Water fluoridation has been haled as "the most significant public health measure of the century (Northern Daily Leader, 2 January 1981)" by numerous health professionals especially public health dentistry specialists. Based on the most acclaimed experiments carried out world-wide and local survey and trial results, Guangzhou, a city in southern China with a current population of 8 million (half permanent residents, half migrant workers), jointed in the trend in 1965 to become the first city in mainland China to have its public water supply fluoridated. The people who started the Guangzhou water fluoridation program hoped that Guangzhou would set an example for other mainland cities with high caries occurrence. The fluoride debate among the dental workers never ceased. Some times it became fierce. As a result, in 1983, 18 years after the program started, Guangzhou was still the only city in mainland China with fluoridated central water supply. Even worse for certain people, the program was cancelled in the same year due to mounted pressure from the anti-fluoridation group.

By way of contrast, water fluoridation in Australia is a well-known success story. In 1994, knowing I would study public health dentistry under Professor Barnard’s guidance, Professor Shen Yanmin, who had played a major role in the Guangzhou water fluoridation program, asked me to learn from the Australian experience, hoping that I might find something better than those of the American water fluoridation program to help the pro-fluoridation group of mainland China to get the Guangzhou water fluoridation program re-started. I also believe that to find something new is important, because the literature on the American water fluoridation program is widely available in mainland China and many of them are translated into Chinese. The American approach is criticised by some anti-fluoridationists in mainland China.

To following Professor Shen Yanmin’s instruction, I started by studying the literature on Australia water fluoridation. However, I have found very limited amount of literature that is "Australian". In fact, the Australia water fluoridation program is based on the American water fluoridation model, with the same idea and approach. It is understandable that when water fluoridation is concerned, Australia is similar to America in most ways.

The following conversation will highlight this similarity. It occurred in April this year. "Why there is so little Australian water fluoridation literature? How did people start water fluoridation in Australia?" I asked Professor Barnard. "It was started because it works, so people do not write a lot about it."

In this essay, I would reveal the problems and doubts I encountered, during my study, related to water fluoridation, and by discussing the situation related to water fluoridation in Guangzhou, I would put forward my suggestion in an effort to argue for the re-installation of the water fluoridation program in Guangzhou. This essay would also try to provide scholars who wish to help mainland China with its water fluoridation program with certain information.

The following quotation will serve as a backdrop of this essay:

A review on water fluoridation in mainland China, USA, and Australia.

In this part, some aspects of water fluoridation, which are the concern of this essay, are recounted and discussed. The content is mainly related to medical concern.

1. Guangzhou Case study

In this section, the DMFT, fluorosis rate and fluoride ingestion is discussed. This discussion leads to the discussion of the necessity of water fluoridation in Guangzhou.

1.1 Caries

In 1965, fluoridation of the public water supply in Guangzhou was started. Prevalence of dental caries of children aged 8-11 was surveyed in 1965, 1971, 1975, 1981 and 1983. In a control area, Shipai, Guangzhou, prevalence of dental caries of children aged 8-11 was surveyed in 1966, 1972, 1975 and 1983. In both areas, the results of surveys were standardised with the distribution of case numbers of four age groups in the first survey. In an 1964 survey, the caries rate in one suburb of west Guangzhou was found to be as high as 73.5% (Professor Liang Shaoren 1965). In fluoridated area, DMFT decreased 59% in 1971, 60% in 1981 and 49% in 1983, and dft decreased 39% in 1971, 60% in 1975, 52% in 1981 and 35% in 1983, respectively compared with the dft of 1965. In the control area, DMFT remained approximately stable at the level of fluoridated area in 1965 and control area in 1966 (Shen Yanmin 1985).

In mainland China, dft is frequently used by dental workers. The reason can be seen by comparing the two tables above: the mean dft is much higher the mean DMFT.

The data shows us that water fluoridation is necessary when caries is considered; it is effective from public health dentistry’s point of view, and other data not present in this essay also demonstrate the water fluoridation in Guangzhou is cost effective, costing each person 9 Chinese cents (1.5 A$ cents) in 1982(Shen Yanmin 1986).

After the water fluoridation was suspended, the DMFT has risen. (See Table 3.)

So why did people make the effort to stop the Guangzhou water fluoridation program? Of course we start to wonder how bad fluorosis was in Guangzhou, because fluorosis is traditionally used as a counter-weight to the benefit of water fluoridation. we also will look at fluoride ingestion, because background fluoride has to be measured prior to adding fluoride towater supply.

1.2 Fluorosis

It is interesting to look at the following two tables (Tables 4 & 5) related to fluorosis.

Table 4

Table 5

These two tables are the results of two separate surveys done by different people. Both of them followed the national standardised method which is based on the WHO guide (WHO: A guide to oral health epidemiological investigation. WHO: Geneva 1979, 17). Dean’s method of classification was used in both surveys. The variables and codes used in the tables are the same, but the results differ greatly. This may be caused by two factors which can not be represented by symbols or numbers: human error and the subjectiveness of the measurements. General human error can be intentional or unintentional, which one it was in this case is hard to say and it is not the purpose of this essay. But the other factor, the subjectiveness of the measurements, is the taproot of human error. This will be discussed later in the essay. In fact, we should consider the dentists lucky because the lack of variation in tooth size and morphology enables the dentists to use the same unit of one-dimensional space measurement to gauge all of their clients. We even had the WHO devise a millimetre-marked probe for us to decide the periodontal conditions on all of our clients. The physicians are not so lucky though, for they have to cope with a certain unit of mass measurement to gauge people’s weight to put them under the catalogue of obesity or health. We all understand the joke that the slimmest person of the Friendly Islands visiting Guangzhou went for a medical checkup and was advised to go through weight-loss acupuncture treatment.

1.3 Fluoride ingestion

Fluoride reaches humans through the lithosphere, the hydrosphere, the atmosphere and the biosphere. Water and food are accountable for almost all normal human fluoride intake (Ole Fejerskov et al. 1996).

The natural water fluoride content in Guangzhou before water fluoridation was 0.2-0.3ppm (Liang Shaoren 1964). In 1984 Li Lanxin from Department of Chemistry, Zhongshan Medical University, and Shen Yanmin carried out a survey on daily total fluoride intake and urinary excretion of residents of Fangcun. They reported that:

These figures all fall comfortably within the "suitable amount of fluoride intake" brackets set up by McClure, Shupe JL and Singer L. (Shupe JL et, 1976. Singer L et al. 1949. Mc Clure 1949).

To make their survey result more credible, samples of rice and flour were sent to Professor Singer of Minnesota University, USA and Professor Taves of Rochester University, USA. They revealed in their report titled "Micro-quantitative determination of fluoride in rice and flour":

We understand that rice is the major ingredient of Chinese food.

Professor Guo Yuanzhu and her team also carried out surveys on fluoride ingestion in Guangzhou. Their latest survey result was publicised in 21 May 1995, on the first page of the most influential newspapers in Guangzhou, the Yangcheng Wanbao. The report titled "Guangzhou residents are not short of fluoride" told people that "the experts pointed out that water fluoridation had done more harm than good in Guangzhou" and that "carrot, tomato, pig and poultry livers and other vegetables fed to children in Guangzhou are high in fluoride, thus caries can be prevented without water fluoridation."

Back in 1980, the Guangzhou Health and Epidemic Station, a government body supervising public health issues, reported after carrying out a survey on fluoride ingestion in Guangzhou that the fluoride content in local food is more than high enough to make water fluoridation unnecessary. For instance, mean rice fluoride is reported as high as 3.77mg/kg, while mean flour fluoride as high as 6.18mg/kg (comparing with the figure of 0.43mg/kg (SE=0.10) for rice and 0.45mg/kg (SE=0.21) from Shen Yanmin, Singer and Taves).

After going through this case study, we can see that the water fluoridation debate in China is still alive and well. According to Shen Yanmin and his like, water fluoridation is necessary in Guangzhou, while Guo Yuanzhu and Guangzhou Health and Epidemic Station insist that water fluoridation is not needed at all in Guangzhou. It seems that both sides base their arguments on their results of their own surveys.

To probe the phenomenon a little bit further, we have to look at the American water fluoridation experience. The following section is a very brief re-count. However, it will help us to understand the background of the Chinese water fluoridation debate.

2. The American case study

USA is the pioneer of water fluoridation. During this literature study, most, if not all, of the literatures I find are written by American authors. In this section, I focus on two issues: (1) the HOW related to the endorsement of water fluoridation; (2) the WHAT related to the fluoride debate.

2.1 How water fluoridation started in USA.

In the late 1920s and early 1930s three American researchers (among them dentist Fred McKay) independently discovered the link between stained teeth and the high content of fluoride in water. McKay reported a relative absence of decayed teeth and associated this fact with the presence of fluoride (B.J.Kruger 1976).

In 1945, Grand Rapids, Michigan, America, was selected as a water fluoridation trial city, to be compared over a ten-year period with Muskegon as a control city in the same state. After just five years into the trial, with the experiment incomplete, the United States Public Health Service (USPHS) endorsed water fluoridation. Any dentist will know that very few of the permanent teeth of the children who had been drinking artificially fluoridated water all their lives had erupted (Philip R.N.Sutton, 1979).

In 1951, six years into the ten-year experiment, Muskegon, the control city, was fluoridated. How can people draw conclusion of an experiment without a control group? But the USPHS would not care. At that time, several other experiments had been set up but long before and results from these could be examined, the USPHS had embarked on a vigorous campaign to promote water fluoridation (George L.Waldbott 1965).

In the 40s and 50s, water fluoridation became a trend in America. As Ralph Nader stated:

The Journal of the American Dental Association refused to publish articles and letters with anti-fluoridation views (Anne-Lise 1975).

It should be mentioned that there were also Canadian and other US studies, and early studies in natural fluoride areas.

2.2 The WHO scenario

In July 1969, at the 22nd WHO assembly in Boston, the WHO endorsed its support for water fluoridation:

USPHS Surgeon General Leonard Scheele, a keen advocate of fluoridation, was the President of the World Health Assembly. To what extent the USA influencing the WHO is not an issue in the essay, by it is an open secrete that "basic demands about the role and activities of WHO were met to satisfy the American contingent, so the influence of American medicine has been strong and persistent in the international body." (Varney p16.)

2.3 The center of debate

In the USA, central to the question of water fluoridation is the question of the safety of fluoride. There is plenty of literature supporting that water fluoride at 1 ppm will significantly reduce the caries rate and cause minimum fluorosis increase. But "the claim of fluoride safety rests not on studies but on the claimed absence of substantial proof of harm".(Varney p35). After only five years of experiment water fluoridation was declared safe, but:

Considering the above factors, no wonder that the anti-fluoridationists try to look into the basics of fluorine. They argued that fluorine is not an essential nutrient (Waldbott 1978). There is numerous literature questioning the safety of fluoride. Fluoride is claimed as safe, but based on what this claim is made? How many studies have been carried out on fluoridation’s safety? Anti-fluoridationists asked. Wendy Varney, an Australian journalist, made the investigation. Her findings can be demonstrated by one title of a section in her 1986 book: Paucity of studies on fluoridation’s safety.

In 1993 the American National Research Council published "Health effects of ingested fluoride." This book answered many of the fluoride safety questions and made readers believe in the safety of fluoride. It is not this essay’s purpose to evaluated the safety issue. The point here is that how this large scale public health project started and how the whole issue was handled will haunt many of us for years to come.

3. The Australian success story

Even if I fail to find more Australian literature on water fluoridation, I certainly believe that the 1991 NHMRC water fluoridation report sheds light on the most important points regarding the safety of water fluoridation. Also I believe I can understand the situation of Australia a bit more than that of American because I have been living here for nine years. For a while this section will venture a bit off-center from the main theme of the essay to document the Australia water fluoridation success story. This is not only because Professor Shen Yanmin and some of my colleagues back in mainland China asked me to learn from the Australia water fluoridation experience, but also because I always feel proud to share with them the enormously beneficial knowledge which Professor Barnard has given me over the year.

In this section, I will present the distribution of fluoridated population, the effectiveness and cost effectiveness of water fluoridation, then by reviewing some contents of the NHMRC water fluoridation report, bring up the main points that this essay is trying to make.

3.1 The success

Australian water fluoridation began in 1953 in a town named Beaconsfield in a state called Tasmanian. This "beacon" certainly reached far: many of the other states and cities soon followed suit in the 60s and 70s. By the early 80s, 65.5% of the total Australia population were using artificially fluoridated water (Commonwealth Department of Health, 1982).

Now, most of the Australian major cities have fluoridated public water supply; two thirds of Australians drink fluoridated water. Besides the famous Sydney and Melbourne, Adelaide, Perth, Darwin and Hobart also have their water supply fluoridated to approximate 1ppm F (Barnard 1993).

3.1.1 The effectiveness

Professor Barnard’s studies show that for 12 years-old, the decrease in caries between 1963-1973 was 48.8% and between 1963-1979 was 71.4% in a town called Tamworth. When the Tamworth water was fluoridated in 1963, the dmft for 6 years-old and 12 years-old were 7.2 and 8.4 in that order. In 1979, the dmft for the 6 years-old decrease to 1.4. in 1988 the DMFT for 12 years-old became 0.9 (Barnard 1989,1990).

There are plenty data showing the effectiveness of water fluoridation. Only one table is selected for this essay for it clearly show the different dmfs between fluoridated and non- fluoridated areas.

Blue Mountain and Hawkesbury are two suburbs of the Sydney area similar in many aspects. The latter has fluoridated water supply but the former does not. Table 6 shows the differences of mean caries experience between these two towns.

3.1.2 The cost effectiveness

In Australia, there is an organisation called the National Health and Medical Research Council (NHMRC). It is an advisory body made up of medical professionals that provides public health advice to the Australian government. NHMRC published a report titled "The effectiveness of water fluoridation" in 1991. With regard to cost-effectiveness, American data, and only American data, was happily presented. These data include data from Birch (1990) and data from a workshop in Michigan (Burt,1989):

Considering the fact that one simple filling can cost a patient A$60 in Australia (Barnard 1991), the cost-effectiveness is obvious if the American data could be applied to Australia. In my study I do not find any anti-fluoridationist picking on the cost-effectiveness issue of water fluoridation, so I believe it must be cost-effective. In Australia, all tax-payers pay a certain amount of the their wages as a health levy. The people here are very conscious about how the government spends money, because the know that it is their money. If the water fluoridation is not cost effective, the anti-fluoridationists will certainly make it an issue, telling people that water fluoridation is a waste of money, their money.

3.2 The fluoride debate

The director of National Centre for Epidemiology and Population Health of the Australian National University pointed out in 1991:

They argued that (1) the claimed benefits of fluoridation were being grossly overstated; (2) the efforts of anti-fluoridationists to warn the community of the adverse consequences of this policy were being suppressed, and that the evidence in favour of fluoridation was being exaggerated to point of fraudulence.

A speech made by Dr. J. Colquhoun in 1992 in Japan, was translated into Chinese and made available to the public. In his speech, he told the audience that (1) water fluoridation is ineffective in the prevention of caries; (2) water fluoridation causes fluorosis (Chinese Journal of Fluoride Study Information, 1993, vol 8(3):15). Because Australian data was extensively use in their research, the Australian fluoridation program was once agian in the spot light in mainland China.

This section will provide with main points of the debate. This, along with the Chinese and American case study, will lead to the revelation of the major differences between the Chinese debate and their western debate.

Central to the debate is the safety of fluoride, as the case of American. Actually, we can draw a parallel between the American and the Australian cases. Minimum fluorosis increase was used to verify Dean’s 1ppm ‘optimal’ level. Regarding other toxicity possibilities, there have been a lack of relevant studies, at least before fluoride was put into the public water supply. One typical example is that when addressing a local council on fluoridation in 1985, Dr Ford, the NSW Health Commission Cancer Register, assured councillors that two cancer epidemiologists of the Division of Human Nutrition of the Commonwealth Scientific and Industrial Research Organisation (CSIRO) ‘have not at any time shown any relationship between fluoridation of water supplies and cancer, excess cancer or the development of any of the cancers.’ But, as Dr Potter was later to point out,

3.2.1 The safety issue

Even in 1991, Robert M. Douglas pointed out:

3.2.2 The fluoride intake

The Australian NHMRC has used Market Basket Surveys (1987, 1988,1990) to estimate the dietary sources of fluoride intake. Infant foods are included in the surveys. It is noted that the first survey was carried out after 30 years of fluoridating the public water supply. The NHMRC was clearly aware of, when presenting their 1991 Working Group report on the effectiveness of fluoridation, that,

Two pairs of discrepancies are brought up by the above paragraphs. They are worth special notice and emphasis here because the guideline of this essay is derived from these two pairs of contradictions. In fact, the attitude shown in these two sentences gave me the courage to construct my essay around the water fluoridation debate. In the following part of the essay, the importance of these considerations will be discussed in some detail.

4. The difference between the USA and Chinese water fluoridation debate.

The difference is obvious by now: in America, it is the contradiction between "good and bad"; while in mainland China, it is that of "necessary or unnecessary". For Australia, I have the impression that water fluoridation being "good" and "necessary" is taken as an act of faith, at least at the time when decisions were made to carry through with the idea of water fluoridation. In fact, dental students were once asked by their teachers to pick out points from the anti-fluoridationist argument to refute (Barnard’s lecture, 1996.) rather than really look into the problems.

One issue important to the western countries is that of civil liberty. When water fluoridation starts in a region, it becomes compulsory for people of that region to take in added fluoride, even against their will. This is considered by some as a violation of civil liberty. I am not going to risk myself to tackle this sensitive issue because the concept has not prevailed in mainland China just yet. But I believe civil liberty will emerge eventually in mainland China and make the current form of water fluoridation more confusing.

From now on, the major concern of this essay will be put forward based on the background information that has been discussed.

5. The foreign influence in Australia and mainland China.

During my study, I found interesting phenomena related to water fluoridation. One of them is foreign influence.

5.1 "Experts" visiting Australia.

In the 50s, there were many fluoridationists from already fluoridated countries visiting Australia and making outrageous remarks. As Varney recounted:

Anti-fluoridationists also made their visits to Australia. A Committee of Inquiry into Fluoridation in Victoria in 1979, showing the public that the fluoride safety issue was still not settled yet.

5.2 The thesis written by Chinese in Japanese.

In the "selection of theses from 1965 to 1993 on fluoride", the Guangzhou anti-fluoridationists published a total of 4 thesis. Of these four, two are in Japanese, with no use of Chinese at all. The fluoridationists published about 60, 11 of them with abstracts in English, one in Japanese (the first author of this thesis is a Japanese).

It is obvious the anti-fluoridationist group has a close relationship with Japan. In the 80s the Japanese anti-fluoridationist group invited the leading Chinese anti-fluoridationists to Japan for a conference, with all expenses paid for by the Japanese.

Analysing the water fluoridation debate from non-dental point of view.

The content of this part is mainly cultural, political, and philosophical.

In this part, I will try to look on the debate from an outsider’s point of view. One purpose is to find the hidden notes behind the suspension of water fluoridation in Guangzhou, and consequently making the issue more approachable. Hardly an outsider to the water fluoridation debate in Guangzhou, I will try to distance myself from my pro- fluoridation stand. To achieve this goal, the method of self-criticism is employed. This "self" does not mean an individual (myself), but indicates some part of the dental profession as a whole. At the end, an argument to reduce the variables of water fluoridation will be put forward. Since the fluoride debate is a social phenomenon, Anthony Giddens (1983) "forms of sensibility" towards social analysis are adopted. These related forms are:

1. Historical aspect;

2. Cultural aspect;

The historical aspect has been dealt with in the Part one; only a short remark is given in this section. The critical aspect is spread out over the whole essay as supporting and connecting tissues, however in this section it is sifted out as an independent organ: the heart of this essay.

1. The historical aspect.

When people look into any debate, they will review the history of the whole issue. When they see the history of water fluoridation recounted in part one of the essay, they would not easily believe what the fluoridationists are going to tell them. It does not matter that fluoride has been proven safe now or in the future, the way the campaign was pushed will always cast a shadow over the whole issue, undermining the credibility of certain organisations. Water fluoridation might be fully justified as medically right, but when it comes to the way it was implemented at the first place, it will always remain politically wrong.

2. The cultural aspect.

In this section, the social status of dentists in Mainland China and America is looked upon and compared. This will lead us to see that within different cultures; the opinion of dentists (or dental workers as a more proper word), has very different force of impact on the society in which they exist. Hence when the Guangzhou water fluoridation debate is concerned, we might have to look far beyond the horizon of dentistry.

2.1 Modern dentistry - a profession with political muscle

The third assignment Professor Barnard gave to his new students (including myself of course) when the course started this year was "Investigate literature - is dentistry a profession? (Wednesday, 13th, March, 1996).

The following is part of my answer to the question.

There is very little doubt that dentistry is a profession, even as I still have reservations of questions. Afterwards I also learnt that the dentists in America and Australia have their autonomous organisations independent from government control and vigorously defending their own interests. In USA, a dental conference with 10.000 American dentists attending is not uncommon.

The USA developed the modern concept of dentistry, it is still the centre of dentistry of the world. The leadership of water fluoridation falls naturally on America. So it is of some significance to understand the importance of dentists in America. In Australia, the dental organisations are not as powerful as that of America, but the dentists hold social status similar to that of America.

The dentists in private practice enjoy a high economic status. It is not this essay’s purpose to discuss income of dentists. There are surveys on this done by Barnard. How many people are drawn into this profession by the promising economic prospects is unknown; but in "democratic societies ruled by law," such as America and Australia. For example, the 1995 Sydney University admission cut-off point for dentistry was 98.90 out of 100%, comparing that of 98.10 for law (University Admissions Centre, 1997). I assume that this happens not because dentistry requires higher IQ that law, but because places for dentistry is very limited but attractive to the students.

I believe that students who get into the dental school and finally graduate will be confident with themselves, and trust in their beliefs because they know they are of a very higher rank on the educational ladder.

So in America and some other countries, the dentists are great in number, financially well off, confident, organised, and have their representatives in the government. This enables them to influence, some time to a considerable extent, some of the government’s policies, for whatever they think right.

Money and power attract each other; once twisted and interwoven, they produce more money and power.

2.2 Dentistry in mainland China: ranks low.

Lu You (1125-1210), a poet in the Song Dynasty, once wrote: "seeing my wig and false teeth, people laugh at my silliness." Some Chinese scholars argued that the Chinese had invented dentures a long time ago. If it was true or not has very little significance here, apart from my fear of false pride of old history.

The first dental school, the Western China Dental University, was established by the American in the 30s. Most dental facilities in Mainland China are directed by the early graduates of the this university until they retired recently. Many of them hold America D.D.S degree. Before 1949, the dentistry in China followed the America path, and the dentists had a relative economic status similar to those of the USA. But even they had high economic gain, they might not gain high social status. One live example is that of Hong Kong, where dentists still hold a low social status in spite of their substantial economical gain (C.S. Chu, T.W. Chan, H.M. Hui, L.P.Samaranayake, J.C.Y. Chan, S.H.Y. Wei 1995). Even the Japanese, with a culture similar to that of China in many ways, but now living in a highly developed economy, do not hold their dentists in high regard.

In the Chinese history, people were so often, sometimes generation after generation, tormented by famine and war. The focus was survival rather than health. From the working class’s point of view, the government that could keep them away from hunger was a good government; for the government, any policy that will help to satisfy the people’s basic needs (so they would not revolt) was a good policy. If people could not guarantee their mere existence, they would not care too much about their teeth. Since the Han dynasty (221BC - 220AD), 258 years after the death of Confucius, the Chinese rulers adopted Confucius’ teaching as the principal of governing. Poor and often in hunger when alive, Confucius was honoured as "the teacher and sample for ten thousands generation to come". Possessing many skills himself, Confucius believed that who has the ability of using his mind is superior to those using their hands. To work for the government as a decision maker was regarded as high achievement. He once said, "Having no official employment, I acquired many arts." (Yang Bojun, Wu Shuping 1993). He spent most of his life on teaching people the love for propriety and righteousness. To the Chinese feudal rulers, propriety and righteousness mean obedience and loyalty to their dictatorship. So in two thousand years, the Chinese education system’s emphasis on moral teaching surpasses any thing else including medicine. Medicine remained a father - to - son skill and knowledge in China till the 20's century. People have little idea of dentistry, they would not give many thoughts to a branch of medical sciences dealing with non - life threatening tooth ache. Since 1919, the general Chinese intellectuals started to rethink and held Confucius’ ideology responsible for the backwardness of China. However, after almost two thousand years of application, I believe Confucius has become an inseparable part of the Chinese culture and has been embedded in the genes of Chinese, even though the modern generations might not know what the heritage is. This leads to my belief that the negligence of dental health has become part of the Chinese culture, and this might not change without an effort even when people’s economical status improves. Last year I spent six months touring mainland China, covering half of the country. I found that in most rural area I visited, dentistry is a backyard industry. I took a photo showing a person with a pedal-engine drilling another person’s teeth in the pedestrian way, while right beside the pedal-engine, was a shoe repairer doing her business. I visited many dental clinics and spent time working at some of them. I met people who would not hesitate spending 10,000 for one implant. I found that they wanted the treatment not because they care about their dental health, but because they believe that good teeth are part of the property of the social elite, and only the most expensive treatment can fit in with their self-projected social status. Some of these successful entrepreneurs do not even have the habit of tooth-brushing. The latest United Nation’s report (September 1996) revealed there are 35 million, almost 1/3 of the current population, live under the poverty line.

Even though there are no dentist literally in mainland China, people call the stomatologists dentists. (In fact, most of the stomatologists of mainland China are dentists by the nature of their daily work; only a small number of graduates from stomatology faculties practise oral-facial surgery as their main daily job.) Dentists deal with tooth problems, and not dental diseases that are life threatening, a tooth can always be pulled out and the pain will go. So people know that they can do without dentists. And in present mainland China, stomatologist do not even have an economical status higher than average. If they are dispensable and poor, why should people listen to them?

So in mainland China, when the dentists promote dental health procedures, like water fluoridation, people would not pay attention to them. Even if they do pay attention to what the dentists are saying, they would not take it as a faith, they will make their own judgment. When it comes to adding chemicals to the public water supply, people, especially decision makers, will not accept the dental workers’ theory without scrutiny, especially if it is of foreign origin (sometimes the Chinese people are suspicious of foreign ideas because the country was devastated by foreign powers so many times). I will come back to this later in the essay.

3. The structure of water fluoridation: who is in control?

In this section, the structure of water fluoridation as a public health measure will be looked upon briefly, trying to reveal who is debating and who is in control of the whole issue.

It is obvious that politics overshadows academics, no matter which country, Australia or mainland China, is concerned. But there are differences that lead to different endings of a public health policy.

3.1 The Australian saga

Some American dentists found the beneficial effect of fluoride; some American organisations including that of the dentists saw water fluoridation as a great public health measure and endorsed it; other organisations in America or other countries identified themselves with the trend and promoted it, for what ever reason only known to themselves. This is the picture I have obtained during my study of water fluoridation.

Wendy Varney, a journalist with no particular stand towards the water fluoridation debate, carried out a research of the politics of fluoridation in Australian in the 80s for her political science honours thesis:

Both parts of the debate will use media for propaganda to further their own cause and damage that of the opposition. The media’s role is important and complex, it is beyond my comprehension without specific study.

The structure of water fluoridation program is clear by now:

(1) the dentists come up with the fluoride theory;

(2) based on the theory, some dentists promote fluoridation; many dentists are against it (among them, some do so to protect their current source of income).

(3) the government (or authority) implement or oppose water fluoridation for improving public health and/or self - interests.

(4) the passive role of the public.

(5) the media has great influence over the public.

The important point is that the government is in control.

The structure can be visualised with figure 1.

The vested interests of particular groups and foreign influence in the water fluoridation debate are worth noticing. Any thing is going hand in hand with money nowadays in many parts of the world. Mainland China has been no exception in the last decade, if not to an extent greater than in other counties due to its current stage of economical development--In mainland China, the government hold the old ideology, but people, educated and no-educated alike, are out to make new money. For instance, a scholar who is against water fluoridation may promote fluoridated milk, and receive kickbacks from milk companies.

4. Critic - from an outsider’s point of view.

The fifth assignment Professor Barnard gave us is to write a critical review of an article

The title of the given article is " Advanced patient records: some ethical and legal considerations touching medical information space", written by E.H.W.KLUGE, Philosophy Department, University of Victoria, Canada. By discussing this excise, Professor Barnard guided us to understand the importance of being critical to "orthodox" knowledge. Also by studying the article chosen by Professor Barnard, and combining with later studies, I came to realise that, although a branch of dentistry, Public Health Dentistry is closer to the level of arts, while dentistry at large, is technique centred, that is, concentrating on the use of hands. If we use the ancient Greek classification of knowledge, arts deal with That, What, Why, and Wherefor, while science deals with How. Through the passage of time, some branches of sciences, like quantum physics, cosmology and psychology, has risen to the level of "That", inquiring into the very existence of being itself, while dentistry remains on the level of "How", that is, to find a way to solve certain problems encountered without knowing "What". One instance is the consideration of time. In 500 AD, the Greek philosopher Heracleitus and his disciples held that the time flow is of the essence of reality (W.K.C.Guthrie 1962.). People feel, think, and act in the time flow (J. T. Fraser 1986). Any events, including diseases, take place within a certain measure of time. Time is an inseparable property of any events on earth. That is, whenever an event is concerned, the time factor must be considered at the same instance. But in dentistry, the time factor was neglected for decades until recently in the case of establishing the cause of dental caries and the cariogenicity of food (the frequency of consumption). Another instance is the age-related dose recommended for fluoride supplements application (Burt 1996). Not understanding why the dose is age-related rather than weight-related, I asked Dr. Shanti, the lecturer of public health dentistry, Sydney University. "Because they are worked out by the dentists," she answered without a moment of hesitation. I believe the weight-related dose could not be worked out because of the lack of accurate data related to the safety of fluoride. Sidestepping the controversy, people come up with an age-related dose.

For all reasons, the politicians, whose duty is to look after the overall interests of a nation, have every right, out of necessity, to put the dentists’ ideas under scrutiny.

The decision to suspend Guangzhou water fluoridation program was finalised in 1983 by the Deputy Mayor of Guangzhou, a statistician by profession. A statistician needs accurate figures to decide the meaning of figures. He knows that if he draws conclusions from "assumed" and "estimated" data, the whole situation might be misjudged, just as the old saying goes, a miss is as good as a mile.

It is said that lookers-on see most of the game. In this section, I will try to analyse why the Guangzhou water fluoridation program was stopped by local authorities, not by recounting events, but by digging in behind the "facts". The chemical and biological properties are not discussed (not throughout the essay in fact). Medical or dental knowledge is not relied upon. The only tool will be employed to lead to the conclusion of this essay is commonsense.

Commonsense is only common in a given cultural background. For example, sacrificing personal interests in order to serve the people is the commonsense among many of my generation but obvious not among the youth of mainland China today. Ideology is a major part of a certain culture. During Mao’s era of mainland China, people were required to learn dialectical thinking, to concentrate on politics rather than economics. Now things have changed around, economics has become the top priority. But people, typically the decision makers, can not forget the dialectical concept (and why should they?).

Dialectics, found by Hegel and adopted by Marx, is still the philosophy behind the current Chinese constitution. Philosophy is always important in any logical debate. In 1980, the American Dental Association remarked that some people are against water fluoridation for philosophical reasons (American Dental Association 1980). In 1985, Shen Yanmin published his "Looking on some of the water fluoridation debate questions from philosophical point of view", pushing the debate for medical level to philosophical level. This is of long lasting effect. For in mainland China, the academic and social influence of philosophy is way above that of dentistry, judging from the definition held by the ruling party for philosophy as "the generalisation and summation of the knowledge of nature and society."

For the above reasons, the commonsense used in this section is that of dialectics.

4.1 The "optimal" level of water fluoride.

Ever since Dean found the co-relation between caries and fluorosis, 1ppm fluoride level in drinking water is respected as the "optimal". The highly regarded fluoride experts remarked in their 1996 publication: "Some 50 years after the 21 cities study (done by Dean - my own note), we can now see that the choice of 1.0 mgF/L as the "optimum" concentration for fluoridated water was based on the view (implicitly rather than explicitly) that the dental caries of the day was a far greater problem than the milder levels of fluorosis. With the passage of time, the nature of the trade-off between caries and fluorosis that is inherent in the decision to fluoridate drinking water became lost, and 1.0 mgF/L often came to be seen as an absolute requirement for fluoridation. In the 1990s, however, the fact that the fluoridation decision involves this trade-off has come to be far better understood (Burt 1996).

It is absolutely right to the point to describe the "optimum" view as "implicit". It is also truthful to bring up the "trade-off" issue that was seldom mentioned or disliked by many fluoridationists in the past.

In this section, I will list the doubts I have related to the use of fluorosis as a counter-weight to caries reduction.

4.1.1 The subjectiveness of fluorosis index.

Even one scale in the index itself is identified as "questionable". How could a "questionable" index to be used in scientific studies is a mystery to me. Very few dental workers deny the subjectiveness of fluorosis index we use today.

Ten years ago, the leading anti-fluoridationist of mainland China, Professor Guo Yuanzhu, showed her students (I was one of them) a number of cases of fluorosis on patients. Minutes later, Professor Wang from Beijing, a dentist specialised in tooth discolouring, told us that the abnormity on the same patients was caused by tetracycline.

The subjectiveness of fluorosis index is also reflect by the great variations of fluorosis rate in the result of varies surveys carried out by different groups in Guangzhou. We can always put the blame on human error, but it is the subjectiveness of the index itself that allows such errors to happen.

4.1.2 The fluorosis and caries correlation

Discovering the correlation between caries and fluorosis, Dean worked out the "optimal" fluoride level. This level is balanced by two factors: minimum fluorosis increase and maximal caries reduction. In 1982, M. Bellemare reiterated this balance in his report to the FDI/WHO/Kellogg Foundation Joint Conference of Fluorides (WHO 1982).

But their relationship with the body as a whole is fundamentally different:

1. Caries is progressive; it will eventually affect the function of the body as a whole;

2. Fluorosis will not progress, will not eventually affect the function of the body if it does not do so at the first place.

Also the relationship between the two and fluoride is fundamentally different:

1. Fluorosis is a direct result of excessive fluoride intake during certain time; the toxicity of fluoride is direct and the possible harm of fluoride to body metabolism might be direct. The relationship between fluorosis and fluoride is direct.

2. Fluoride has no direct link with dental caries. Dental caries is not caused by the lack of fluoride, but by bacteria. Fluoride exerts its anti-caries effect through strengthening the enamel and hampering the related bacteria. So the relationship between fluoride and caries is indirect. Even the WHO declared fluoride as an "essential nutrient" in 1973, I personally have doubts towards it. We can not list a chemical as essential nutrient because it is beneficial in a certain amount and we can not eliminate it from our food chain. For a chemical to be essential, I believe that it has to be related directly to the normal functioning of the body and without it the body will not function properly. The difference between fluoride and other trace elements like vitamins are: vitamins affect body metabolism directly. Should the intake of a certain vitamin become insufficient, an additional dose of that vitamin will mend the related problems directly. Fluoride does not possess such a property.

Citing the above differences between caries and fluorosis, I believe to balance the safety of fluoride on fluorosis and caries is not up to scratch. If we regard caries reduction, fluorosis, and fluoride as entity A, B, and C respectively, we will find that A and B do not share the same kind of relationship with C, so it would be improper to use A and B as the opposite sides of a contradiction which is inside C.

4.1.3 The contradiction of the part and the whole.

According to dialectical materialism, the part and the whole can make a pair of entities. Sometimes the part and the whole share the same interest, sometimes not. If not, there is a contradiction between the two. However, the whole is the controlling side of the contradiction in most cases, and people try to intervene, the interests of the whole should be protected and the interest of the part may be sacrificed to suit the whole. In the case of water fluoridation, both caries and fluorosis are parts. When the safety issue is concerned, the focus is better focused on the whole, that is, the body. The safety issue would be better balanced on the contradiction between the interest of the part (in this case, the tooth) and the interest of the whole (in this case, the body), rather than be balanced on the not directly related entities of the part.

Another rule related to the part and the whole in dialectics is that there is always a relationship between the part and the whole. Sometimes change in the part is the indication of changes in the whole. The leading anti-fluoridationist remarked:

It is possible to use the changes on the part as an indicator to the changes on the whole, provided the index is accurate. But fluorosis is not a reliable indicator, for we can have an entire tooth chipping away because of fluorosis while the rest of the body remains in perfect health.

When discussing the safety of fluoride, the amount of fluoride ingested is regarded as quantity, while the safety or toxicity of fluoride is regarded as quality. Only when the quantity exceeds a certain point, the transformation of quality occurs. In physics, the point of transformation, like that of nuclear fission, is relatively certain. But in medicine, this point varies due to individual susceptibility of human beings. However, one may find a range within which the transformation will not take place. This range is called the safety margin. The bigger the margin, the less likely the transformation will occur on a human body whose susceptibility is close enough to the mean susceptibility of the same clan. What is the safety margin of fluoride? I have gone through the literatures on hand, I could hardly come across any without the word "assumed" or "estimated" before the numbers. The dose for acute toxic fluoride dose is called Probability Toxic Dose (P.T.D).

The commonsense is, if one can not substantialise a claim, especially when a public safety issue is involved, wait for further studies before make the claim, because the claim might be dangerously misleading, especially when an actual number is represented. Actual numbers are convincing. I could not satisfy myself with the "assumed" data on such a serious safety issue.

"Principles of dental public health" by Dunning is regarded as "the Bible for public health dentistry". In his 1986 edition of this book, page 401, the book shows the readers in italic that the best definition for a Poison is "too much" when the safety of fluoridation is discussed.

But how much is "too much"?

The speed of change in quantity will also affect the change in quality. A sudden change, even small in amount, may transform into the change of quality, while a gradual change, even large in amount, may not lead to the transformation of quality. People have lived in high fluoride areas for generations might not suffer from any systemic abnormalities. However, for those who live in low fluoride area for their whole life, it may be a sudden jump of fluoride in their drinking water when water fluoridation starts. The speed of the change in quantity is a factor worth considering.

We have to come back to the 1991 NHMRC report on the effectiveness of fluoridation. In that report, NHMRC clearly stated that we need accurate knowledge rather than assumption. Also local data rather than overseas data should be made available to assessing the local needs. In the Chinese water fluoridation debate, the anti-fluoridationists accused the Chinese fluoridationsts of "failing to consider the local geography, climate, the chemical nature of the river water, the residents living condition and their dietary habits. Based on only mere caries surveys, they blindly adopted the foreign measures of the 40s." (Guo Yuanzhu 1981). The accusation is not totally true because Professor Liang Shaoren and Shen Yanmin and others have done many studies on local population and relevant data was collected over the years. Nevertheless, all the studies followed the America approach.

Without accurate knowledge of the quantity and the transformation point, there is very little room allowed to discuss the change of quality. When the nature of the quality transformation is related to human health, that is, from trace element to poison, it is extremely irresponsible to use assumptions.

We must consider the chief elements that must find a place in any philosophy of science:

1. Empirical data and their theoretical interpretation;

2. Conceptual elements;

3. Formal and mathematical elements or mathematical elements alone:

Mathematics is honoured as the "crown of sciences", because the nature of quality can be represented by actual quantitative date. In fact, the modern scientific world relies on the fast processing of digits that represents reality; and the reality is analysed and stored in digital form.

The diagnosis procedure of modern medicine relies on actual quantitative data. Although variable, there is a statistically sound range. On the opposite hand, the lack of empirical data represented by numbers in the diagnosis procedure of traditional Chinese medicine has left the traditional Chinese doctors with a dilemma they have to face. Without mathematical measurements, the theory will not be convincing and the acknowledge will not be easily gained.

Dentistry shall not be an exception to the above rules, because dentistry is regarded as a branch of medical sciences. The problem is, that empirical data, for example, the total fluoride ingestion, is hard to obtain following the current approach.

All available study results show that fluoride does not affect normal tissue like skin by contact. It has to be absorbed by the body to affect the mechanism of the body. This means that depending on the fluoride ingested is not enough to decide if the amount of fluoride in the body is at a safe level. We also have to measure the amount of fluoride that is excreted. But this is difficult to do, because it is almost impossible to collect and analysed all the solid and liquid excrement naturally discharged by a human body.

How much a person eats and drinks is personal, regional, cultural, seasonal and changeable. Fluoride ingestion is affected by too many factors. Actually, all factors related to space and time will affect human diet. Any "food basket survey" can only give us a rough idea about what and how much people eat, for that particular time period when the survey is carried out.

As cited in part one, Shen Yanmin, Jiang Junrong, Li Lanxin painstakingly carried out a survey on daily total fluoride intake and urinary excretion of residents in Fongcun, Guangzhou, in 1981.(ACTA Academiae Medicinae Zhong Shan 1983). In the 90s, with the introduction of western fast food, the diet of Guangzhou children may not be the same as that of the 80s. How valid the data collected then is today anyone’s guess.

It becomes clear that the empirical data is hard to gather in the fluoridation case; and the dentists have to make do with assumptions.

Now I must argue that:

Part Three

In this part of the essay, the use of biomarkers of fluoride exposure is emphasised. The purpose is to raise the issue, rather than discussing in detail. However, this is the most important point this essay trys to bring up, because it must be understood that looking forwards is better than looking back on the history, even we have to review the history in order to plan for the future.

1. The positiveness of water fluoridation.

After considering the following two factors, I have no doubt about the effectiveness and safety of water fluoridation at present:

(1) The results of studies on the possible systemic harm of fluoride, which show no correlation between water fluoridation and known human diseases included in these studies;

(2) The third law of dialectics, that of the negation of the negation. Ever since water fluoridation started, there have be two opposite groups, the fluoridationists and the anti-fluoridationists. We label these two groups as A and B respectively, and water fluoridation as C. A and B are arguing about the nature of C, that is A for positive and B for negative. There are three likely outcomes:

In the water fluoridation debate, possibility (2) is out because we know they are not all wrong. We have to settle between possibility (1) and (3). (When we mention "wrong" or "right", we have to remember that the first law of dialectics, that of the transformation of quality into quantity, is applied here when defining the meaning of "right" and "wrong".)

Here I pick out two main arguments of the debate. One is the effectiveness of water fluoridation; the other is the safety of water fluoridation. The fluoridationists can offer me a substantial amount of data showing the effectiveness of water fluoridation, while failing to offer data of the same quantity and quality to convince me the safety of water fluoridation. On the other hand, the anti-fluoridationists fail to overrule the effectiveness data provided by the fluoridationist, neither can they come up with substantial data to prove water fluoridation being a public health hazard.

So the case is, A can substantiate part of its argument, while uncertain towards other part of its argument; B can not substantiate all of its argument. No to no is yes. This put an A on the winning side of the debate.

The commonsense is, the anti-fluoridationists have always been arguing that water fluoridation is unsafe; if it was unsafe, most if not all evidences of the danger of water fluoridation would have been found out by them or researchers after half a century of debating.

This does not serve to justify that the fluoridationist is right in the first place; I consider it to be lucky instead.

The fact remins that the Guangzhou water fluoridation program has been cancelled, and the debate goes on. With the economic reform in China going ahead full-steam, comes the abolition of a guaranteed public dental health care system and a soaring of service fees. Many people can no longer afford medical treatment including dental care. The DMFT is set to rise because of the changing diet. Tea is high in fluoride, and tea drinking is a Guangzhou tradition. But how many children will retain that habit? According to local Chinese newspapers, children prefer sugar-laden Coca-Cola (Yangchen Wanbao, January 1996). The manpower in the dental workforce falls far behind treatment demanded. All these negative factors indicate that effective, economical and practical preventive public dental health program is urgently needed for the long-term interests of the public. The dentists, no matter how low they are ranked in the society, still can contribute their bit to serve the people.

Through the great efforts of the humble Chinese dental workers, 20 September was dedicated as the "National Dental Day" in 1989 by the Chinese Ministry of Health, Ministry of Education and seven other ministries. The slogan for national dental day 1995 was "Use fluoride adequately to prevent dental caries". The water fluoridation debate was hotted up again, and two questions were asked:

(1) What is the "adequate" way, topical or systemic?

(2) How much is "adequate"? Is extra fluoride intake needed?

Both the fluoridationists and anti-fluoridationists had their opinions published in the newspapers. But apart from reciting the success stories of America and other countries and regions, and the overwhelming promotion of toothpastes, the readers could hardly find anything new and convincing.

As analysed above, the lack of empirical data is the host to many concerns in the water fluoridation debate. Also the debate is multi-leveled. It is personal, economical, social, and political, and so often non-academic when the safety of fluoride is a concern.

Although the water fluoridation debate is a reflection of the current level of human evolvement (both individual and social), the basic arguments are academic. Although water fluoridation is a public health measure, which could make it a social issue, the effectiveness and safety of water fluoridation should be judged on rigorous academic grounds.

As has been discussed, the empirical data related to water fluoridation is hard to obtain because of numerous variables. A more simple index of fluoride intake in human body may offer possible solutions by cutting down the number of variables one has to go through when gathering related data.

This is where biomarkers of fluoride come into consideration.

2. The biomarkers of fluoride exposure.

It is not this essay’s purpose to discuss the technology side of the use of fluoride biomarkers. The issue here is that of objective over subjective ecaluation.

2.1 The usage.

The report of a WHO expert committee on oral health status and fluoride use (1994) states:

However understated, this statement tells us that the biomarkers are being noticed as of a DIRECT indicator of fluoride intake; and what is more important, a DIRECT indicator to the amount of fluoride ingested.

By employing a direct indicator of one entity in another entity, variables indirectly linked to the entities can be by-passed, so the relationship between these two entities can be seen more clearly.

Physicians do not ask people what they eat to decide their cholesterol level; they do blood tests instead. I believe this practice is accepted because (1)Cholesterol is directly related to certain diseases; (2)These diseases are life-threatening. In the fluoride case, to do similar tests to decide the fluoride level in the body might be an overaction because caries is not fatal.

2. The classification of fluoride biomarkers.

(1) Contemporary markers: urine, plasma, saliva. Urinary fluoride excretions and concentrations are variable because of variations in urinary flow and pH. Plasma and saliva samples taken from fasting subjects have the best value because the fluoride concentrations in these two fluids are influenced significantly by intake during recent hours.

(2) Recent markers: nails and hair. The concentrations in these tissues reflect the average plasma fluoride concentrations over time. Additional research should clarify the physiological factors that can influence fluoride uptake and accumulation in these tissues.

(3) Historic markers: bone and teeth. The body burden of fluoride is best reflected in the calcified tissues. Extracted tooth can be used. Pre-eruptive fluoride levels can be obtained.

3. The starting point.

Searching for empirical data related to the relationship between fluoride and the whole body is the starting point for the consideration of using biomarkers.

(1) The biomarkers can offer relatively actual figures, unlike the subjective fluorosis index;

(2) The biomarkers can provide time-related data, that is contemporary, recent or historic, unlike the only historic indirect index by appearance of fluorosis;

(3) The biomarkers are directly related to fluoride in the body, unlike the indirect relationship between fluoride in the shopping basket and fluoride in the body;

(4) The biomarkers let us consider the whole subject rather than a part (the teeth);

(5) All samples, especially nail and hair, are technically easy to collect. The collecting of nail and hair will not cause the subject any physical or mental harm, and is extremely safe with regard to infection control.

4. The possible goal.

If subjectiveness can be replaced with objectiveness, empirical data can be approached. Once the empirical data is obtained and justified, many arguments might hopefully end.

5. The legislation factor.

It was Professor Shen Yanmin’s idea for me to learn the usage of fluoride biomarkers, considering it a new technology that might be in use in Australia. Being aware that Professor Spencer of the University of Adelaide is engaging in a survey involving the use of hair and nail as fluoride biomarkers, Professor Barnard directed me to write to Professor Spencer inquiring for any information related to the use of fluoride biomarkers. Michael Davies, the research officer of AIHW Dental Statistics and Research Unit, wrote back, stating that "there has been little work conducted in Australia with regard to fluoride biomarkers. Although we have conducted studies to estimate the level of exposure, this work has not progressed to validating exposures through biological specimens."

I understand that, as Dr. Shanti has once pointed out, it is difficult to gather human biological specimens, even from criminals, in Australia because of the legislation factor. I think it is also the case in other "rule by law" countries.

However, the situation of mainland China allows the authority to take specimens from people without difficulties. Although a character of dictatorship, some practices of collecting human specimens will be accepted by the people if it will do the community good as a result.

The Guangzhou water fluoridation debate in China has been multi-leveled, involving personal, social, political factors. Many arguments in the debate have lasted for decades because of the lack of empirical data related to the effectiveness and safety of water fluoridation. By using fluoride biomarkers as indicators, the debate might be brought back to academic grounds and empirical data obtained. This will lead to a better understanding of water fluoridation and in turn, hopefully, the Guangzhou water fluoridation program will be restarted.

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