April 8, 2011

Via Fax: 780 422 0154

Director of Southern Region

Alberta Environment
Regulatory Approvals Centre
Ninth Floor, 9820 106 St
Edmonton, Alberta T5K 2J6

Dear Director:

Statement of Concern of Adverse Impacts Related to Application

No. 032-476 Request by City of Calgary to Amend License to Stop Water Fluoridation

In my role as Medical Officer of Health, Calgary Zone, I am writing on behalf of Alberta Health
Services to request that the application by the City of Calgary, that requirements related to
fluoridation be removed from their approval, be denied.
Alberta Health Services is requesting that the existing approvals be maintained. Specifically that
the City of Calgary continues to:

1) adjust the level of naturally occurring fluoride which ranges from .1 to .3 mg/liter to .6 to .8
mg/liter;

2) continue to include fluoridation within existing and planned “Plant Capabilities” including
any current or future capital improvements and replacements; and

3) continue fluoride monitoring requirements.

Standing of Alberta Health Services

AHS has standing to submit this Statement of Concern. Section 109 of the Water Act requires that
a party submitting a Statement of Concern demonstrate that it is “directly affected” by the
application.1 AHS is directly affected by the City of Calgary’s application to amend its water
licence in two main respects:

(1) The proposed amendment to the City of Calgary’s water licence is a public health
issue. The mandate of AHS is to “promote and protect the health of the population
in the health region and work toward the prevention of disease and injury”2
[emphasis added]. A healthy environment and high quality of life are inextricably
linked to the promotion and protection of the health of the population; and

(2) AHS provides both dental treatment and preventive services to Albertans. The
1
Water Act, R.S.A. 2000, c. W-3, as amended, (“Water Act”) s. 109.
2
Regional Health Authorities Act, R.S.A. 2000, c. R-10, as amended, s. 5.

Calgary • Southport Tower • Public Health

10301 Southport Lane SW, Calgary Alberta, Canada T2W 1S7

www.albertahealthservices.ca
 2

proposed amendment to the City of Calgary’s water licence may result in increased
costs for both treatment and preventive services.

The Environmental Appeal Board (the “Board”) has held that “a person will be more readily found
to be ‘directly affected’ if the interest in question relates to one of the policies underlying the
[Environmental Protection and Enhancement] Act.”3 The interest that AHS seeks to advance in
this Statement of Concern is directly related to one of the main purposes of the Water Act, which is
“to ensure a healthy environment and high quality of life...”4 and to one of the main purposes of the
Environmental Protection and Enhancement Act, which recognizes that “the protection of the
environment is essential to the integrity of ecosystems and human health and to the well-being of
society.”5

The “directly affected” test must be applied generously by the Director when receiving and
considering Statements of Concern. The Board in Re Ouimet held that “the Director’s more
inclusive approach to directly affected, for the purposes of his decision, is entirely appropriate. In
fact, it is to be encouraged and is in keeping with section 2(d) of the Water Act.”6 The Board has,
in the same spirit, held that the Director should “err on the side of inclusion” because “[t]he Board
considers it invaluable to have the Director receive as much input as possible at the Statement of
Concern level.”7 Furthermore, “...the concerns expressed in the Statements of Concern should be
considered whenever possible....”8

The Director’s duty at the Statement of Concern stage of the process is to gather information so
that an informed decision may be made. The Board held in Re Ouimet that “[t]he process that the
Director is engaged in is non-adversarial information collection — he is collecting information
regarding the views and concerns of a broad range of parties to assist him in making a decision.” 9
The “directly affected” test is to be applied purposively so as to assist the Director in fulfilling his
duty to gather information, views, and concerns from a broad range of parties. Again in Re
Ouimet, the Board held that “[t]he purpose of the directly affected test with respect to the
Statement of Concern process, and the Director’s decision, is to promote good decision-making
taking into account a broad range of interests.”10

Calgary Health Region (“CHR”), a predecessor to AHS, was granted party status in hearings
before the Board on at least two occasions. The reasons given by the Board for allowing CHR to
be an intervener are relevant to the Director’s information gathering role in the present
circumstances. CHR was recognized by the Board as being a valuable source of information. In
Imperial Oil v. Alberta the Board considered issues relating to soil contamination in a subdivision in
Calgary. The Board observed that “[b]y allowing the Calgary Health Region to participate as a
Party, the Board has the opportunity to more thoroughly understand the health effects that may

occur at the Subdivision.”11 The Board further observed that, “[t]he Calgary Health Region has a
3
Kostuch v. Alberta (Director, Air & Water Approvals Division, Environmental Protection), 1995
CarswellAlta 735 (Env. App. Bd.), para. 35.
4
Water Act, supra, s. 2.
5
Environmental Enhancement and Protection Act, R.S.A. 2000, c. E-12, as amended, s. 2.
6
Re Ouimet, 2002 Carswell Alta 464 (Env. App. Bd.), para. 23.
7
Jericho v. Alberta (Director, Southern Region, Regional Services, Alberta Environment), 2004
CarswellAlta 1487 (Env. App. Bd.) at para. 80.
8
Ibid.
9
Re Ouimet, para. 24.
10
Ibid.
11
Imperial Oil Ltd. v. Alberta (Director, Enforcement & Monitoring, Bow Region, Regional Services,
 3

keen interest in the matter of this appeal, as the issue is the health of its residents. Its purpose in
appearing before the Board is to provide information to the Board to assist in protecting human
health.”12

Discontinuation of Communal Water Fluoridation creates a real and substantive health risk

The City of Calgary request to stop water fluoridation as required by their current license
represents a real and significant risk to the health and well being of residents of Calgary and other
communities who are provided with potable water from the City of Calgary. Communal water
fluoridation reduces the risk of dental caries by at least 14% 13, 14. The discontinuation of water
fluoridation increases the risk of dental caries by up to 21.6% 15. The Ontario municipality of
Dryden discontinued fluoridation in 2001. The provincially mandated dental survey of elementary
school children showed that, in Dryden, the caries level of 5 year olds increased by 26% from
2001 to 2008 16.

Early childhood caries is the most common infectious disease of childhood. The 2009 City of
Calgary Census found that there were 188,247 children in Calgary between 0 to 14 years of age.
These children are at risk of dental disease and at risk of harm by the City of Calgary’s request to
stop water fluoridation.

Communal Water Fluoridation is safe and effective

The safety and effectiveness of water fluoridation have been reaffirmed by numerous regulatory
agencies and health organizations 13, 14, 15. 17 Indeed this was the finding of the City of Calgary’s
own 1998 review 18, which recommended water fluoridation at the level of 0.7 ppm in the treated
drinking water.
Alberta Environment) 2002 CarswellAlta 1017 (Env. App. Bd.), para. 42. See also, Re Court, [2002]
AEABD No. 51.
12
Ibid., para. 46.
13
National Health and Medical Research Council. A Systemic Review of the Efficacy and Safety of Water
Fluoridation. Australilia Government, 2007
(http://www.nhmrc.gov.au/publications/synopses/eh41syn.htm)
14
Guide to Community Preventive Services. Preventing dental caries: community water fluoridation.
(www.thecomunityguide.org/oral/fluoridation.html. Last update 09/28/2010) Last updated
09/28/2010
15
University of York (UK). A Systemic Review of Public Water Fluoridation.2000.
(http://york.ac.uk/inst/crd/fluores.htm)
16
McKeown D. Medical Officer of Health Report to the Toronto Board of Health. Water Fluoridation in
Toronto, 2011
17
Health Canada. Findings and Recommendations of the Fluoride Expert Panel. 1997. (http://www.hc-
sc.gc.ca/ewh-semt/pubs/water-eau/2008-fluoride-fluroure/index-eng.php)
18
City of Calgary and Calgary Regional Health Authority. Report of the Expert Panel for Water Fluoridation
Review. 1998
19
Alberta Health and Wellness. A Review of Water Fluoridation: Prepared by Dr. S. K. Patterson. 2011
20
City of Calgary. Utilities and Environment Protection Report to Council, 2011 March 21.
 4

Since 1998 systematic reviews have reaffirmed the safety and effectiveness of water fluoridation,
several of which have already been referenced. Most recently Health Canada and Alberta Health
and Wellness have reaffirmed the safety and effectiveness of water fluoridation and continue to
recommend it 17, 19. No evidence has been presented by the City of Calgary to support that
discontinuing water fluoridation can be done without an adverse impact on health. In fact, the
Dean of the Faculty of Medicine at the University of Calgary offered to assist with a review of
recent evidence, but City Council voted to decline. The City Manager’s report accompanying the
proposed by-law to repeal water fluoridation was a single page indicating no social, environmental
or economic implications or any risks at all from discontinuing water fluoridation 20.
In contrast, the City of Toronto which reaffirmed water fluoridation on April 4, 2011 had received a
19 page report addressing the safety and effectiveness as well as concerns raised by people
opposed to water fluoridation. 16 The City of Hamilton received a nine page information update. 21

Water fluoridation is endorsed by Dr. Andre Corriveau, Chief Medical Officer of Health of the
Government of Alberta as safe, effective and an important measure for protecting and improving
health. Numerous health and dental organizations endorse the safety and effectiveness of water
fluoridation, and a sampling is included in the evidence binder.

Health Inequalities will be increased

The populations that will be most impacted by discontinuing water fluoridation include children
from low income families. A Calgary dental survey in 2006 found that 24% of four year old children
from families with annual income below $60,000 had at least one cavity, compared to only 10% of
those children from families with annual income greater than $60,000 22. This finding was
consistent with a longitudinal survey in the United States 23. These children already experience
significant health inequalities and increasing their risk of dental caries adds further to the
disadvantages that they experience.

Over a quarter of the population is not covered by dental health insurance. The Australian
systematic review found that water fluoridation saves between $69.86 and $249.45 per person
annually. 13 Research the United States has demonstrated that for children residing in fluoridated
communities the costs paid by insurance companies for dental procedures were less. 24

12.5% of all Calgarians are considered to live in poverty. (Fact Sheet: Poverty in Calgary, City of
Calgary, 2003) These individuals are not in a position to assume the additional costs for dental
treatment. Without water fluoridation, individuals will experience unnecessary pain and suffering
from dental disease that could have been prevented.
13

1321
Richardson E. Medical Officer of Health Report to Mayor and Members, Board of health, November 17
2008
22
Veronneau J and Shwart L. Early Childhood Cavies, Surveillance 2006
23
Centre for Disease Control and Prevention. Fact Sheet: Key Findings from Nhanges 1999-2002
24
Centres for Disease Control and Prevention. Water Fluoridation and Costs of Medicaid Treatment for
Dental Decay. Louisiana,
1995-96. (http://www/cdc-gov/mmwr/preview/mmwrhtm/mm4834a2.htm)
25
Centre for Disease Control and Prevention. Cost Savings of Community Water Fluoridation.
http://cdc-gov/fluoridation/fact_sheets/cost.htm
Ibid
 5

Although the City of Calgary has indicated its intent to explore the development of a program to
provide dental care to children to reduce the impact of its decision on the dental health of children,
no details have been provided on the nature of the program, who would be eligible and the number
of children that could be treated.

Alternatives will be more costly

The cost and viability of alternate mechanisms for providing fluoride to populations need to be
considered when examining the City of Calgary’s request to stop water fluoridation. The City of
Hamilton conducted an analysis of the cost of delivering fluoride through four methods: water
fluoridation; topical fluoride application twice per year by public health services; topical fluoride
application twice per year by private dentists; and, distribution of tooth paste and tooth brushes.
The results of this analysis are presented in the table below.16

Table 3. Annual costs of alternate fluoride delivery approaches for City of Hamilton, 2008

Annual
Preventive measure
Cost/person
Topical fluoride application twice per year to all high risk
$44.50
individuals by Public Health Services
Topical fluoride application twice per year to all high risk
$96.12
individuals by Private Dentists
Distribution of tooth paste and tooth brushes to all members of
$8.50
the population

In contrast, the annual operating cost for water fluoridation is estimated to be less than 80 cents
per person annually. This information is consistent with the American experiences as well 25.

Procedural Concerns

Although the City of Calgary held a public forum on January 26th, 2011, the notice of motion to stop
water fluoridation, included in the application which is stamp dated on December 9, 2010 by the
City Clerk’s office was signed by 10 aldermen. This was well in advance of the public consultation.
It raises concerns over whether there was a fair and transparent process at the public forum and
subsequent council decision in relation to the consideration that was given to the health
recommendations and assessments provided by Alberta Health Services at the public forum and
to Calgary City Council. This is of particular concern and interest given that under Section 5 of the
Regional Health Authorities Act, Alberta Health Services has the statutory responsibility to
“promote and protect the health of the population in the health region and work toward the
prevention of disease and injury”.

25
Ibid
 6

Action Requested

On the basis of the significant adverse impact of stopping water fluoridation and given the current
evidence in support of the safety and effectiveness of water fluoridation, and in the view of the
previous last two plebiscites in support of water fluoridation, we would request that the application
by the City of Calgary be denied on the basis that they have failed to carry out the necessary and
required studies and necessary public consultation. Similarly, the City of Calgary has not
presented evidence contrary to recommendations of their own 1998 Expert Panel Review whose
recommendations are consistent with other more recent reviews.

We would be pleased to respond to requests for further information or clarification.

Yours sincerely

Richard Musto, MD, FRCPC

Medical Officer of Health
Calgary Zone