Universal and targeted policy to achieve health equity: a critical analysis of the example of community water fluoridation cessation in Calgary, Canada in 2011

Abstract

In May of 2011, a decision was made by city council in Calgary, Canada, to cease community water fluoridation and to re-allocate the annual operating costs to targeted dental programming. The purpose of this study was to critically analyze this decision as an example of a shift from a universal approach (fluoridation) to a targeted approach (dental programming delivered to children in low-income communities). We were especially interested in how the concept of equity played out in the deliberations, and we used Hilary Graham’s three conceptualizations of equity as a framework. We examined publicly available municipal council documents pertaining to this policy decision, with a prominent focus on the 26 January 2011 meeting of the Standing Policy Committee on Utilities and Environment at which Calgarians (citizens and professionals) were invited to speak. We extracted and critiqued statements or exchanges pertaining to equity or related concepts (e.g. poverty). We observed different perspectives on the concept of equity, and the notion of community water fluoridation as equitable. In particular, there was a tendency, expressed strongly by some participants in the debate, to conflate equity and poverty (Graham’s ‘disadvantages’ conceptualization of equity), such that a targeted approach was seen as the only viable way of addressing the dental health needs of children living in poverty. This research is timely considering the apparently increasing frequency of cessation of fluoridation in Canada, the consequent search for alternative approaches to preventive dental health, and the apparently strong appeal of a targeted approach.

Keywords:

• Community water fluoridation
• prevention and control
• public policy
• public health

Introduction

In May 2011, a decision was made by city council in Calgary, Canada, to cease community water fluoridation, and to re-allocate funds to targeted dental programming. The purpose of this study was to describe and critique this decision as an example of a shift from a universal approach (fluoridation) to a targeted approach (dental programming delivered to children in lower income communities) to intervention, focusing specifically on how the concept of equity played out in the deliberations.

Universal and targeted approaches to policy

Our study is situated within scholarship on universal and targeted approaches to intervention (i.e. programs or policy), which sits at the intersection of public health and social policy (e.g. Alcock, Glennerster, Oakley, & Sinfield, 2001; Carey & Crammond, 2017). In public health, the population-level (universal) approach describes interventions (e.g. mandatory food product fortification policy; population-wide health promotion campaigns) delivered to whole populations while the high-risk (targeted) approach (e.g. counseling, prophylactic drugs) concerns individuals identified as having elevated risk of a particular health problem (Rose, 1992). In social policy, which has significant implications for health (e.g. Schrecker & Bambra, 2015), the universal approach describes policy provided to a broad population regardless of income or social circumstances (though it may be constrained by parameters such as age), whereas the targeted approach, especially in its residual or means-tested variety, is directed toward a population segment deemed to be vulnerable based on certain indicator(s) (e.g. income and assets, with proof of need) (Alcock et al., 2001). Although the two-category classification is an oversimplification (Carey & Crammond, 2017), it suffices for our purposes here.

In the present study, we are interested in universal and targeted approaches vis-à-vis equity (i.e. fair distribution of opportunities or outcomes across social groups; Grabb, 2006). In public health, some (e.g. Link & Phelan, 1995) have expressed concern about the potential for universal interventions to be inequitable in their impact, due to inequity in uptake. A suggested alternative is a vulnerable populations (i.e. targeted) approach (Frohlich & Potvin, 2008). On the other hand, there is a growing empirical literature showing that some universal interventions are equitable in their impact (i.e. greatest impact among those with the lowest socioeconomic resources) (e.g. Lorenc, Petticrew, Welch, & Tugwell, 2013). There is support for the contention that universal interventions of a ‘structural’ nature (McLaren, McIntyre, & Kirkpatrick, 2010) or for which uptake is not mediated by resources (Chang & Lauderdale, 2009), are more likely to be equitable in their impact. The concept of equity has thus been mobilized to support both universal and targeted approaches in public health.

In the social policy literature, the concept of equity figures prominently in discussions of universal and targeted approaches. Although the universal approach perhaps most obviously aligns with equality (treating everyone the same), it also has strong connections with principles of equity and social justice. That is, in contrast to a targeted approach, which identifies need and then delivers a policy in such a way that some individuals are included and some are excluded, the universal approach – at least theoretically – does not exclude and is thus socially and symbolically inclusive (Alcock et al., 2001; Béland, Blomqvist, Goul Andersen, Palme, & Waddan, 2014). British social policy scholar Richard Titmuss (1907–1973), a founder of the academic discipline of social policy, argued strongly in favour of universalism on the basis of its egalitarian and inclusive nature, famously asserting that ‘a service for the poor [i.e. a targeted service] becomes a poor service’ (Alcock et al., 2001). The appeal of a universal approach from an equity point of view is also supported by comparative welfare regime research, wherein regimes that tend to favour universal policies (i.e. social democratic countries) have lower poverty rates, a smaller gap between rich and poor, and better population health outcomes, than regimes that tend to favour targeted policies (Carey & McLoughlin, 2016; Esping-Andersen, 1990).

There is a trend, in at least some areas of scholarship and policy, away from the universal approach and toward a targeted approach. In public health, for example, the past decade has seen growing attention to ‘unintended consequences’ of universal interventions. Although the concept of unintended consequences is not new (e.g. Merton, 1936), its application to universal interventions in public health is gaining recent momentum, and it is easy to find recent examples of scholarly work that critiques universal interventions in diverse domains including tobacco control, physical activity promotion and folic acid fortification, among others (e.g. Barua, Kuizon, & Junaid, 2014; Scollo, Zacher, Durkin, & Wakefield, 2014).

A trend away from universalism is also apparent in some areas of social policy, when viewed over a longer time horizon. In Canada, for example, Béland et al. (2014) observed that, since WWII, there has been a decline in universal approaches (and an increase in targeted approaches) in the domain of family benefits policy. Growing pressures on universal systems in other policy domains, such as health care and seniors’ pensions, have been observed in several countries (Béland et al., 2014; Carey & McLoughlin, 2016; McKee & Stuckler, 2011).

A trend away from universalism and toward targeting reflects a number of factors, including ‘neoliberalism’ and the ‘politics of retrenchment’, which favour a residual (targeted) approach to policy on ideological and economic grounds (e.g. Schrecker & Bambra, 2015); a sentiment of declining public trust in government and authority, and demand for engagement in science and technology (Bucchi, 2008; Carstairs, 2010); demographic shifts (e.g. aging population) which raise concerns about the affordability of universal policies (Emery, Still, & Cottrell, 2012); and recent advances in information systems which may make it easier to identify individuals and groups for targeting, such that the administrative ease of universalism (historically part of the appeal of that approach) may be reduced. Within this context, it is becoming increasingly difficult to defend a universal approach (Carey & McLoughlin, 2016).

Overall, in light of these trends, there would appear to be value in further study of universalism, targeting, and equity. To navigate this complex and intersecting set of issues, it is helpful to have a focal case example.

Case example: community water fluoridation cessation in Calgary, Canada in 2011

Community water fluoridation is the controlled addition of a fluoride compound to a public water supply for the purpose of preventing dental caries (tooth decay) in populations (Burt & Eklund, 1999). Dental caries is an important public health concern: it is prevalent (Health Health Canada, 2010), inequitably distributed (Ravaghi, Quiñonez, & Allison, 2013), and can have serious consequences (Canadian Institutes of Health Information [CIHI], 2013). One avenue for prevention is appropriate exposure to fluoride, including via community water fluoridation. Mechanistically, fluoride benefits teeth by inhibiting tooth demineralization, enhancing re-mineralization, and inhibiting enzyme activity of plaque bacteria (Featherstone, 1999). Community water fluoridation was first implemented in 1945 (in the U.S. and Canada) and positive results from early trials prompted implementation in many other communities. The percentage of the Canadian population exposed to fluoridation increased from 6% in 1960 to 45% in 2007 (Rabb-Waytowich, 2009).

The literature on benefits and risks of fluoridation is voluminous. Briefly, findings from systematic reviews (McDonagh et al., 2000; Australian National Health and Medical Research Council [NHMRC], 2007) support (more than they refute) the benefits of fluoridation for preventing tooth decay, particularly in children. However, there are important limitations of the evidence. In the most recent systematic review (Iheozor-Ejiofor et al., 2015), for example, most of the included studies were conducted prior to 1975. Conclusions were limited by the observational nature of the study designs and uncertainty about the application of evidence to current lifestyles (e.g. exposure to various fluoride sources including toothpaste). Economic analyses have concluded that the economic benefits of fluoridation (i.e. reduced dental costs) continue to exceed the intervention cost, especially in larger communities (Ran, Chattopadhyay, & Community Preventive Services Task Force, 2016).

Research on the effectiveness of fluoridation has been interpreted in different ways (Peckham, 2012). Some have argued that fluoridation’s benefits are overstated. For example, three years after the publication of the well-known and comprehensive ‘York Review’ (McDonagh et al., 2000), the York Centre was so concerned about ‘misrepresentation of the evidence’ (i.e. overstating the benefits without adequate regard to the limitations), that they deemed it necessary to release a statement, titled ‘What the “York Review” (…) really found’ (University of York, Centre for Reviews & Dissemination, 2003). On the other hand, others have argued that fluoridation’s benefits are understated. For example, following the publication of the 2015 Cochrane systematic review on fluoridation (Iheozor-Ejiofor et al., 2015), which lamented the limited number of recent studies, Rugg-Gunn et al. (2015) criticized what they saw as overly restrictive inclusion criteria (e.g. well-designed cross-sectional studies were excluded). The restrictive criteria applied, they argued, are not a good fit with public health measures that are delivered at the population level and must be evaluated using observational designs for important practical and ethical reasons.

In terms of adverse outcomes, it is well established that fluoridation is associated with dental fluorosis (i.e. mottling of the teeth) (Iheozor-Ejiofor et al., 2015; McDonagh et al., 2000). There are debates around the importance of this outcome (Nuffield Council on Bioethics, 2007). Although much of the available research is from areas with high levels of naturally occurring fluoride in water (e.g. up to 5 ppm); dental fluorosis occurs even at optimal concentrations (Beltrán-Aguilar, Barker, & Dye, 2010; Iheozor-Ejiofor et al., 2015). Assessing individual risk is complicated by fluoride variations in drinking water (even in fluoridated areas) and individual-level variations in, for example, body weight and amount of water consumed (Scientific Committee on Health and Environmental Risk (SCHER), 2011). However, aside from dental fluorosis, the weight of the evidence does not support an association between fluoridation and other adverse health outcomes (e.g. Public Health England, 2014). Studies that show associations between fluoride and various adverse health outcomes continue to emerge (e.g. Choi, Sun, Zhang, & Grandjean, 2012). In at least some cases, these studies have significant methodological concerns and/or limited relevance to community water fluoridation; nonetheless, they cause significant concerns among some members of the public (Podgorny & McLaren, 2015), and are thus an important part of the discussion.

Fluoridation is emblematic of a core tension in public health ethics, around implementing measures to improve the population’s health that are not unduly intrusive (Nuffield Council on Bioethics, 2007). The Nuffield Council on Bioethics (2007) recommends that the acceptability of fluoridation should include consideration of the potential for alternative interventions that are less intrusive (lower on the ‘intervention ladder’) to achieve the same outcome. Targeted dental programming, in which fluoride is delivered topically to a subset of the population (as is the case in Calgary), is one potential example.

From the point of view of health equity, both universal and targeted approaches in this context have strengths and weaknesses. On the one hand, fluoridation is a universal intervention that is ‘structural’ or not mediated by resources (Chang & Lauderdale, 2009; McLaren et al., 2010), and indeed research has demonstrated that social inequities in dental caries are larger in non-fluoridated than in fluoridated communities, including in Canada (McLaren & Emery, 2012). However, there are important trade-offs to consider between reduction of tooth decay on the one hand, and increased risk of dental fluorosis, especially among those who may also receive fluoride from other sources (e.g. toothpaste, regular dental visits). Further, although fluoridation has elements of being ‘upstream’ in that it is an example of primary prevention that can reach everyone in a community, it is a singular approach to one aspect of preventive dental health (fluoride delivery). One could thus argue that, aside from its socially inclusive nature, it does not broadly address the social determinants of health. Conceivably, a targeted approach could begin to address some of the social determinants of health, if it were to address multiple factors associated with social disadvantage or exclusion. However, this would depend on the specific program and how it is implemented; for example, whether or the extent to which the program further entrenches social divisions via identification of eligible recipients; and how sustainable the program is.

A recent trend provides opportunity to explore some of these issues: in some regions, a growing number of communities are revisiting their fluoridation status, and in some cases opting to discontinue. In Canada, fluoridation has reportedly been ceased in over 30 communities since 2005 (JCDA, 2013); including Calgary in 2011. The city of Calgary first implemented fluoridation in 1991, following a ‘heated’ debate and plebiscite in 1989 (Carstairs, 2010). Prior to the 1989 plebiscite, at which 53% voted in favour of fluoridation, 4 other plebiscites had been held, none of which secured majority support (Carstairs, 2010). Main points of opposition mirror those observed elsewhere and include concerns about safety, questions about effectiveness, and perceived violation of civil liberties (McLaren & McIntyre, 2011). These and other factors culminated, in May 2011, in the discontinuation of the practice in Calgary, based on a city council vote (Kapoor, O’Neill, & McLaren, 2016).

The decision to cease fluoridation in Calgary was accompanied by the decision to re-allocate the money saved to targeted dental health programming; specifically, the Alex Dental Health Bus (https://www.thealex.ca/mobile/), which provides dental services including application of sealants and fluoride varnish to children attending schools in lower income communities, and the Calgary Urban Project Society (https://cupscalgary.com/), for expansion of children’s dental health services facilities, available to lower income populations in the community. In Canada, dental services are not part of the publically funded health care system, and are overwhelmingly (95% of expenditures) privately financed, paid through employer-sponsored insurance or out of pocket (Canadian Academy of Health Sciences [CAHS], 2014). The minimal amount of public sector dental service across Canada is mostly targeted toward children in socioeconomically disadvantaged circumstances (Shaw & Farmer, 2015). This is true in Calgary, which has a provincially funded targeted fluoride varnish program. The recipients of funds saved from fluoridation cessation, above, were thus in addition to existing targeted services.

Conceptual framework and methods

We adopted as a framework Graham’s (2004) work on different conceptualizations of equity. In her 2004 paper, which was based on an analysis of UK policy documents, Graham described three ways in which health equity was conceptualized: (1) health disadvantages (focus is on health concerns of those experiencing the greatest social/economic disadvantages); (2) health gaps (focus is on the discrepancy between those experiencing the most disadvantage, and those experiencing the least or average); and (3) social gradient (focus is on the stepwise relationship between socioeconomic resources and health outcomes across the population) (Graham, 2004). We considered whether/how these conceptualizations played out in our data.

From the City of Calgary online archives (https://agendaminutes.calgary.ca), we retrieved documents from meetings of Calgary city council and relevant standing policy committees between 1 January and 1 June 2011, which captured the fluoridation deliberations from the initial notice of motion (10 January 2011) to the finalization of the discontinuation (9 May 2011). The 26 January 2011 Standing Policy Committee meeting on Utilities and Environment (SPC-UE) was a full-day meeting where Calgarians (citizens and professionals) could attend and speak for up to 5 minutes each. For that meeting, we reviewed the video archive and transcript, which permitted us to gain additional detail, clarity, and verbatim quotes from speakers (Calgary City Council, 2011c). From the 26 January 2011 SPC-UE meeting, we identified instances of ‘equity’ and related terms through multiple readings of the transcript, coupled with a text search (e.g. ‘equit’, ‘equal’, ‘poverty’, ‘poor’, ‘income’, ‘disadv’). We extracted comments and exchanges where equity (and related concepts) appeared substantively vis-à-vis fluoridation and/or targeted approaches to dental programming, and which in our judgment appeared to shed some light on how equity played out in this debate. Below, we describe and interpret the data with reference to Graham’s (2004) work and other relevant scholarship in population/public health. We situate our findings chronologically within the deliberations as a whole.

Findings

A Notice of Motion (NOM) put forth at the 10 January 2011 regular meeting of council, in which 10 of 15 councilors moved for a repeal of the city’s existing Fluoridation Bylaw (Bylaw 37M89, initially implemented in 1989). In light of our research objective, we focus particularly on the amendment to the NOM, also introduced on 10 January 2011:

AND FURTHER BE IT RESOLVED THAT Council direct Administration to establish a stakeholders group to identify a funding amount to be taken from the monies saved from the discontinuation of fluoridation, and the appropriate administrative body, in order to provide fluoride treatment for children of low income families. (Calgary City Council, 2011b)

This amendment embodies the shift from a universal to a targeted approach. In terms of the reasoning behind the amendment, the councilor who led the NOM explained that it arose from a ‘feeling’ within council and the public’s specific concern for ‘people of low income, specifically children’ (Calgary City Council, 2011a). She further posed the question to councilors, ‘Who are we trying to help here, and is there a better way to target our assistance by taking some of the moneys we’ve saved from fluoride […] and actually [targeting] the people who need the help most?’

The motion and amendment were referred to the 26 January 2011 meeting of the Standing Policy Committee on Utilities and Environment to provide an opportunity for public input, as per the public participation provisions outlined in the Municipal Government Act (2000). A total of 35 speakers were heard, who spoke to a range of topics and concerns (Table 1 [supplementary online material]). We identified four types of comments that seemed to speak to different perspectives on issues of equity/poverty vis-à-vis fluoridation and/or targeted dental programming.

Fluoridation is equitable

Several speakers (four in total) made the argument that fluoridation is equitable, i.e. it is beneficial for all but especially those living in lower socioeconomic circumstances. In all cases, these individuals spoke in favour of fluoridation, in their capacities as public health, medical, or dental professionals. One example is a speaker who identified himself as a family doctor and Associate Professor at the University of Calgary. In response to a question from one councilor as to whether he felt the city had an obligation to look at other choices for fluoride delivery post-cessation, he responded as follows:

City decision makers should be held accountable, and if there is an incredibly well-documented way to promote oral health, particularly for people in the lowest socio-economic classes and you as a group decide to abandon that, then you have caused a problem I would suggest. […] While [diverting the money for fluoridation to some sort of dental care program] may sound attractive, I am quite concerned about how far $750 000 will stretch across a city this big …Water fluoridation is your best cheapest way to protect the oral health of Calgarians. Period. If you do something else it’s going to be incredibly expensive, and I don’t know if the city wants to take on that burden. (Calgary City Council, 2011c)

This individual points out the benefit of fluoridation to the population as a whole, including (‘particularly’) those with fewer socioeconomic resources, thus conveying a connection between fluoridation and equity, and aligning with Graham’s (2004) ‘gradients’ conceptualization of equity. This speaker’s position is also consistent with population health scholarship around the leverage and efficiency of a universal approach, as well as the equitable impact of some (‘structural’) universal interventions, including but not limited to fluoridation (McLaren & Emery, 2012; McLaren et al., 2010). While this individual is not opposed to a targeted dental program on principle, he cautions – with reference to the annual costs of fluoridation – that such an alternative would be expensive and, with the amount of money being discussed, unsustainable.

A second example was the Dental Public Health Officer for Alberta Health Services, who commented as follows:

there is no simple way to find and reach the people who are most at risk of tooth decay, but fluoridated water is available to everyone. It doesn’t stigmatize our fellow citizens who might not have enough money to pay for their dental care or preventive services or may not be able to brush at all. I would suggest making the easy choice, the good choice. Drink tap water. By fluoridating the community says that it values the dental health of all its residents. (Calgary City Council, 2011c)

This individual explicitly referenced some of the key limitations of the targeted approach (Alcock et al., 2001; Rose, 1992); namely, the challenges of accurately identifying those who are most at risk (i.e. the recipients of a targeted intervention), and the potential to increase stigmatization associated with being a member of a vulnerable group; and the ability of a universal approach to sidestep these issues. This speaker also makes reference to key ideas in population and public health, including ‘making the easy choice, the good choice’ which bears strong resemblance to the Ottawa Charter for Health Promotion’s (World Health Organization, 1986) slogan of ‘making the healthier choice the easier choice’. Also, the comment ‘by fluoridating the community says that it values the dental health of all its residents’ aligns with public health’s collective orientation (MacDonald, 2014).

Overall, comments by speakers that we grouped into this category are strongly aligned with Graham’s ‘gradients’ conceptualization of equity, in that they focus on the population as a whole, including (and especially) those with more limited resources; and they convey recognition that the line between those with more, versus less, disadvantage is fluid. From this perspective, fluoridation is entirely compatible with health equity concerns.

Poor children can’t afford alternatives to fluoridation

Some speakers argued against fluoridation on the basis that children and families in lower socioeconomic circumstances cannot afford alternatives to fluoridation or measures to address the consequences of fluoridation. One speaker, who identified as a citizen, talked about her adult son’s experience with dental fluorosis, which she described as:

permanent dental fluorosis from too much fluoride; teeth that cannot be repaired, only covered up to hide the damage. Poor children can’t afford cosmetic dentistry. (Calgary City Council, 2011c)

When asked what the cost would be to address the fluorosis, the same speaker responded:

I think the damage to my son’s teeth is too severe (…) You can get veneers put on but you will be replacing them eventually and the cost is just huge. And it is not a solution. (Calgary City Council, 2011c)

Other speakers referenced the cost of alternatives to fluoridation, such as purchasing bottled water, or treatment systems to remove fluoride from their tap water. For example, a speaker who identified as a citizen stated,

I tried to buy non-fluoridated bottled water and dispensers, costing me thousands of dollars over almost 20 years. And I am still paying for city water. (Calgary City Council, 2011c)

Overall, these comments convey a combination of concerns pertaining to equity and ethics. These speakers explained that it is difficult and costly to opt out of fluoridation, and that these challenges are experienced most strongly by those with the fewest socioeconomic resources. The prominent role of ethical issues related to the compulsive nature of fluoridation is conveyed through comments such as the following, from another citizen who spoke against fluoridation:

I just think it’s very unfair for the city to be having people jump through hoops in order to just get a glass of water. (Calgary City Council, 2011c)

Fluoridation is good for poverty

A third type of reference to equity was evident, which we termed ‘fluoridation is good for poverty’. In some ways, these comments were similar to those in the ‘fluoridation is equitable’ grouping above, and likewise came exclusively from individuals who spoke in favour of fluoridation. There was a subtle but important difference, however, whereby the emphasis tended to be less on the population as a whole and more on ‘the poor’. An example is the following statement from a speaker who identified as a dental hygienist:

Proponents of removing water fluoridation have suggested alternate methods of delivery for disadvantaged populations. Alternate methods may not mitigate the risk of dental decay as effectively as fluoridation. Literature recommends fluoridation in combination with adjunctive topical fluoride varnish. At-risk populations may fail to utilize alternative methods of fluoride because of language or economic constraints. (Calgary City Council, 2011c)

Though similar to ‘fluoridation is equitable’, this comment places relatively more emphasis on ‘disadvantaged populations’ who are of concern because they may ‘fail’ to use alternative measures. We thus viewed it as aligning more with Graham’s (2004) ‘disadvantages’ conceptualization of equity, where the focus is on ‘those at the bottom’. As another example, a speaker who identified as a citizen commented as follows (in response to a question about dose):

The point I was wanting to make about the fluoride drops is that it’s not a good alternative. Because it really takes a high level of compliance. And people – if we’re thinking, not of my grandchildren, but of disadvantaged children to have parents that would be able, willing, capable of ever doing that may or may not be an option. (Calgary City Council, 2011c)

This comment also conveys the sentiment that ‘fluoridation is good for poverty’, but it does so in a way that implies that disadvantaged parents are not able to comply (with fluoride drops, which is one alternative that had historically [pre-fluoridation] been recommended in Calgary). The tone is somewhat patronizing, and the comment aligns with Graham’s ‘disadvantages’ conceptualization of equity. Further, this speaker’s reference to ‘people – not of my grandchildren – but disadvantaged children’ also gives a sense of an ‘us versus them’ perspective, or a separation between social groups, that concerned early social policy thinkers in the context of targeted approaches (e.g. Alcock et al., 2001).

A final set of comments in this category came from a speaker (also a citizen) who conveyed her first-hand experience with socioeconomic disadvantage, as follows:

I was a single mom of three kids for years (…) but I can guarantee you, if you take the fluoride out of this water, (name) is going to hear quite a bit coming from these poor people while their children’s teeth are literally rotting out of their mouth. (Calgary City Council, 2011c)

This individual made the ‘fluoridation is good for poverty’ argument, drawing on perspectives from her lived experience with poverty. The emphasis on poverty and ‘these poor people’ aligns with Graham’s ‘disadvantages’ conceptualization of equity, but in a slightly different way from the other comments.

Fluoridation and equity/poverty are not connected

Whereas the comments above were characterized by the presence of different types of connections between equity and fluoridation, which may have been positive or negative depending on the perspective of the speaker, in our final type of comment the most prominent aspect was a lack of connection. That, coupled with the prominent focus on poverty in these comments, led us to view them as strongly aligned with Graham’s ‘disadvantages’ conceptualization of equity, but in a different way from comments considered above.

Our first example was a speaker who identified as the Director of Vibrant Communities Calgary, a non-profit poverty reduction organization. This individual argued that money spent on water fluoridation was not the best way to address the dental needs of Calgarians living in poverty. He explained that he spends his time talking to people living in poverty about what the city can do to alleviate some of the pressures that they may be facing, and pointed out that,

not once has someone answered that question with the statement, ‘Gosh, thank goodness for that fluoride …’. (Calgary City Council, 2011c)

He went on to suggest that, with the money saved, ‘we could change the nature of this city for people living in poverty’ (Calgary City Council, 2011b).

This speaker emphasized the importance of allotting resources to those who need it most, thereby endorsing a targeted approach. His comments align with Rose’s (1992) ‘prevention paradox’ in that the experienced benefits of a population-level intervention (here, fluoridation) at the individual level would be far smaller than those of an intensive targeted intervention directed at those living in poverty. Though an important limitation of his argument is the significant imbalance between the costs of fluoridation on the one hand, and the costs of ‘changing the nature of this city for people living in poverty’ on the other, it is clear that this speaker makes no connection between fluoridation and equity.

The final comments involve an exchange between a speaker who identified as a health professional from the Aboriginal Health Program at Alberta Health Services, and one city councilor. The speaker spoke in favour of fluoridation, stating:

As a measure that is equally accessible to all, [fluoridation] reaches those in greatest need and at highest risk. Because everyone has easy access to it, water fluoridation is an effective and socially equitable strategy for reducing tooth decay across our communities … Water fluoridation, in the face of lack of access to oral and dental services cannot be underestimated as an effective preventative strategy against the persistent poor oral health of urban Aboriginal people residing in Calgary. (Calgary City Council, 2011c)

The councilor responded as follows:

A lot of the dental decay [in the urban Aboriginal population] has something to do with poverty … Fluoride isn’t the panacea, and I find it offensive to think that some people might thinking it is … (Calgary City Council, 2011c)

The speaker did not state that fluoridation was a solution for poverty, yet her comment appears to have been interpreted in that way. According to this exchange, not only was there no connection between fluoridation and equity, but the idea that a connection could exist was seen by one councilor to be offensive.

The final decisions

At the 21 March 2011 Regular Meeting of Council, a bylaw repealing bylaw 37M89 (the water fluoridation bylaw) was read twice with both votes being opposed by only two members of council. A report (Figure 1 [supplementary online material]) from city Administration was presented that considered – under the City of Calgary’s Triple Bottom Line Policy Framework – the social, environmental, and economic implications of discontinuing fluoridation. That report concluded that there were no such implications of the bylaw. The two votes required to finalize the discontinuation of fluoridation took approximately 30 seconds: in the words of the Mayor, ‘that was easy peasy’ (Calgary City Council, 2011d). Fluoridation was officially discontinued on 9 May 2011 following a third reading and signatures (Calgary City Council, 2011e).

On 4 July 2012, a report (Calgary City Council, 2012) was released which contained the recommendation that of the $750,000 saved from the discontinuation of water fluoridation, that $585,000 be given to the Alex Community Health Centre via an endowment fund to provide ongoing capital lifecycle funding; and that $165,000 be given to the Calgary Urban Project Society in capital funding for the expansion of children’s dental health services facilities. This recommendation made the shift from universal to targeted forms or prevention official.

Conclusions

In the 2011 Calgary fluoridation deliberations, which led to a decision to cease fluoridation and re-allocate funds to targeted dental programming, we observed different perspectives on the concept of equity (Graham, 2004). Some speakers’ comments (i.e. ‘Fluoridation is equitable’) were very consistent with Graham’s social gradients conceptualization of equity. In contrast, there was strong indication by others (i.e. ‘Fluoridation and equity are not connected’) of a health disadvantages conceptualization of equity, or in other words, a conflation of equity and poverty. As noted by Graham, these different conceptualizations have implications for policy. A social gradients conceptualization, because of its focus on the stepwise association between socioeconomic circumstances and health across the population, permits consideration of solutions (policies) that are likewise population-level or universal in scope, such as fluoridation. In contrast, the health disadvantages conceptualization has the effect of ‘turning socioeconomic inequity from a structure which impacts on all to a condition to which only those at the bottom are exposed’ (Graham, 2004). From that point of view, the goal becomes to improve the health of the ‘worst off’, and a targeted approach becomes seen as the only viable option.

Interestingly, we also detected a health disadvantages conceptualization among some individuals who spoke in favour of fluoridation (i.e. ‘Fluoridation is good for poverty’). One could argue that there is a dissonance within that set of comments, in that the argument for a universal measure (fluoridation) was made on the basis of a target group (poor or disadvantaged people), which was perceived by speakers in that group as somewhat distinct. In his foundational work, Rose (1992) explained that, if one can identify a high-risk (targeted) group with reasonable accuracy, such as when risk is concentrated – versus distributed – in the population, then a high-risk approach makes sense. In our example, these speakers seemed to conceptualize disadvantaged children (analogous to a ‘high risk’ group) as separate, yet they advocated for fluoridation, a universal measure.

The decision was ultimately made to discontinue fluoridation and re-allocate funds to targeted dental programming. Although the decision reflected a number of factors (e.g. effectiveness, safety, ethics, ideology, financial; Kapoor et al., 2016), we believe that, among those factors, different perspectives on equity played a role. We argue that a strong tendency by some individuals involved in the debate to endorse a ‘disadvantages’ conceptualization of equity, or to conflate equity and poverty, contributed to the decision to shift to a targeted approach in this context.

Though a ‘gradients’ conceptualization of equity was present, and was articulated by ‘experts’ (i.e. health/medical professionals), it was apparently not enough to convince decision-makers to vote for fluoridation on the basis of equity. Though there are many potential reasons for this, it could in part reflect inconsistency in the message conveyed by supporters of fluoridation. That is, among speakers included in our analysis, those who spoke against fluoridation consistently conveyed a ‘disadvantages’ conceptualization of equity (based on our interpretation), whereas those who spoke in favour of fluoridation conveyed a ‘gradients’ conceptualization in some cases (i.e. ‘Fluoridation is equitable’), and a ‘disadvantages’ conceptualization in others (i.e. ‘Fluoridation is good for poverty’). The strength of the case being made in favour of fluoridation, on the basis of equity, may thus have been diluted.

Undoubtedly, the targeted dental programs in Calgary constitute an important resource for some families. However, some shortcomings must be pointed out. First, the funds were to be provided on a one-time basis. This, coupled with uncertainty about subsequent funding, especially considering that not-for-profit associations are often the first to receive cuts during economic downturns, raises questions about sustainability that harken back to Titmuss’ work on the precariousness of targeted policy (Alcock et al., 2001). Second, as with all targeted programs, these programs by definition serve only a subset of the population. To illustrate, during the 2014–2015 year, 997 children were served by the Alex dental health bus school program (https://www.thealex.ca/about/annual-reports/), whereas 179,000 school aged children (between ages 5 and 14) were projected to be living in Calgary (Calgary Economic Development, 2016), over half of whom would be affected by dental caries based on survey estimates (Health Canada, 2010). Third, as noted above, historical thinking on the targeted approach highlights the inherent potential for social divisiveness (Alcock et al., 2001). Finally, although we are not aware of a formal evaluation of these local initiatives, a population-based study of dental caries pre- versus post-fluoridation cessation by our group concluded that socioeconomic inequities increased in Calgary over the time frame (McLaren et al., 2016); thus the targeted programs were not sufficient to offset inequities at the population level. This is not to say that a targeted approach, or some combination of universal and targeting, could not overcome these shortcomings, but to do so, public investment in and commitment to dental public health would need to grow substantially.

Our study has limitations. First, because of its rich content, we focused largely on one source of information: the 26 January 2011 SPC-UE meeting. Second, we focused specifically on equity and related concepts, and one could argue that parsing out a specific set of concepts has the effect of truncating or oversimplifying the deliberations. However, because the concept of equity is so closely tied to critical scholarship on universal and targeted approaches to policy, we feel that our focus on equity has merit. We have considered the 2011 Calgary deliberations in a more fulsome way elsewhere (Kapoor et al., 2016).

We examined the 2011 Calgary fluoridation deliberations as an example of the broader issue of universal and targeted approaches to intervention, focusing specifically on how equity played out. Our example is complex, due to the multitude of issues (e.g. effectiveness, safety, ethics, ideology, financial), and unique aspects of the local context. Future studies that explore universal and targeted approaches using other examples in public health and social policy will help to flesh out generalities versus idiosyncracies.

Funding

Lindsay McLaren is supported by an Applied Public Health Chair award funded by the Canadian Institutes of Health Research (Institute of Population & Public Health; Institute of Musculoskeletal Health & Arthritis), the Public Health Agency of Canada, and Alberta Innovates – Health Solutions.

Disclosure statement

Both authors declare that they have no conflict of interest to declare.

Supplemental data

Supplemental data for this article can be accessed https://doi.org/10.1080/09581596.2017.1361015

Acknowledgements

Rachel Petit worked on this project for her honour’s thesis in the Bachelor of Health Sciences program at the University of Calgary.