The story of how Queensland fought for, but is now losing, its fluoridated water is a fascinating window into the historical anomalies that come with federalism and how complex debates are managed in local councils today.
The de-fluoridation of Queensland, so soon after its implementation across most of the state, speaks volumes about the ways in which notions of individual “freedom” can be mobilised against public health initiatives.
How we understand these potential tensions between personal autonomy and collective welfare has far greater implications beyond fluoridation, but it’s in the vexed space of so-called “mass medication” that these strains are most instructively revealed.
A short history of fluoridation in Australia
In October 2012, the International Dental Journal published a study by retired dentist and oral health historian Dr Harry Akers, co-authored with fellow dentist and public health academic Dr Michael Foley. The paper retraced the “long and winding road” to Queensland at last embracing water fluoridation — the practice of controlling the proportion of fluoride in public water supplies to reduce tooth decay. The relief is evident in their account: a battle fought for over half a century had finally been won and, in time, Queenslanders might no longer lag behind their compatriots in oral health outcomes.
Controlled water fluoridation ranks among the most significant public health success stories in Australia. The National Health and Medical Research Council (NHMRC) has found that fluoridation reduces the incidence of dental caries (tooth decay and cavities) by 26-44 per cent in children and by 27 per cent in adults. The NHMRC further estimates that for every $1 invested between $7-18 is returned in savings on health expenditures.
It is hard to imagine a more cost-effective public health program that serves entire populations — and one that is particularly effective at reducing oral health inequities among disadvantaged communities. As one clinician put it, “water fluoridation gave poor children rich kids’ teeth”.
First introduced in Beaconsfield, Tasmania, in 1953, fluoridation was adopted by most parts of the country over the following decades, including all state and territory capital cities by 1977. The conspicuous exception was Brisbane. In contrast to the rest of the country, Queensland has stubbornly resisted fluoridation. As Dr Akers documented in admirable detailacross multiple studies, cultural and political complexities unique to Queensland rendered fluoridation a perpetually losing battle. These historical obstacles have included a range of factors, including but not limited to:
- misplaced, though understandable, concerns that fluoride may have adverse consequences for the pastoral industry that is so crucial to the state’s prosperity;
- fear that occupations requiring a high fluid intake — such as sugar cane cutters working in the oppressive heat — would result in excess fluoride consumption;
- distrust of public health authorities — including after a disastrous 1928 diphtheria vaccination program that killed 12 children;
- general wariness towards any dictates, public health or otherwise, originating from outside Queensland;
- a Fluoridation of Public Water Supplies Act 1963 (Qld) that made a public referendum the likely forced outcome of any fluoridation proposal — given most referenda fail to pass this heavily advantaged anti-fluoride proponents.
This confluence of factors meant that until 2008 only 4.8 per cent of Queensland residents had fluoridated water, while across the rest of Australia the proportion was around 90 per cent. Aside from a handful of Queensland regions where the potable water supply is naturally fluoridated within recommended levels, only Townsville and three other small towns had controlled fluoridation prior to 2008.
In fact, as Emeritus Professor John Spencer observed, the measurably better oral health outcomes in Townsville — which began fluoridation in 1964 — compared with unfluoridated Brisbane proved crucial in finally persuading legislators to take action.
After numerous false starts, in 2008 Anna Bligh’s Labor government mandated that fluoridation would be rolled out across the state. By its 2012 peak, around 87 per cent of Queenslanders had fluoridated water. Suddenly, what had been a decades-long outlier and needless detriment to the health of Queenslanders, especially children, was now finally being resolved. Akers and Foley noted that the “political repercussions were minimal” and the matter had seemingly been settled. Life went on much as before, only with fewer dental cavities.
Alas, in the very same month of 2012 in which Akers and Foley published their celebratory account, the Liberal-National Party’s (LNP) newly installed premier, Campbell Newman, took to cabinet a proposal to devolve responsibility for fluoridation back to local councils. Moreover, not only would local government be responsible for the decision, but they would soon thereafter also be lumped with the ongoing costs of retaining fluoridation.
Newman claimed to be a supporter of fluoridation himself, though this is hard to believe given the grimly predictable outcomes of withdrawing state support. By shifting the financial burden onto local councils the LNP effectively rendered fluoridation “economically unsustainable in less well-resourced parts of Queensland”. In abdicating their responsibility, the Newman government needlessly resurfaced concerns about fluoridation’s safety and efficacy. Intentionally or not, they poisoned the well.
Culture wars in our local councils
One by one, Queensland’s regional councils have voted to cease fluoridation. Most recently it was the turn of Gympie Regional Council, which voted 5-3 to end fluoridation. Before Gympie it was the Cook Shire Council, voting 4-3, bringing into sharp relief how decisions with generational effects can hinge on swaying the vote of just one or two councillors. In December last year Cairns councillors voted again to reaffirm their opposition to fluoridation, after being among the first to cease the practice in 2013. Today, among Queensland’s 77 local councils only 16 have water that is fluoridated by controlled measures, while another five have naturally occurring levels of fluoride within the recommend range.
It will prove difficult to arrest this trend, particularly given our councils are not only grappling with perpetual budget constraints, but have become a battleground in the so-called “culture wars”.
A range of fringe interests have identified local government as a space where they can secure formal representation, build legitimacy and foster a wider political movement that could reach into the upper echelons of power. Sovereign citizen movements — which often have a loose overlap with “conspiritualism” and the embrace of alternative health practices — have expressly targeted fluoride not only for its own sake, but as a soft target in undermining the state more broadly. Groups like My Place are known for their deep mistrust of the state and promotion of conspiracy theories about COVID-19, vaccines, 5G, wind turbines and fluoride.
While, of course, we should remain vigilant against the potential harms caused by any unfounded or dangerous claims, we must also recognise the anxieties typically driving these views. We live in a world beset by existential risks beyond our control, with governments seemingly unable to reckon with such challenges and an increased burden placed upon individuals to practice “personal responsibility” to mitigate these threats.
Amid this suffocating dread, we should be wholly unsurprised that many people earnestly seek ways to achieve any kind of positive change and meaningful coalition-building. They might, therefore, reach for what is conceivably within their sphere of control or influence — such as matters decided at the local government level. Given it can be a challenge simply to get enough candidates to contest local government elections, and with lower confidence in democratic institutions in regional areas, it is perhaps little wonder that once “fringe” views are more readily finding their way into the council chambers.
Consider, for example, the case of Allona Lahn, who was recently elected to the Gympie Regional Council and was arguably the single most influential councillor during their debates on fluoridation. Staunchly anti-vaxx, a believer in One World Government conspiracies, and a participant in the Convoy to Canberra protests against COVID-19 mandates, Lahn had spoken at My Place events and was actively supported by My Place during her election campaign. Public figures like Lahn can prove incredibly effective in extending the precautionary principle to an extreme, under which any doubt about the potential harms of a public health program warrants its removal, regardless of its comparative benefits.
While the de-fluoridation of Queensland was under way before Trump’s rise to power, the elephant in the room we have avoided thus far is the spectre of Robert F. Kennedy, Jr, the US Secretary of Health and Human Services, who is also clearly haunting the Australian context. Fluoridation is among Kennedy’s primary targets and, while he cannot directly disestablish these programs, his outspoken fearmongering has opened a policy window to allow states to take such action. Utah and Florida have already done so, effectively banning controlled fluoridation across their entire state systems. In Australia, Kennedy’s views have already been taken up by figures like Matt Canavan, Malcolm Roberts and Ralph Babet.
Still, despite the current impasse in Queensland there are reasons to remain hopeful. Consider the case of Calgary in Canada, which ceased fluoridation in 2011. Within a decade it became clear that this was resulting in comparatively poorer oral health outcomes for children. Concerned by these trends, Calgary’s local government held a plebiscite that confirmed public support to re-introduce fluoride, which was implemented earlier this year.
Similarly, Victorian-based research has confirmed that genuine community consultation combined with substantive state support can boost public confidence and improve access to fluoridated water in regional communities. And yet, for the most part, this is currently not occurring in Queensland, resulting in acutely risk-averse and budget-conscious councils pulling the plug on fluoride.
The “unassailable values” stoking fluoride scepticism
Over the last two years, we have examined the arguments through which Queensland councils have opted against fluoridation. In councils across the state, this complex public health matter has been delegated to a handful of time-poor and under-resourced councillors, and is being significantly influenced by a vocal minority of residents strongly opposed to fluoridation.
In these council meetings we noted several types of recurring arguments used to challenge the science of fluoridation. These disagreements over the “facts” of fluoridation and its asserted benefits and harms fall into the realm of “assailable claims” — which is to say, with sufficient empirical evidence one party could conceivably persuade the other to change their stance and thus reconcile their competing views. As sociologists and anthropologists, our focus is not squarely on the veracity of these claims. Similarly, we are not primarily concerned with addressing any potential logical inconsistencies in the arguments put forward in these council debates. There is a wealth of resources from oral health experts, chemists and public health practitioners in this respect.
Rather, we are interested in the wider cultural trends that have led to this battle over scientific knowledge, and the potential implications of distrust in public health programs. What we have found is that many councillors connect their respective views on fluoride’s efficacy to a higher order of “unassailable values”, a set of ethical precepts deemed fundamental to safeguarding individual rights against egregious harms.
A few examples will help to explain how an “assailable claim” is used to support an “unassailable value”. One trend engaged by fluoride critics is the privileging of anecdotal evidence. As Councillor Allona Lahn of the Gympie Regional Council noted:
I had fluoride as a child and I have a mouth full of fillings. My daughter on the other hand, at the age of 11, who has never had fluoride, doesn’t have any fillings.
This lean towards authentic, personal narratives is linked to a broader populist pattern whereby “common sense” and personal, lived experience is valued as more trustworthy and persuasive than expert science, which is considered the domain of elites. Local empowerment is thus preferred over state paternalism.
Another type of argument regularly espoused is that because fluoride is toxic at very high doses, it therefore must be unsafe in any amount. Thus Councillor Brett Olds of Cairns Regional Council:
And this naturally occurring nutrient, this fluoride, that’s safe and effective? Why do they wear hazmat suits when they’re when they’re moving it around?
Often accompanying these queries is a kind of negative association, in which it is contended that because controlled fluoridation involves using fluoride derived from phosphate fertiliser production, our water is being dosed with “industrial waste”. At the heart of these concerns is the fact that cultures almost universally associate water with purity. A wilful act of introducing an external “contaminant” may therefore offend our sensibilities, because it both materially and symbolically adulterates this fundamental element of life itself.
Yet, while what constitutes “pure” and “natural” water is contested — and beyond the scope of this article — it is worth briefly noting that fluoride is a naturally occurring element found in varying quantities in practically every water supply and an extensive range of food products.
A third argument observed in council debates over fluoride is rejecting proposed solutions that are not perfect. Although water fluoridation is only ever one part of a suite of public and personal strategies in service of oral health, such as free dental check-ups for children, critics suggest its benefits have been overstated. So Mayor Amy Eden of Cairns Regional Council:
… and I don’t believe fluoride in the water is the silver bullet that it is claimed to [be].
Or Councillor Olds of Cairns Regional Council, again:
I just don’t think this is going to be the unicorn dust that you think it is by putting it in. It’s not going to fix all your problems.
Advocates for fluoridation might respond by noting that experts have never claimed that fluoride is a “silver bullet”. But ultimately these claims about “unicorn dust” are not actually assertions of fact, but of feeling. The implicit argument isn’t about how effective fluoride may be at the physiological level, but a wider lament about what this provision of public health does to our psyches, weakening our individual resolve to be wholly self-governing citizens.
A fourth tendency we noticed is the framing of evidence against water fluoridation as equally expansive and credible as that in its favour, as the aforementioned Allona Lahn does here:
The science isn’t clear, it’s constantly changing … there’s hundreds of studies pro-fluoride, there are hundreds of studies anti-fluoride and proving that there are health risks to do with fluoride … the concern is that it’s just not clear and the science is debatable on both sides.
Given scientific knowledge is “constantly changing” and we live in worlds of perpetual uncertainty where everything is “debatable”, we are thus enjoined to adopt a default position of epistemological humility. Comments from the Mayor of Gympie, Glen Hartwig, in the same council meeting demonstrates similar rhetoric:
You know, we all have to be aware that at one point in time science said there was nothing wrong with smoking … so science is a continual movement and what was, you know, at one point thalidomide was a good thing, you know, and science said it was a good thing … So we have to understand that — particularly with science — today’s truth is maybe not tomorrow’s truth. And that we need to be respectful of people that might have a different idea, because we can stand there and try to belittle and berate them and find out in 10 years’ time that they’re actually 10 years ahead of us.
The invocation of smoking and thalidomide are, of course, infamous examples in which there was a lag in public health knowledge and subsequent regulation of harmful products. We need not look far for myriad other examples of reckless hubris that caused extraordinary harms, with white phosphorus and radium being prominent examples that remain in our cultural memory.
Consciously or otherwise, these spectres continue to loom large as motivators of hesitancy and caution. However, widely applying this value of epistemological humility — that “today’s truth is maybe not tomorrow’s truth” — presents a troublesome dilemma: where does that leave public health initiatives? If every population-wide measure is seen as a violation-in-waiting of civil liberties, simply because it may cause unintended harms, are we compelled into a public health paralysis? And is the hasty dismantling of public health programs that have delivered clear benefits for many decades not its own form of hubris, which will indeed result in entirely avoidable harms?
We contend that a cultural shift towards invoking unassailable values against public health could result in far greater long-term consequences.
Turning public health against itself
In leaning on this concept of “unassailable values” we are drawing on the work of Kirsten Bell, an Australian anthropologist now based in the UK. Specifically, we are concerned with Bell’s insights on how key concepts which are initially developed and operationalised in public health and related fields, such as bioethics, are now routinely deployed to undermine such expertise. By drawing on the language and logics of concepts like “informed consent”, the “right to refuse”, “bodily autonomy” and “human rights”, we are presented with seemingly non-negotiable trump cards against public health initiatives.
Consider, for example, how anti-vaxxers regularly invoke “My body, my choice”, an ethical claim quite obviously appropriated from reproductive justice movements (despite many anti-vaxxers being morally opposed to abortion). A broadly similar adoption of liberal principles is evident in the local council debates we observed, specifically the assertion that bodily autonomy and sovereignty should extend to the matter of water fluoridation. In the following example — from Councillor Gai Sypher of the Central Highlands Regional Council — this claim is also paired with an appeal to fiscal responsibility:
I think you can purchase fluoride in different forms at your own choice and take it yourself. By removing it, it gives people the right to choose what they want to put into their bodies. So I’m very supportive of this and I think for the operation of our council, cost saving, that’s a benefit. We’re trying to, you know, save a dollar wherever we can. This way people can choose what they want to put into their bodies.
In deploying unassailable values, like bodily autonomy, the intent is to present the logical stopping point of debate, because to be against these ethical principles would seem to be against health itself. Indeed, opposing these principles could even be framed as aligning oneself with the historical horrors that necessitated codifying them in the first place. This is why framing fluoridation as “mass medication” is so rhetorically effective in stoking deep-seated cultural fears that we are repeating injustices of the past. It immediately shifts the locus of debate away from the substantial evidence supporting water fluoridation as safe, effective and not coercive in any meaningful sense of the word. Instead, we find ourselves entering a realm of moral absolutism.
Our concern is that over-extending these unassailable values may occlude our necessary interdependence in pursuing collective wellbeing. Put differently, an ethos of hyper-responsibility masquerading as “freedom” is seemingly being used to justify abandonment by the state, and abdication of responsibility towards future generations. These unassailable values are framed as “hard-won” but now self-evident forms of unimpeachable “common sense”, which are deemed to be flagrantly violated by the fluoridation of public water.
In the face of such accusations, to even gesture towards fluoridation’s clear benefits and negligible impositions on personal autonomy is to supposedly endorse the autocratic denial of individual freedoms that must not be compromised under any circumstances. Rather, we are informed, it is better to lean further into ideals of “personal responsibility”, urging citizens to make “good choices” for themselves and their family across all aspects of their lives.
However, if “liberty” is assumed to be synonymous with health — that is, to maximise one’s wellbeing requires maximising one’s personal freedoms — our ability to defend public health programs is severely weakened. By their very design, public health initiatives may require some curtailing of our personal autonomy, often in only very minor ways, to realise significant collective benefits. And yet, in council meetings we observed an overriding insistence on the “freedom to choose”. In fact, not only was this framed as an unassailable value, but a relative indicator of healthy democratic participation. Consider the following examples from Amber Robinson, utilities manager for the Central Highlands Regional Council, and Mayor Hartwig of the Gympie Regional Council, respectively:
With Central Highlands region being home to a modern contemporary community, it is reasonable to expect that the community would want to have a choice over what they consume.
And:
My concern with fluoridation is that it’s an option [rather than a medical necessity], and that overarching democratic principle of people having the freedom to choose. We’re sort of, we’re actually taking that away, and [after ceasing water fluoridation] those that want it can still go and get either fluoride tablets or other opportunities to have fluoride in their diet.
The chain of logic here is that adding fluoride constitutes a restriction of choice, and a restriction of choice is a constriction of freedom, and any constriction of freedom is a repression of democratic possibility. In this way, fluoridation is framed as unjustly paternalistic and unbefitting of our contemporary liberal societies. Such sentiments are echoed in another claimed unassailable value, “informed consent” and the “right to refuse”. Thus Councillor Matthew Tickner of Cairns Regional Council:
As any health professional would understand, a patient always has the right to refuse treatment and medication, regardless of its potential health association. If that is the law that underpins your profession, then what justifiable reason do we as a local council have to take that right of freedom of choice away from our community?
For our purposes, we can leave aside the question of whether fluoride is a “medication” or more aptly considered a supplement akin to the mandatory fortification of flour and bread products. In any case, we are sympathetic to the difficult situation that Queensland councillors face in being compelled to make decisions on matters usually decided at the state level. Understandably they may be inclined towards exceedingly precautionary stances, preferring to be potentially complicit in harms of inaction that diffuse responsibility, rather than taking decisive action that squarely identifies them as the primary cause of an alleged harm. As Councillor Brett Moller of Cairns Regional Council asked:
If the state government through Queensland Health — who are responsible for administering and leading public health — are of the view that it’s not important enough to mandate fluoridation of the water supply in our local communities, and who are experts in this field, who are we as councillors without that expertise to override and implement such?
Such views are not unexpected, precisely because we tend to be more forgiving of harms of omission than harms of commission, and less likely to draw causal links between such omissions and their resulting harms. This is a perpetual challenge for public health, which is often predicated on undertaking wide-ranging acts of commission under the broad consequentialist view that allowing avoidable harms to occur is morally equivalent to doing harm. Still, it is hard to blame local councillors for not thinking similarly and instead retreating to inaction.
However, one position we are far less sympathetic towards is what we deem a “libertarian moral panic.” This view frames fluoridation as symptomatic of a wider moral decline in rendering us pathologically dependent on state support to alleviate our personal failures. Thus Councillor Tickner again:
A much larger issue is at play, and it underpins why I’ll vote the way I do today [against water fluoridation]. Personal responsibility seems to be slipping through our collective fingers, replaced by a growing tendency to shift blame and rely on external solutions, from ignoring the consequences of our actions to expecting governments to solve problems for us. We are witnessing a cultural shift where accountability is often avoided. This erosion of responsibility weakens our social fabric, leaving communities less resilient and more dependent. Freedom of choice is the most important precursor to improved personal responsibility. Anyone with a child would understand that to grow your little one’s sense of personal responsibility, you must allow them the freedom to choose and the ability to make decisions based on their own reasoning.
This is the extreme version of the “perversity thesis” of welfare, where any unconditional provision of support is deemed to have a corrosive effect on our virtue, particularly in relation to self-governance. For proponents, fluoridation reflects the pragmatic state seeking to address inequities, reduce the burden of preventable disease and anticipate expected shortcomings in the oral health of children, because we know that one out of every five don’t brush their teeth twice a day. However, Councillor Tickner suggests that the greater ethical imperative is letting children “make decisions based on their own reasoning” and thus better cultivate self-reliance.
It is precisely these narrow and rigid interpretations of “liberty” and “freedom” as unassailable values that have led to this strange situation. During a council meeting debating fluoridation, Gympie’s Mayor Hartwigoffered this reflection:
I am not an expert in this field. I don’t know whether the evidence presented by the experts is correct and I don’t know whether the evidence presented by others is correct. What I do know, and what I think we all are experts on, is freedom of choice. And that democratic principle, that is the foundation for everything that we do. And I would rather see people utilise their own freedom of choice and go and add fluoride to their diet, rather than force it on those individuals that don’t.
But is it actually self-evident that we are experts in “freedom of choice”? To adapt Isaiah Berlin’s “two concepts of liberty”, we worry that in the rush to rescue the freedom to choose from state tyranny we close off the greater proliferation of “choice” in our lives made possible through collective provision. Personal autonomy means little if one does not have genuine prospects for social mobility, good health care and other functioning public services.
This debate over freedom is, moreover, a classic story of neoliberalism. The assumption that we all have autonomy to make healthy choices ignores the structural inequalities baked into our society that dramatically affect choice and decision-making. One of the obvious benefits of fluoridation is that it can be efficiently delivered across entire populations and requires practically no effort on our part to receive its benefits. This makes it especially helpful in reducing inequities in under-served or disadvantaged communities.
In ceasing fluoridation and delegating responsibility to cover this gap in oral hygiene to the personal or family level — or, in Tickner’s case, seemingly to the children themselves — we make it far harder for “poor kids to have rich kids’ teeth”. The tragedy is that ceasing fluoridation may not necessarily be enabling freedom, but rather repressing it in crucial ways.
Finding a “freedom” worth defending
Throughout its history, water fluoridation has been an easy target. In part, this is because the stakes appear lower relative to other public health initiatives, such as childhood vaccination programs. If the fluoridation of your local water supply ceased tomorrow, you wouldn’t immediately be subject to any risk of sudden catastrophic harms. Rather, you would suffer the slow accumulation of a harm of omission. Your everyday drinking water could be reducing your risk of cavities and thus delivering significant health benefits, but currently is not.
These differences in perceived risk leads to stark variances in public engagement. That is, while most people tend to be broadly in favour of fluoridation, they are not nearly as impassioned as those opposed, who are far more likely to agitate vociferously on the matter. It’s the people who think fluoride is an “industrial waste” that sign the petitions and pack the gallery at council meetings.
But the rest of us should start caring more. Not because fluoridated water is a “silver bullet” or “unicorn dust” — it obviously isn’t. Rather, fluoridated water is both effective in itself and emblematic of our wider commitment to public health principles, such as critically informed confidence in carefully accrued scientific evidence, commitment to collective benefit and our willingness to make compromises on individual preferences in pursuit of more liveable worlds. Fluoride not only fortifies the teeth, but our support for fluoridation acts as a bulwark against the undermining of public health more broadly. In too easily ceding ground by assuming the stakes are comparatively low and not worth our time, we give tacit credence to the claimed unassailable value that we must secure all varieties of individual “freedom”, regardless of the collective cost.
Dr Harry Akers — with whom we opened this piece — was a dentist who clearly thought deeply about freedom and how it must be defended. On April Fool’s Day in 1978, at 2:45 am, Akers and his dog Jaffa undertook an “illegal procession” down a street in Bundaberg in an act of defiance against an effective total ban on protest marches imposed by Queensland premier Sir Joh Bjelke-Petersen. Akers paid a heavy price for his courage in standing up to “The Hillbilly Dictator”, including years of “both ridicule and hate” and briefly being compelled to resign from the Australian Dental Association. Those same freedoms that Akers marched to defend are now once again being eroded.
We understand the anxieties that may come with any treatment of our drinking water, for it requires placing trust in others regarding the most fundamental sustenance for life itself. To seemingly cede control can therefore feel like a profound loss of autonomy. The alternative, however, is not more freedom, but the onerous burden of finding alternative ways to supplement a health benefit no longer provided.
Invoking unassailable values can prove a source of comfort in asserting individual rights in a world that increasingly feels out of our control. Yet pushing this too far weakens our overall prospects for collective self-determination. We need to expand notions of “liberty” beyond the freedom to reject all impositions in our daily lives, and instead recognise that the freedom to realise personal aspirations often depends upon shared investments in public health and welfare.
Original article online at: https://www.abc.net.au/religion/fluoride-and-freedom-queensland-effort-deflouridate-public-water/106050464