Fluoridation of Water: hearings

Meeting report

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The aim of this report is to summarise the main events at the meeting and identify the key role players. This report is not a verbatim transcript of proceedings.

PORTFOLIO COMMITTEE ON WATER AFFAIRS AND FORESTRY
12 June 2002
HEARINGS ON FLUORIDATION OF WATER

Chairperson: Ms B.P. Sonjica

Documents handed out:
Statement by Minister Ronnie Kasrils, MP on Fluoridation of Water;
Why (Water) Fluoridation in South Africa?
Opinion Survey Amongst Water Professionals About Their Views on Fluoridation of Potable Water;
The Role of the Department of Water Affairs and Forestry in the Fluoridation of Water;
Regulations on Fluoridating Water Supplies.

(Copies of the documents which are currently available in electronic format can be found on our website)

SUMMARY
The Committee listened to the testimony of professionals representing both sides of the fluoridation debate. The Department of Health, The African Health and Development Organisation, SAAWU, RandWater, and the Department of Water Affairs and Forestry all presented on the issue. The overall outcome of the debate was the general understanding that there was not enough conclusive research done on the issue (particularly in the South African context) that would lead the Committee to believe that the fluoridation of water was or was not in the best interest of South Africans.

MINUTES
Chairperson, Ms B.P. Sonjica (ANC), opened the hearings by stating that the debate over fluoridation of water was inconclusive and that there was no firm evidence proving that there should or should not be fluoride treatment in water supplies. She pointed out the fact that there was a White Paper in place that regulated public fluoridation and that there was a National Committee on Fluoridation in South Africa, who could not attend the proceedings. Finally, she said that there's a local government mandate to supply water, and the national government had a responsibility to remain informed on the issue.

Department of Health
Dr F.J. Smit (Department of Health) presented on behalf of fluoridating South Africa's water supplies. He stated that tooth decay was the most common chronic disease known to human kind and that the fluoridation of water in South Africa could drastically improve the health of its people. To emphasize the benefits of fluoridated water, Dr Smit pointed out the following benefits:

-Fewer toothaches
-Fewer and smaller dental bills
-More people keeping their teeth throughout life
-Better looking teeth because they are not affected by decay
-Reduced need for dentures, crowns and bridges
-Less fear and anxiety about visits to the dentists, as treatment would become less -complicated with less drilling and anesthesia
-Fewer school and working days lost due to dental disorders or visits to the dentist
-More opportunities for dentists to concentrate on other preventative work and health education
-Better general health for all as a result of improved dental health.

Furthermore, he pointed out that the fluoridation of water is cheaper than toothpastes, and fillings. Dr. Smit believed that it had the potential to benefit all age groups and all socio-economic strata, especially the less deprived, who had the highest cavities and the least accessibility to oral health services. The main constraint was inaffordability and the lack of services. It was also pointed out that a great number of international organisations throughout the world endorsed water fluoridation. He concluded his statements by debating the main anti-fluoridation sentiments.

Questions and Discussion:
Mr G. McIntosh (DP) asked how many water service providers had complied with the government mandate.

Dr Smit responded that some service providers had applied for exemption from the mandate, and others already had optimal levels of fluoridation.

Mr S Simmons (NNP) stated that 99% of the Western World had banned fluoridation because of adverse affects, and that many government reports from fluoridated countries have reviewed and questioned their practice of fluoridation.

Dr Smit said that fluoridated countries had a lot of dentists to fix tooth problems, as well as people who can afford to buy fluoridated tooth paste. He pointed out that in South Africa, the majority of the population could not afford proper dental care and hygiene.

African Health and Development Organisation:
Mr Richard Weeden presented against fluoridating South African water. He noted that his research in the United States has linked the high rates of Attention Deficit Disorder (ADD) in that country to the consumption of fluoridated water. He also recognised that Ireland, a country that strongly practices fluoridating water, was experiencing abnormally high rates of bone cancer, although the evidence that it was caused by fluoride was inconclusive. He pointed out that many of the American and international organisations that Dr Smit mentioned in his presentation were losing support of fluoridating water. It was also pointed out that calcium fluoride, the form that appears naturally in the environment, was much less toxic than the kind of fluoride that would be used in fluoridating water, some of which were waste products of other industries. It was also possible that human error or mechanical breakdowns could lead to harmful overdoses of fluoride, sickening large portions of the population. It is also possible that fluoridated waste water could have adverse affects on the environment, particularly in rivers and streams. Illustrating the South African context, Mr Weeden found that in many areas of South Africa, the levels of fluoride in the water were already above the optimal level and would actually benefit from a reduction in fluoride levels. Furthermore, most South Africans did not know what fluoridation was, and those who did became angry at the idea of forced medication. This concern over mass medication from fluoridated water has also been noted in European countries as well. In response to Dr Smit's list of international organisations that support the fluoridation of water, He also pointed out that South Africa was one of the few countries that did not allow its communities to chose to fluoridate or not and questioned the constitutionality of it. Finalising his presentation, Mr Weeden called upon the Committee to put a hold on fluoridation and call for an investigation, as well as send a letter of concern to the Minister of Health.

RandWater:
They raised several rhetorical questions in the presentation to the Committee. RandWater asked whether or not water service providers were prepared to start fluoridation and whether or not water services should be the medium used to distribute fluoride. The representative asked why people were assuming that what worked in the Western World would work in the South African context. RandWater asked what percentage of the population would be able to receive it? And how long would it take to assure that people from all areas of the country would acquire fluoridated water.

The representative from RandWater presented the results of a questionnaire that he handed out to 768 water professionals regarding the issue of fluoridating water. Seventy four percent of those interviewed stated that they were not in favor of fluoridating water. The majority of the 74% not in favor sited negative health effects as the leading reason why they were not in favor. Fifty seven percent stated that they were dissatisfied with the legislated regulations on fluoridation. RandWater highlighted the need for aggressive information sharing and awareness to educate South Africans on the issue of fluoridation, a national opinion survey amongst all stakeholders, and research to be focused on the fluoridation needs amongst communities and options for satisfying identified needs together with cost benefit studies.

Questions and Discussion:
Ms R. Ndzanga (ANC) asked how over dosing on over-fluoridated would be monitored and prevented. She was concerned with the possibility of human error in the fluoridation process and wanted to know what other alternatives existed. Finally, she noted that if communities were actually informed on the issue, the Committee would have a better understanding of what the people wanted.

Ms L. Ngwenya (ANC) noted that the issue was very controversial. It scared her that it was stated that certain areas already had fluoride levels well above the optimal, because tooth decay was a big problem in her home community. She stated that tooth decay was causing relationship problems among people. Ms Ngwenya wanted to know who was interviewed in RandWater's survey, because the people in the questionnaire obviously had the education and ability to understand the issue.

Ms H. Ngubane (IFP) stated her concern over the research. She asked if those who responded to the questionnaire were from diverse backgrounds. She also wanted to know more of the toxic nature of fluoride and its adverse effects on the environment and human health.

Ms B.P. Sonjica (ANC) noted her concern over the lack of awareness of those from low socio-economic backgrounds.

The presenter responded said that the survey was conducted amongst water professionals, who attended a conference together.

The Department of Water Affairs and Forestry:
The Department of Water Affairs and Forestry (DWAF) stated that the implementation of water fluoridation must be done in conjunction with DWAF and the Department of Health (DOH). In terms of the National Water Act, DWAF had a responsibility to protect the aquatic resources for future generations, as well as to ensure that all water service institutions achieved the objectives of the act. In terms of fluoridation regulations, DWAF had a responsibility to evaluate all applications to determine the impact on the water resources and to assess the respective institution to ensure that objectives of the Water Service Act would be met. DWAF will evaluate applications to fluoridate water supplies, and if no negative environmental impact be found, the application will be considered in terms of the principles of the Water Services Act, then will be sent with DWAF's decisions and recommendations to the DOH.

Responses:
RandWater noted that 99% of the water used in South Africa went to agriculture, mines, and other industries and therefore there needed to be more consideration of the effect fluoride would have on the environmental. It was also pointed out that 7 million people in Africa do not have running tap water, so the target recipients of the fluoridated water would not even have access to it. The point was made that RandWater did not approve or disapprove of fluoridating water, but questioned if there were not better mediums to get fluoride to the people, for example mealie meal, which is widely consumed among the poor. He appealed to the Committee not to pass legislation until proper research had been done and all stakeholders were informed.

Dr Smit (DOH) responded that both children and adults should benefit from the fluoridation of water. He emphasized that the service was cheap at only R2/person, whereas there is over R1 billion spent on dental care per annum in South Africa. He stated that he believed that water was the best mechanism through which they could bring fluoride to the people, because consumption levels of food (such as mealie meal) varied greatly. Finally, Dr Smit concluded that there were no adverse health effects of people drinking optimal levels of fluoridated water.

Ms B.P. Sonjica (ANC) believed that the cost effectiveness of water fluoridation needed to be weighed against the financial consequences of treatment for adverse effects. She reiterated that she saw no evidence that led her to believe that fluoridation of water was entirely safe and that they should go ahead with the provision.

One member of DWAF noted that fluoride was severely toxic at high levels, and there have been mechanical failures that have led to overdoses and even deaths in the United States. He emphasized that if water is going to be fluoridated, it needed to be done safely. He further questioned whether this could be done in the rural areas.

Dr Hassan pointed out that South African research had not been done on this subject. South Africa was a unique case and should not base its decision on research done in the United States and other Western countries.

Questions and Discussion:
Ms R. Ndzanga (ANC) asked if it was possible to ensure that there would not be any human error leading to overdoses. She wanted to know if it were possible to enquire about the health of people who had not received fluoridated water in relation to those who had. She concluded by asking if there were any alternative to fluoride.

Mr P.M. Mathebe (ANC) stated that sodium fluoride, the kind used in water fluoridation, was more toxic than calcium fluoride, the kind that is found naturally in the environment. He wanted to know why sodium fluoride was used over calcium fluoride.

Ms H. Ngubane (IFP) agreed that there needed to be more research done on the subject and that the focus needed to be on mothers and children. She was worried that mothers who breast fed their children were putting their children at risk of overdosing on fluoride from the mother's milk.

Mr M Masala (ANC) was concerned that there was still a debate going on among scientists. He believed that the Committee should let the debate continue amongst scientists so that the Committee could make an informed decision.

Mr G. McIntosh (DP) noted his concern over water delivery, as the majority of people received their water from boreholes. He added that it might be prudent to find some other medium for fluoride to reach the population. Mr McIntosh also agreed that there was an environmental issue that needed to be addressed. He stated that the issue of whether fluoride should be used in water was not an issue of the committee, and that it should be left to the Health Committee.

Mr E.M. Sigwela (ANC) asked what other alternatives already existed on the market. He agreed that the issue needed scientific evidence and that the Committee did not have the expertise to make an informed decision. He stated that the water research scientists and DOH needed to provide more input on the matter.

Ms B.P. Sonjica (ANC) stated that the Minister of Water Affairs and Forestry had released a statement of support for the fluoridation of water. She emphasized that the Committee would share their concerns with the Minister.

Mr S. Simmons (NNP) noted that the decision by the Department of Health was made based on research from overseas. He stated that he had heard evidence that showed that water fluoridation caused children's IQ's to decrease, uterine cancer, changes and weakening of bone structure, caused birth defects, impaired immune systems, and caused tooth problems.

Responses:
Dr Smit responded that he had heard the previous accusations. He instructed those in attendance to go to http://fluoride.oralhealth.org for more information on the subject. He explained that those physical maladies could occur only if fluoride levels were well in excess of the optimal level. He stated that the health professionals in South Africa and in the Department of Health were there to help the people of South Africa and would not knowingly endanger them in any way.

Ms B.P. Sonjica (ANC) emphasized that the Water Affairs and Forestry Committee did not question Smit's expertise and good will. However, she wanted to know how the level of fluoride put in water would be monitored. She stated that she was worried about unintended consequences of water fluoridation.

A Department of Water Affairs representative noted that water fluoridation would not be cost effective for small communities.

Ms L.C. Mothiba (UDM) wanted to know why certain towns chose to stop fluoridation.

Mr M.S. Mogoba (PAC) said that it was very important to weigh both sides of the argument and make the correct decision, before there were irreversible consequences. He stated that he was pleased that they were considering alternatives to water.

Mr Weeden pointed out that the issue was clearly highly controversial and should be put on hold, until there was more conclusive evidence. He warned against the substitution of mealie meal for water, because people would still be consuming the fluoride. He stated that with adequate diet, tooth problems are not much of an issue. He warned against leaving this debate up to dentists, because they are not qualified to discuss the chemical's impact on the rest of the body (only the teeth and mouth). He also warned that fluoridated water should not be used to mix baby formula.

Mr Hlaneki (ANC) asked if it were possible that fluoridated water caused HIV. He stated that it is believed to cause cancer.

Dr Smit responded that there are a lot of theories thrown around to scare people. He stated that fluoride was not the cause of HIV.

One of the presenters stated that experts needed to come together to discuss and debate the issue. He felt that it was wrong that the government made a decision like this without its people being informed on the debate. He introduced the idea of the Committee assigning a joint team to this issue.

In closing, Ms B.P. Sonjica (ANC) asked whether South Africa was ready to start fluoridating water without scientific evidence of the benefits and dangers. She stated that even South Africa's National Fluoridation Committee appeared to be divided on the issue. She asked why water was selected as the medium for the provision of fluoride and why other options were not discussed. She expressed her concern that the target groups who needed the fluoride the most were left behind in the debate and are unaware of the issue. She was further concerned that the law was mandatory, because it will make going back difficult. She continued to ask the members if fluoridating water was a priority for the committee. She told those in attendance that the outcome of the meeting and recommendations from the Water Affairs and Forestry Committee would be presented to DWAF and DOH. She concluded by saying that there needed to be an integrated approach to solving this debate, as their purpose was to benefit all South Africans.


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