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Lord Livsey of Talgarth: My noble friend Lord Tordoff should note that I did not say that I was out and out opposed to fluoridation. I am saying only that the professor raised important points of principle to which we need answers. I hope that the Minister will respond accordingly.

Baroness Trumpington: I think that I am entitled to say my bit just to prove that I am not just a simple old scrubber.

The Countess of Mar: I must put the noble Baroness, Lady Trumpington, right—she implied that I was one.

Baroness Trumpington: That changes the whole picture. Having taken this Bill through this House originally, anything I have to say is superfluous. I hope the Committee listened carefully to my ex-boss, with whom I did not always agree, but he made a magnificent speech on this occasion. Typical, typical Liberal, sitting on the fence as usual. I wonder whether the noble Lord, Lord Livsey of Talgarth, carefully read the whole of the proceedings for the last time the fluoridation of water Bill was in this House. If he had, he would have found the answers to many of his questions. The noble Countess, Lady Mar, should return to the goat's cheese again.

Lord Monson: Time and again, the Prime Minister has declared passionately that he wants Britain to be at the heart of Europe. If Mr Blair is really determined that Britain should be at the heart of Europe, the very first thing he should do is to order this amendment to be torn up and thrown into the dustbin. Of the 18 countries in western Europe, some of them within the European Union and some outside it, no fewer than 15 have totally rejected fluoridation. Some of those had experimented with fluoridation only to abandon it when they concluded that the disadvantages and dangers outweighed any possible benefits. That counters the assertion made by the noble Lord, Lord Fowler, that we have been here before, because when he introduced fluoridation, rather more western European countries practised it. Time has moved on and many of them have changed their minds.

Indeed, exactly three months ago today, on 9th April 2003, the Swiss canton of Basel-Stadt—the home city of the splendid Wimbledon men's singles champion—abandoned fluoridation after 41 years. Among other reasons for the decision was that there was no evidence that the incidence of caries in the area had been reduced.

I shall read to the Committee a list of countries that have rejected fluoridation: Austria, Belgium, the Czech Republic, Denmark, Finland, France, Germany, Iceland, Italy, Luxembourg, the Netherlands, Norway, Portugal, Sweden and Switzerland. Only three

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countries out of the 18 still practise fluoridation—this country, in part, the Republic of Ireland, although not Northern Ireland, and, to a minor extent, Spain.

The total population of countries where some fluoridation takes place is 98.5 million. The total population of countries and regions that shun fluoridation is 286 million. In the latter figure I have included Northern Ireland, but excluded La France d'outre Mer, which, although technically part of France and the EU, is in reality not part of western Europe.

If we assume that the ratio of doctors, dentists and other medical professionals to the population as a whole is roughly the same throughout western Europe, it follows that there are approximately three times as many medical experts living in non-fluoridating countries as in partly fluoridating ones. Unless we believe that, quite unlike their British counterparts, continental medical experts are timid and frightened of raising their heads above the parapet, which is an unlikely scenario, it figures that a minimum of 75 per cent of medical experts throughout western Europe are at least hostile to fluoridation or, at best, doubtful that its alleged benefits outweigh its disadvantages and possible dangers.

Sweden, for example, has been a country greatly admired by members of the British Labour Party over past decades. Sweden is a highly efficient, highly safety-conscious country, yet it outlaws fluoridation. It is a criminal offence to add fluoride to the water supply in Sweden. I invite noble Lords on the Government Benches and, indeed, some on the Opposition Benches to ponder that.

I have not even started on the libertarian objections. For the time being, I shall not do so, because I know from experience that libertarian arguments cut little ice with many on the Government Benches and quite a few on the Opposition Benches. However, the weight of expert medical and environmental opinion throughout western Europe must surely give noble Lords food for thought.

Lord Beaumont of Whitley: I declare an interest, because I have not got a single natural tooth in my head. That has nothing to do with fluoride one way or the other, but to do with reading books while riding bicycles.

Having declared that I have no interest in that way, I must say that I am totally on the side of the noble Countess, Lady Mar, which I usually am when she speaks in your Lordships' House. I am also speaking on behalf of the Green Party. We think that mass medication is wrong and that mass medication of poisons is especially wrong. The jury throughout the world is out on the medical effects of fluoridation, and this is by no means as open and shut a case as the pressure groups that have been bombarding us would have your Lordships believe. This is a bad amendment and we should reject it.

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Earl Baldwin of Bewdley: I shall refer briefly to a couple of points before moving on to consider the scientific evidence for fluoridation. I apologise, because there was something that I forgot to say earlier. I would like to ask the Minister, who may write to me afterwards if he wishes, what provision is made for any areas which, after some years of fluoridation, wish to change their minds and stop existing schemes. If that is already provided for and I have misread it, I can leave it, but I was going to make the point that it is already an issue up in the North West. I hope that there are mechanisms for expressing and giving effect to change in local opinion.

I would like to preface my remarks with just a repeat from our earlier debate. I stress once again that it is a mistake to believe, sadly, that the dental lobby or the Government or health authorities give always impartial information in this controversy. Some of that will become apparent as I speak.

I have probably put in as much time on the recent scientific arguments over fluoridation as anyone. I asked the Questions in your Lordships' House which led, when I was supported by Sir Iain Chalmers of the UK Cochrane Centre (for evidence-based medicine), to the setting up of the systematic scientific review of the evidence world-wide at the University of York, which reported in 2000 and on whose advisory panel I sat for nearly a year. Since then I have been involved, unfortunately, in numerous debates arising from the spin that has been put on that report. This has kept me in close contact with the senior independent scientists who took part in the review process—and by independent I mean not affiliated, professionally, financially or emotionally, to the pro- or anti-fluoridation lobbies. Always I have taken care to write or say nothing that they would consider scientifically unsound. I say all this, my Lords, because I recognise how difficult it is to be heard to criticise the big and respected organisations such as the British Dental and Medical Associations. But criticise them I must.

First, however, a word about scientific reviews. The problem with the traditional review or inquiry, and there have been many on fluoridation, is that you do not always know what studies the chosen "experts" have selected to look at, or why, how reliable those studies are, what might have been omitted, how much they have relied on other people's views, and indeed what the affiliations or preconceptions of those "experts" might be.

In contrast there is the much rarer and more thorough systematic scientific review, which to their credit the Government set up in the case of fluoridation. In this, a specialist review team searches the world literature, relying only on primary studies and not on the past opinions of others, according to established criteria, which ensures as far as possible that nothing is missed, and that everything relevant is assessed and graded for reliability. With the York review this was all conducted publicly on a website which invited contributions from around the world; it was openly peer-reviewed; and the whole exercise was overseen by a panel which, as I said, was carefully

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chosen to represent opponents as well as proponents of fluoridation, which ensured, as I can testify, that biases were recognised and allowed for.

I make this point to illustrate the difference between what is known as "eminence-based" medicine and "evidence-based" medicine. I am disappointed that the Chief Medical and Dental Officers' briefing paper did not bring out this distinction as a guide to understanding where the most reliable evidence is to be found. Of course traditional reviews have their uses; but they are open to inconsistency, selective presentation, and influence from the prevailing scientific culture, in a way that systematic reviews are not. And thus it is quite possible for a systematic review to produce an answer that contradicts what previous less rigorous reviews reported.

This—this is an answer to the point that the noble Lord, Lord Fowler, made about there being nothing new since 1985—is what has happened with York, though you would not guess it from the briefings we have all received from the big campaigning organisations. York, for all the lip service paid to it, was a considerable shock to the dental and medical communities who have promoted fluoridation so long and loud, and it has been misquoted, misrepresented and downplayed ever since. I was particularly pleased to hear the quotation used by the noble Lord, Lord Livsey of Talgarth. He might have added that, in a later letter, Trevor Sheldon included the British Medical Association on the list of miscreants who had spun the report. Damage limitation has been the name of the game, as also—here is an analogy—with hormone replacement therapy which was recently shown by high-quality studies to be harmful to the heart, not protective as everyone thought on the basis of previous inferior research which, interestingly, the senior reviewer at York tells me was actually of better quality than we have for fluoride. That, my Lords, should give pause for thought.

York could not find one good-quality study in 50 years of the world literature. This meant, and it said so clearly, that it could conclude nothing with confidence: not effectiveness, not safety, not harm, and certainly not the hoped-for reduction in inequalities in dental health for which the evidence was weakest of all. It found varying degrees of probability across the questions it addressed, depending on the quantity and quality of the evidence: the less reliable, the more likely the conclusion could be wrong—an obvious point that has eluded many commentators. My distinguished colleagues from York assure me that no prescription drug would get a licence on evidence like this. Most probable—York was careful here to say "suggests", not "concludes" or "confirms" which is how pro-fluoride groups have changed the wording—is a reduction in caries, which might be of the order of 15 per cent (dentists used to claim 50 per cent or more). York stressed that it would need better-quality studies to be confident of this finding. An unexpectedly high level of dental fluorosis, or mottling, also looks probable.

What about safety? We read in our briefings "Water fluoridation is safe"; "there is no evidence that fluoride causes bone disease, cancer, birth defects". I refer your

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Lordships to Section 8 of the York report, on page 48: 14 analyses from studies found an association with bone fracture. In Section 9.6, page 58, nine analyses found an association with cancer. In Section 10, pages 59-61, there are similar associations with Down's syndrome, all-cause mortality (including infant mortality), and mental functioning. No evidence, my Lords? No evidence?

Let me complete the picture. These associations were weak, because the few studies were of poor quality. And there were a roughly equal number of poor studies that found no association. So the picture is mixed: there is "no clear association", in York's words. But this is not the same as "no evidence": a phrase too often used recklessly, not least by the President of the Faculty of Public Health and others in a letter in yesterday's Times, which some of your Lordships may have seen. The implications for policy and research are quite different. This is why York recommended further research in three areas of possible harm (not two, as the CMO and CDO's paper wrongly states; their briefing is not a sound guide to the research needs that have been identified).

These are not quibbles. To those who would dismiss them I would say, "Do you want your policy to be based on good science, or not?" Because if you do, then you still have work to do. If you do not, you have no business promoting it to the public. To claim water fluoridation is safe is as scientifically indefensible as to claim that it causes hip fracture or excess mortality. At this stage of the evidence, we simply do not know.

I ought to quickly mention the Medical Research Council, which was asked to make research recommendations in the wake of York. Unfortunately, among much helpful work, it muddied the water by second-guessing some of the findings, without York's care or rigour, and came up with the erroneous statement that York had "confirmed" fluoridation's effectiveness, which has been much quoted as an MRC finding. I have, in fact, placed a detailed critique of this report, endorsed by the senior reviewer from York, and of another recent report by an all-party group, in your Lordships' Library.

It has been a learning experience for me, my Lords, having come in a few years ago as an outsider to the scientific process, to observe how even the most eminent participants find it hard to abandon old beliefs when they are shown to be unsupported, and how unvalidated comparisons in dental health between the fluoridated West Midlands and other areas continue to be advertised. The noble Lord, Lord Fowler, was, unfortunately, as guilty of that as many other people. They are not, I am afraid, when it comes to such issues, good science and nor are league tables. The other side, if you want to play that game, can trade you league table for league table. I will not start now. It is the good studies that are needed, not the uncontrolled comparisons. If there had been any good science supporting that, it would have been found by the York review: it was not, and it did not even meet its admission criteria.

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6.45 p.m.

Lord Faulkner of Worcester: In view of what the noble Earl says about Birmingham, how does he account for the fact that the number of five year-olds in Manchester suffering tooth decay is nearly twice as great as the number in Birmingham?


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