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Fluoridation Queensland | Legal Arguments Against Fluoridation – Summary and Opinion cont.
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Legal Arguments Against F. – Summary & Opinion Cont.
… Should that occur, there is also a real possibility that the Region of Peel would be held legally liable to residents in a lawsuit for harm caused by artificial fluoridation. This memorandum proceeds in three parts.
Part I discusses the factual background to Ontario and Peel’s fluoridation programs and situates these provisions in the global context. Part II discusses the scientific evidence relating to health effects of fluoridation. While fluoridation has significant potential effects on the environment and non-human animal and plant species, I focus on the human health effects because those effects are likely to figure most prominently in a legal challenge to fluoridation. Part III discusses the potential arguments in a legal challenge to fluoridation programs in Ontario as well as other legal issues that may arise in a court challenge to fluoridation in Ontario. I have also appended to this memo an affidavit from Dr. Kathleen Thiessen, a biomedical scientist, who has served on two U.S. National Research Council subcommittees dealing with fluoride exposure and toxicology. Her affidavit was commissioned specifically in connection with the ongoing debate about fluoridation in the Region of Peel.
Fluoride is the anionic or reduced form of fluorine and is the thirteenth most abundant element in the Earth’s crust. Given that fluorine is so abundant, it is not surprising that fluoride compounds are components of minerals in rocks and soil. Due to these components, and the action of ground water acting upon them, fluoride is released into the groundwater and is the major contributor to the small amounts of fluoride present in most water sources. In general, most ground water contains low concentrations of fluoride, typically less than 0.5 mg/L. Fluoridation is the controlled addition of fluoride ions to water that has a low fluoride concentration (sometimes called “artificial fluoridation”). In the early 1900s, significant work was done in understanding the root cause of the mottling of teeth and tooth decay. This mottling, and improved dental health, was ultimately attributed to the high fluoride concentrations in the ground water that was ingested by these individuals. Over time, additional studies were undertaken, which were purported to establish a relationship between fluoride and substantially fewer cavities, ultimately leading to four community wide trials that were established in the mid-1940s. These trials were conducted in Grand Rapids, MI; Newburgh, NY; Brantford, ON and Evanston, Ill. Soon thereafter, the U.S. Public Health Service and many dental associations endorsed community-wide fluoridation as a practical and safe public health measure to prevent tooth decay. Over the past 65 years, additional investigation has examined everything from the health effects of the various fluoride compounds used in the fluoridation process to the dosage levels that provide adequate dental health protection. Over this time-frame, fluoride dosage levels have on average dropped from 1.0 to 1.2 mg/L to between 0.5 and 0.8 mg/L, while the maximum acceptable concentration (MAC) has been established at 1.5 ppm. The Ontario Ministry of Health and Long Term Care, in partnership with the Ontario Ministry of the Environment, have established a guideline of 0.5-0.8 mg/L for fluoride in drinking water. The Region of Peel claims to “closely monitor” the fluoride levels in the water supply to make sure the correct concentration is being maintained.1 Under the Safe Drinking Water Act Regulations, the maximum allowable concentration of fluoride in Ontario drinking water is 1.5 mg/L.2 1 Region of Peel, Peel Public Health, “Fluoridation – Frequently Asked Questions”, online: http://www.peelregion.ca/health/topics/commdisease/dental/fluoridation.htm#10.
2 Safe Drinking Water Act, 2002, Ontario Drinking Water Quality Standards, O.R. 169/03, Schedule 2. 3 Fluoridation Act, R.S.O. 1990, c. F.22. 4 Ibid., s. 2(1). 5 Ibid., s. 2.1(2). 6 Regional Municipality of Peel, A by-law to provide for the fluoridation of the Town of Caledon’s communal water supply, online: http://www.peelregion.ca/health/topics/commdisease/dental/by-law.htm. 7 Danielle Rabby-Waytowich, “Water Fluoridation in Canada: Past and Present” (July/August 2009), 75 JCDA 451, online: http://cda-adc.ca/jcda/vol-75/issue-6/451.pdf. In 1961, the Province of Ontario enacted the Fluoridation Act, 3 which specifically provided for the establishment and maintenance of fluoridation of drinking water within the Ontario waterworks system. The Fluoridation Act does not require fluoridation. Under the Act, municipalities were given the discretionary authority, by way of the passing of a by-law “…to establish, maintain and operate, or require that the local board establish, maintain and operate, a fluoridation system in connection with the waterworks system.”4 Cities that already had a fluoridation program in place were not required to pass a new by-law; the Fluoridation Act permitted the continuation of those programs.5 Accordingly, the Fluoridation Act permitted the continuing fluoridation of the water supplies of the City of Mississauga and City of Brampton. In 2007, the Regional Municipality of Peel passed a by-law establishing a fluoridation system in the Town of Caledon.6 According to the Canadian Dental Association, approximately 45% of Canadians drink fluoridated public water.7 However, the figures vary significantly across the country. Quebec has historically opposed artificial fluoridation, and as such, today less than 3% Quebec’s population drinks fluoridated water.8 Only approximately 3.7% of residents of British Columbia drinks fluoridated water. 9 At 75.9%, Ontario is the most heavily fluoridated province. In recent years, however, some medium-sized municipalities, including Waterloo and Windsor, have ended their fluoridation programs.10 The debate between pro- and anti-fluoride activists in Ontario municipalities is acrimonious, with both sides accusing the other of “cherry picking” research to boost its argument. Health Canada as well as the Canadian Medical Association and the Canadian Dental Association are staunchly pro-fluoride. The Green Party of Canada, and respected NGOs such as the Council of Canadians, Green Peace Canada and Sierra Club, oppose fluoridation of municipal water supplies. 8 Eric Tchouaket et al, “The economic value of Quebec’s water fluoridation program” (June 2013), 21 J Public Health 523 at 524. 9 Ibid. Danielle Rabby-Waytowich, “Water Fluoridation in Canada: Past and Present”, supra at 452. 10 See CBC News, Fluoride no longer to be added to Windsor water” (Jan. 29, 2013), CBC.ca online: http://www.cbc.ca/news/canada/windsor/fluoride-no-longer-to-be-added-to-windsor-water-1.1325977. 11 Centers for Disease Control and Prevention, “Fluoridation Status: Percentage of U.S. Population on Public Water Supply Systems Receiving Fluoridated Water”, CDC.gov online: http://apps.nccd.cdc.gov/nohss/FluoridationV.asp. 12 Fluoride Action Network, “Water Fluoridation Status in Western Europe”, online: http://fluoridealert.org/content/water_europe/. Canada’s rate of fluoridation puts it squarely in the global middle among the Organization of Economic and Cooperative Development (“OECD”) countries. According to a 2002 study, approximately 69% of U.S. residents were living in communities with fluoridated water. 11 By contrast, only approximately 3% of the population in Western Europe currently consumes fluoridated water.12 Despite this fact, the available evidence does not suggest that tooth decay rates are higher in unfluoridated Western European countries than in the United States or other fluoridated countries.
ops in children during tooth formation. Whether to consider fluorosis to be an adverse health effect or merely a cosmetic effect has been the subject of debate. However, the U.S. National Research Council has concluded that severe fluorosis is more than a cosmetic issue because severe fluorosis can lead to enamel loss, leaving the dentin open to decay and infection and causing structural damage to the tooth.17 Muskoskeletal Effects Skeletal fluorosis is a bone and joint condition associated with prolonged exposure to high concentrations of fluoride. Fluoride increases bone density and appears to exacerbate the growth of osteophytes present in the bone and joints, resulting in joint stiffness and pain.18 There is no doubt that high concentrations of fluoride cause skeletal fluorosis. The debate within the scientific community is the extent of the risk of skeletal fluorosis at current levels of fluoridation. 19 Defenders of fluoridation argue that a concentration of 1.5mg/L is too low to present a risk of skeletal fluorosis. It should, however, be noted that the first symptoms of skeletal fluorosis are similar to the first symptoms of many forms of arthritis — stiffness and pain in the joints and pain in the bones. 18 NRC Report, supra, at 5. 19 Ibid. at 6. 20 Ibid. 21 Ibid. at 7. 22 Ibid. at 8. There is also scientific evidence that fluoride can increase the risk of bone fractures. The NRC Report notes that “several strong observational studies indicated an increased risk of bone fracture in populations exposed to fluoride at 4 mg/L.”20 While there are fewer studies dealing with the risk of bone fracture within populations exposed to fluoride at a rate of 2 mg/L or lower, there is a peer-reviewed study from Finland that suggests an increased rate of hip fracture in populations exposed to fluoride at concentrations above 1.5 mg/L,21 which is the maximum allowable rate of fluoridation in Ontario. Neurobehavioural Effects Animal and human studies of fluoride have been published reporting adverse cognitive and behavioural effects. Epidemiological studies conducted in China have reported I.Q. deficits in children exposed to fluoride at 2.5 to 4 mg/L in drinking water. The NRC found these studies to be sufficiently alarming to call for “additional research on the effects of fluoride on intelligence.” 22 In 2012, a group of scientists published a systematic review of the literature on developmental fluoride neurotoxicity. The review concluded that the consistency of pre-existing studies showing a link between fluoride and cognitive deficits shows that potential developmental neurotoxicity of fluoride should be a high research priority.23 23 Anna Choi et al, “Developmental Fluoride Neurotoxicity: A Systematic Review and Meta-Analysis” (2012), 120 Environmental Health Perspectives 1362 at 1367. 24 Ibid. at 222. 25 Ibid. 26 Ibid. at 336. 27 Ibid. at 10. 28 Elise B. Bassin et al, “Age-specific fluoride exposure in drinking water and osteosarcoma” (2006), 17 Cancer Causes & Control 421. The NRC also noted that fluorides “increase the production of free radicals in the brain through several different biological pathways. These changes have a bearing on the possibility that fluorides act to increase the risk of developing Alzheimer’s disease.”24 The NRC has called for additional studies in this area as well.25 Genotoxicity and Carcinogenicity There have been a number of studies that have suggested a link between fluoride and bone cancer. The NRC Report concludes that fluoride “appears to have the potential to initiate and promote cancers, particularly of the bone, but the evidence to date is tentative and mixed”.26 The NRC cautions readers that at the time of the publication of the NRC Report a major hospital-based study on osteosarcoma (bone cancer) and fluoride exposure was underway at the Harvard School of Dental Medicine.27 The Harvard study, which was published in 2006, found an association between fluoride exposure in drinking water during childhood and the incidence of osteosarcoma among males (but not females).28 This is a significant and concerning finding.
decision in Toronto (Metro) v. Forest Hill (Village).34 In that case, the residents challenged a municipal by-law that authorized the City “to undertake the treatment of the …. water supply by fluoridation.” At that time, the Province’s enabling legislation only permitted the municipalities to ensure a “continued and abundant supply of pure and wholesome water.” It did not specifically authorize fluoridation or other forms of mass medication. The City argued that the power to make the water supply “pure and wholesome” implicitly authorized fluoridation. A majority of the Supreme Court of Canada disagreed. It held that fluoridation “is not a means to an end of wholesome water for water’s function but to an end of a special health purpose for which a water supply is made use of as a means.” In other words, the purpose of fluoridation was not to purify the water, but to medicate the population with fluoride. The Ontario Legislature superseded Toronto (Metro) v. Forest Hill (Village) when it passed the Fluoridation Act in 1961. But the Supreme Court of Canada’s conclusion that the purpose of fluoridation is not water purification but rather medication remains the finding of this country’s highest court. As such, Ontario’s fluoridation programs constitute medication without consent and thus deprives Ontario residents of their s. 7 liberty and security-of-the-person interests. Fluoridation Violates the Principle of Gross Disproportionality Given that the Fluoridation Act triggers the s. 7 liberty and security-of-the-person rights, the primary challenge for claimants will be in showing that the deprivation is inconsistent with the principles of fundamental justice. If that can be shown, then the claimant will have succeeded in proving that the fluoridation program is unconstitutional. The most relevant principle of fundamental justice here is the principle against gross disproportionality. A law is “grossly disproportionate” if the state action or legislative response to a problem is so extreme as to be disproportionate to any legitimate government interest.35 In other words, a law will be found to be grossly disproportionate where its benefits are grossly disproportionate to its potential harm.36 35 R. v. Malmo-Levine,  3 S.C.R. 571 at para. 143. 36 Canada (Attorney General) v. PHS Community Services Society,  S.C.J. No. 44,  3 S.C.R. 134 at para. 153; Canada (Attorney General) v. Bedford, 2013 SCC 72 at para. 159. If a claimant can properly marshal the available scientific evidence, they ought to be able to show that the risk of significant harm caused by fluoridation is grossly disproportionate to the speculative benefit of reduced dental carries. As noted above, recent studies suggest that the claimed reduction in tooth decay over the past several decades is more likely attributable to improved dental care rather than fluoridated water. If true, then the benefits of fluoridated water are, at best, marginal, or, at worst, nonexistent. By contrast, the negative effects of fluoridation appear to be real and substantial. As noted above, the authoritative NRC Report concludes that dental fluorosis is more than just a cosmetic effect.37 Peer-reviewed scientific studies show that water fluoridation can have an adverse impact on children’s I.Q..38 Other studies show that fluoride can affect bone and make fractures more likely.39 The 2006 Harvard study shows an association between osteosarcoma and fluoridated water.40 Even if these negative effects are not conclusively proven, the risk of potential harm is significant. It would be reckless to expose residents to the risk of cancer, among other things, for the marginal benefit of reduced tooth decay, particularly where, as here, it is no longer clear that fluoridated drinking water is even a significant contributor to reduced tooth decay. Marginal benefit in exchange for significant risk is the sine qua non of gross disproportionality. 37 Supra at 6. 38 Supra at 7. 39 Supra at 6-7. 40 Supra at 7-8. 41  B.C.J. No. 109 (B.C. Sup. Crt). 42  A.J. No. 926 (Q.B.)). The likelihood of success of a hypothetical legal challenge to fluoridation will turn largely on the strength of the scientific evidence presented in court because the stronger the scientific evidence of risk of harm, the greater the gross disproportionality. Previous Legal Challenges Are Not Indicative of Likelihood of Success in Ontario Skeptics about the viability of a successful legal challenge to Ontario’s fluoridation program will point out that since the Supreme Court’s 1957 decision Toronto (Metro) v. Forest Hill (Village), which was superseded by legislative action (see supra at 10-11), all other legal challenges to fluoridation programs in North America have failed. For the following reasons, I do not regard these cases as barring a legal challenge in Ontario. The Canadian Cases In Canada, there have been unsuccessful challenges to fluoridation programs in Alberta and British Columbia: see, e.g., Millership v. Kamloops (City); 41 Locke v. Calgary (City).42 Those cases, however, are distinguishable on at least three different grounds. First, those challenges were brought by self-represented litigants. While it appears that these individuals did an admirable job at marshaling the evidence and the arguments, novel constitutional challenges such as this are highly complex and require the assistance of counsel. Second, the scientific evidence about fluoridation is improving. More information than ever before is known about fluoridation. At the time that Millership (2003) and Locke (1996) were decided, for example, the NRC Report had not yet been published. Nor had the Harvard study on the association between osteosarcoma and artificial fluoridation been completed. Third, Canadian constitutional law under s. 7 of the Charter has developed significantly over the past five years. The principle of fundamental justice of “gross disproportionality” is a fairly new principle in Canadian constitutional law. Prior to the Supreme Court’s recent decisions in PHS and Bedford, there was some doubt over whether this principle was indeed a principle of fundamental justice and also some doubt over what “gross disproportionality” actually meant. In my view, the best argument against fluoridation relies on the principle of gross disproportionality. This argument was not available to the claimants in Locke and Millership. Each of these factors suggests that these other cases will not bar a successful constitutional challenge to fluoridation in Ontario.
onstitutional because of an unacceptable risk of harm, this could pave the way for lawsuits against the municipality. The Municipal Act, 2001 imposes a statutory duty of care on those who oversee drinking water systems and makes municipalities liable in tort for acts or omissions.60 Moreover, as of December 31, 2012, amendments to the Safe Drinking Water Act clarified the standard of care for municipalities. Under this standard, municipalities must exercise the level of care, diligence and skill in respect of a municipal drinking water system that a reasonably prudent person would be expected to exercise in a similar situation.61 The standard of care also extends to the owner of the municipal drinking water system, and to those people who, on behalf of the municipality, oversee the accredited operating authority or who exercise decision-making authority over the system. 60 Municipal Act, 2001, S.O. 2001, ch. 25, ss. 448(2), 448(3). 61 Ibid., s. 19(1). 62 Ibid., s. 19(2). The Safe Drinking Water Act puts responsibility for ensuring safe drinking water squarely on the municipalities. It also arguably makes those who make decisions about the municipal water supplies — such as Councillors — personally liable for acts or omissions.62 It follows that if a court should find that fluoridation puts residents of Peel at risk of harm, then the Region of Peel and its Councillors may be liable to its residents for damages on the civil negligence standard. It is also worth noting that the Region faces potential liability not only under a potential civil suit brought by residents but may also be prosecuted by the Province. Under the Safe Drinking Water Act Regulations, any person resident in Ontario can ask the Ontario government to investigate the Region for an alleged violation of the Act.63 Furthermore, the Safe Drinking Water Act provides that a violation of s. 20 — the prohibition on putting material into water that could cause a health hazard — shall be a criminal offence. Thus, if fluoride is proven to cause harm or a risk of harm, then a municipality that continues to fluoridate could theoretically face criminal prosecution. 63 Safe Drinking Water Act, 2002, Compliance and Enforcement Regulation, O. Reg. 242/05, s. 7(1). Thus, a municipality that fails to discharge its duty of care under the Safe Drinking Water Act could face (1) civil liability to residents in a civil lawsuit; (2) prosecution by the Ontario government; and (3) potentially, criminal liability. These risks and liabilities ought to be sufficient to encourage municipalities to carefully re-examine their water fluoridation programs.
4. That the Council require that experts presenting their opinions also provide the Council with the underlying data and studies on which they are relying for their opinions. There is enough competing opinion in the scientific community that it will be important for municipalities to understand the bases for scientific opinion as they re-examine this important issue. I look forward to discussing the foregoing with you further.

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