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第６０回日本口腔衛生学会特別講演スライドの日本語訳を担当しました。小林清吾学会長から公開の許可が出ましたので、ここにアップしました。Dr. Michael Foleyの発表原稿も手に入りましたので、努力足らずで英語のままですが、何かの参考にとアップしました。
Dr. Michael Foley (Director, Brisbane Dental Hospital, Queensland, Australia) の英語ー日本語スライド
Dr. Deog-Young Park: 朴徳永 （江陵原州大学校歯科大学予防歯科教授）の英語ー日本語スライド
How to fight the fluoridation battle – based on experience from Queensland, Australia
Most Australian states introduced widespread water fluoridation in the 1960s and 1970s, but until three years ago, only 5% of Queenslanders drank fluoridated water.
Most Australian governments mandated or strongly encouraged fluoridation in their major towns and cities. The Queensland economy relied heavily on farming, and most Queensland politicians already knew that high fluoride levels in Central Queensland artesian water caused harmful skeletal and dental fluorosis in sheep and cattle. The artesian water in Central Queensland often contained high levels of fluoride, and when water was left in open channels, evaporation of water in hot weather resulted in even higher levels of fluoride.
Queensland governments of the 1950s, 60s and 70s were conservative, anti-intellectual, and distrustful of major public health initiatives. To deflect pressure from health groups and avoid making a difficult decision, the Queensland government passed legislation placing all responsibility and costs for fluoridation on to local government.
But most local governments were unwilling to spend money on a controversial issue they knew little about. Dentists, doctors, and water engineers could only convince a few towns and cities to introduce fluoridation, and they were ignored by other Queensland councils.
“While recognizing that the balance of the scientific argument favours the use of fluoride in the pursuit of oral health, it is a principle of ethical public health in that mass, involuntary medication must never proceed without the express consent of the community”.
This policy was accepted by all political parties because none of them wanted to make what they thought would be a difficult political decision. Health professional groups strongly disagreed with this policy, and it was only changed in recent years.
Australian Child Dental Health Surveys provide good data, but they vary slightly from year to year, and we need to understand the conditions in each state. Queensland has the most extensive free School Dental Service in Australia, with a strong emphasis on prevention, but caries levels are always near the top of Australian states.
The Northern Territory (NT) usually has the highest caries levels because of its large indigenous population with generally poor oral health.
New South Wales is not included because their methods of examining children do not match those in the other states, but NSW is known to have relatively low caries levels compared with the other states.
ACT “caries levels” rose dramatically in 2000 because their School Dental Service started to concentrate on seeing the children with higher caries levels rather than seeing all children. The ACT population is generally wealthy and well educated, with low caries levels and good oral health.
The difference in caries levels between fluoridated and non-fluoridated areas is usually greater for 5-6 year old children than 12 year old children.
The Australian Child Dental Health Surveys also measured percentages of children who were caries free, average number of decayed teeth, average number of missing teeth, average number of filled teeth, hospital admissions for dental reasons, d/dmft and D/DMFT (an indicator of how well a child’s dental needs are being met), and other measures of dental health.
Reputable public opinion polls showing 60-70% of Queenslanders in favour of water fluoridation, and only 20% opposed. On-line polls, or polls in which people have to telephone their opinions are likely to be biased, but the polls showing support for fluoridation were organized by reputable organizations; the Local Government Association of Queensland, Central Queensland University, Queensland Health, and the Australian Dental Association. Until their own poll was conducted, the Local Government Association believed that most Queenslanders opposed fluoridation, because most of their mail was from anti-fluoridation groups. They became much more supportive when they realized that the large majority of Queenslanders actually wanted water fluoridation.
Cost-benefit analyses showing massive savings in dental costs if Queensland towns and cities were fluoridated.
Queensland Health Minister signing the 2004 National Oral Health Plan which recommended widespread fluoridation.
The cost benefits were based many factors, including the cost of restoring each cavity with an amalgam filling, the average life expectancy of an amalgam filling, and lost productivity incurred due to the dental visit.
Cost-benefit analysis for fluoridating all towns with populations >1,000
The estimated cost benefits were conservative and based on amalgam restorations. They did not consider the costs of more complex aesthetic restorations, root canal treatments, crowns, implants, bridges, or dentures, or the cost of pain and suffering.
Nor was any value included for improved aesthetic factors due to teeth not lost or filled.
Liquid is also often considered safer and easier to use, as there is no powder residue or dust that could be inhaled. As with all chemicals used in water treatment, care needs to be taken for safety.
The National Oral Health Plan 2004-13 strongly endorsed water fluoridation. The Queensland Health Minister realized that Health Ministers in all other states of Australia also strongly supported water fluoridation.
Younger, better educated politicians elected in 2004 and 2006 who realized that southern states had benefitted significantly from water fluoridation. The 2004 and 2006 Queensland state elections in particular saw a significant turnover of politicians.
The political party in power is much more likely to introduce controversial legislation if they know that other political parties are not going to oppose the legislation. Two of the most senior opposition MPs were a doctor and a dentist, and they both supported fluoridation very strongly.
Queensland has experienced strong population growth over the past thirty years, with large numbers of people with positive experiences of fluoridation migrating to Queensland from the southern fluoridated states.
Drought, and State Government taking over responsibility for water. This was very important. Until the State Government took control of water supplies and connected dams in South East Queensland, all water supplies were controlled by local councils. If a water supply was shared by two or more councils, they would all have had to agree before the water supply could be fluoridated. This was unlikely to happen because different councils often disagreed politically. In any case, most councils thought that fluoridation should be introduced by the State Government.
Anna Bligh was keen to make an impact soon after being elected as Premier. She was popular, had a large majority in Parliament, and the political timing of her decision was very important – soon after the 2007 national election so it didn’t impact on her party’s national election campaign, plenty of time for fluoridation to be accepted in south-east Queensland before the following state election, and towards the end of the year when parliament is not meeting, the media outlets are not as busy, and people’s minds are on Christmas holidays.
Epidemiological evidence is critical. Are caries levels regularly measured in Japan? Does Japan have a significant dental caries problem in children and adults? Are caries rates in Japan worse than other developed nations and surrounding Asian nations? Are caries rates increasing or decreasing? In those parts of Japan with naturally occurring fluoride in the water, are caries rates lower than in other parts of Japan? Do some parts of Japan have significantly higher caries rates than others? Is dental fluorosis common?
Fluoridation is unlikely to be achieved without a public perception that a significant caries problem exists. This perception should be supported by strong and recent epidemiological data.
Do most Japanese people think there is a dental caries problem in Japan that needs to be addressed? If Japan does have a significant dental caries problem that most people are unaware of, it is your job to convince them. Most politicians will be unwilling to make a controversial and politically difficult decision if there is minimal support from the Japanese population.
Do most Japanese people understand the importance of fluoride in combating dental caries? Is topical fluoride widely used in dental surgeries? Have fluoride tablets and drops been widely used in the past to provide systemic fluoride for children? Is fluoride toothpaste widely used and recommended? In the modern era, fluoridation is unlikely to be introduced into a developed country without widespread recognition of the value of fluoride.
Is there a common perception that dental caries is the fault of people who don’t eat healthy food and don’t care for their teeth? If so, make the argument that treatment of dental caries is expensive, particularly if hospitals are involved. Does data exist showing the numbers of hospital admissions for dental caries or abscesses, particularly for young children?
Many will blame families for high caries rates resulting from a poor diet and oral hygiene, but are the children to blame? Directly or indirectly, all of society pays for treatment of dental caries. Reducing the level of dental caries and improving dental health should therefore the responsibility of the whole society.
Don‘t just measure caries levels in permanent teeth for 12 year olds. These tend to be very low, since most permanent teeth have only recently erupted, and anti-fluoride groups know that the caries difference between fluoridated and non-fluoridated areas is often small for 12 year olds. Also use the figures for 5-6 year olds, since the caries experience is usually greater, and public sympathy for small children with dental caries is usually greater.
Traditionally many countries have used fluoride tablets and drops, but these are not now routinely recommended since we know that the majority of fluoride’s benefit is from its topical effect.
Anti-fluoridationists often use the argument that fluoride does not need to be swallowed to be effective because of the mainly topical effect. Remind people that a small systemic effect still exists, and the topical effect means that people of all ages benefit from water fluoridation. It’s not just children who benefit.
Dental caries in elderly people is now a big problem in many countries. Many people retain their teeth into old age, but develop higher caries rates because of changed diets and medication induced xerostomia. Some elderly people also find brushing and flossing more difficult because of poorer health, arthritis, dementia and other conditions. Is coronal and root caries a problem for elderly Japanese people?
Have fluoridation cost-benefit analyses been conducted to show cost savings if Japanese towns and cities implemented water fluoridation?
In 2002, Queensland Health (our state health department) organized a cost-benefit analysis for Queensland. It showed that if the larger towns were fluoridated, Queenslanders would save many hundreds of millions of dollars ($1 Australian = 80 Japanese yen) over the next 30 years. Other Queensland cost-benefit analysis research projects showed similar results.
Analyses in other countries also show large savings. These analyses helped to convince health ministers that fluoridation should be considered. Health budgets in most developed nations are rising very rapidly, and politicians will consider any health measure which will save money.
Politicians and health professionals are very different. Health professionals want to improve the health of the people. Most politicians genuinely want to do the right thing, but they also want to remain in politics for many years, and want to be re-elected at the next election. Politicians who have chosen to make a career in politics will make decisions that will increase their chance of being re-elected. If they feel a decision is likely to result in them or their government being voted out, they won’t make that decision, even if it’s the right decision.
In Queensland, many opinion polls showed that almost 70% of Queenslanders were in favour of water fluoridation, and around 20% were opposed. Even so, many politicians were reluctant to publicly endorse fluoridation. There was a perception that the 20% of people opposed to fluoridation would vote against any politician who endorsed fluoridation.
That made many individual politicians very reluctant to announce their support for fluoridation, even when they personally supported it. Many politicians will also not want to make a controversial and potentially unpopular decision when the benefits will not be seen for at least 5-10 years.
Health professionals don’t make decisions on fluoridation; politicians do. We often think that politicians should eventually make all the right decisions, but that’s not how politics works. Get to know your local and national politicians. The most successful health organizations in Australia are those with very close contacts with politicians and political parties. They attend annual conferences held by political parties, and introduce themselves to politicians.
Do you have any dentists or other health professionals who are members of the major political parties? If so, encourage them to become more involved in their party. Does their party have a Health Policy Committee which provides advice to the Health Minister? If so, try to become a member of the committee to influence any decision on fluoridation and other dental issues.
Politicians are unlikely to endorse water fluoridation if they feel there is little public support or evidence for it. We need to convince them. Politics will determine whether a decision is made and when it’s made. For example, if it’s a controversial decision (as fluoridation usually is), politicians will not want to make a decision in the year of an election because people who disagree with that decision will still remember and vote against them. They will only want to introduce a major controversial decision in the year after an election, so that it can be introduced and accepted before the next election.
Politicians are also more likely to support fluoridation if politicians from other political parties also support fluoridation. That way there will be less opposition in parliament, and less controversy in the media. A doctor and a dentist who both supported fluoridation were high ranking members of the Queensland opposition political party. Are any Japanese politicians also dentists? Talk with them privately about the likelihood of their political party supporting fluoridation.
Most politicians have little knowledge of fluoride and fluoridation. Once a fluoridation campaign begins, warn politicians that they will be inundated with letters and e-mails in a highly organized campaign by anti-fluoridationists from the United States and other countries. This campaign will include information from the US-based Fluoride Action Network at www.fluoridealert.org. Their arguments appear highly convincing and quote people with university degrees who claim to be experts. Most opposition comes from misguided individuals and groups with little credibility. Because of their highly organized and coordinated tactics, many politicians believe that the opposition to fluoridation is much greater than it actually is, and become very worried that they may make a very unpopular decision.
Reassure politicians that major health organizations in the United States and around the world e.g. World Health Organization, Centers for Disease Control, and American Medical Association all support fluoridation. No reputable health organization anywhere in the world opposes fluoridation.
Most opposition to fluoridation comes from three groups:
1. Concerned or mildly opposed people who don’t want anything more added to the water, the council should just give out free tablets, fluoridation is only for kids, we should have a choice, maybe it’s harmful…
2. Strongly opposed people from alternative health/green backgrounds.
3. Strongly opposed people from the socially conservative and often secretive organizations, and New World Order groups, and conspiracy theorists (although much of the early opposition was from people who believed fluoridation was a communist plot).
People from the first group can often be convinced by sensible discussion and providing information from reputable organizations. People from the second and third groups will rarely be convinced. Don’t waste your time with them.
“Why do you personally want to poison all Queenslanders?
“One day soon you will stand in the Court of Justice and you will be put on Oath - God will be your Judge. You will pay for this in eternity”.
“Do you own your own home? Do you own shares? Do you have an investment portfolio? We need this information for the Class Action lawsuit when we sue you”.
“In the past people like you were shot, jailed, hung or castrated”.
“Michael, your days are numbered pal”.
Opposition will be very strong!
Anti-fluoridationists use a wide range of arguments to try to convince people. These beliefs are passionately held, but without a solid scientific basis.
..the greatest fraud ever perpetrated
..makes humans stupid, docile, and subservient
..a deadly poison with no known antidote
..promotes cancer and various mental disturbances
Much of the misinformation from anti-fluoridationists is co-ordinated through the US-based Fluoride Action Network at www.fluoridealert.org. Most of the editors of the journal Fluoride also oppose water fluoridation.
Anti-fluoridationists have also blamed fluoridation for causing or worsening almost every possible medical condition, including cancer, kidney disease, osteoporosis and bone fractures, lowering IQ levels, and causing allergies. These claims are usually supported by impressive sounding “studies” or quotes from people with degrees.
These claims have been repeatedly rejected by the World Health Organization, Centers for Disease Control, and other major health and scientific authorities around the world.
“In the study of 39,000 children, in around 80 communities, the difference in the fluoridated area was on average 0.6 of a surface. That’s a benefit that’s almost immeasurable.”
But this study measured DMFS scores in permanent teeth only, in children aged 5-17 in fluoridated and non-fluoridated areas. The average DMFS difference across the 13 years was 0.6, but the difference rose as children aged and more permanent teeth erupted. By the age of 17, those children who had lived their lives in non-fluoridated areas had an average of 1.58 more decayed, missing or filled surfaces (8.59 vs 7.01 i.e. 23% higher) than those who had lived their lives in fluoridated areas. And the difference was greater when the use of topical fluorides was considered.
“Most of Europe has rejected fluoridation and is 98% fluoride free”.
Not true! Many European countries use fluoridated salt as an alternative to fluoridated water. The European Union recognizes the value of fluoride, and allows any country to fluoridate its water to a level of 1.5 ppm.
“Why swallow fluoridated water? The benefits of fluoride (if they exist) are topical, not systemic.”
The benefits of fluoride are mainly topical, but a small systemic benefit still exists for children. The topical effect means that all people benefit from fluoridated water, not just children. And fluoridated water is the cheapest, safest and most effective way of providing the benefits of fluoride to the greatest number of people.
“Fluoridation chemicals (sodium fluoride, sodium fluorosilicate, and fluorosilicic acid) are untested and unsafe”.
Care is needed with all chemicals used in water treatment. These fluorides are chosen because they dissolve 100% in water, and they break down 100% into simple and safe constituent ions and molecules. None of the original chemical is left in the drinking water.
Anti-fluoridationists frequently misquote scientific articles and legitimate experts. If a claim sounds wrong, it probably is. The American Dental Association web site has good responses to anti-fluoridation arguments.
If fluoridation was introduced in Japan, who would make the decision? Which level of government is responsible for water supplies: national government, prefectures, cities or towns? If a number of towns or cities share a water supply, would they all have to agree before fluoridation could be introduced? In Australia and the United States, fluoridation is more easily introduced at a state level than at a town or city level. Most small towns and cities do not have high level public health expertise, and are more likely to be influenced by anti-fluoridation arguments.
Many local councillors will ask why the State Government doesn’t make fluoridation compulsory if it is so safe and effective. Why are local governments forced to make the decision? If high dental caries rates are a state-wide problem, shouldn’t it be addressed by the State Government?
Ideally, a high level decision involving the whole country or prefecture is preferable to numerous debates in smaller towns and cities.
But if a high level decision is not possible in Japan, the fluoridation battle may need to be fought in separate municipalities. Do you have the energy for many battles? Do you have a large number of dentists and doctors willing to talk about fluoridation to patients and the general public?
Fluoridation in Queensland became much easier after 2006. Prior to this, all water supplies were controlled by towns and cities, and little progress was achieved. After many years of severe drought, the state government took over control of all water supplies in 2006, and mandated widespread water fluoridation in 2007.
Anti-fluoridation groups usually prefer fighting local fights because most local councils don’t have public health expertise. Anti-fluoridation groups bring all their resources from around the world to that area and overwhelm the local health professionals who are promoting fluoridation.
In Australia, fluoridation is taught in all dental schools, and almost all dentists support its introduction. Almost all dental schools have a strong department of population oral health and a strong emphasis on disease prevention. Is this also the case in Japan?
All journalists and local, state and national politicians need to visit a dentist occasionally, and this provides a good opportunity for dentists to talk with them about fluoridation.
Don’t just have dentists involved in the argument. Try to get other respected health professionals involved e.g. medical, nursing, and pharmaceutical groups. The anti-fluoridationists build coalitions with natural health groups, environmental groups, dissatisfied community groups, and anti-government groups. We need to build similar coalitions, so fluoridation is not just considered a dental issue.
Anti-fluoridationists often argue that fluoridation is promoted by dentists who don’t understand the rest of the body and toxicology. Ensure that any material promoting fluoride mentions other groups that endorse fluoridation. Stress the links between poor dental health and other health conditions.
Also try to obtain support from respected individuals, scientific, school and community groups to build up a broad coalition in favour of fluoridation.
Try to get media involved in your campaign. Health professional groups should regularly send out media releases to ensure that dental health issues are widely known in the community. In the early stages of a campaign, media releases do not even need to be about fluoridation. Before fluoridation is promoted, politicians and media need to accept that there’s a serious oral health problem in Japan. Learn how to write a media release that will attract the attention of media outlets. If the campaign develops, consider hiring marketing and lobbying experts who know how to sell an argument or proposal to politicians and the public.
If television or radio organizations want someone to interview about fluoridation, pick someone who is highly respected, well dressed, authoritative, and speaks very well. Anti-fluoridation groups usually have a representative who looks respectable and speaks well. You should too.
TV, radio and newspapers don’t want a boring one hour scientific lecture that puts people to sleep. Talking with the media is not the same as talking to a scientific conference. You’re trying to convince the people who read newspapers, listen to the radio, and watch TV. Most of these people don’t have scientific or dental training, so keep your messages simple. If you are being interviewed frequently, consider attending a media training course. These are usually run by former journalists. Politicians and business managers often attend these courses to learn how to respond to questions, get their message across, and even occasionally to avoid answering questions.
Do you have photos that support your arguments? The media like photos because they will be remembered long after statistics and facts in your interview have been forgotten.
If you’re being interviewed, remember that the media are probably not interested in dentistry or fluoridation. They only want a story that will sell newspapers or make people listen to their radio or TV station. It’s your job to give them information in a way that sounds interesting. Before the interview, plan the main brief messages you want the journalist and the general public to remember.
If your interview appears on TV or radio, they will probably only replay a few seconds of the interview, so try to give them just a few brief facts and statistics that will be remembered rather than a lengthy argument that will be difficult to include in a news report.
Be wary of taking part in interviews if you know that the interviewer or their TV or radio station is opposed to fluoridation.
Politicians regularly use sound bite messages during an interview, and you should too. Sound bites are usually witty and clever short phrases that succinctly give your message in a way that people will remember long after the interview or speech.
Sound bites can also be humorous, but remember that you still want to appear to the general public as an authority on dental health, not a comedian. The best sound bites sound natural, but are prepared before the interview and included in an appropriate answer to a question.
If you’re being interviewed over the phone, try to be somewhere quiet, preferably with a desk and a computer in front of you. The important messages should be printed and spread over the desk so you can read them while you’re being interviewed. Practice reading them aloud before the interview, so it sounds natural. If you’re asked by a radio or TV station to take part in a debate or to talk about fluoridation, ask who else will also be interviewed. If they give you the name of an anti-fluoridation campaigner, Google their name and organization to see what they’ve previously said or written. Prepare and remember responses to their main arguments. If you have a choice, try to speak after the anti-fluoridation campaigner so you can refute their arguments.
Inevitably anti-fluoridationists will write letters to major newspapers once any fluoridation campaign develops. Expect to see letters from all over the world sent to newspapers and politicians. Be cautious about responding to all anti-fluoridation letters to newspapers. The anti-fluoridation groups will keep responding well after you’re tired of writing letters. An occasional single authoritative letter quoting very well respected authorities e.g. World Health Organization or Japan Medical Association works best. A long running newspaper argument where each side writes five or ten letters only reinforces the belief that scientific opinion is equally divided. Offer an interview to the editor or reporters from major newspapers. If you convince them, they are less likely to publish anti-fluoridation letters.
The anti-fluoride lobby prefers public referendums to decisions by governments, since scare tactics can be used to influence undecided and uninformed people. Try to avoid a referendum if possible, even if polls show a majority of people in favour of water fluoridation. A majority often disappears once the referendum starts. There’s also usually an obligation to fund both sides of a referendum argument equally. In Australia, most referendums fail because people tend to maintain the existing situation and vote against change.
Referendums in Australia are only passed if all major political parties are in favour. Most major public health initiatives e.g. smoking legislation, speed limits, alcohol restrictions, vaccinations etc are made by governments and are not subject to referendums. Why should fluoridation be.
Try to avoid debates in public or on radio or TV in which anti-fluoridationists also appear. Taking part in a debate with anti-fluoridationists gives them a respectability that they don’t deserve. Anti-fluoridationists are always keen to have a public debate since they rely on emotive language rather than science. Their arguments are usually simple, because they’re trying to convince the general public, not scientists. Most of their arguments are wrong, taken out of context, or out of date, but disproving anti-fluoridation claims takes considerably longer than making the claims in the first place, and some degree of doubt from the original claim will often still be left.
In any case, even if you win the debate, simply holding a debate reinforces the perception that both sides have equally valid viewpoints. Don’t give them that respectability. Do not take part in debates if they are organized and chaired by anti-fluoridation groups.
Have you considered promoting salt fluoridation as an alternative to water fluoridation? Salt fluoridation has been introduced in many European and Central and South American countries. The number of people obtaining supplementary fluoride through salt is probably now greater than the number obtaining it through water. The benefits of salt fluoridation are probably greater when its use is mandated in all processed food, or when its cost is subsidized so that it becomes the cheapest option, particularly for lower socio-economic groups which tend to have the highest levels of dental caries.
Where it has been introduced, salt fluoridation has tended to attract less opposition than water fluoridation, partly because there’s a slightly greater element of choice. Many countries also acknowledge the benefits of iodized salt. Countries should use either water or salt fluoridation, but not both.
“…universal access to fluoride for dental health is a part of the basic human right to life.”
(World Health Organization, 2006)
“…fluoridation of water supplies, where possible, is the most effective public health measure for the prevention of dental decay.” (World Health Organization, 2001)
“Community water fluoridation … one of ten great public health achievements of the twentieth century.” (Centers for Disease Control, 1999)