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Earl Baldwin of Bewdley: Without good science, I cannot account for it. Observers were not blinded to the status of the people whom they looked at, so that they knew whether they were fluoridated or not when assessing the decay. There is a lot of variation in assessment of decay, well described in the dental literature. There was no controlling for sugar consumption in different areas. The science in that area was a mess. That is why one cannot make firm assumptions however clear the observations seem to be to people on the ground. I am sorry, but in this instance one has a right to ask for good science, as I said before.

I was going to go on to say that in many ways the question of abandoning beliefs is no different for many of us. In answer to what the noble Lord said, it is the enthusiasm, to some extent, I could say, of the crystal healers who say, "Who needs proper science? We can see that it works and we know that it works so we do not need to do any proper studies". In addition to this, some pretty disgraceful things have been written by people in positions of power and responsibility who should know better. I just want to mention a couple because some of them will be things that your Lordships have seen. In May Sir Iain Chalmers, Professor Sheldon and I had a letter published in The Sunday Times in which we made some of the points from the York report that I have made this afternoon. Alongside our letter was one from a representative of the British Medical Association supporting fluoridation. Her opening sentence read:

Since this is demonstrably untrue in the case of the largest and best, York, and the most recent, the Medical Research Council—I know these two reports well enough—I challenged her three times to substantiate this from the reports themselves, or else publicly retract a statement which will have misled thousands of readers. In three replies she simply defended the BMA's support for fluoridation; only in her final letter did she address my point with the words that her Association,

    "interprets the York report as further evidence that water fluoridation . . . [etc. etc.]"—

a very different matter from what she had publicly claimed. She gave her position, by the way, as Head of Science and Ethics.

I cite this, my Lords, as an example that can stand proxy for much that has been said and written after York: reckless, and in my view an abuse of a privileged position. The main offences have been lack of scientific rigour and selective presentation of evidence. What you are not told in briefings is often just as important as what you are. Other examples have come through

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the post recently, notably a briefing yesterday—I believe one of your Lordships quoted this—from the Chief Executive of something called the International Dental Health Foundation, who has clearly never read the York report but has convinced himself that it "totally refuted" any adverse health claims. No wonder some local communities vote for fluoridation when fed material like this by people with degrees after their names.

I wish there were time to dissect the BMA's current parliamentary briefing, which is one of the most scientifically disreputable documents I have seen on the subject. But there is not. Nor, alas, is there time to go into the other elements of the fluoridation controversy—which other noble Lords have covered—which are no less important than the science. I would simply, as a way towards finishing my remarks, invite your Lordships' attention to one short paragraph on the second page where the BMA, drawing a parallel with the iron and calcium that doctors give to children who are deficient, says:

    "Fluoride as a deficiency should be treated no differently".

This is about the only part of the briefing I agree with. Leaving aside that fluoride deficiency is not recognised by the Department of Health as a condition, fluoride could indeed be given like iron or calcium: tailored to individual need, in a controlled dose, for a limited period, monitored, always respecting the patient's right to refuse treatment. That is how medicines and supplements are given. This would indeed be the way to give fluoride.

But consider fluoridation, my Lords. It is given indiscriminately—forget the notion of "targeting", which is simply not possible via the mains water supplies (Czechoslovakia and Switzerland stopped fluoridating partly because over 99 per cent of fluoridated water misses its "targets")—to populations many of whom do not want it and cannot benefit from it, without the normal procedures of individual informed consent, which is a hallowed principle, as we heard, of medical ethics enshrined both in the Patient's Charter and the European Biomedicine Convention, without any medical licensing procedures—that is an odd area—by an uncontrolled dose (you get however much you drink or cook with), and for a lifetime. It is the most peculiar medical treatment of our times—which is perhaps why few countries practise it—one which common sense and caution suggest would need the very highest standards of evidence for safety and efficacy.

If proponents want to promote it on evidence which is substantially less good than for a drug prescribed one-to-one by a doctor who knows your history, and in the full knowledge that the two most recent scientific reports have highlighted the need for more research because we do not know enough about its effects, then this is enthusiasm run wild. Fluoride is already given to over 5 million people, which on the most recent figures is probably more than are taking any other drug. For the sake of the further millions who may be at risk from this measure, and on grounds both of medical ethics and good science, I urge your Lordships

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to reject an amendment which, given the unshakeable conviction of one party to this debate, is likely to bring this situation much nearer.

Lord Turnberg: First, I express an interest as an ex-physician with a scientific bent—in case it is unclear where I am coming from with my comments. We have all been inundated with a large number of letters of support for fluoridation. Personally, I have not had any letters against. As has been suggested, the weight of letters alone is hardly a reason for agreeing. But in this case I find myself in the unusual position of agreeing with the majority.

There is not a great deal that is new that is not already in much of the literature which most noble Lords received. I believe that the evidence for benefit seems strong. I, too, now have had the opportunity to read the York study, largely after being prompted by the noble Earl, Lord Baldwin. I am rather more reassured than he is, having read it fairly quickly but, I think, thoroughly. There does not seem any doubt that areas of the country where fluoride has been introduced have, by and large, reduced the incidence of caries. Where fluoride has been withdrawn—as it has been in one or two places—the incidence has risen.

We may argue—certainly the York report argues—that the evidence varies from place to place and that some evidence is not terribly strong. But all the evidence points in the same direction; it all seems to say the same thing. On page 43—

Earl Baldwin of Bewdley: My Lords, perhaps I may correct the noble Lord. While the probabilities are as he said, in fact, the range included a possible disbenefit. They did not all point in that direction. The fact that they were all open to possible bias does not help the case in adding studies to it. I hope that the noble Lord noted the word "suggests" and not "concludes". I go with him; it looks a probability. But the question is: is a probability of that degree enough? Perhaps we differ.

Lord Turnberg: My Lords, there have been a very large number of studies, most of which were discarded in the York study because they did not meet certain criteria of reasonable evidence. On page 14 of the report, there is a series of results from about 12 studies, all of which show the same thing—that is, there is benefit. Presumably, those were selected because they seemed to be relatively unbiased.

One of the problems is that it will not be possible to do a gold standard double blind trial in this type of situation where large populations are involved. We cannot get that. We may obtain increasing amounts of studies which lend weight to the proposal; I believe that we have a rather large number in that direction.

I should touch on one aspect which has not been mentioned. Children with caries often require a general anaesthetic for treatment. While general anaesthetic for children is fairly safe, there are clearly determined risks. Every so often one reads of a disaster from dental anaesthesia. So preventing even the rare occurrences alone seems a valuable, worthwhile aim.

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There is also some evidence—not strong; certainly not enough to produce it as strong evidence—suggesting that chronic mild infection in the mouth predisposes to chronic ill health. For example, it may predispose to heart attacks. The evidence is not strong but there are hints and people are looking at chronic infection in the mouth. A healthy mouth is worth while, provided that fluoridation itself does not cause commensurate harm, as the noble Earl suggested. Again, however, all the evidence favours no measurable risks.

I went through the York report looking for the evidence. Perhaps I may quote some statements from the report:

    "Using a qualitative method of analysis, there is no clear association of hip fracture with water fluoridation . . . A meta-regression of bone structure studies also found no association with water fluoridation . . . There were 26 studies of the association of water fluoridation and cancer".

Eighteen of these were thought to produce rather poor evidence and were not counted, but eight provided very reasonable evidence. The report continues:

"There is no clear association between water fluoridation and overall cancer incidence and mortality. This was

    also true for osteosarcoma and bone/joint cancers. Only two studies considered thyroid cancer and neither found a statistically significant association . . . Overall, no clear association between water fluoridation and incidence or mortality of bone cancers, thyroid cancer or all cancers was found".

To my mind, for a study to quote in that way was not bad evidence.

7 p.m.

Earl Baldwin of Bewdley: Does the noble Lord agree with my point that no clear association, which is what I said that York had found, is not the same as no evidence, which is what people are saying in our briefings? That is where we go wrong; that is, in the suggestion that there are no studies which suggest it. They go both ways and it cannot be said that there is cancer any more than it can be said that it is safe. I think we are probably at one on that, but it is not the same as saying that there is no evidence.

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