SYNOPSIS

Studies over the last half-century show that community water fluoridation is safe and is effective in reducing tooth cavities, especially among children. Dental and medical professional organizations endorse water fluoridation as a public health measure.

State Assembly Bill 733 (AB 733) which became effective January 1, 1996 requires fluoridation of public water systems in California with at least 10,000 service connections. There are fourteen water systems in San Diego County with more than 10,000 service connections. None of them are currently fluoridating their water supply. San Diego County is the most populous county in the State without any public water fluoridation.

AB 733 exempted water systems from compliance until funds were made available to them from sources other than ratepayers, shareholders, local taxpayers, bondholders or fees or charges levied by the water system.

Funds were recently made available to two major water systems in the County that will enable them to fluoridate their water systems pursuant to AB 733. The Grand Jury recommends that the Board of Supervisors identify possible sources of funds that may be used for fluoridation and assist water providers in obtaining such funds. It further recommends that County water providers and the Board of Supervisors work together with the County Water Authority to determine if coordinated planning of fluoridation could reduce overall capital and ongoing costs.

BACKGROUND

Water fluoridation is the process of adjusting the natural fluoride concentration in drinking water to the recommended concentration for optimal dental health. Fluoridation was a major factor responsible for the decline in dental caries during the second half of the twentieth century according to the Center for Disease Control and Prevention, Atlanta, Georgia (CDC).

Extensive dental caries were common in the United States and in most developed countries at the beginning of the twentieth century. Dental caries is an infectious, communicable, multi-factorial disease. Among several factors operating in the production of caries are: the presence of bacteria in the mouth, the bacteria that act on sugars to produce acid that destroys tooth enamel, and the degree of resistance of the enamel to decay which may be influenced by genetic factors. If the cavity progresses through the dentin and into the soft pulp, it will result in the loss of tooth structure and discomfort, and may progress to an acute systemic infection.

In the early 1900's a Colorado Springs dentist, Dr. Frederick McKay, noted an unusual brown stain that mottled the tooth enamel of his patients, especially young children. He later developed the theory that an agent in the water supply was probably responsible for the condition. He noted that teeth affected by this condition seemed less susceptible to dental caries.

Dr. McKay and Dr. Grover Kempf of the U.S. Public Health Service (USPHS) traveled to Bauxite, Arkansas, a company town owned by the Aluminum Company of America (ALCOA), to investigate the unusual stain and to analyze the water supply from a deep well abandoned in 1927. The chief chemist at ALCOA used the newly available photospectrographic analysis on samples in 1930. The analysis identified high levels of fluoride in the water. McKay had the water samples analyzed from other locations where mottled enamel was noted and concluded that the elevated fluoride level caused the discoloration of tooth enamel.

Dr. H. Trendley Dean joined the research in the 1930's. Dr. Dean determined the optimum level of fluoride in the drinking water which protected teeth from caries to be one part per million (ppm). This fluoride level did not produce an unacceptable incidence of fluorosis (mottled teeth). The hypothesis was developed that dental caries could be prevented without producing fluorosis by adjusting the fluoride level of community water supplies.

Studies of community water fluoridation began in 1945 in Michigan, New York, Illinois and Canada. About 15 years later it was found that caries were reduced 50 to 70 percent among children and tooth loss was reduced 40 to 60 percent among adults in the communities with fluoridated water. The results prompted adoption of fluoridation as a public health measure throughout much of the United States.

Public water system fluoridation is especially beneficial for communities or individuals of low economic status in that many families cannot afford dietary or dental fluoride supplements. Such persons have disproportionately more dental caries and have less access to dental services and other sources of fluoride than those in higher income communities.

In October 1995 Governor Wilson signed into law AB 733 which required fluoridation of public water systems meeting certain conditions. Under this law each public water system with 10,000 or more service connections must commence capital improvements to implement fluoridation when funding is available. Each affected public water system must commence and continue operating and maintaining the system for fluoridation of the water supply when funding becomes available.

The Grand Jury decided to investigate whether the public water suppliers in San Diego County are in compliance with State Law.

PROCEDURE

The Grand Jury interviewed state, county, municipal, and special district officials and representatives of both pro-fluoridation and anti-fluoridation groups. Public meetings were attended.

1. San Diego City Attorney Report to the Committee on Natural Resources & Culture, Fluoridation of Water Supply, dated September 6, 1996.

2. California Attorney General Opinion No. 99-1112, dated February 18, 2000.

The following documents were reviewed:

a. Reprint from the Center for Disease Control and Prevention, MWR Weekly Report, entitled "Achievements in Public Health, 1990-1999: Fluoridation of Drinking Water to prevent Dental Caries", JAMA, March 8, 2000-Volume 283, No. 10;

b. "California Fluoridation Implementation Project", California Department Health Services, 1999;

c. "Fluoridation Treatment Capital Cost Estimate Priority List", California Department of Health Services, 1999;

d. "San Diego County Water Authority Fact Sheet 1998-99", Annual Report-1998, September 1999;

e. "San Diego County Water Authority Fact Sheet for Fiscal year 1999-2000", with Member Agencies data sheets 1 through 18, April 10, 2000;

f. "Fluoridation Facts", American Dental Association, 1999;

g. "Causes of Fluorisis", American Dental Association, 1995;

h. "Achievements in Public Health", American Dental Association, 1999;

i. San Diego County Science Advisory Review Report, August 10, 1999;

j. "Benefits vs. Concerns on Fluoridation", Department of Dental Medicine & Public Health USC, April 9, 1997;

k. "A Neglected Epidemic", California Dental Health Foundation 1997;

l. Report of the California Oral Health Needs Assessment 1993-94 to the California Department of Health Services;

m. "Open letter to: Mayors, City Council Members, Boards of Supervisors, Water District Boards and Managers, and other Keepers of the Well", Citizens for Safe Drinking Water, undated;

n. "Request for Due Diligence", Citizens for Safe Drinking Water, undated;

o. "Drinking Water and Ingested Fluoride Scientific Risk Assessment", Transcript of Video News Release, June 19-21, 1998, San Diego, CA;

p. "Comparative Toxicity of Fluoride Compounds", Journal of Industrial and Engineering Chemistry Volume 26, No. 7, July 1934;

q. Citizens for Safe Drinking Water Scientific Information Pack #2, undated;

r. "Abuse of the Scientific Literature in an Anti-fluoridation Pamphlet", American Oral Health Institute, 1985;

s. List of Endorsees; California Fluoridation Coalition, October 1, 1999;

t. "Implementation of AB 733 Fluoridation", California Department of Health Services letter, dated January 31, 1996;

u. "Review of the California Oral Health Needs Assessment, 1993-1994:, SENES Oak Ridge Inc., January 31, 2000.

FACTS

Fluoride is only one of more than 80 different chemicals that may be added to public water supplies in the United States. The United States Public Health Service (USPHS) has established the optimum concentration for fluoride in the water in the United States to be in the range of 0.7 to 1.2 parts per million (PPM). Existing natural fluoride levels in drinking water supplies are adjusted in order to raise them to this level. The CDC has endorsed this practice.

Hundreds of scientific studies over the past 50 years have shown that public water fluoridation is safe. It has been utilized for more than half a century by over 62 percent of Americans with access to community water. The CDC reports that currently 144 million Americans are drinking fluoridated water. However, only 17 percent of Californians are provided the benefit of fluoridation, ranking California 49^th of 50 States. The County of San Diego is the most populous county in the State without any public water system fluoridation.

The California Department of Health Services reports that the average cost to provide fluoridated water to an individual for one year is approximately 50 cents. By contrast, a July 1998 survey of dental fees conducted by the American Dental Association reported that the national average fee for a two surface amalgam (silver) restoration placed by a general dentist in a permanent tooth is $75.84. The annual cost per person depends on variables such as the size of the community, labor costs and type of fluoride compounds and equipment. Applying the average cost to San Diego County would represent a total annual cost of about $1.4 million. There are additional start-up capital costs related to equipment installation.

Water fluoridation reduces health care expenditures by prevention of dental caries and the need for restorative care. Recent studies show that water fluoridation reduces dental caries up to 60 percent in young children and 40 percent in adults. Fluoridation, as a preventive measure, provides considerable cost savings for the affected individual and also for the general public through reductions in the cost of publicly provided medical program services.

One economic analysis estimated that fluoridation saved $39 billion in total dental care expenditures in the U.S. during the 1979-1989 period. On the basis of proportionate population, that would represent an annual savings potential in the County of San Diego of over $40 million per year.

A dedicated minority of the population opposes implementation of public water fluoridation. Some claim fluoridation causes osteoporosis and contributes to hip fractures in senior citizens, and some that it is only effective in preventing tooth decay in young children. Others claim that fluorides from fluoridated water systems cause a variety of life threatening diseases. Another claim from the opponents to fluoridation is that fluoridated communities suffer an increased amount of dental fluorosis.

Others object to fluoridation on public policy grounds - believing that community fluoridation by government agencies (described as "mass dosing") constitutes an infringement on their freedom to choose what they eat or drink.

Researchers examined the medical allegations in depth and have concluded that, with the exception of dental fluorosis, the allegations are not true. Ongoing research continues to confirm the safety, efficiency, cost effectiveness and environmental compatibility of public water fluoridation. Most researchers have determined that there is no significant fluorosis at the level of one PPM in drinking water. There is also evidence that where fluorosis is found in communities with water fluoridation, it is often caused by intake of fluoride from sources other than public water fluoridation.

Former Surgeon General C. Everett Koop stated, "Fluoridation is the single most important commitment a community can make to the oral health of its children and to future generations." Most experts conclude that the scientific case for fluoridation is now beyond dispute. The World Health Organization strongly recommends the use of community water fluoridation where it is technically feasible. A policy statement on fluoridation by the USPHS, reaffirmed in 1995, stated that water fluoridation is the most cost effective, practical and safe means of reducing the occurrence of tooth decay in a community. The American Dental Association is strongly in support of fluoridation. Over ninety local civic, health and professional organizations in San Diego endorse fluoridation, including the San Diego County Science Advisory Board, the San Diego County Dental Society, and the local chapter of the American Academy of Pediatrics. The American Water Works Association, an international nonprofit scientific and educational society dedicated to the improvement of drinking water quality and supply, supports the practice of fluoridation of public water systems.

The State enacted AB 733 which assigns certain responsibilities to the Department of Health Services with respect to the fluoridation of public water systems. Section 116410 of the Health and Safety Code states, (in part):

"(a) In order to promote the public health through the protection and maintenance of dental health, the department shall adopt regulations.… requiring the fluoridation of public water systems. By July 1, 1996, each public water system with at least 10,000 service connections shall provide to the department an estimate of the total capital costs to install fluoridation treatment. The regulations adopted by the department shall take effect on January 1, 1997…"

The Department of Health Services adopted California Code of Regulations, Title 22, Sections 04433 - 04434 pursuant to this section.

Section 116415 states (in part) that; "(a)(1) A public water system is not required to comply with Section 116410, or the regulations adopted thereunder by the department, in either of the following situations:

"(A) If the public water system is scheduled to implement a fluoridation program pursuant to paragraph (4) of subdivision (b) of Section 116410 and funds are not available sufficient to pay the capital and associated cost from any source other than the system's ratepayers, shareholders, local taxpayers, bondholders or any fees or charges levied by the water system.

"(B) If the public water system has obtained the capital and associated funds necessary for fluoridation as set forth in subparagraph (A), however, in any fiscal year (July 1-June 30) funding is not available to the public water system sufficient to pay the non-capital operation and maintenance costs described in subdivision (g) from any source other than the system's ratepayers, shareholders, local taxpayers, bondholders or any fees or charges levied by the water system…"

The fact that the legislation did not provide funds for fluoridation need not deter communities from establishing fluoridation by treating their water systems. Some communities have found the funds to handle the initial and annual costs on their own.

The California Endowment, a private foundation, has provided $15 million in grants to urban and rural areas to improve the oral health of residents through fluoridation of water systems. These funds are held by the California Dental Association Research Fund for the Fluoridation 2000 Work Group which allocates the funds to qualified public water systems.

No significant new fluoridation of public water systems occurred until private funds became available. In March 1999 California Endowment grants provided $1.4 million in startup capital costs to fluoridate Sacramento’s drinking water. In August 1999 the Los Angeles City Council voted to fluoridate its water system. Sacramento and Los Angeles will pay their own operation and maintenance (O&M) costs.

The Metropolitan Water District (MWD) of Southern California is a consortium of 27 cities and water districts including the San Diego County Water Authority. MWD is the water wholesaler to more than 16 million people in parts of Los Angeles, Orange, San Diego, Riverside, San Bernardino and Ventura counties. It receives water from the Colorado River via the Colorado River Aqueduct and from Northern California via the State Water Project California Aqueduct.

The San Diego County Water Authority (SDCWA) takes delivery of water from MWD at a point approximately six miles south of the Riverside - San Diego County line and transports it through five pipelines to its 23 member agencies located within San Diego County, including the public water systems affected by the fluoridation legislation.

Section 116410 of the Code required each public water system to report their estimates of system installation and annual O&M costs to the Department of Health Services. These estimates were then used to list the 167 qualifying public water systems in California. The list is based upon cost per connection, in descending order of priority, with the lowest cost per connection at the top.

Qualifying San Diego County public water systems in order of priority are as follows:

Since publication of the above list, the Vallecitos Water District has qualified under the requirements of AB 733 with approximately 12,000 service connections. There are other water suppliers in San Diego County with fewer than 10,000 service connections which are exempt from the requirement of AB 733 to fluoridate but may do so.

The establishment of community fluoridation in this County is complex from both economic and political viewpoints. City boundaries do not necessarily correspond to water district service areas. For example the Helix Water District provides water to Padre Dam and Otay Water Districts and customers in Lemon Grove and parts of El Cajon, La Mesa, and Lakeside. The Otay Water District serves parts of La Mesa, El Cajon, Spring Valley, Jamul, Chula Vista and Bonita. The California American Water Company serves Coronado and also parts of Chula Vista, San Diego, and Imperial Beach.

"(1) does state law requiring the fluoridation of public water systems supersede the city's ordinance when outside funds are made available to install and operate a fluoridation system; and if so, (2) what level of outside funding must be in place for a conflict to exist between state law and the city's ordinance."

The Attorney General concluded that Section 116410 deals with a statewide concern which the legislature may address by its own tailored enactments. Requiring fluoridation of water delivered by public water systems is reasonably related to the State’s concern with public health.

The Opinion addressed the issue of whether state law preempts a charter city's local ordinance prohibiting fluoridation. The Attorney General opined that fluoridation of public water systems is of statewide concern rather than being merely a "municipal affair", that "the laws relating to fluoridation are specifically directed to the protection and maintenance of dental health", and concluded that, "when the exemptions of Section 116415 are not applicable, Section 116410 supersedes a conflicting ordinance enacted by a charter city…"

In March 2000, the Fluoridation 2000 Work Group notified the Mayor and City Council of San Diego that $4 million was being made available to the City of San Diego for design of a fluoridation system, the purchase and installation of capital equipment and an estimated two years O&M expenses. That funding was contingent upon the written acceptance by the City Council. On April 5, 2000, the City Manager recommended to the City Council that it should, "Authorize City Auditor to accept the grant funds….and direct the City Manager to return and implement a fluoridation plan." On April 11, 2000, the City Council voted eight to one to accept the City Manager's recommendation.

The privately owned California American Water Service Company operates under the jurisdiction of the Public Utilities Commission. It provides water to Coronado and customers in adjacent communities, a population of about 80,000. The company does not fluoridate the water it supplies to its customers. Under Health and Safety Code Section 116415 (h), "…a public water system subject to the jurisdiction of the Public Utilities Commission shall be entitled to recover from its customers all of its capital and associated costs, and all of its operation and maintenance expenses associated with compliance with this section and Section 11640…". Subsection 116415.(g) states (in part) that, "…The Public Utilities Commission shall approve rate increases for an owner or operator of a public water system that is subject to its jurisdiction within 45 days of the filing of its application or an advice letter…".

The remaining affected water providers have not adopted a position on fluoridation. These ten suppliers serve a population of about 850,000. They are currently in compliance with AB 733 in that they have not been notified of the funds that would require them to fluoridate. AB 733 does not prohibit voluntary fluoridation.

In addition to public and private grants, there are other potential sources of funding. They include Tobacco Settlement Funds and monies derived from tobacco taxes (Proposition 10). Tobacco Settlement Funds resulted from the settlement of a suit by the Attorney Generals of several states, including California, against the tobacco industry. It is estimated that the County of San Diego will receive $945 million in such funds over a period of 25 years. The City of San Diego will receive an additional $312 million over 25 years. San Diego is one of four cities in California that will separately receive funds from this source.

The San Diego County policy for the use of funds derived from the tobacco settlement is that all of the proceeds be dedicated to health care issues. San Diego County is believed to be the only county in California to establish such a policy.

The California Children and Families Act of 1998 (Proposition 10) creates an annual funding stream by adding an additional 50 cents per pack tax on cigarettes. Child health care not provided by existing programs is eligible for this funding. The funds are distributed locally by the San Diego County Children and Families Commission and are required to be used to provide a comprehensive, integrated system of early childhood development services for children through five years of age. This Commission has concluded that dental health can be included in qualified health care programs. The County will receive an estimated $30 million this year from tobacco tax revenues.

The County Board of Supervisors has expressed no position on the implementation of public water system fluoridation. The Director of San Diego County Health and Human Services Agency has been directed to work with health related non-profit agencies to develop a health care policy for expenditure of anticipated tobacco settlement revenue in San Diego County. Dental health programs in the County are eligible for tobacco settlement funds.

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FINDINGS

1. The benefit of community water fluoridation has been documented.

2. California ranks 49^th out of the 50 United States in regard to community fluoridation.

3. San Diego is the most populous county in California without any fluoridation of its public water system.

4. The California fluoridation legislation was passed without identifying a funding source.

5. The most economical way to fluoridate San Diego County public water systems would be at the wholesale source, the Metropolitan Water District.

6. The Helix Water District voted in 1999 to request that funding for fluoridation of water be withheld.

7. The City of Escondido passed an ordinance in 1999 prohibiting fluoridation of its water system.

8. The voters of the City of San Diego, a charter city, passed an ordinance in 1954 prohibiting fluoridation of its water system.

9. The Attorney General opined that State law preempts charter cities' municipal ordinances prohibiting fluoridation.

10. The Attorney General opined that a charter city must take action to commence fluoridation when sufficient outside funding is made available.

11. Public water providers in San Diego County are in compliance with AB733 until funding is made available.

12. The San Diego County Board of Supervisors has expressed no position on countywide fluoridation.

13. The County will receive an estimated $945 million over the next 25 years from tobacco settlement funds.

14. The Board of Supervisors has dedicated all proceeds of County tobacco settlement funds to health care issues.

15. The City of San Diego will receive approximately $312 million over the next 25 years from tobacco settlement funds.

16. San Diego County is the only county in California to establish a policy of spending all tobacco settlement funds on health care issues.

17. Proposition 10 – Tobacco Tax revenues are dedicated to services for young children.

18. Tobacco Tax revenues may be used for dental health care.

19. San Diego County will receive an estimated $30 million per year from Tobacco Tax revenues.

20. The City of San Diego was offered $4 million by the Fluoridation 2000 Work Group to implement a fluoridation treatment system.

21. The San Diego City Council voted to accept the $4 million offered by the Fluoridation 2000 Work Group.

22. The Board of Directors of the Helix Water District was offered $375,000 in March 2000 by the Fluoridation 2000 Work Group to implement a fluoridation treatment system.

23. The California Department of Health Services is charged with implementing the provisions of AB 733.

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RECOMMENDATIONS

00-42: That the Board of Directors of the Helix Water District comply with AB 733 with respect to implementation of fluoridation since funding has become available.

00-43: That the Board of Directors of the Helix Water District formulate a plan to obtain funding for future Operating and Maintenance costs.

00-44: That upon sufficient funding becoming available, the Escondido City Council reconsider Ordinance No. 99-05 in light of Attorney General Opinion No. 99-1112, dated February 18, 2000.

00-45: That the City Manager of the City of San Diego explore sources of funding for future fluoridation O&M costs, including the use of a portion of the City’s tobacco settlement funds.

00-46: That the San Diego County Board of Supervisors develop a program to implement, or assist in the implementation of, AB 733 among public water systems in the County as a public health measure.

00-47: That San Diego County Board of Supervisors identify funds which may be available for fluoridation of public water systems.

00-48: That the San Diego County Board of Supervisors assist water departments and districts in the County in obtaining funds to fluoridate public water systems.

00-49: That the San Diego County Board of Supervisors explore with the San Diego County Water Authority the feasibility of fluoridating the water received at the wholesale source.

00-50: That the San Diego County Water Authority explore, with the Metropolitan Water District, the feasibility of fluoridating the water prior to receipt.

00-51: That the San Diego County Board of Supervisors establish liaison with the California Department of Health Services to assist San Diego County water suppliers in efforts to fluoridate their water systems and to monitor their progress.

 

REQUIREMENTS AND INSTRUCTIONS

The California Penal Code §933(c) requires any public agency which the grand jury has reviewed, and about which it has issued a final report, to comment to the Presiding Judge of the Superior Court on the findings and recommendations pertaining to matters under the control of the agency. Such comment shall be no later than 90 days after the grand jury submits its report to the public agency. Also, every ELECTED county officer or agency head for which the grand jury has responsibility shall comment on the findings and recommendations pertaining to matters under the control of that county officer or agency head, as well as any agency or agencies which that officer or agency head supervises or controls. Such comment shall be made within 60 days to the Presiding Judge of the Superior Court with an information copy sent to the Board of Supervisors.

a. As to each grand jury finding, the responding person or entity shall indicate one of the following:

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1. The respondent agrees with the finding.

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2. The respondent disagrees wholly or partially with the finding, in which case the response shall specify the portion of the finding that is disputed and shall include an explanation of the reasons therefor.

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b. As to each grand jury recommendation, the responding person or entity shall report one of the following actions:

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1. The recommendation has been implemented, with a summary regarding the implemented action.

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2. The recommendation has not yet been implemented, but will be implemented in the future, with a time frame for implementation.

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3. The recommendation requires further analysis, with an explanation and the scope and parameters of an analysis or study, and a time frame for the matter to be prepared for discussion by the officer or head of the agency or department being investigated or reviewed, including the governing body of the public agency when applicable. This time frame shall not exceed six months from the date of the publication of the grand jury report.

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4. The recommendation will not be implemented because it is not warranted or is not reasonable, with an explanation therefor.

c. If a finding or recommendation of the grand jury addresses budgetary or personnel matters of a county agency or department headed by an elected officer, both the agency or department head and the Board of Supervisors shall respond if requested by the grand jury, but the response of the Board of Supervisors shall address only those budgetary or personnel matters over which it has some decision making authority. The response of the elected agency or department head shall address all aspects of the findings or recommendations affecting his or her agency or department.

Comments to the Presiding Judge of the Superior Court in compliance with the Penal Code §933.05 are required from the:

Board of Directors, Helix Water District Recommendations: 00-42, 00-43

City Council of Escondido Recommendation: 00-44

City Manager, City of San Diego Recommendation: 00-45

San Diego County Board of Supervisors Recommendations: 00-46, 00-47, 00-48,
00-49, 00-51

San Diego County Water Authority Recommendation: 00-50