Saving teeth, removing inequalities: Fluoridation in Birmingham, 1964-2014

Jonathan Reinarz

In June 2014, dozens of people (myself included) gathered in Birmingham Council House to ‘celebrate’ fifty years since fluoride was first added to the city’s water supply. Fluoridation is a process of raising the concentration of fluoride (a naturally occurring mineral) in water (to approximately one part per million) in order to improve a population’s dental health. Water fluoridation in Birmingham started in 1964 and, briefly, extended across the region. Today, approximately 5.5 million people in England drink fluoridated water, the majority located in the midlands and the north east. Rates of fluoridation vary similarly globally, with less than 10% of Canadians in British Columbia, for example, consuming fluoridated water, compared with more than 70% in Manitoba and Ontario. Its promoters claim that the prevalence of tooth decay has declined by as much as a half in all fluoridated regions. Although celebrated by some as a proven public health measure, one might equally question why the event in Birmingham was invitation only and held behind closed doors. Some would argue it has to do with a small and vocal group of opponents who have largely questioned the ‘science’ backing arguments in favour of fluoridation. Faced with conflicting testimony, the majority of people today remain cautious. Noticeable, too, is a growing scepticism of orthodox medicine that began to emerge in the 1960s, just as UK fluoridation campaigns were underway.

The history of fluoridation begins in the United States, when Colorado dentist Frederick McKay noticed, in 1901, that his patients’ teeth were badly stained, though healthy, while the enamel had a mottled appearance. Similar findings were confirmed in the high-fluoride town of Maldon, Essex, where children’s teeth also had fewer cavities than the national average, despite conspicuous specks, later described as fluorosis. In 1942, Dr H. Trendly Dean of the U.S. Public Health Service first demonstrated the relationship between decay and fluoride content of water, recommending one part per million as an effective preventive level, causing minimal mottling. Fluoride was later introduced in the UK towns of Anglesey, Watford and Kilmarnock, starting in 1955. As fluoride was added to water supplies where it had previously been absent, the results were dramatic. Previously, many children by the age of five had four decayed milk teeth, but this average dropped to only two cavities under the new initiatives. On average, at aged fifteen, 10 of the 28 permanent teeth of every English child were either decayed, missing or filled. With fluoridation, dental practitioners, who were already recognised to be in short supply, could deal more easily with the huge amount of dental work that still remained to be done in communities. An investment of a few pennies per head of urban population was estimated to save millions of pounds in dental expenses, not to mention lost work hours.

There have been many obstacles to public health campaigns in the past. The use of vaccination to deal with infectious diseases in the nineteenth century, not to mention recent opposition to MMR will be familiar examples to many readers of this blog. Not only do anti-fluoride campaigns share similarities with anti-vaccination debates today, but opponents were also very successful in delaying further fluoridation initiatives. Although the World Health Organisation adopted a resolution recommending member states to fluoridate water supplies that contained low levels of natural fluoride, a resolution that was reaffirmed in 1975, progress was not guaranteed. Four years earlier, Sweden repealed legislation supporting fluoridation. Kilmarnock already ended their scheme a decade earlier, and new initiatives clearly slowed with the reorganisation of local authorities and the National Health Service in April 1974. Between 1974 and 1979, no further plans to implement fluoridation were introduced in England, despite the fact that more than 80% of Area Health Authorities passed resolutions in favour of such intervention.

Cases, both for and against fluoridation, multiplied in pamphlets and local newspapers. Endless attacks and defence campaigns led other organisations, such as the British Consumers’ Association and the Royal College of Physicians, to conduct their own investigations into the practice. Often reports recount identical stories of the earliest trials in Grand Rapids Michigan, but also introduce new theories that capture the zeitgeist of the various campaigns. A 1976 report by the RCP, for example, addressed the idea that fluoridation was a communist plot, as mooted in Stanley Kubrick’s cult classic, Dr Strangelove (1964). Throughout the 1970s, concerns about food additives and contamination from DDT, mercury, and PCBs encouraged new groups to question fluoridation. As a result, at this time, one also begins to see unusual alliances, those on the right of the political spectrum, or religious minorities, joining forces with early environmentalists and health food advocates, for example. Most recently, fluoridation has been linked by its opponents to increasing rates of obesity. Strangely, few contemporary discussions mention thalidomide, but one can be sure it was the elephant in the room during discussions in the 1960s. Interestingly, it was never mentioned in Birmingham Council House last June.

The context of fluoride campaigns has noticeably changed over the years, and schemes appear to have ‘died on their feet’, as recent challenges to fluoridation in cities like Southampton seem to indicate. Some feel that a change in diet might be the best way to reduce cavities. Others claim the recent decline in tooth decay rates might be associated with fluoridated toothpaste, the use of which has become widespread since the 1960s. Given the ease of implementing such interventions, it has become less burdensome for parents, rather than the state, to care for their children’s teeth. Interestingly, the prosperous south of England appears less willing to adopted fluoridation, a reverse to the pattern seen in countries such as Canada, where poorer regions have been most vocal in their opposition. An investigation into the subject, as is currently being undertaken in the History of Medicine Unit in collaboration with a former practitioner of public health dentistry, can teach us a lot about the way populations have evaluated potential health risks and benefits and certainly how the British people have responded to state intervention in public health over the last half century.

Further Reading:

Paul Castle, The Politics of Fluoridation: The Campaign for fluoridation in the West Midlands of England (London: John Libbey & Co., 1987).

Catherine Carstairs, ‘Cities without Cavities: Democracy, Risk, and Public Health’, Journal of Canadian Studies, Vol. 44, No. 2 (2010), pp. 146-170.

Brian A. Burt and Scott L. Tomar, ‘Changing the Face of America: Water Fluoridation and Oral Health’, in J. W. ward and C. warren (eds), Silent Victories: The History and Practice of Public Health in twentieth-Century America (Oxford: Oxford University Press, 2007), pp. 307-322.

Allan Freeze and Jay H. Lehr, The Fluoride Wars: How a Modest Public Health Measure Became America’s Longest-Running Political Melodrama (New Jersey: John Wiley & Son, 2009).

Web Links:

http://www.bbc.co.uk/news/uk-england-hampshire-12223552

http://www.nature.com.ezproxye.bham.ac.uk/bdj/journal/v199/n7s/full/4812863a.html

http://www.bfsweb.org/

https://www.gov.uk/government/publications/water-fluoridation-health-monitoring-report-for-england-2014