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Lord Rea: My Lords, before my noble friend sits down, he said that no case has been made for levels of one part per million. What about Hartlepool, which has natural levels of one part per million? Teeth there are very good, people are healthy and no harm has been done.

Lord Dixon: My Lords, that is one of the arguments that was put forward. There are arguments both ways. I have heard scientists and I have heard lawyers. In that regard I was once told that there are over 100,000 laws on the statute book and lawyers have not yet improved on the Ten Commandments. I feel that that probably applies in the case of some health scientists as well.

7.22 p.m.

Lord Clement-Jones: My Lords, this has been a difficult and hotly debated topic for over 30 years, as many noble Lords made clear. The passionate and powerful contributions to this debate testify to that. But this debate, instituted by the noble Earl, Lord Baldwin, is very timely in view of the White Paper on public health due in the New Year. I cannot pretend to have the extent of scientific and technical expertise which Members of this House displayed during the course of the debate, but one thing is clear; that is, that the Water (Fluoridation) Act 1985--now consolidated in the Water Industry Act 1991--is not working. It was originally meant to settle the issue. I was interested in the note of slight exasperation in the speech of the noble Lord, Lord Dean, in that respect.

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Since then some 60 health authorities have made requests to water undertakers to fluoridate the supply. Each of those requests was preceded by a procedure laid down in the original Act which involves close consultation between health authorities and local authorities. Yet each request was refused. The water companies--no doubt we all received the briefing from them--say that they wish to be completely indemnified by the Department of Health for so doing. The worst case has been in the north west where over 20 local authorities made the request for fluoride but were refused. Ironically, the water company adopted what it believed to be the precautionary principle for fluoride but, as we have seen from recent reports, has been slow to accept the threat from cryptosporidium or deal with it. As a result, detailed publicity and consultation exercises carried out by health authorities prior to each request to fluoridate have been a waste of limited NHS resources.

Millions of young children, many of whom live in deprived areas, continue to suffer from painful, distressing, yet preventable dental disease. We heard the statistics tonight--figures released on 2nd November. One in five children living in the poorest districts of the UK can expect to have had a tooth extracted under general anaesthetic by the age of five. The noble Baroness, Lady Gardner of Parkes, described the problems of delay that restrictions on general anaesthetics will create in the future.

Sir Donald Acheson recently pointed out that the differential between the better off social classes I, II and III and others in terms of dental health has grown over recent times. He strongly recommends fluoridation. The evidence of the beneficial effect of fluoride in the right dose is very clear. The most recent evidence shows that the rate of decay of young children's teeth in cities with fluoridated water such as Birmingham and Newcastle is four times lower than that of children in cities with non-fluoridated water such as Glasgow, Liverpool and Manchester. A clear example is Sandwell in the West Midlands. Its water supply was fluoridated in 1986; 10 years later the rate of tooth decay in five year-olds has halved.

For many years now anti-fluoride campaigners have been fighting a rearguard action against fluoridisation. But what is the real evidence? The noble Earl, Lord Baldwin, was kind enough to give me copies of his papers. I read them carefully and am prepared to accept that in high doses fluoride can cause skeletal fluorosis. I do not believe that there is any evidence to date that low doses of one part per million of fluoride is causing harm. I did not see evidence properly attested to in that regard in those papers.

Water fluoridisation has been endorsed as being safe and effective, as we heard from several noble Lords tonight, by every reputable scientific body in this country, and 39 organisations belong to the national alliance. We need to look at those credentials. The noble Lords, Lord Rea, and Lord Dean, were right to point to them.

I am not a great believer in medical orthodoxy but I am a lawyer. I do not believe that this is the same as MMR, organophosphates or the Gulf War syndrome. I

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want to see evidence of harm. Where are the legal cases? Where are the allegations of harm? Where are the litigants? This is not like organophosphates. We need to see a clearly defined group of victims and I have yet to see that. However, on these Benches we would not object to and indeed would support the Government commissioning further research or a review into aspects of fluoridation to lay to rest some of those fears. We would be interested to see evidence from other European countries and the reasons why they have either withdrawn fluoride from the water or would not wish to see it added.

In terms of the action we wish to see in the short term the Government must base their decision on existing evidence of the benefits and the extensive practical experience of this public health measure. They should act on behalf of the great majority of people who support this public health measure, and in particular on behalf of those children who continue to suffer unacceptable levels of tooth decay. Putting fluoride in toothpaste is simply not enough.

Some opponents of fluoridation raised the issue of human rights today and on other occasions. On that subject I cannot improve on the words of my noble friend Lord Avebury, who is a noted human rights campaigner when he said, in 1994,

    "Fluoride is a natural constituent of water supplies, as it is indeed of many foods. The adjustment of the quantity to an optimum level cannot be compared with the addition to water of a substance not found there ordinarily".
I feel that that settles the matter in relation to human rights.

On these Benches our health team wishes to see action on this issue during this Parliament. We believe that the arguments on health inequalities carry the day. In their Green Paper--Our Healthier Nation--the Government supported making fluoridation mandatory once the proper procedures had been followed and a request had been made to water suppliers. I do not know what responses were forthcoming to that Green Paper, but we agree with that approach.

The Government must make a commitment on this issue in the public health White Paper, due in the New Year. If that involves an indemnity to the water companies, so be it. I do not believe that it will ever need to be invoked to any great extent. If we need to improve consultation procedures, let us do it. That should be the proper forum in which to air these doubts and fears. Above all, the Government need to grasp the nettle.

7.30 p.m.

Earl Howe: My Lords, I am sure that we are all grateful to the noble Earl, Lord Baldwin of Bewdley, for initiating this short debate. Although I should declare my hand at the outset by saying that in common with my noble friend Lady Gardner and the noble Lords, Lord Dean of Beswick, Lord Rea and Lord Clement-Jones, I do not share the noble Earl's concerns, nevertheless, I have nothing but respect for his persistence and continuing questioning of the scientific and ethical issues associated with the fluoridation of water supplies.

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This evening the noble Earl has raised some issues which clearly merit a serious and considered response from the Minister. However, many of them seem to me to have been dealt with satisfactorily already in Written Answers in Hansard--notably those that appeared on 10th June, 3rd September and 11th November this year. I say to him, in all candour, that nothing that he has said tonight persuades me that there is a substantive case to answer. Nevertheless, on these Benches we are glad to have the opportunity of restating our views on the subject.

I know that my noble friend Lord Colwyn--a vice-president of the British Fluoridation Society--wanted to take part in the debate and to reiterate his own personal and professional support for fluoridation as a public health measure. He is unable to be here, but he has made it clear to me that he is well aware of the problem of tooth decay and the role that fluoridation can play in reducing it.

The previous government, in which I was proud to serve, were convinced of the safety and efficacy of adding fluoride to water at the level of one part of fluoride per million parts of water. Our position in opposition remains unchanged. Independent scientific advisers consistently endorsed fluoridation as safe, as I understand do the present Government's advisers. That confidence about the safety of fluoridation is based on well documented evidence, drawn from over 50 years of practical experience and extensive research. Nevertheless, the numerous and varied charges levelled against the safety of fluoridation have always been properly investigated. On each and every occasion, the charges have been found to be totally without scientific or medical foundation.

We need to be absolutely clear that there is no controversy within the scientific community about water fluoridation. Every reputable scientific body which has ever considered the issue has pronounced that this public health measure is safe. I have a list of the major authoritative reviews which I can pass later on to the noble Earl, if he wishes, although from what he has said I expect that he is already aware of most of them.

Tooth decay is a painful, distressing and disfiguring disease which all too often results in the removal of teeth under general anaesthetic. I am told that babies as young as two commonly undergo gas anaesthetics for the removal of rotten, infected teeth. That experience is not just extremely traumatic at the time, but there is also the inherent risk of undergoing an anaesthetic. In addition, it has been shown to undermine a child's ability to establish regular dental attendance patterns throughout life.

Fluoridation has led directly to a halving in the incidence of tooth decay. That is particularly welcome for the vulnerable in society; for example, very young children living in socially deprived areas. In fact, water fluoridation has been shown to benefit most those who have the greatest social and material deprivation. That is surely one of the key points to be made in answer to those who believe that fluoride toothpaste, for example, could achieve equivalent results on its own. Fluoridated

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water reaches those who seldom brush their teeth and seldom see a dentist. In addition, the benefits of fluoridation are not confined to young children. The evidence indicates that all age groups, including older adults, can benefit from a fluoridated water supply.

There are those who, although accepting overwhelming evidence of the safety and efficacy of fluoridation, oppose this public health measure on ethical grounds because they believe that it infringes civil liberties. The trouble with that argument, it seems to me, is that it seeks to belittle or trivialise a major public health problem; namely, dental caries.

As many noble Lords have pointed out, no individual is at liberty to drink water entirely free from fluoride, as fluoride is found to be present naturally, at varying levels, in all water supplies. As the noble Lord, Lord Clement-Jones, so succinctly pointed out, fluoridation is simply the process of topping up the level of fluoride in the water to the optimum level for dental health, so, for example, the residents of Birmingham can enjoy the dental benefits that the residents of Hartlepool enjoy naturally. A recent survey by the British Association for the Study of Community Dentistry found that the residents of the West Midlands enjoyed the best dental health in England.

Anyone who is inclined to follow the noble Lord, Lord Stoddart, in seriously doubting the evidence of the efficacy of fluoride would find it instructive to look not only at the examples of various inner cities, but also at Anglesey. That example was quoted in a Written Answer in another place on 1st December this year, which stated:

    "The dental decay rate of children aged five years in Anglesey was reduced by 50 per cent. after fluoridation was introduced there in the mid-fifties. However, since withdrawal of the last of the Anglesey fluoridation schemes in 1991, there has been a 168 per cent. increase in tooth decay".--[Official Report, Commons, 1/12/98; WA 35.]

When we know, as certainly as we can know anything, that a public health measure is safe and that it can benefit millions of people, I think it can be argued that it is unethical not to implement that benefit. The charge that the general public do not want fluoridation is not supported by the evidence of properly conducted opinion polls, which have consistency shown overwhelming support for the measure. By all means, let questions be asked about fluoridation, but, in my view, it is quite wrong and highly regrettable that as a result of that process a key plank of public health policy should have unnecessary doubt cast upon it and thereby become undermined.

The previous government, in their determination to take practical steps to improve the health of the nation, introduced, as many noble Lords have mentioned, the Water (Fluoridation) Act 1985 with cross-party support. Although that piece of legislation stands as a testimony to the real commitment to improve public health, it is clear that the Act has not worked in the way in which it was intended. When the Act was introduced, it was expected that technical feasibility would be the only grounds on which water undertakers would refuse to fluoridate. Regrettably, that has not always proved to be the case. The last Minister of State for Health in the

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previous government, Gerald Malone MP, consistently called for water suppliers to co-operate with health authorities so that the policy could be implemented. Despite those vehement efforts, over 60 health authority requests to fluoridate have been turned down by water companies and no new fluoridation scheme has been introduced since 1985.

The Opposition welcome Sir Donald Acheson's recent recommendation on water fluoridation. The Independent Inquiry into Inequalities in Health points out, with regard to oral health, that although overall dental health in children is improving, inequalities in dental health are widening. The report highlights the proven efficacy of water fluoridation in reducing those inequalities and recommends the fluoridation of the water supply.

In order for the Government to fulfil their promise to reduce inequalities in health, those recommendations must be acted upon. The Minister for Public Health stated that the conclusions of Sir Donald's report will,

    "contribute to the development of a new strategy for health".
In the case of water fluoridation, the strategy required is not the commissioning of another review or inquiry at the taxpayers' expense, but amendment of existing legislation so that fluoridation schemes can be implemented at the request of health authorities. Under existing legislation the scope for dialogue has, I fear, been exhausted. The Opposition await, with eager anticipation, the arrival of the forthcoming public health White Paper and hope that it will contain a clear statement of policy which will take us beyond the current stalemate on the issue of water fluoridation.

7.40 p.m.

Lord Hunt of Kings Heath: My Lords, perhaps I may start by congratulating the noble Earl, Lord Baldwin, on securing a debate on what I regard as an important issue. It also allows me to acknowledge his work in the field of complementary medicine, which I have long appreciated.

I should also like to acknowledge the contribution of other speakers to what has been an excellent and wide-ranging debate. As the noble Lord, Lord Clement-Jones, suggested, the subject is one which provokes forceful reaction. Certainly, in my 25 years in the health service before coming to your Lordships' House, fluoridation often played a part in my working life, first as a CHC Secretary in the 1970s; secondly, holding public meetings to discuss the issue as a member of the British Fluoridation Society Council and, thirdly, as director of the National Association of Health Authorities and Trusts where many of our health authority members have been wrestling with those issues for well over 20 years.

In responding to the debate I want to start by discussing it in the broader context of public health. Indeed, I would argue that we should always see the oral health of the population as an integral part of its general health. We need to assess any scientific evidence for health problems caused by water fluoridation as carefully as we examine the evidence for oral health benefits.

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This country has seen dramatic improvements in health over the past 50 years, and oral health is no exception. In addition to the key role played by the dental profession, addition of fluoride to both toothpaste and water has made a significant contribution to reducing the level of dental decay, particularly in the teeth of children. That, of course, is in line with the first of the two key aims we put forward in our consultative Green Paper Our Healthier Nation. That was

    "to improve the health of the population as a whole ...".

But we cannot be complacent. More than half of the country's 15 year-olds have still experienced decay in their permanent teeth. We also have very good evidence that significant inequalities remain in the oral health of the population. Even at regional level there are significant differences in the levels of tooth decay in children. For example, in 1995 five year-olds in the West Midlands had on average less than half the numbers of decayed, missing or filled primary teeth than those in the north west--a point forcefully made by my noble friend Lord Dean. Nineteen per cent. more five year-olds in the West Midlands had no tooth decay at all compared with their counterparts in the north west.

A similar picture emerges when you look at 12 year-olds and their permanent teeth. One further thing stands out when you consider smaller population groups, at health authority level: other things being equal, the worst off in society have the poorest oral health. Now, the Government are determined to change that and to narrow the health gap--the second key aim in Our Healthier Nation.

The challenge for health authorities is how to improve oral health generally and to tackle these inequalities in health status. I do not think that anyone suggests that will be easy. Some people have a history of sporadic dental attendance. As noble Lords have suggested, many people visit a dentist only when they are in pain, and they may have difficulty in maintaining a regular brushing routine with fluoride toothpaste.

There is, of course, the further option then of fluoridating the water supply in areas with high levels of dental decay. The evidence shows that fluoridation of the water supply to the optimum level of one part in a million can reduce the amount of tooth decay in children from similar backgrounds by one third to a half. About half a million people in this country receive water which is naturally fluoridated at or about the optimum level of one part of fluoride per million of water. A further one million people receive water which is naturally fluoridated at a lower level, but which still confers some dental benefit. These areas are generally found in a band running down the eastern side of the country, from Hartlepool in the north to parts of Essex. Some 5 million people receive water where the fluoride content has been artificially increased to a level of one part per million. Major schemes are in operation in Birmingham, throughout the West Midlands, and also in Tyneside.

The Government recognise that fluoridation is an important and effective method of protecting the population from tooth decay. It also has the advantage of benefitting the whole population. I make no apology for drawing your Lordships' attention to the example of

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fluoridation quoted in Our Healthier Nation. Other noble Lords have also referred to it. The example was Sandwell, in the West Midlands, where the water supply was fluoridated in 1986. Over the following 10 years the amount of tooth decay in children had more than halved. During the same period an area with a comparable population mix--Blackburn--saw little change in its children's oral health. That example has been replicated in many other places over the past 50 years. The point made by my noble friend Lord Rea and the noble Earl, Lord Howe, about the particular advantage this can give in deprived areas is very significant. It is also, sadly, true that where fluoridation schemes have been withdrawn--Anglesey and Kilmarnock have been quoted--levels of tooth decay in children have risen after having improved during the periods of fluoridation.

The noble Earl, Lord Clanwilliam, said that dental decay and dental problems are not life-threatening. However, the noble Baroness, Lady Gardner, made a significant point, as did the noble Earl, Lord Howe, about the use of anaesthesia in young children and the pain which many children suffer as a result of dental problems.

As I have said, we must carefully examine any risks which may attach to fluoridation, as well as the benefits. The noble Lord, Lord Monson, talked about risks. Over the years, many health problems alleged to be linked to fluoridation have been investigated and no link has been found. There is yet to emerge any convincing evidence of harm to general health as a result of drinking artificially-fluoridated water at one part per million. Indeed, it is estimated that around the world some 210 million people drink artificially-fluoridated water.

The noble Lord, Lord Harris of High Cross, thought that I might pray in favour expert advice. Yes, I do. The view that fluoridation of water at this level is safe is based on medical and scientific opinion throughout the world. As the noble Earl, Lord Howe, said, that is based on practical experience and research over the past 50 years. There is currently evidence of just one minor, cosmetic side-effect of optimal fluoridation-dental fluorosis or slight tooth mottling. Even where that happens, teeth are still endowed with extra resistance and I want to reassure the House that that is not a sign of any greater harm and is not significant at the optimal concentration of fluoride used in the water supply.

The noble Earl, Lord Baldwin, raised a number of issues about the safety of fluoride. He has put down a number of questions on some of these matters. As he stated, he met with my noble friend Lady Jay and officials earlier in the year. Rather than respond specifically to every point raised by the noble Earl and other noble Lords on the scientific impact, I want to discuss them in more general terms. However, on the more specific detail, I am sure that discussions between the noble Earl, other noble Lords and the Department of Health will continue. I would encourage that. Certainly, the Department of Health would be happy to explore what kind of study Professor Iain Chalmers at the Cochrane Centre has in mind.

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I respect the thoroughness of the scrutiny which the noble Earl made in relation to the scientific evidence on the safety of fluoride. However, I make two points on the question of safety. First, it is true that virtually all medical and public health intervention carries risks as well as benefits. It is for the scientific community to advise on the balance of those risks to the benefits and for the Government to decide what is acceptable. Secondly, it is impossible to prove a negative. However many studies attest to the safety of a procedure, it is still not possible to say categorically that it carries no risk.

However, within that context, the evidence I mentioned earlier is highly persuasive. Half a million people in this country receive water which contains fluoride naturally present at a level close to or above the optimal one part per million, and five million receive water supplemented to that level. The corresponding figures for the USA are 10 million and 135 million respectively. Before and during the past half-century of fluoridation, there have been extensive studies of the health of those populations and, apart from improved oral health, the health experience of those receiving the optimal concentration of fluoride is no different from that of the population at large. I thought that that point was very well made by the noble Baroness, Lady Gardner of Parkes.

I should also like to refer to the point made by the noble Lord, Lord Clement-Jones. Given the readiness with which American citizens resort to litigation on health matters, it seems inconceivable to me that, as fluoridation could be harmful to health, no claim for compensation has gone through their courts.

Of course, too much fluoride can be harmful, just like too much oxygen, too much water, or too much of some vitamins. As has been mentioned, the experience on the Indian sub-continent, where much drinking water comes direct from wells dug locally, reinforces the need for the rigorous controls we have on water purity in the UK. It is impossible to say precisely how much fluoride is too much, but fluoride at the optimal concentration of one part per million has always been present in some water supplies. All of the evidence from here and other countries practising fluoridation indicates that the total intake from such water, together with that from food and beverages, such as tea, is harmless. Naturally, this is a matter which we will continue to keep under review; for instance, in assessing the forthcoming new estimates of dietary intakes in the UK.

The noble Earl, Lord Baldwin, asked about major control studies which are relied on to support the effectiveness and safety of water fluoridation. Over 60 years of research into the effects of fluoride and fluoridation has resulted in tens of thousands of published scientific studies. That is the foundation for the overwhelming view of medical and scientific authorities that fluoridation of water supplies is effective and that no likelihood of harm has been demonstrated. In addition, many detailed and authoritative scientific reviews of the literature have been published. I am sure that the noble Earl is aware of several of the most prominent and most recent of those reviews.

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The noble Earl also mentioned the question of skeletal fluorosis. This is a condition in which accumulation of fluoride in the bones leads to thickening within the bone. In its early stages it may be found on X-ray but cause no symptoms and no harm. Excessive accumulation may result ultimately in hardening of ligaments, stiffness and pain in joints, weakening of the bones, muscle wasting and compression of nerves. The fact is that studies of the fluoride content and structure of bone, and radiological surveys, in communities in the UK and the US have not demonstrated clinical skeletal fluorosis, even when fluoride levels occurring naturally in drinking water were several times that used in optimal fluoridation.

The noble Lord, Lord Monson, referred to studies from Boston on the effect of fluoride on the central nervous system. These were studies which used very high levels of fluoride on rats. The author does not claim that fluoridation of water is harmful; indeed, she claims only that there are effects at much higher doses. There is epidemiological evidence available; for example, the 1986 paper from New Zealand in which seven years of study of more than a thousand children found no effect of fluoridation on child health and behaviour. That supports the conclusion that fluoridation is harmless.

The noble Lord, Lord Monson, and the noble Earl, Lord Clanwilliam, raised the issue of water fluoridation in Europe. In fact, many countries in Europe have opted for fluoridation of salt; namely, Switzerland, parts of France and Germany. The concern that we would have in following likewise is that this practice could convey a confusing message when it is the advice of many of our health and nutritional experts that we should eat less salt.

My noble friend Lord Dixon referred to the use of bottled water. He may not be aware, but many popular bottled waters are natural mineral waters and that, unlike drinking water, there is no limit on the concentration of fluoride in natural mineral waters. Indeed, some of them contain concentrations which are much higher than the one part per million used in fluoridation.

I should like to turn now to a point raised by the noble Lord, Lord Monson, the noble Earl, Lord Clanwilliam, and my noble friends Lord Stoddart and Lord Dixon; namely, whether fluoridation can be described as "mass medication". I would say no. Almost all water contains some naturally occurring level of detectable fluoride. Even where that natural level reaches or exceeds the optimum level for dental benefit, it cannot be described as mass medication. Artificial fluoridation merely adjusts that level to the optimum level for dental health benefits and does not therefore add any substance or medication which is alien to the water supply. It is worth making the point that many substances, like chlorine, are added to the water to make it safe to drink without it being termed "mass medication".

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I move on now to the point raised by my noble friend Lord Rea about current legislation. He is right. The final decision on implementing fluoridation schemes rests with the water undertaker. The Water (Fluoridation) Act 1985 was consolidated in the Water Industry Act 1991. Section 87 (1) of that Act states:

    "Where a Health Authority have applied in writing to a water undertaker for the water supplied within an area specified in the application to be fluoridated, that undertaker may, while the application remains in force, increase the fluoride content of the water supplied by the undertaker within that area."
I give way to my noble friend.

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