his comments about costs, to which I shall return shortly.
Representations were made to the Minister by the Water Companies Association, the president of which is our distinguished ex-colleague, Sir William Elliott, as well as from the water authorities. I quote just one paragraph, which clearly summarises the worries of the industry. The Water Companies Association states:Our most serious concern arises over the fact that, as drawn, the Bill places the responsibility for the decision to fluoridate both on health authorities and water undertakers. In our view, this is quite wrong. Not only will this give rise to the difficulties which always occur whenever responsibilities are 'split' but it is quite inappropriate that water companies should be required to involve themselves in a decision which is essentially political, medical and ethical. Water companies have no wish to involve themselves in these issues and certainly they are not medically competent' to do so. The decision as to whether fluoridation is appropriate should be left entirely to health authoritiesor, in the water authorities' view, to the Government as well as the health authorities.A water company should be required to comply with a request to fluoridate from a health authority subject only to the proviso that the water company could refuse to comply with such a request on the grounds of technical feasibility.
The Bill puts on water companies and water authorities a burden that they should not be asked to carry. It is the statutory duty of water undertakings to supply wholesome water. To add or not to add—that is a question that they should not be required to answer.
§ Mr. Kenneth Clarke
It would be more difficult for me to deal with these points if I waited until later on. My hon. Friend's point is perfectly valid. The answer to it is that the Government took a conscious decision merely to seek to reinstate the existing policy and practice. Had we conceded the case of the water companies that they should have no discretionary power and that the responsibility should rest with the health authorities alone, the Government would have been attacked by a number of my hon. Friends for making fluoridation easier and removing an existing element of local discretion. The only reason why we have not been able in the Bill to meet the requests of the water undertakers is that we have been, if anything, over-scrupulous in meeting the concerns of my hon. Friends that we should not make it any easier than it is now to add fluoride to the water.
98 The decision of two local bodies will therefore be required—the health authority and the water authority—before fluoride can be added. It will be up to the water authority to decide to what extent it wishes to be guided by the health authority.
§ Sir John Page
I am disappointed by that explanation. The vague messages previously sent down from the Elephant and Castle are now to be inscribed in the tablets of the law. We have an opportunity sensibly to place the responsibility where it should rest—either on the area health authority or on central or local government. I had hoped for a different reply from my right hon. and learned Friend. Perhaps he will think about the matter again, during the passage of the Bill.
My right hon. and learned Friend says that he mentioned in his speech the question of cost. I understand that the question of cost is not covered in the Bill, and that the responsibility would remain with the area health authority. If that is so, I am extremely grateful.
I should like my right hon. and learned Friend, or the Under-Secretary who is to reply to the debate, to clarify one more point. If the Bill were rejected tonight—I hope that it will not be—what would be the status of the existing agreements between the health authorities and the water authorities? I presume that they would not be affected.
§ Mr. Kenneth Clarke
My hon. Friend the Under-Secretary is anxious that I should reply to this point now as he expects to have other matters on his hands when he replies to the debate. If the Bill were rejected tonight, the position of England would remain in doubt, as it is now, and would await litigation. In Scotland, a Mrs. McColl has challenged the satisfactory arrangement described by the right hon. Member for South Down (Mr. Powell) and fluoridation has been declared ultra vires. There are actions pending in England and presumably sooner or later someone would force such an action through and obtain a judgment for or against the existing arrangements. Water authorities could either carry on with their present arrangements until such time as they were challenged in court or they might decide, because of the continuing legal doubt and the refusal of Parliament to resolve it, to err on the side of caution and end the present arrangements. That is not satisfactory, and that is the main reason why we felt compelled to legislate, and commend the Bill to the House.
§ Sir John Page
I have never had so many wise responses from a Minister and I have one more question for my right hon. and learned Friend. Why does clause 3(2) allow a period of two months from the time that the Act is passed before it comes into force? Is that period to allow companies to renegotiate existing agreements—if that is the case it is not long enough—or is to give those involved a short breathing space after the Bill has been passed? Will my right hon. and learned Friend say that during this two month period, after the Bill is passed and before it comes into operation, existing agreements will remain as they are at the present time?
§ Mr. Kenneth Clarke
My hon. Friend is obviously anxious to investigate this question. I am a little uncertain about the two-month period. I think that the answer will be that it is the usual practice in drafting, and if a better argument is produced in Committee, no doubt it will be 99 changed. On the important question of what happens in that two months, I am sure that the existing indemnities would carry through existing agreements, and there is no prospect of anybody litigating and getting the agreements declared illegal. In practice, there would be no threat to the existing arrangements and water authorities can be untroubled while waiting for the Act to come into force.
§ Sir John Page
Again, I am extremely grateful to my right hon. and learned Friend.
Although the points I have made are undramatic and unemotional, which will perhaps be unusual in the course of this debate, they are of vital importance to the authorities and companies that are doing their best to supply wholesome water to the community.
§ Mr. Michael Meadowcroft (Leeds, West)
I am sure that the problems of water authorities are important, but I shall return to issues of principle in the Bill. As the debate has progressed, it has become clear that this is one of those issues—fortunately for politicians, these are very few—in which there is a genuine clash of principle behind the different arguments. I appreciated the peroration of the speech of the hon. and learned Member for Perth and Kinross (Mr. Fairbairn), although I did not accept all the points that he made earlier in his speech.
Quite rightly, there is a genuine fear of mass medication among the public. I cannot concede that someone would enter lightly into proceeding with a Bill such as this if they were not convinced about it. Those who vote in favour of the Bill must also be convinced that the arguments have been thoroughly tested and the balance of advantage lies with those who wish to see a particular form of prevention of dental decay being utilised in this form. Therefore, I am prepared to put on one side as being the worst of arguments the crucial principle that we must not lightly consider giving a substance to everybody in general in the community without being sure that we can do them good.
The hon. and learned Member for Perth and Kinross appeared to accept that the compulsory wearing of seat belts was legitimate, because it did good to oneself rather than to other people. However, there was a paradox in what he said, because it was accepted even by those such as myself who were advocates of compulsory seat belts that in a minority of cases, the wearing of seat belts may be harmful to a person. For example, the car might catch fire and the person might be unconscious. The argument always lay on the balance of advantage, which might come from statistical sources, of wearing a seat belt. Therefore, the hon. Gentleman's argument is defective.
Some members of the Liberal party, not only in the House but in the country, believe fervently in the arguments put forward by the hon. and learned Member for Perth and Kinross. The argument has two bases: one is the fear that this is a dangerous precedent—that is a legitimate fear—and the other is a fear of the unknown. Many people believe that fluoridised water may cause some side effects about which we know nothing now, but which could emerge in generations to come and which would cause us to wish that we had not done it.
However—no doubt this has happened to all right hon. and hon. Members— many of my political colleagues in the Health Service have urged me 100 passionately to support the Bill, because they believe strongly, having studied all the arguments and the research, that the balance of argument lies with their case. The most telling fact is that during the 20 years or more since the argument has been contested in and out of the public arena—I have been involved with it since 1962 or 1963—with the continual stream of material being circulated in opposition to the fluoridation of water, and even in the light of the terrible tragedy of thalidomide and the side effects of other drugs, which have increased considerably the sensitivity and awareness of people in the medical profession of the possible problems of drugs, no professional health body has changed its mind about the efficacy of fluoridating water. That is extremely significant, because people have become much more sensitive to the effects of drugs, and have become much more concerned with the labelling and contents of food and health in general.
My responsibility in the House is for health, and the Minister will recall that I have belaboured him for not giving as much attention as I believe he should to prevention. I have urged him to maintain the inclusion of thiamin and calcium in flour and bread; I cannot now say, "But I do not wish you to assist people by fluoridating water." I would not wish it to be thought that the fluoridation of water is a panacea that will solve all the problems of dental health. If the Government are seriously worried about tooth decay I hope that they will consider the adverse effects of sugar in the diet, and look to the better prevention of dental decay by the better labelling of food and by educating people about the contents of foods.
There was a suggestion that the statistics may not be as powerful as has been suggested because other substances in the water in some places where fluoride has been added may have assisted in reducing dental decay. However, the evidence of Birmingham during the past 20 years must counter that suggestion. It is not suggested that dental decay was already low or that in controlled neighbouring towns and cities the level of decay was similar, because those other substances were also present in the water. During those 20 years, dental decay has been reduced dramatically. For example, the number of children attending clinics for the relief of toothache dropped from over 10,000 in 1965 to under 2,000 in 1977. Only 62 Birmingham children were supplied with false teeth in 1983—about one in 3,500 of the school population. In neighbouring Wolverhampton, the corresponding figure is one in 280—about 12 times higher.
The protection offered by fluoride has to begin at birth to do the most good. If fluoride is put into school milk or into toothpaste, it is too late to have the maximum effect. Fluoride occurs naturally in many areas and it is significant that people living in those areas have never suggested that they wished fluoride to be removed from their water supply. None of the studies and evidence, even from opponents of fluoridation, have suggested that fluoride should be removed from water supplies.
The one weak point in the Government's case is that the authorities that are to have power to implement the Bill when it becomes an Act are not directly elected. The right hon. Member for South Down (Mr. Powell) said that it would be better if fluoridation were introduced by democratic authorities. Sadly, neither health authorities nor water authorities are accountable to the electorate and it is a shame that that weakness in the system cannot be rectified in a short Bill.
101 If the whole population turned against those who have the authority to introduce fluoride, they would not have to resign, face the electorate or ask any outside body for support or approval. With that caveat, I shall support the Bill.
§ Mr. David Atkinson (Bournemouth, East)
As my right hon. and learned Friend the Minister for Health explained, the Bill attempts to confirm the legality of a situation whose legality was not in doubt before the Strathclyde judgment.
The Bill enables the decision to introduce fluoride to be made where it should be made—not at Westminster or in Whitehall, but by those whom we appoint to health authorities because of their special interest in health or their professional expertise. We believe those people to be the best to take into account local opinion, priorities and needs and to do so more objectively than any politician or civil servant could do. I am sorry that several of my hon. Friends want to deny their local health authorities the right to take that decision on behalf of their constituents.
Before health was removed from the responsibilities of local councils, I sat on a county borough council that took a decision on fluoridation. I believe that we took that decision as well as any decision could be taken. All the members were personally briefed by those representing both sides of the argument, we listened to various deputations and we read a wealth of documentation and research relating to experience at home and abroad.
We decided not to introduce fluoride because there was already a high fluoride content in our local water and it did not justify any addition. We took the decision in the best interests of the area that we served and we would have resented Parliament denying us the right to make that decision. Unfortunately, a number of hon. Members are suggesting that local authorities should be denied that right.
Health authorities are not directly elected. The right hon. Member for South Down (Mr. Powell) and the hon. Member for Leeds, West (Mr. Meadowcroft) advocated a return to directly elected health authorities, and we have some sympathy with that view. But I see no reason why those who have been appointed to local or area health authorities cannot make an objective decision. Indeed, my local health authority plans to do so if the Bill is approved, after taking into account a local working party report with recommendations, as well as the views of the local community health council.
I have every confidence in the ability of those who have been appointed to serve on my local health authority, the east Dorset health authority. I shall list the representation: those appointed by the Wessex regional health authority include one hospital consultant, one general practitioner, one nurse, one Southampton university representative, one TUC nominee, seven "generalist members", including voluntary organisation representatives, and five members appointed by local authorities including two from Dorset county council and three from the district councils. That is a pretty representative list, notwithstanding the fact that they are not directly elected.
Very soon, those representatives will have before them a recent dental survey for the area of my constituency which shows that nearly half of Bournemouth's five-year-olds and two thirds of our 12-year-olds suffer from tooth decay. Those figures are very similar to those from 102 national surveys covering non-fluoridated areas. Moreover, we know from national surveys that nearly half the population will have lost at least half their teeth by the age of 40, and in so doing will undoubtedly have suffered great pain, great inconvenience in having to go to the dentist and heavy expenses for dental treatment. That is the sort of information that will come before my local area health authority.
It would be irresponsible to deny the authority those facts in asking it to make decisions on behalf of my constituents. I admit that it is rather tempting to use the free vote tonight to vote against the Bill. Most of the letters that I have received from my constituents urge me to vote against it. Many of them refer to the fact that fluoride is a poison. Much evidence has been referred to tonight, but we have the assurance of my right hon. and learned Friend the Minister that it is not a poison. Obviously, the Government would not introduce such a measure and respected organisations such as the World Health Organisation would not approve of any measure that remotely related to poison.
But of course no one wants to be unpopular. One has to think very deeply before voting against the advice of many of my constituents who have urged me to reject the Bill. However, I would be a party to a sad and retrogressive step if I voted against giving the Bill a Second Reading. It would be sad for present and future generations of my constituents who would never then have the opportunity of enjoying a level of dental health that it has been proved beyond all reasonable doubt would be available to them. They would then be condemned to suffer needlessly the consequences and cost of tooth decay for the rest of their lives. I would not want to be a party to that.
It would also be retrogressive to vote against the Bill because it would mean that future generations in those areas— including many of our big cities— that have benefited from fluoride in their water supplies for many years would no longer enjoy the same level of dental health— until, that is, a future Government decided to introduce a national policy. If, through the introduction of fluoride into our water supplies, dental decay can be avoided, we will do our constituents no service by denying their health authorities the right to decide— which is what we are talking about—to introduce a proven, safe, economic and effective way of dramatically reducing the incidence of tooth decay.
Therefore, I hope that the House will show its good sense by giving the Bill a Second Reading.
§ Mr. Laurie Pavitt (Brent, South)
The hon. Member for Bournemouth, East (Mr. Atkinson) effectively underlined the way in which the Bill has been drawn to enable a legal muddle to be cleared up and so that the local people can decide. I reassure him about pressures from his constituents. He is experienced enough to know that the people who take the trouble to write to him do not necessarily represent all his constituents. When "Mr. Clavell-Blount" and his fluoridation lobby are at work, letters will not necessarily be in line with his judgment.
I spent last year attacking Tory Health Ministers, but now I congratulate the Minister on this measure. He will recall that in the debate on the Gracious Speech I chided him for being a coward and running away from the issue.
103 I asked him why the measure was not mentioned in the Gracious Speech. Fortunately, he has had second thoughts.
I spend most of my time considering health issues and crossing swords with Tory Ministers. I was pleased by the contribution by the right hon. Member for South Down (Mr. Powell), because I cut my political teeth on NHS matters when he was Minister responsible for health. The right hon. Gentleman made an important decision after Prime Minister Macmillan ordered three years of extensive research in three areas— Kilmarnock, Anglesey and Watford. That followed five years of research in the United States. The results proved beyond peradventure that one of the greatest moves towards the prevention of unnecessary pain and suffering was at hand in the fluoridation of water. That impeccable precedent is being followed tonight.
We have heard platitudes from all Ministers responsible for health about prevention. An example is smoking, and the 100,000 deaths that occur prematurely every year. At least we now have an enabling Bill so that something can be done about a serious problem.
Most hon. Members have concentrated tonight on the effects of fluoridation on children, but one must remember that we are talking about the teeth of children who will one day be 40 or 60 years of age. We try to stop young people from becoming addicted to cigarette smoking, but we are not worried so much about the older generation. In this measure we are also concerned about health care and prevention. Such measures apply to children because they have a life ahead of them.
Caries and the consequential toothaches, fillings and extractions could, within 20 years, be as unknown as the Charles Dickens' workhouse of the last century. Hon. Members have referred to the Royal Commission's findings. Fluoridation and a number of other factors could ensure that in the next century toothache, dental caries and extractions never occur. A number of measures are required to achieve that, but Fluoridation is the first step.
The main objective is to establish a healthy body for the young and to maintain it during growth and later life. The House has heard about the number of people of 40 and 60 years who have mouths filled with china and porcelain instead of natural teeth. A recent Army survey of 18-year-old recruits shows that a staggering number suffer decay and need dentures.
The arguments for Fluoridation rest upon thorough medically qualified research in many countries. The arguments against rest mainly on fairly dogmatic assertions. As the Minister has already said, 200 million people in the world are already benefiting from the prophylactic of Fluoridation to prevent dental caries.
The phrase "mass medication" is a slogan. Those hon. Members who are worried about it should not drink anything in the House of Commons, because the Thames water authority adds 33 different medical substances as a prophylactic against illness—
§ It being Ten o'clock, the debate stood adjourned.