Abstract

The objective was to identify principles invoked in a population-based health policy, taking as case a legislative proposal aimed at revoking water fluoridation in Brazil presented in 2003. We conducted a descriptive study through documentary research on records generated in the course of the Bill proposal No. 510/2003 in the Federal Chamber of Deputies. We highlighted discourse strategies used by the actors as per their own interests and the conflicting context by utilizing historical institutionalism as theoretical ground. The proposal was debated for 13 months, going through the House Plenary, three committees, and was finally filed. Three deputies from different parties, federal executive agencies, regulatory agencies, and entities representing dental, public/collective health, sanitary engineering, and sanitation companies participated directly in the debate in which the principles of intervention security, economic costs and the right to health emerged. Regarding the discourse strategies used, the main elements invoked in the debate on population-based health policy were: the principle of uncertainty, creating false scientific categories in order to overvalue unfavorable effects and to support the implementation of individualizing measures; and the moral principles that define different types of economic goods and dimensions of freedom associated with the exercise of rights.

Keywords:
Public Policy; Health Policy; Water Fluoridation

Introduction

Health determinants correspond to a variety of environmental, economic, social and personal conditions acting as causative factors in the health status of individuals and populations. This expression entered the glossary of Public Health due to the expanded concept of health, among other notions developed from a theoretical point of view, in response to the increasing awareness related to the limitations of the health services for tackling the population aging and increased morbidity and mortality associated with non-communicable diseases (WHO, 1998WHO - WORLD HEALTH ORGANIZATION. Health promotion glossary. Genebra, 1998. Disponível em: <Disponível em: https://bit.ly/2MA0KuM >. Acesso em: 20 out. 2018.
https://bit.ly/2MA0KuM... ).

Government strategies to improve the levels of population health by coordinated action between health sector and other State sectors have received great attention recently; a variety of intersectoral policy initiatives covering aspects such as housing, water, food, work, among others, have been implemented (Freiler et al., 2013FREILER, A. et al. Glossary for the implementation of Health in All Policies (HiAP). Journal of Epidemiology and Community Health, Londres, v. 67, n. 12, p. 1068-1072, 2013.; WHO, 2011WHO - WORLD HEALTH ORGANIZATION. Intersectoral action on health: a path for policy-makers to implement effective and sustainable action on health. Kobe, 2011. Disponível em: <Disponível em: https://bit.ly/2Qqz4cR >. Acesso em: 20 out. 2018.
https://bit.ly/2Qqz4cR... ).

These initiatives involve a complex political process including actors that belong to different sectors around a health-related problem that requires the articulation of a set of shared strategies and activities. This arrangement between sectors faces important obstacles related to different political principles, moral values, conflicting agendas, competition for resources, pieces of evidence and pressure from influence groups, among other aspects (Howlett; Ramesh; Perl, 2013HOWLETT, M.; RAMESH, M.; PERL, A. O contexto da política pública. In: HOWLETT, M.; RAMESH, M.; PERL, A. Política pública: seus ciclos e subsistemas: abordagem integral. Rio de Janeiro: Elsevier, 2013. p. 57-71.).

Depending on the context and the political process, the confluence of certain private interests may dismantle public regulations related to health, safety and environment. One of the strategies used is the exploitation of scientific uncertainty, questioning the quality of evidence to delay or to soften regulatory action, blocking the discussion of social values and priorities (Hoppin; Clapp, 2005HOPPIN, P. J.; CLAPP, R. Science and regulation: current impasse and future solutions. American Journal of Public Health, Washington, DC, v. 95, p. S8-S12, 2005. Suplemento 1.).

Despite the growing awareness about the relevance of understanding the constraints that lead to decision-making in relation to policies based on public health strategies, there are no studies addressing issues of the political process nor its context (Burchett et al., 2012BURCHETT, H. E. et al. National decision-making on adopting new vaccines: a systematic review. Health Policy and Planning, Oxford, v. 27, p. ii62-ii76, 2012. Suplemento 2.), including the strategies and tactics used by stakeholders (Hoppin; Clapp, 2005HOPPIN, P. J.; CLAPP, R. Science and regulation: current impasse and future solutions. American Journal of Public Health, Washington, DC, v. 95, p. S8-S12, 2005. Suplemento 1.).

As the decision-making process is complex in the field of public policies, and decision-makers suffer multiple influences about different policy alternatives, the investigation of values underlying the discourse strategies present in the debate of an intersectoral health policy may contribute to more transparent decisions reflecting a balanced and informed consideration involving the most relevant aspects.

The objective of this study was to identify the principles invoked in a population-based health policy, examining the course of the legislative proposal to repeal water fluoridation in Brazil presented in 2003 in the Chamber of Deputies.

Methods

A descriptive study was conducted through documentary research, selecting as case the Bill proposal No. 510/2003 presented in the Chamber of Deputies of the Brazilian National Congress. This case was selected because it has a claim for the repeal of the Law No. 6,050 of May 24, 1974, which “provides for water fluoridation in supply systems when there is a water treatment plant,” an important public health technology recommended by eminent scientific, sanitary and professional institutions around the world due to their effectiveness and safety (Kumar, 2008KUMAR, J. V. Is water fluoridation still necessary? Advances in Dental Research, Thousand Oaks, v. 20, n. 1, p. 8-12, 2008.). Although present in more than 25 countries worldwide, the majority of the population with access to the benefit lived in the USA (US-DHHSF, 2015US-DHHSF - U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES FEDERAL. Panel on community water fluoridation: U.S. Public Health Service recommendation for fluoride concentration in drinking water for the prevention of dental caries. Public Health Reports, Thousand Oaks, v. 130, n. 4, p. 318-331, 2015.), Brazil (Frazão; Narvai, 2017FRAZÃO, P.; NARVAI, P. C. Water fluoridation in Brazilian cities at the first decade of the 21st century. Revista de Saúde Pública, São Paulo, v. 51, p. 1-11, 2017.) and Australia (Manton et al., 2018MANTON, D. J. et al. Australia’s oral health tracker: technical paper 2018-02, Australian Health Policy Collaboration, Victoria University, Melbourne, 2018. Disponível em: <Disponível em: https://bit.ly/2SywKDo >. Acesso em: 10 nov. 2018.
https://bit.ly/2SywKDo... ), populous countries in which more than half of the inhabitants were encompassed by the measure in the first decade of the 21st century.

Similar to many countries, Brazil is a multiparty capitalist democracy. In 2008, about 80% of the population had access to treated water and 75% access to fluoridation (Frazão; Narvai, 2017FRAZÃO, P.; NARVAI, P. C. Water fluoridation in Brazilian cities at the first decade of the 21st century. Revista de Saúde Pública, São Paulo, v. 51, p. 1-11, 2017.). Although the country experienced a phase of growth and reduction of inequalities, its position in the ranking of social indicators remains far below in relation to its position in the ranking of economic indicators: in 2016, Brazil ranked 9th place in relation to gross national income and the 90th in relation to life expectancy at birth (World Bank, 2018).

The documentary sources of this study were the website and the Official Gazette of the Chamber of Deputies, of the Executive Branch and the Journal of the Federal Council of Dentistry. Audios, transcription of speeches, minutes of ordinary commission meetings, technical opinions and pieces of news in means of dissemination of professional entities generated during the course of the Bill proposal (between 2003 and 2004) were used to compose the material research, seeking to identify the contents and meaning nuclei related to the discussion on the proposition according to the underlying ideas, principles and institutions, as indicated by North (1991NORTH, D. C. Institutions. Journal of Economic Perspectives, Nashville, v. 5, n. 1, p. 97-112, 1991.), in order to enable the interpretation of the conflicting context present in positions based on historical institutionalism, a theoretical framework that focuses on understanding the reality, the way institutions work and influence individual and collective behaviors as well as on the decision-making process over time (Lima; Machado; Gerassi, 2015LIMA, L. D.; MACHADO, C. V.; GERASSI, C. D. O neoinstitucionalismo e a análise de políticas públicas de saúde: contribuições para uma reflexão crítica. In: MATTOS, R. A.; BAPTISTA, T. W. F. Caminhos para análise das políticas de saúde. Porto Alegre: Rede Unida, 2015. p. 181-219.).

In this sense, it was based on the premise that the values instituted have an important effect on the modelling of restrictions and opportunities that will manifest themselves in the debate of public policies directing the path to be followed in the decision-making of a public policy (Hall; Taylor, 2003HALL, P. A.; TAYLOR, R. C. R. As três versões do neoinstitucionalismo. Lua Nova, São Paulo, n. 58, p. 193-223, 2003.; North, 1991NORTH, D. C. Institutions. Journal of Economic Perspectives, Nashville, v. 5, n. 1, p. 97-112, 1991.).

Results

According to Chart 1, the Bill was maintained for 13 months. According to the House Rules, the proposal was presented to the Directing Board of the National Congress, numbered and dispatched to the Family and Social Security Commission, where it was rejected on 10/8/2003 unanimously. The Bill, after being discussed by the Commission of Mines and Energy and the Commission of Constitution, Justice and Writing, an appeal period of time was opened against the filing. The Bill proposal was filed on 04/14/2004. Three deputies from different parties, organization of the federal Executive Branch, regulatory agencies and representative entities of public/collective health, sanitary engineering, dental profession and sanitation companies participated directly in the debate.

The excerpts from the documentary material resulting from the course of the Bill proposal can be found in Chart 2, highlighting the meaning nuclei of the narratives presented by the main actors during the process. While at one end of the debate, a strategy to underline possible harms (poisoning, osteoporosis, cancer) arising from the measure, unjustified costs, and the defense of access to fluoride only through an individualizing approach in dental practice was observed, at the other end, the strength of existing scientific evidence in favor of the public policy, its economic advantages and its compatibility with health guidelines provided for in the Brazilian Constitution of 1988 was reiterated. In spite of the content presented, some implicit principles focused on the intersectoral public policy debate were highlighted for the next section, including the safety of this public health intervention, the economic costs involved, and the relationship between individual freedom and the right to health.

Discussion

Principles invoked in the debate of a population-based health policy were identified in this study. This policy consists of an intentional action aimed at maintaining or achieving a certain level of health in the population, either by health promotion or disease prevention, or by the provision of certain health services and programs. This action is generally instituted through a normative provision that can range between more general laws regulating a country or region, and more specific rules, of local and organizational scope.

The main contribution of the case examined was to show that, despite the government having the authority to approve or veto the application of measures that affect the population health, in democratic countries, political leaders and representatives of society play an important role in this area, relying, among others, in different community interests, of identity and market linked to certain principles. The extent and degree of any public health intervention are sustained in democratic regimes over time, according to the strength of social or cultural authority and the level of mobilization of individuals and organizations aspiring or resisting the normative provision. In a key expression, implementation and maintenance or interruption of such interventions ultimately depend on State-society relations. In times of accelerated transformations and increasing challenges, knowing these principles is a crucial task of public health professionals (Hunter, 2010HUNTER, D. J. Meeting the public health challenge in the age of austerity. Journal of Public Health, Oxford, v. 32, n. 3, p. 309, 2010.).

As every public policy, adjusting the fluoride concentration of water supply systems also expresses a way of regulating these relationships and involves multiple interests and values. In this case, the safety of the public health intervention, the economic costs involved and the relationship between individual freedom and the right to health were highlighted.

Similar to water fluoridation, several public policies have been discussed in relation to the safety of the intervention, including the iodization of salt (Pearce; Andersson; Zimmermann, 2013PEARCE, E. N.; ANDERSSON, M.; ZIMMERMANN, M. B. Global iodine nutrition: where do we stand in 2013? Thyroid, Larchmont, v. 23, n. 5, p. 523-528, 2013.), immunization (Burchett et al., 2012BURCHETT, H. E. et al. National decision-making on adopting new vaccines: a systematic review. Health Policy and Planning, Oxford, v. 27, p. ii62-ii76, 2012. Suplemento 2.) and even the water chlorination in the public supply system (Gopal et al., 2007GOPAL, K. et al. Chlorination by products, their toxicodynamics and removal from drinking water. Journal of Hazardous Materials, Amsterdã, v. 140, n. 1-2, p. 1-6, 2007.).

In this study, the safety of the intervention was inquired using the artifice of associating a public health technology with a problem affecting some regions of the planet whose populations depend on water sources with naturally occurring fluoride at very high levels and unfit for human health (Chart 2). Without identifying the distinctive aspects that characterize each situation, the interlocutor can become confused. It is an artifice by which specific contexts of one situation are mixed in a completely distinct one. Knowledge from thorough research outside its original context can more easily be shifted to the campus of provisional science in order to explore sources of uncertainty, to overvalue unimportant experimental or epidemiological variations, to weaken the meanings of the results, and to disseminate doubts about the safety of the intervention. Some experts have drawn attention to the disproportionate approach as which results can be interpreted, showing the lack of understanding of the scientific method (Freeze; Lehr, 2009FREEZE, R. A.; LEHR, J. H. The fluoride wars: how a modest public health measure became America’s longest-running political melodrama. Hoboken: John Wiley and Sons, 2009.).

This narrative strategy has been documented in certain cases where industry-funded organizations have defied thorough pieces of evidence that demonstrated links between exposure to something and disease in humans. Non-explicit interests could manipulate science and create false categories to influence decisions that affect the lives of the population that relies on intersectoral policies related to public health and environmental regulations (Hoppin; Clapp, 2005HOPPIN, P. J.; CLAPP, R. Science and regulation: current impasse and future solutions. American Journal of Public Health, Washington, DC, v. 95, p. S8-S12, 2005. Suplemento 1.).

In relation to fluoridation of water supply, the debate tends to assume a bipolar form, treating this intersectoral policy sometimes as an advantage recognized by its strength as preventive health measure, sometimes as a disadvantage, claiming that it would be a toxic pollutant to the human body and to the ecosystem (Mendoza, 2011MENDOZA, R. L. Flouride-treated water and the problem of merit goods. Water Policy, Hoboken, v. 13, n. 1, p. 38-52, 2011.). The examination of systematic reviews published between the years 2000 and 2009 showed that water fluoridation between 0.6 and 0.9 mg F/L is effective for caries prevention and it is safe for human health, with fluorosis being an alteration characterized by the hypomineralization of tooth enamel, the only undesirable effect resulting from this measure (Frazão; Perez; Cury, 2011FRAZÃO, P.; PERES, M. A.; CURY, J. Drinking water quality and fluoride concentration. Revista de Saúde Pública, São Paulo, v. 45, n. 5, p. 964-973, 2011.).

Undesirable effects may be present in any public health policy. One of the discourse strategies used by certain economic agents is the overvaluation of the unfavorable aspects of a regulatory policy to favor the establishment of individualizing measures that can be transformed into merchandise.

As there is a strong tendency to assume that the primary solution of health problems involves individual medical care, policymakers often focus on measures to ease obstacles to financial and geographic access to personal services of the most vulnerable population groups. Depending on the economic viability, extent, and depth, such approach may produce health gains, but generally it neglects the main social and economic causes of vulnerability and health inequalities. Although access to individual care is a necessary component, intersectoral actions on health determinants are essential to raise the population’s health levels (Lantz; Lichtenstein; Pollack, 2007LANTZ, P. M.; LICHTENSTEIN, R. L.; POLLACK, H. A. Health policy approaches to population health: the limits of medicalization. Health Affairs, Bethesda, v. 26, n. 5, p. 1253-1257, 2007.).

Thus, all attention should be focused on the data and information brought to the debate and on the effect that the interruption of such health policy could generate on the population or its portion that benefits most from it. This aspect is more visible with the idea that water fluoridation would be economically unfeasible, bringing a burden to the government, whose resources could be directed to other actions. This narrative strategy is supported by the defense that preventive actions using fluoride should be individual and clinical, i.e. individuals should have access to topical fluoride applications and procedures concerning oral hygiene orientation through dental appointment. Thus, implicit to the argument of the proposition contrary to fluoridation, one can perceive the idea of transforming a semi-public good, such as supply water adjusted for dental caries prevention purposes, which provides access to fluoride to all families using the treatment network, in a very cost-effective way (Ran; Chattopadhyay; Force, 2016RAN, T.; CHATTOPADHYAY, S. K.; FORCE, C. P. S. T. Economic evaluation of community water fluoridation: a community guide systematic review. American Journal of Preventive Medicine, Amsterdã, v. 50, n. 6, p. 790-796, 2016.), something good whose access would depend on dental appointments.

Unlike private goods, such as a car that is paid by a single consumer, excluding others from using it, fluoridation of water supply can be considered a semi-public good, as the costs of provision for an additional consumer are insignificant (the additional cost for new housing supplied is insignificant) and no individual is excluded from their consumption, and some can even make use without paying for it (Mendoza, 2011MENDOZA, R. L. Flouride-treated water and the problem of merit goods. Water Policy, Hoboken, v. 13, n. 1, p. 38-52, 2011.).

The economic issue is also relevant in the debate of other population-based health policies, such as immunization (Burchett et al., 2012BURCHETT, H. E. et al. National decision-making on adopting new vaccines: a systematic review. Health Policy and Planning, Oxford, v. 27, p. ii62-ii76, 2012. Suplemento 2.; Tapia-Conyer et al., 2013TAPIA-CONYER, R. et al. Strengthening vaccination policies in Latin America: an evidence-based approach. Vaccine, Amsterdã, v. 31, n. 37, p. 3826-3833, 2013.), enrichment of foods with vitamin A (Jallier et al., 2013JALLIER, V. et al. The global, centralized approach of the GAIN Premix Facility has made oil fortification in Indonesia more affordable. Food and Nutrition Bulletin, Thousand Oaks, v. 34, n. 2, p. S43-S49, 2013. Suplemento 1.) and the iodization of salt (Pearce; Andersson; Zimmermann, 2013PEARCE, E. N.; ANDERSSON, M.; ZIMMERMANN, M. B. Global iodine nutrition: where do we stand in 2013? Thyroid, Larchmont, v. 23, n. 5, p. 523-528, 2013.). While in such cases, all the effort has been focused to find funding sources to expand the coverage of these policies, in the case of the proposal to repeal water fluoridation, the intention was to condition access to the purchasing power of each one, i.e. the ability to access consumer goods in a business environment, ignoring the evidence about the cost-benefit of this public health policy. About $32 per inhabitant was saved due to fluoridation in the U.S. in 2013 (O’Connell et al., 2016O’CONNELL, J. et al. Costs and savings associated with community water fluoridation in the United States. Health Affairs, Bethesda, v. 35, n. 12, p. 2224-2232, 2016.). In Brazil, fluoridation costs are also extremely low compared to any other intervention alternative (Frias et al., 2006FRIAS, A. C. et al. Custo da fluoretação das águas de abastecimento público: estudo de caso: município de São Paulo, Brasil, período de 1985-2003. Cadernos de Saúde Pública, Rio de Janeiro, v. 22, n. 6, p. 1237-1246, 2006.; Martinez et al., 2013MARTINEZ, E. H. S. et al. Per capita cost of fluoridating the public water supply in a large municipality. Revista Gaúcha de Odontologia, Campinas, v. 61, n. 4, p. 549-556, 2013.).

This narrative strategy relates to the principle of the right to health. While in one end of the debate this principle is translated as an individual right of access to dental services for fluoride applications in a controlled manner at the outpatient level, in the other end of the debate values related to the expanded concept of health and their implications of the right to health predominate, supporting the scope and effectiveness of the public health strategy, including to reduce the need for outpatient dental care.

Thus, underlying the defense of individual freedom, would be the option for promoting policies of economic liberalization that would favor the accumulation of wealth and the concentration of ownership of goods whose effect is the deepening of social inequality, and by the denial of health as a sphere for the exercise of rights.

The debate seems to reflect the dispute between the two conceptions of freedom. On the one hand, the negative concept of freedom that is associated with civil rights and classical liberalism, i.e. the notion that the State should not interfere with the freedom and property of citizens, whose interests must be considered legitimate provided that it does not threaten the rights of other citizens. On the other hand, the positive concept of freedom associated with political and social rights, the freedom to participate in the government, to deliberate and to supervise the allocation of public resources (Bresser-Pereira, 2002BRESSER-PEREIRA, L. C. Citizenship and res publica: the emergence of republican rights. Citizenship Studies, Londres, v. 6, n. 2, p. 145-164, 2002.).

For some political actors, these conceptions rival each other, while for others they are complementary to each other. Those who position them in opposing poles consider individual rights more important than political and social rights, as if the liberal citizen protecting his own interests and the republican citizen protecting the general interests does not represent two interdependent dimensions of the same statute. In the most extreme conception, it is not recognized that individual rights can only be guaranteed within a society in which collective action is effective in the creation of liberal and democratic institutions that ensure both their application and collective rights, which are also the rights of each individual citizen.

In this bipolar view, population-based health policies are falsely portrayed as a choice between individual responsibility versus the restriction of freedom. Consequences on population’s health resulting from the omission of health authorities are not seen as a regulatory option. It is as if the absence of a cigarette-free workplace is not considered a political decision that engenders greater exposure of workers to carcinogens and increased risk of acute myocardial disease (Chokshi; Stine, 2013CHOKSHI, D. A.; STINE, N. W. Reconsidering the politics of public health. JAMA, Chicago, v. 310, n. 10, p. 1025-1026, 2013.).

Overcoming this bipolar vision and recognizing both the rights that protect citizens against a powerful State and the rights that protect the State against powerful citizens are also a crucial task for health leaders in the important and legitimate debate on the appropriate role of regulatory approaches to improve the health of populations. By covering both dimensions, the Universal Declaration of Human Rights is an important instrument for guiding such decisions.

In the United States, where more than 70% of the population benefits from the public policy, lawsuits in U.S. appeals courts for the interruption of the water fluoridation have been denied for many reasons, including the justification that the Articles of Incorporation for the institution of fluoridation are valid state regulatory exercises. Private rights are not absolute and must be modulated in the name of collective objectives legitimately acquired and related to the means of law enforcement (Mendoza, 2011MENDOZA, R. L. Flouride-treated water and the problem of merit goods. Water Policy, Hoboken, v. 13, n. 1, p. 38-52, 2011.).

In a view in which rights complement each other, fluoridation would not violate individual rights of choice for it is an element that is naturally present in surface and underground springs. Water, when captured and treated, has its content adjusted for the concentration considered optimal in the prevention of dental caries at levels below the maximum permitted value considering its potability. On the contrary, not promoting such adjustment, it may increase the risk of new dental caries injuries, especially among the most numerous social segments and worse socioeconomic conditions. Values concerning collective rights would boost the approval of rules in favor of the most numerous social segments which are excluded and present worse socioeconomic conditions. Because it constitutes a safe, inexpensive, effective and comprehensive public health measure, its implementation should express the collective decision associated with the exercise of the right to health as a universal human right.

In this study, three principles were identified and discussed in the debate of a population-based public policy grounded on the investigation of the procedure of the Bill proposal 510/2003, which proposed the repeal of water fluoridation in Brazil. Although the limits between the phenomenon and its context are not clearly defined, and the design does not enable the generalization of the conclusions, it is known that the study may be useful for understanding the scenario of tensions and disputes around the values involving initiatives of regulatory health policies in countries of multiparty capitalist democracy.

In relation to the discourse strategies used, we concluded, based on results presented, that the principle of uncertainty - creating false scientific categories in order to overvalue the unfavorable effects and sustain the implementation of individualizing measures - and moral principles - which define different types of economic goods and dimensions of freedom associated with the exercise of rights - were the main elements invoked in the debate on population-based health policy.

References

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