Exploring why European countries do not fluoridate water supplies led me to studies that cast doubt on the benefits and add concerns about its health costs. I have been using fluoridation as it is usually presented in the USA to make a conceptual and sociological point that variation within a population can be discounted when the population can be controlled which requires appropriate social infrastructure (see below). After reading Colquhoun (1997) I am looking for an alternative example of Rosean population health to make my point and wondering why I hadn´t delved further into flouridation studies before.
Imagine a comparison of the dental health of two communities that have the same range of health problems except that the one with naturally high level of fluorides in its water supply has better than average dental health. In each community there will be variation around the average dental health. However, if the variation is small relative to the differences in the two averages, it might seem reasonable to advocate fluoridation of water supplies lacking natural fluoride. In doing so the variation around the average (the very simplest form of heterogeneity) is discounted, as are other deviations from type, such as teeth discoloration that occurs in some individuals. Public health policy-makers discount the variation because the benefits exceed the costs when summed up for the community. The policy-makers are able to do this as long as the infrastructure for water-supply fluoridation remains part of public expenditures covered by taxpayers and as long as individuals who bear disproportionate cost (e.g., those who teeth are discolored) do not effectively mobilize resources and allies to resist—in other words, as long as the population is well controlled. Opponents of fluoridation of the water supply who accept the data on benefits and costs (many opponents do not; Colquhoun 1997) could still promote a participatory alternative: fluoride tablets to be taken by each individual, which would allow people subject to teeth discoloration to adjust the dosage or to choose to manage their dental health without fluoride. This approach is not preferred by most public health policy-makers, who point to lack of “compliance” when individuals are responsible for administering their own preventative medicines. Participation is seen as unreliable; control is more effective. Population health is the guiding idea; variation within the communities is not troubling (Rose 2008).
Colquhoun, J., Why I changed my mind about water fluoridation, Perspectives in Biology and Medicine 41 29-44, 1997.
Rose, G. (2008 ). Rose’s Strategy of Preventive Medicine. Oxford, Oxford University Press.