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Comment by ErikBjare | Hacker News Reader

As a Swede I always found it interesting we were one of the few countries which do not flouridate tap water.

Our country took a principled stance against mass-medicating the population with fluoride many decades ago, after a lot of push-back from some prominent scientists (including Arvid Carlsson, Nobel-prize recipient for his work on SSRIs).

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> As a Swede I always found it interesting we were one of the few countries which do not flouridate tap water.

Wikipedia doesn't support this claim. Here are two quotes from different articles:

(1) "As of November 2012, a total of about 378 million people worldwide received artificially fluoridated water. The majority of those were in the United States. About 40 million worldwide received water that was naturally fluoridated to recommended levels.", from https://en.wikipedia.org/wiki/Water_fluoridation#Worldwide_p...

(2) "Out of a population of about three-quarters of a billion, under 14 million people (approximately 2%) in Europe receive artificially-fluoridated water. Those people are in the UK (5,797,000), Republic of Ireland (4,780,000), Spain (4,250,000), and Serbia (300,000).

The first water fluoridation in Europe was in West Germany and Sweden in 1952, bringing fluoridated water to about 42,000 people. By mid-1962, about 1 million Europeans in 18 communities in 11 countries were receiving fluoridated water.", https://en.wikipedia.org/wiki/Water_fluoridation_by_country#...

It seems that Sweden no longer adds fluoride, but it's really besides the point since it says,

> 57.4 million people receive naturally occurring fluoridated water at or above optimal levels in countries such as Sweden, China, Sri Lanka, Finland, Zimbabwe and Gabon.[1]

I’m struggling with the exaggeration of calling mineralization as “mass medication”. Would you refer to remineralization of anything out of e.g. a desalination plant “mass medication”?

What is "mass medication"?

Here, if fluoride is added to water for the purpose of preventing tooth decay, then that is rather plainly a medical intervention, as the purpose is to prevent tooth decay.

Whether it is harmful or not (I have seen a Harvard study that claims to find negative effects on intelligence scores), it is a rather odd and arbitrary medical intervention. Tooth decay? Even if we accept that tooth decay deserves this degree of attention, we no longer live under conditions that motivated the original fluoridation of water when dentistry and brushing of teeth with fluoride toothpaste was not as common.

I simply fail to see justification for such a broad and heavy-handed intervention, or the cost of such an intervention.

Would you consider iodized salt "mass medication"?

Non-iodized salt is easily available at large quantities for a price very similar to iodized salt. A person who doesn't want to consume iodine via their salt can just choose not to buy it. It is not mass medication, because it is a choice.

Drinking water is a completely different story. You can't survive more than a few days without it, and it is being pumped straight into our homes. Bottled water is literally orders of magnitude more expensive, so it cannot be used as a suitable alternative for drinking - let alone for activities like showering and washing dishes. If the water contains fluoride, a significant portion of the population cannot make the choice to consume unadulterated water instead. They are forced to drink it.

So fluoridated water is mass medication because the alternatives are bottled or expensive, not pumped into the house, and salt is non-mass medication even though its “natural”-marketed alternatives are more expensive too. I guess milk and grains (vitamin D and folate added) are just normal non-mass medicated foods too given that they aren’t pumped into the house like water either? Or is it mass medication in the grains case because the FDA requires folic acid to be added?

This is starting to sound real silly.

Social categories cannot be both comprehensive and consistent and you're asking for both.

I'm asking for consistency from one person.

I know. Not even one person has consistency. There will either be cases of ambiguity or contradiction. You're arguing against Gödel's incompleteness theorem. You're asking for something that's not possible.

> So fluoridated water is mass medication because the alternatives are bottled or expensive, not pumped into the house, and salt is non-mass medication even though its “natural”-marketed alternatives are more expensive too

Correct. You already get most of your salt intake from salt-containing foods. In most cases there is zero need to add salt to your food. You can get a 3lbs box of kosher salt for less than $4. Assuming the maximum recommended daily salt intake of 6g, if you get half of that via added salt, that's less than $0.01 / day.

Alternatives are widely available at no significant burden, so it is not mass medication.

> Or is it mass medication in the grains case because the FDA requires folic acid to be added?

Debatable because grain-free diets are possible. But I would indeed consider this a form of mass medication because it is mandatory to add it. In fact, for a long time my country explicitly forbade adding it to grains! These days it is allowed here, but of course optional.

My position is incredibly simple, actually: don't require adding random stuff to food which doesn't need to be there! It is my body, the government doesn't get to decide what I do with it. It is irrelevant whether that is helpful (like fluoridated water and folic acid almost certainly are) or harmful, they should not have that power in the first place.

I don't think so. It is supplementation, though you could make the argument that it, too, should not be mandated (these things are subject to public consensus). And indeed, you can easily buy salt that isn't iodized. The same holds for vitamin D supplementation in milk. It, too, is avoidable (though I can't see why you would go out of your way to avoid either, in general).

I don't think you can construe fluoridation as supplementation, especially given that it is not really needed, especially under current circumstances. There are also mixed studies about the health effects of consuming fluoride (I mentioned intelligence studies, but fluorosis of the bones also comes to mind). Also, you must factor in the gravity of the health concern and the efficacy of the treatment. Fluoride doesn't seem to be justified in this regard. Iodine, and even vitamin D, I would argue, are much more justifiable, and as I wrote above, more avoidable.

I would say the principle we should be working from is that such intervention must be justifiable and proportionately so. You're in a bad place if your basic argument for something is "It's not harmful". That's not a reason to institute something. The burden of justification is on those who institute things.

Yes, you're one of the only countries that does this.

Adding something explicitly for medical benefits, because it was recommended by medical professionals, is "medication", yes.

Here's a question for you then: If you had drinking water that had an excessively high natural amount of fluoride that was causing medical issues, is it considered medicating to then filter that water to reduce the fluoridation? Why is it only 'adding' and not 'removing'?

As "medicating" implies addition, I'd not call such filtering "medicating", but it's definitely still be a "medical intervention", a purposeful change from the default motivated by health concerns.

Except that fluoride naturally occurs in drinking water around the world. Some places have far too much. Would removing the excess amount also be "mass medication"?

By this logic, sunshine is medication too, among many other things medical professionals recommend. Should be used as directed.

Not all sunshine would be 'medication', but if a doctor recommended an extra hour in the noonday sun (or equivalent time under appropriate lamps) over a patient's baseline, that extra increment of light would be 'medication'.

I hate to cite Wikipedia as a source [1], but it looks like the majority of countries do not add fluoride to tap water (only 24 countries in total do).

But Sweden seems to have an interesting history with it indeed.

[1] https://en.wikipedia.org/wiki/Water_fluoridation_by_country

I bet that is roughly related to the countries that have potable tap water at all.

> As a Swede I always found it interesting we were one of the few countries which do not flouridate tap water.

How much fluoride is naturally present in your water? Maybe that's why.

Or maybe you have good dental care so people get their enamel fluoridated at the office to the point that it doesn't pay to add it to the water.

Where I live it's 0.5mg/L from natural sources. Lower range of the recommended span given by WHO (0.5-1.5mg/L).

Adding 0.7ppm of fluoride to drinking water is hardly "mass medication". Do you also refuse to iodize salt out of principle?

I wasn't the one arguing it all the way back in the 70s, feel free to read up on the history: https://en.wikipedia.org/wiki/Water_fluoridation_by_country#...

I recommend testing your tap water for fluoride. You might be surprised.

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