Fluoridation of drinking water

Fluoridation of New Zealand’s water supplies is back in the spotlight. What will the government’s recent announcement to shift the responsibility for adding fluoride onto District Health Boards really mean, and are we ready?

In mid-April, the government announced it was shifting the responsibility for adding fluoride into New Zealand’s water supplies onto District Health Boards.

Suddenly, this controversial subject has been brought back into the spotlight. Or has it?

I want to explore what’s currently happening in the aftermath of the announcement, and where we might be heading.

Currently, the decision to add fluoride to our water supplies for oral health reasons rests with local government. The announcement to shift this responsibility onto District Health Boards has generally been received positively, for example by Local Government NZ (LGNZ). LGNZ has long argued that our city and district councillors are not the right people to be making this decision. Minister Coleman believes that by giving the decision-making to DHB boards, he will not only get democratic input into the decision, but also have the benefit of DHBs’:
  • knowledge of the health needs of their communities
  • resources to gather the scientific information
  • ability to make the right decision.

The Minister’s expressed hope is that the change will lead to "much more fluoridation".

What’s been interesting so far, is that I haven’t seen the expected outcry in the media from those opposed to fluoridation. A check of one website shows they published a press release the day after the announcement: “Mandatory Nationwide Fluoridation by Stealth”; and has a plea for help to oppose the change (including an invitation to sign a petition and make a donation).

We will no doubt see candidates running on an anti-fluoridation ticket in this year’s DHB elections.

What I have observed over the last few years, is a shift in the debate – increasingly commentators and the public have been prepared to accept what the science has demonstrated – an acknowledgement of the risks, but that the risks are offset by the tangible benefits that adding fluoride brings.

On the risks side, I’ve found over the years that pro-fluoridationists tend to gloss over the risks and consequently underestimate the costs. To maintain public confidence, I think the risks need to be carefully managed.

As a water supply engineer, I’m proud to have taken a leadership role in getting a code of practice for fluoridation off the ground and completed in 2014. This code will provide the foundation for reducing the risks to an acceptable level in the design of the new fluoridation systems that are likely to flow from the Minister’s decision. The code also sets a timeframe for the upgrading of our existing fluoridation systems by January 2020.

I also led the work on the estimates of costs for implementing fluoridation in the recent cost-benefit analysis of fluoridation. My team derived cost estimates to reflect the diversity of treatment plant types and capacities, as well the level of existing treatment plant infrastructure. These all impact on the costs of adding fluoridation.

The study of the benefits (by Sapere Research Group) found that over a twenty year period, the discounted net saving from adding fluoride to water supplies (supplying water to more than 500 people) would be $1.4 billion, which is nine times the estimated costs. The study concluded that fluoridation is far more cost-effective than most other health interventions across New Zealand.

What was missing from the first tranche of information made available in the public domain was, despite the demonstrated benefits, who is going to pay for the costs of providing fluoridated water to another 1.4 million Kiwis? In the Cabinet paper released in the second tranche a few weeks ago, it stated that “any additional funding from the Crown for these [fluoridation] costs would be subject to future budget discussions.” The unqualified support from LGNZ suggests they are hoping for a positive outcome from these discussions. For such a great return on each dollar invested ($9 for every $1), it makes sense for central government to fund it from the health budget.

The experience of Queensland in its mammoth roll-out of fluoridation across the state in the years 2008 to 2012 is worth bearing in mind. The State Government seriously underestimated the costs of the implementation of fluoridation and had to increase its initial budget by a factor of three. New Zealand doesn’t need to repeat this lesson.

The anticipated timeframe for the legal changes to come into force is mid-2018. This means that the allocation of costs and other responsibilities can be worked through in an orderly fashion, and hopefully sensible decisions made.

Overall, I think that the decision to shift the responsibility for adding fluoride into our water supplies onto DHBs is a good one. It seems likely that from 2018 onwards, we’ll see an increased level of fluoridation, down to water supplies serving perhaps as few as 500 people. Fortunately, we have good foundations to build the implementation on – a code of practice, generally reasonable treatment plant infrastructure, and a good cost data base.

I reckon we are ready. Do you?

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