CALGARY—In a tiny waiting room sandwiched between makeshift screening areas on a converted bus in northeast Calgary, sixth graders sit patiently waiting for their dental exams.
The chilly winter morning is typical for the Alex Community Health Centre’s dental bus. Parked outside schools, shuttling kids through appointments one after the other, the mobile dental office can help as many as 90 kids a week. The kids hopping in and out of the mobile dental chairs tend to come from families who have trouble getting them to a more conventional dentist’s office, and the children often have concerning enough dental decay that they need repeat checkups.
The idea for the bus was born back in 2011, with organizers looking ahead to what they saw as a looming challenge for low-income families in Calgary: that’s when city council voted to end water fluoridation.
Calgary has long had a prickly relationship with fluoride, having voted on the issue no less than five times. Calgarians rejected fluoridation through plebiscites in the 1950s, 1960s and 1970s before approving it in 1989, and residents gave it a green light a second time in a 1998 plebiscite.
In 2011, council switched course again, with a majority of councillors voting to remove fluoride from the city’s water supply after a lengthy and contentious public hearing that lasted more than 10 hours.
But a recent vote in Windsor, Ont., to reintroduce water fluoridation has some public health advocates wondering if the debate could be revived at home. Windsor city council voted 8-3 last month to reverse a 2013 vote to stop fluoridation, and many health professionals in Calgary say they’d like to see city council follow suit here.
Fluoride is a naturally occurring mineral that is released into soil, water and air. But it’s also routinely added to water supplies in many countries to prevent tooth decay and cavities. In Canada, fluoride at 0.7 mg/L is considered the optimal level to support dental health. There’s still naturally occurring fluoride in Calgary’s water, but at lower levels that vary between 0.1 mg/L and 0.4 mg/L, according to the city. The first Canadian community to begin fluoridating its water was Brantford, Ont., in 1945.
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The majority of scientific research favours appropriate levels of water fluoridation, and it’s recommended by the World Health Organization and the Centers for Disease Control and Prevention in the United States.
Community water fluoridation is widespread in Canada, but some parts of the country have little or no fluoride in most of their water systems. In Newfoundland, New Brunswick, British Columbia and Quebec, less than 3 per cent of the population had a fluoridated water system as of 2017, according to the Public Health Agency of Canada. Ontario has the highest rate of community water fluoridation in the country, with 71 per cent of the population drinking fluoridated water.
But opposition to it has been heated in some circles, with some critics questioning the health benefits or chalking it up to personal freedom — arguing the government shouldn’t dictate the chemicals to go into people’s drinking water. The latter argument swayed some Calgary councillors when they ultimately decided to take fluoride out of the water in 2011.
But Windsor’s vote came from a council that had almost entirely turned over since the last time fluoridation was on the agenda. All but one of the city councillors elected after 2013 supported putting fluoride back in the water. And this time, their discussion focused on a new Windsor-Essex County Health Unit report that found the percentage of children with decay or requiring urgent dental care increased 51 per cent between the 2011/2012 and 2016/2017 school years.
In presenting the case for restoring fluoridation, Windsor-Essex County Health Unit acting medical officer of health Dr. Wajid Ahmed said he stressed to council: “It’s not only (that) we saw an increase in the number of children with more cavities, but also the severity was very high as well.”
Ahmed said he’s pleased with the outcome of the recent vote.
“Issues like dental cavities definitely impact a child’s ability to to grow up to become a fully developed adult and develop their full health potential,” he said.
“We are looking forward that our city may act as a leader to setting an example to other cities that they should be looking back at their own local data to see if there are any negative impacts.”
A University of Calgary study from 2016 found a greater increase in tooth decay in Calgary compared to Edmonton, where the water remains fluoridated. Researchers found this increase for primary teeth decay consistent with a negative effect of ending fluoridation. That prompted an ultimately unsuccessful move on council to ask public health experts for more advice.
But the fluoride debate has never fully died in Calgary: a coalition tried to make it an election issue in the 2017 municipal vote, tracking each candidate’s stance on adding it to city water.
About half the Calgary council members currently in office were elected prior to the 2011 fluoride debate, and all of them except Mayor Naheed Nenshi, who was absent, voted in favour of removing fluoride at the time. Since then, some of those councillors say they’re unsure where they fall on the issue.
At least one of the fresh faces on council would like to see the debate return: Ward 11 Councillor Jeromy Farkas, elected for the first time in 2017, said he’s in favour of restoring water fluoridation in Calgary.
But in terms of whether council is interested in rehashing the issue right now, “I don’t think that the will is there,” he said.
He’s planning to submit a request for city administration to provide information on exactly what the cost would be to go back to fluoridating the water, but his ultimate hope would be for it to inform another plebiscite on the issue during the 2021 election.
“I think that there is a requirement for elected officials to go back to Calgarians on this as an issue given the past precedent,” Farkas said.
Ward 10 Councillor Ray Jones, who was first elected in 1993, said he’s not sure there would be much more to say about fluoridation eight years after council decided to remove it.
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“It would be the same dog-and-pony show. You get the naysayers and you get the people who are in favour of it.”
Jones said he thinks council had a “healthy discussion” when they voted to remove fluoride, but it was a tough issue to sift through with strong opinions coming from both sides.
“It’s not as easy as a yes or no. It really, truly isn’t,” he said.
University of Calgary political science associate professor Brenda O’Neill recently published a study examining the politics behind the decision to stop water fluoridation in Calgary. It’s an interesting case, she said, because it’s an example of a long-standing policy being stopped, which can be a hard political sell.
“People will get up in arms over no longer getting the benefits of the program, but there are obviously reasons why that might not be the case. And one of them is if the benefits of the program are diffuse, and they’re hard to nail down — like fluoride,” she said.
For now, she said, without any other major changes, “it seems to me you’d have to have some precipitating factor for the decision to be revisited.”
In Windsor, the health unit issued several recommendations, including bringing back community water fluoridation, improving access to oral health services, and advocating to expand public dental-health programs. Some in Calgary have argued that should be the real focus of the fluoride debate.
Ward 7 Councillor Druh Farrell, who brought the motion that ultimately led to the decision to end fluoridation, maintains that responsibility for health rests with the province, and the onus is on those officials to look for ways to provide more equitable access to dental care.
“Alberta Health Services needs to look at cities that are successful and adjust,” she said. “They keep going back to the city, and that’s an old idea. In Europe, they have a much higher success rate (with tooth decay) and they don’t fluoridate their water.”
Ward 3 Councillor Jyoti Gondek, currently serving her first term, agrees with Farrell’s assessment.
“This is provincial jurisdiction,” she said. “They should be responsible for it fully.”
In the city, health-care workers say they’re seeing the impact of fluoride being removed from city water. The Alex bus visits schools in Calgary’s high-need areas each week, using Alberta Health Services information on tooth decay rates to find which parts of Calgary residents are most likely in need of dental care. The children they help are largely from low-income populations.
The bus provided dental checkups for 2,200 Calgarians over the last school year. But program lead Denise Kokaram said the number of people they reach annually is a drop in the bucket for a city of Calgary’s size.
“To think that we or other social organizations can keep up with this on our own without any additional community measures is ridiculous,” Kokaram said.
Kokaram said the bus has seen roughly 26 per cent of their patients in need of an urgent procedure over the past year, a number she finds staggeringly high.
“I’ve heard people who oppose community water fluoridation saying, ‘Oh, well these people need to teach their children how to brush their teeth, they need to take them to the dentist, they need to give them better food.’ Yes, you’re right. Those are all the barriers — plus more — that these families face.”