In September last year the South African Department of Health (DOH) legislated regulations to fluoridate potable water to 0,7 mg/l by September 2002 and, as anticipated by the department, the regulations have ignited a heated public and scientific debate.
In an effort to control this sensitive issue, DOH mandated a provision to obtain a court interdict against any water provider to prohibit the spread of misinformation concerning water fluoridation.
However, despite this clause, the South African Association of Water Utilities (Saawu) and South Africa's largest water utility, Rand Water, have publicly questioned the department's decision to fluoridate potable water.
Saawu CEO John Connolly and Rand Water CEO Vincent Bath have stated that the two organisations will abide by the regulations.
The DOH's rationale for supplementing potable water with fluoride is simple – South Africans have an unaccecptable level of tooth decay, and it is likely that these levels will increase, particularly among the poor, who do not use fluoridated toothpaste.
DOH oral health director Dr Johan Smit tells Engineering News that all water naturally contains fluoride, and that water fluoridation is the process of adjusting the fluoride content to the recommended level for optimal dental health (0,7 mg/l in South Africa), which can reduce tooth decay by as much as 60%.
The water utilities do not dispute the benefits of fluoride to combat tooth decay, nor do they challenge the rationale for augmenting diets with fluoride. However, some have expressed serious concerns with the decision to fluoridate potable water.
Most of South Africa's poor rural population do not have access to piped water.
Therefore, Rand Water and Saawu argue that, as the rural poor are the population that stand to benefit the most from fluoride, a delivery method other than piped water should be sought.
Smit accepts the point that rural communities often do not have piped water services.
However, he does not view this as an obstacle to prevent the public-health measure from benefiting those communities that do receive water on tap and are in need of additional fluoride in their diets.
He also comments that the estimated population of seven million currently living without potable water will shrink as the Department of Water Affairs and Forestry improves its service delivery.
Smit estimates that the large water utilities, such as Rand, Umgeni, Bloemfontein, Port Elizabeth and Cape Town collectively supply 50% of South Africa's population.
He also reassures the water utilities that alternative methods of supplementing diets with fluoride have been considered and found to be uneconomical or impractical when compared with the water option.
Rand Water has also questioned the priorities of national government.
It believes that water fluoridation, which will cost the South African public R30-million a year, should be shelved in favour of the provision of basic water services and to extend the provision of free water.
Based on Rand Water's experience the R30-million could extend water provision to some 300 000 unserved consumers.
Smit dismisses the R30-million figure as inaccurate.
"Not all of the utilities will be required to fluoridate their water – a number are too small to justify the expense, while there are a few that already have satisfactory fluoride levels," he explains.
In terms of cost-effectiveness the DOH expects fluoridation to cost between R1 and R2 a person each year.
For the increased level of dental protection Smit believes that this is a small price to pay when compared to the expense of dental treatment or even fluoridated toothpaste.
Smit maintains that, while basic water delivery is a challenge that the Department of Water Affairs and Forestry is contending with, his department is fighting a battle against the most common chronic disease known to humankind – tooth decay.
In South Africa, as in many other developing countries, the situation is deplorable, with 90% of the population living with tooth decay by the time they reach adulthood.
A key concern is that water providers may be held liable for certain health and environmental effects that may result from the fluoridation of water.
For example, Rand Water will need 1 500 kg of fluoride a day to meet the required standard of 0,7 mg/l.
Almost 1 000 kg of fluoride will find its way into water streams every day and this may have negative long-term effects on the environment.
Smit allays these fears by pointing to 50 years of international experience without negative effects on the environment.
This fact has been substantiated by the US Centre for Disease Control fluoridation engineer Tom Reeves. The department has communicated its legal position to the utilies explaining that any claims against the regulations will be brought before the department and the Minister.
However, the implementation of the regulations is the responsibility of the utility and not the department.
Connolly says that the approach of Saawu and its members will be to direct all public complaints and queries to the office of the Minister of Health.
Saawu and Rand Water have published position papers, which state their concerns and grievances regarding water fluoridation.