Fluoride is a natural mineral occurring in all water sources and is also one of the most commonly used industrial chemicals. High-octane petrol is refined by hydrofluoric acid, freezers and air-conditioners require fluorocarbons and chlorofluorocarbons, and computer screens, fluorescent light bulbs, semiconductors, plastics, herbicides, and fluoride toothpaste all make use of this chemical. However approved and utilized in industry, fluoride stirs heated controversy when it is added to public water.Fluoridation is the practice of adding fluoride to public water in order to reduce dental decay, especially in young children. Usually a compound containing or producing fluoride is added to water in order to reach a level of one milligram of fluoride ion per litre (1 part per million). A Maximum Contaminant Level (MCL) was set in 1986 by the EPA at 4 ppm to avoid skeletal fluorosis, a bone-decaying disease. Fluoridation has been under scrutiny for the past 50 years and has come under severe criticism from many quarters in the last decade. Critics of fluoridation say that past research is biased or has been shown to be false and outdated by recent research, while proponents of fluoridation cite their own research and insist that fluoridation has proven itself useful and safe in preventing dental decay. Both sides have creditable supporters, and the issue has no straightforward solution. Aside from the question of whether fluoridation is a scientifically proven health benefit to people or not, another debate revolves around whether the rights of individuals are violated when they are forced to partake of fluoridated water. Some have gone so far in protest as to acquire their own sources for unfluoridated water, and many feel that because fluoride is so easily attainable and its benefits so hotly disputed, the public water supply should be free of fluoride. By 1992 nearly 60% of Americans drank from fluoridated water systems. Fluoridation began in the US in 1945 and has since been implemented in almost every major city. In Europe, the 1980 European Water Quality Directive imposed a maximum amount of fluoride that water could contain, and many countries have fluoridated their water systems. Where piped water is unavailable, many have turned to salt fluoridation to provide a fluoridated water source. Over thirty countries have utilized this including Switzerland, Columbia, Jamaica, Costa Rica, Mexico, France, Spain and Germany.Other critics of fluoridation do not speak so softly. Fluoridation has been labeled ‘A 50 Year Old Blunder and Cover-up’, and has been thought responsible for numerous adverse health effects. If water is fluoridated in order to ensure that people receive an adequate amount of fluoride, what happens when too much water is ingested? The amount of water the public drinks is obviously uncontrollable and some people will invariably consume large amounts. Some claim that excessive fluoride accumulates in the biosphere and increasingly shows up in soil, food, and water without any deliberate fluoride addition. Because no disease can be shown to be caused by its deficiency, fluoride cannot be an essential nutrient to humans, yet neither have fluorosis and other unwanted effects been sufficiently linked to fluoride to convince the public that fluoridation is a bad idea.The most common-sense reasoning to date for not fluoridating drinking water supplies, especially in developing countries. EditorFluoride, in the correct concentration, is effective in protecting teeth and is especially necessary in children within the 1 to 10 year age group. The rationale for supplementing potable water with fluoride is that South Africans, particularly those in rural areas who do not use fluoridated toothpaste, would benefit. Given that most people in rural areas do not receive piped water the benefit will not reach the target population. Furthermore only 0,65 % of the water produced by Rand Water is used for drinking purposes. This equates to 19 000 m3 of the 3 000 000 m3 sold daily, which means that 99,35% or R25 000 of the direct costs (chemical costs per day) is not effectively utilised for the intended purpose. The question thus arises, how cost effective is this method of augmenting dietary fluoride intake? Rand Water will introduce 1 500 kg of fluoride daily into potable water.Approximately 1000kg of fluoride per day will find its way into water streams. This may have long-term negative consequences on the water environment. The cost of de-fluoridation can amount to as much as R5.50/m3 if reverse osmosis is used and the cost of using alternative methods of removing fluoride from water such as the use of activated aluminia is estimated at R1.80 m3 Who will be expected to pay this cost?Another issue involved in the fluoride debate regards the autonomy of individuals. This question is related but separate to the scientific disputes over the benefits of fluoridation. It is related because it is taken into account along with the results of scientific research in determining public policy. But it is separate because aside from the benefits or harm that fluoridation might bring, a moral question exists pertaining to the way in which individuals retain their freedom. Bioethics is the examination of the moral questions and problems that result from biological and scientific research and involve the well being of humanity. If science concludes that something is beneficial to the human body, should the government legislate and require people to have it? No one ostensibly desires the government to enforce children to eat their daily dose of broccoli, but some fear that we are moving this way. This question would remain even if fluoridation were universally agreed upon to be healthy. Everyone agrees that vegetables are healthy, but people want their freedom to stick to junk food. Many groups opposed to fluoridation argue that the public should not be forced to pay for something they do not want, or do not even know they are getting. Sources for fluoride are numerous and easily attainable without fluoridating drinking water.This plea is intensified by the contradictory conclusions of fluoridation research. Many label the research of the past 50 years as obsolete, but others cite it as building evidence of benefits. Science, to any student of history, is notoriously fickle in its conclusions. What will our research show 50 years from now? If we judge on past examples, the majority of what is thought to be credible now will be consigned to the rubbish bin in the following generation. Unfortunately, the moral side of the debate rarely makes it into the public discussion. The premises are quietly assumed and the legislation passes mostly unnoticed. Public ignorance of fluoridation ‘benefits’ is one of the pro-fluoridation groups main arguments for it. They cite studies showing tooth decay is worse among the lower classes, classes that would greatly benefit from fluoride in their public water-poor people hardly have the luxury of concerning themselves with fluoride supplements. Thus fluoridation becomes a type of aid program to the less privileged, and this benefits everyone because less public money will have to be spent on tooth decay. For those against fluoridation regardless of its benefits, this begs the question because the government should not intrude on personal freedom in the first place; they would object to public money being spent on dental care anyway. But most people against fluoridation do not reject the limiting of personal autonomy per se. The problem is the uncertainty of the benefits of fluoride. What 50 years ago promised to rid the next generation of much lamented dental decay has come under shadows of doubt.The endemic problem in China is converse to that of the rest of the world-they know they have too much fluoride. The debate continues over how much fluoride is too much and whether water fluoridation is an acceptable way of delivering fluoride to communities. Perhaps the most perplexing element of the discussion is the depth of support on both sides. Many agencies still support and endorse fluoridation with research in-hand, while increasing opposition unites to oppose and discontinue it. It seems the most fair-minded, informed opinions assert that the benefits of fluoride, both financial and medical, are as of yet inconclusive and require further high-standard, independent scientific research. Unfortunately, as many people already drink fluoridated water, the research cannot be conducted too quickly. In the meantime, representatives of communities ought to make the debate known to their people and pressure health organisations for further research.
