WHAT WORKS
For lawmakers who are committed to the benefits of fluoride, there are several approaches to ensuring optimal fluoridation for a state's communities. Some states have enacted laws mandating that community water systems that serve more than a specified number of people fluoridate; others have gotten results without a mandate. States with very low fluoridation rates often look for other ways to intervene.
Fluoride Mandates
Statutory-Legislation mandating water fluoridation has been enacted in 11 states, the District of Columbia and Puerto Rico. Statutes vary widely. All municipalities are required to fluoridate their water in Delaware, Georgia, Illinois, Minnesota, and Nebraska, while other states require fluoridation of water systems serving a threshold population. For example, in Nevada, counties with populations of more than 400,000-a threshold so high only Las Vegas' Clark County qualifies-must fluoridate, while in South Dakota, fluoridation is required in communities with more than 500 people. In several of these states, communities can be exempted from complying with the fluoride mandate if a public vote rejects it.
As with any other divisive legislative topic, attempts for statewide legislation can do more harm than good. A decade ago, Connecticut attempted to modify its fluoride law by lowering the population threshold for fluoridation. By the time it wound its way through the legislative process, the bill was altered so completely that it banned fluoridation in the state. In the end, the bill was killed, and Connecticut retained its mandate for communities of 20,000 or more, but the story is a cautionary reminder. For this reason, Tom Reeves, CDC national fluoridation engineer, typically advises that, if a substantial proportion of the state's water is already fluoridated, attempting a state mandate could be risky. If community water fluoridation is low, the risk might be worth taking.
Regulatory-Kentucky's public health department was given blanket statutory authority for the "...establishment, maintenance, monitoring, and enforcement of water fluoridation programs for the protection of dental health." From this general language, the department crafted regulations that require fluoridation for all community water systems that serve populations of 3,000 or more. As a result, nearly 90 percent of Kentucky's population receives fluoridated water without specific legislation.
Local-Many states have successfully encouraged fluoridation without a state mandate. In Virginia-where local governments can authorize fluoridation without referenda-93 percent of communities have fluoridated their water. Fluoridation coordinator Lisa Syrop credits the high fluoridation rate to a 50-year effort by the oral health program, strong and consistent support from the dental community, and a Centers for Disease Control and Prevention grant.
Public Referenda
Some statutes-such as those in Maine, New Hampshire and Utah-require a public vote before water fluoride levels can be adjusted. Nevada added an interesting twist to the process. The governor refused to sign the fluoridation measure in 1998 unless it allowed Clark County to vote on the issue. The law took effect on Jan. 1, 2000, and the county's water systems were fluoridated in March. However, the referendum did not take place until November-eight months after fluoridation began.
Although referenda allow voters to decide, they also reflect the varying abilities of fluoride promoters and detractors to promote their views. According to Cheri Seed, Montana's oral health consultant, an understaffed oral health office can feel as though it is waging an uphill battle against a well-funded and vocal minority. She was disappointed by the narrow defeat of a fluoride initiative in Billings in November 2002, despite strong support for the initiative by the medical and dental communities and the city water plant directors. Most people assume their water already is fluoridated and may not be motivated to vote for a referendum; others reject adding any substance to their water. In Montana, Seed believes the population is particularly sensitive to the possibility of fluorosis because of excessive natural fluoride in some communities near the Missouri River. To compensate for Montana's low fluoridation rate-less than a quarter of the population receives fluoridated water-schools in about 38 counties that serve approximately one-third of the state's students participate in a school-based fluoride mouth rinse program.
Funding
Water districts often pass on the low cost of fluoridation to consumers. Delaware's 1998 mandate offered funding for fluoridation equipment during the first three years of the law, assuming the cost of chemicals and routine maintenance could be borne by consumers. The authors of California's 1995 fluoridation law were wary of passing the cost of fluoridation directly to water companies and ratepayers, so cities are required to obtain the money from outside funding sources such as private businesses or foundations. Many California city councils will not even consider fluoridation unless a funding strategy has been developed. Some believe the "outside funding" provision is raising the cost of fluoridation in California. Water companies have an incentive to submit high cost estimates-sometimes including expenses only tangentially related to fluoride, such as new fencing, roads and staff-since grants will be paying for the upgrades. The state health department reviews engineering estimates to prevent potential profiteering by water companies and helps communities find sources of funding. Despite the law, the state expects ratepayers to shoulder the long-term cost of fluoridation, although technically fluoridation can stop when grant funds dry up. Only about one-third of California's population has access to fluoridated water.
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