The science of fluoride in water is effectively settled. It has been one of the most thoroughly worked questions in public health science over some decades. There is a voluminous scientific and lay literature that needs to be considered.

There is no doubt that the presence of low amounts of fluoride in water (either naturally occurring or adjusted to between 0.7 and 1 mg/litre) reduces the incidence of dental caries and this is even in advanced economies where dental hygiene has been much improved and where fluoride toothpastes are available. In some countries, fluoride need not be added to the water supply because their geology naturally provides water with fluoride in at least these concentrations. But for some decades, in countries such as New Zealand, where fluoride levels are very low in natural water, fluoride has been added to the water supply.

Notably, both the very young and the old benefit from fluoride in the water supply. They develop fewer dental caries and thus have a significant reduction in the downstream effects such as the need for invasive dental surgery associated with problematic dental status. As in all populations the burden of poor dental health is considerably greater for those in less advantaged socioeconomic conditions and it is this population that benefits most from water fluoridation.

In other areas of the world, natural levels of fluoride in water can reach well above 4 mg/litre – this level is considered by authorities to be the level at which water is still determined to be perfectly safe for human consumption. It is absolutely clear that at doses used in New Zealand to adjust the natural level to a level consistent with beneficial health effects (0.7-1.0mg/litre), there is no health risk from fluoride in the water. Like any agent, including salt, sugar and water itself, if you eat or drink enough it can become toxic. At the doses used in New Zealand water, however, one would in all likelihood become very ill or succumb to water intoxication before any toxic effect of fluoride was discernable.

However there is one side effect of fluoride that is found even at this low level of fluoride in the water supply; in a portion of the population, it causes minimal white mottling of the enamel of the permanent teeth. This is very rarely discernible and is definitely not the severe fluorosis that is so often pictured on websites of those opposed to fluoridation of the public water supply. The latter is associated with drinking water with very high naturally occurring levels of fluoride (more than ten times levels in New Zealand water after fluoridation) or from other sources of high fluoride – for example that found in some forms of black tea, generally in parts of Asia. The exposures needed are chronic exposures at levels many times that in our water supply.

So why is there any issue at all? There are at least two primary questions on which public debate seems to be hinged.

The first issue is an inherent challenge for any public health intervention: How to balance the common good of a population-based intervention with individual rights? This is primarily a question of societal values not science. Indeed, the balance between doing good (reducing caries) and not doing significant harm (minimal dental mottling) is scientifically clear. Thus in some ways any remaining debate has analogies to the immunization situation and to the imposition of regulations such as those requiring the wearing of seat belts. However whether to apply the science-based knowledge in this equation is a question of public health ethics and societal values.

The second issue is yet another values debate: Can food be used as a medium for delivering a public heath intervention? Is it OK for public water to be manipulated for an additional health benefit or for a potentially medicinal purpose? As it happens we already do so with iodine – our salt is iodised to prevent the developmental delay (cretinism) and goiters (big thyroid glands) associated with iodine deficiency and which was so common in New Zealand 100 years ago. There is no scientific issue here -it is purely an issue of values.

But because both such questions are values-based, for many people they are difficult to discuss. As with other issues where science and values are seen to converge – such as climate change – it is often easier for those seeking to advance values-based concerns to make the science sound scary or more uncertain than it really is. Indeed, it becomes a tactic amongst those who become passionate about their cause. Because biology and medicine are complex, studies can be difficult to put in perspective and odd results can be given undue weight. I have discussed this problem extensively elsewhere (http://www.pmcsa.org.nz/wp-content/uploads/Interpreting-Science-April-2013.pdf).

The fluoride debate is based in no small part on numerous examples of inappropriate extrapolation from what happens at hugely higher doses of fluoridation, combined with what is frankly scaremongering. Further, because the way one looks for side effects following population interventions requires particular epidemiological approaches, the language of evidence-based medicine can be confusing to the non-expert and easily exploited.

With regard to fluoride, there have been genuine concerns raised regarding risks of bone disease, thyroid disease, brain disease and cancer. While these issues have been settled, they continue to be emphasized by those who oppose fluoride. Some of this continued emphasis is based on inappropriate interpretations of studies in rats or from humans who have fluoride poisoning or live in areas where there are extremely high concentrations of fluoride naturally occurring in the water or diet. Obviously the medical and public health science community has put a lot of effort into being sure that this is not the case at the doses being used to adjust natural levels in water. Safety has been the subject of major assessments by many health authorities in Western countries. It is clear that there is no risk of such disorders at the doses of fluoride being used and extensive epidemiological surveys have repeatedly confirmed this to be the case.

So why does this concern continue? The misuse or inappropriate and alarmist use of science is a classic example of science being a proxy for values debates. Others, who have a more skeptical view of the medical-scientific sector, have seen this as some bizarre form of conspiracy. Alternatively, it could be that it simply provides a platform for people looking for a cause to fight because of their personal ideology.

The scientific basis for stating that fluoride in water (at the concentrations recommended) is a safe and very effective approach to improving dental health is clear. Where there is debate, it is with the values-based issues, even though these can be overstated. Sadly, rather than having dialogue on such values issues which is a proper discourse for society, the debate has been hijacked by a misinterpretation of science. Such values debates are critical for a healthy democracy, but they cannot proceed usefully if the debate is shifted inappropriately to another domain.

The Ministry of Health and its expert dental, public health and scientific advisors have been well positioned to opine on the science. Indeed their conclusions are in accord with other major scientific and public health authorities that have looked at the question repeatedly. But irrespective of the conclusions that the scientific community has reached, scientists do not have a privileged position within a values debate beyond clarifying when science is being misused. Such values based debates should focus on any real issues of contention and be resolved through the political process – whether local or nationally.

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The next round of workshops are not intended to relitigate the agreed themes but to help identify the big scientific opportunities that the NSCs create. From these this and the past round of workshops the Panel and MBIE will identify groups of key scientists who will them be asked to lead future workshops to development of the science plan for each challenge in consultation with the appropriate scientific communities.

Thus engagement in these preliminary workshops has no implications for how the challenge funds will ultimately be allocated. They are simply a further step in ensuring that a coherent and targeted plan emerges for each challenge. But the desire is that after this coming round of workshops, the key leaders for each of the challenges can be identified and start taking responsibility for developing a research plan.

I cannot reiterate often enough that these challenges are not just another funding stream but are designed to induce significantly greater science-led collaboration for common goals. Thus mindsets have to move from the traditional highly contestable and institutionally focused approaches that have dominated our system in recent years. The process of developing a challenge will be an iterative process and once the key components have been identified, MBIE and the key science leaders will have to engage institutionally to develop a governance and management plan appropriate to the challenge.

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Both countries have some very active research into this problem, and there are several vaccine candidates in different stages of development. However, tackling rheumatic fever has not been seen as a priority for the major vaccine developers for a variety of reasons. The joint funding by the Australian and New Zealand governments is needed because while rheumatic fever may not be a global priority, it is certainly one for Māori, Pasifika and Aboriginal populations.

The project arose from discussions initiated by Mr Key while visiting the Auckland Medical School. In turn, this led to the Prime Minister requesting my Office and that of my Australian counterpart, Professor Ian Chubb, to work together to promote the development of a joint proposal by scientific experts in the field from the two countries. The proposal was subjected to independent international review by distinguished experts. This enabled both myself and Professor Chubb to independently make recommendations to our Prime Ministers.

Developing any vaccine is complicated and fraught with scientific problems. Rheumatic fever is caused by an immune reaction to a bacterium, the group A streptococcus. There are many strains of the bacterium worldwide, and the vaccine needs to deal with the strains that cause disease in our populations. It should also target components of the bacterium that make it less likely that vaccine resistance will evolve, and the vaccine itself should not cause the damaging immune reaction. There was sufficient evidence from the scientists’ work to date that these issues can be addressed. Thus we recommended that an initial funding be made to progress the science to a point where a decision could be made to take a vaccine into clinical development.

I am delighted that the two Prime Ministers felt able to commit resources to this project. We are still some way from a clinical trial of a vaccine suitable for New Zealand, but this is the essential next step. It is also an illustration of how New Zealand and Australian science planners and scientists can work constructively together more closely than they have in the past.

The prospect that a vaccine against rheumatic fever will be available some years into the future does not obviate the continued need for public health approaches to tackle the issues that lead to such a high incidence of this disease in parts of our population — something that has been remarkably resistant to reduction over some 40 years since I was a young paediatrician.

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But this move is not without its tensions and conflicts. There remains a significant group of academics who believe that such engagement is against academic tradition, or that in some way such applied research is of lesser standing than academic research. This perception indeed has echoes of C. P. Snow’s ‘two cultures’. It still finds its way into the assessment of the academic CV and sometimes grant applications.

But beyond that is the deeper issue of the perception and reality of conflicts of interest. This issue has been most acutely studied in the medical sciences, but it is generic. At the same time that stakeholders expect researchers to be more engaged with the private sector, there is a growing concern about bias and perceptions of bias that might be associated with such sponsorship and interactions. Most journals now properly demand a conflict of interest statement.

The issue is how academic-commercial associations can be used and misused. There have been occasions where journals have refused contributions because of an author’s associations. This is not a trivial matter, because if this practice was generalised beyond extreme circumstances, it would create impossible tension for all parties. This would be problematic, in part because there are many areas of science where the private sector has taken a lead.

There is an irony in all of this. Academia is generally rather good at dealing with private sector interests (as long as they are declared); it is much less accomplished at dealing with its own internal conflicts. All said and done, the modern research model has a high level of internal competition. Stories of biased reviews of grants and papers are common and indeed are part of nearly every scientist’s war stories, in both big and small countries.

Clearly much is changing in the interplay among science, society and the private sector in particular. As we seek greater permeability between publicly funded science and the private sector, issues are arising which will cause tensions. But the academic community also needs to be honest in dealing with its own internal conflicts.

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A recent report from the World Economic Forum (WEF) entitled Global Risks 2013 summarizes both the likelihood and impact of a number of global risks as perceived by the Forum’s experts. There is a simple graphical summary of its findings in February’s edition of the Scientific American (page 72) but the full report is well worth reading. This report is produced annually and what is interesting is how this year’s edition gives increasing focus to scientific and technological issues. An obvious issue is climate change and how humankind may or may not respond to it. What has also emerged is rising concern about unsustainable population growth and its consequences. There is comment that there may be hazards associated with various new life science technologies such as synthetic biology and artificial cognitive enhancement. The potentially very negative consequences of massive digital misinformation and indeed issues in the cyber-world are also given real focus in the report. This is also the topic of commentary in a recent article in the January 10 2013 issue of Nature.

No nation can afford to ignore risks, the need for hazard identification and risk management. Indeed, even considering global risks, while in an ideal world they would be addressed globally, it is clear that in general they must be covered off at national levels. The WEF report discusses some aspects of what is needed for national risk management and resilient systems, but New Zealand needs to put these ideas into the context of how nations and societies currently operate. The report assumes that a non-rhetorical approach can be taken to risk identification and management. However, this is difficult to achieve as risk has very different meanings to individuals, scientists and politicians. In general, people have not achieved a way to maintain dialogue about risk management that integrates such diverse perspectives and understandings. Yet if New Zealand is to both respond appropriately to the challenges it faces and take advantage of what science and technology can offer, a more intelligent and less reactive form of conversation must be created. Often a technology is confused with its application. Every technology has its upside and its downside – this has been the case ever since our ancestors co-opted fire and developed tools that could be used to obtain food. What has changed has been the scale of impact of technologies for good or for bad and changes in societal structure in which system 1 ‘fast and instinctive’ thinking (to use Daniel Kahneman’s terminology) operates and tends to dominate at a collective as well as an individual level. Indeed, that is the inevitable consequence of participatory democracy in a world where 5 second TV spots and 140 character tweets prevail.

Every decision we make as a country involves trade-offs – if taxpayers’ money is spent on one thing then there is less to spend on another. If there is the desire to protect ecosystems and environments then there are costs in terms of constrained use of these places for resource extraction. Yet at the same time there is understandable public and political expectation of better living standards linked to economic growth. What trade-offs must be made to achieve these differing ambitions and desires? Most will involve assessment of technology and risk and many will involve science and technology in their application. New Zealand’s future depends on risk assessment and management. It seems obvious to me that while ultimately decisions will always be political and societal, the more that objective data are used rather than rhetorical hand-waving, the more likely that both known and unknown challenges will be well accommodated.

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But beyond that domain-focused approach to science priority setting, there are two other very important dimensions. The first is the need to focus on the people doing the research. We have tended for over two decades to play that down in our assessment process, yet the evidence is clear that recent performance and skills in research leadership are critical in the allocative process – the exception is obviously the need to have systems that allow for new entrants. I canvassed the issues in my discussion paper Which science to fund, and Sir Paul Nurse, President of the Royal Society of London and Nobel laureate, made very similar remarks in his recent speeches in Auckland and Wellington.

The second dimension, which I also addressed, is the need to promote both interdisciplinary and intellectually more risky research. There is little doubt that our funding system, with its highly specific portfolios, has disadvantaged multidisciplinary research, yet this is where so much innovative science occurs. The traditional structure of university science sadly also contributes to intellectual silo-ism. As I discussed in my paper, there is no doubt that a constrained system with a sub-optimal grant assessment process favours conservative research over that which is truly novel. Too much of our scientific enterprise has become unduly conservative and risk-averse with consequences that will incur a significant cost to New Zealand in the long run. This issue extends well beyond our shores – just recently the (US) President’s Council of Advisors on Science and Technology (PCAST) published a report Transformation and opportunity; the future of the US research enterprise which observes that too much investment is for incremental research because the peer review process rewards safe bets. The report recommends that research funding agencies adopt mechanisms to encourage transformational interdisciplinary science and focus on high-risk research efforts led by investigators with a strong track record.

I would contend that in a small science system like New Zealand’s that is expected to leverage exceptional value from modest amounts of available funds, the need to think in similar terms may be even greater.

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This phrase was used by one of my counterparts to describe the outcome of poorly constructed or operated contestable funding systems. It arose in the course of a discussion about the problems of contestation and grant awards, problems that are particularly acute in small countries. How do we create a system that ensures that excellent research gets funded and is not compromised by the various pressures of institutionalism, parochialism and the inevitable and often subliminal conflicts of interest that can influence decision making?

These issues are obviously confounded by the levels of funding available and by the design features of many funding systems.

Another important factor is the nature of the peer review system that is generally used. The outcome can be that the research that gets funded is not necessarily the most innovative; rather, there is an almost inevitable progression towards predictable and safe activity – hence my colleague’s remark.

Later this week I will be releasing a discussion paper on these issues – after all, perhaps the most important factor in shaping a science system is the process that leads to decisions about what projects and which people to fund.

Are there better ways to do it without compromising the basic principles that should underlie grant awards? Indeed are we clear on what those principles are? It is a discussion worth having. All said and done, we must aspire to be spectacular but not mediocre.

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The Commissioner’s report is a timely reminder that the position of science and technology is very different to what it was some decades ago. As I have noted in earlier blogs, the relationship between science and society has changed greatly. Where science in the past acquired a justifiably bad reputation for being patronising and distant from society, in recent years the science community has understood that it is not distinct from society, and indeed that society has a critical role in determining the impact of scientific findings.

Science has developed the capacity to undertake research that coincides intimately with societal concerns and values in areas ranging from reproductive biology and nanotechnology to ecological and social science. As a result, science has learned that it must engage proactively with the community if it is to be effectively used.

This lesson is even more acutely understood when we consider technology. Society is right to be concerned about many new technologies and there is a danger that if the dialogue between scientists, technologists and the community is not well conducted then misunderstandings will arrive. This can manifest itself as a muddle involving global restrictions on a particular technology itself and/or restrictions on particular uses. Given that virtually every technology has both advantages and disadvantages, it is important to understand this distinction as the Commissioner has quite rightly done.

As technologies ranging from synthetic biology to geo-engineering are presented as potential solutions to the various dilemmas and challenges facing society and indeed the world, it is inevitable that important debates will arise between those with biases different from those informed by science. Science alone cannot determine the balance that must be achieved between community uptake and restriction of any technology. Rather, society must and does make that determination through democratic processes.

Exactly how that dialogue proceeds and its outcome depends on many things, not the least the quality and nature of the conversation between scientists, technologists and the broader community. There must be a true engagement — and it should occur early and continuously so that science and societal engagement progress in parallel. There is a strong case for social scientists being engaged with the science community from the earliest stage of the development of any new technology. We have seen how varied different societies can be in their acceptance of many technologies — for example, the different western democracies have shown very different attitudes towards stem cell biology and genetically modified foods.

One of the fundamental reasons for this variation is the result of differences in societal values. However, another is based on how well the scientific community has engaged with society. A key issue here is public understanding of concepts of probability, risk and risk management. Scientific data are often variable or incomplete. As a result, advocates — be they lay or scientific — can often present data in ways that confuse rather than assist social engagement.

I will be releasing a discussion paper aimed at improving the interpretation of scientific data in such dialogues in a few days time. In general, I remain convinced that science should where possible be presented in a values-free way, providing society with unbiased information that can be incorporated into societal debate within a values framework. That is the role of the public scientist as knowledge broker. Scientists should not allow their values to bias their science. In my view, the community is best served by scientists in public positions such as myself acting as knowledge brokers.

Involved scientists generally think in terms of formal estimates of probability, whereas the broader population thinks in quite different terms. Perceptions of risk are based on emotional assessment and inherent biases. Political risk is something else again! Thus there are real dangers of people talking past each other when they think they need engage in a true dialogue. Equally, the community needs to acknowledge that they are best served by having access to knowledge that will inform their considerations. Developing social license is not easy, but it is critical if we are to gain the best from science and technology and use it to our national and global advantage.

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A lot of the discussion focused on three contemporary issues (I will return to other topics discussed at a later date).

Firstly, how does one assess the value of public investment in research, especially when a significant proportion of research has its value to society in areas broader than simply direct economic transformation (although the latter must be a critical and key driver of policy settings). This question is at the heart of decisions policy makers must make as to the priority they give to public investment in R&D versus other aspects of public expenditure.

Secondly, can one and how should one assess the impact of research. The European states have been quite active in considering this issue, but it is not easy as impact means very different things to the academic and researcher versus the policy maker and public.

Thirdly, the vexed question of priority setting within the public science system. Because in a small country there is neither the funding nor the capabilities to do everything that a large science system can do — choices have to be made, but with what granularity? Research with value and impact must be of high quality and that requires certain features, such as critical mass, adequate funding, appropriate infrastructure and a degree of certainty; on the other hand a quality academic enterprise needs scholarship across all domains.

Choices are being made when governments assign levels of funding to different funding agencies, but choices are also made in deciding on the types of funding tools and the focus on individual or strategic direction. What is the appropriate balance between investigator-led research and strategically driven research initiatives? How much focus needs to be given to developing critical mass and ensuring national focus, rather than the institutional and individual focus that tends to dominate in public science systems?

With the increasing utilitarian focus on public investments, this creates interesting policy dilemmas. Thus the question emerges: should there be explicit priorities in a small nation’s funding system? Both Ireland and Finland, for example, have very explicit processes in place in setting science priorities.

Within the context of this discussion, an exciting and important initiative has been announced by the Minister of Science and Innovation: public and academic consultation on National Science Challenges. The idea of the challenges is to identify strategic initiatives that the science community can coalesce around that would add significant value to New Zealand. The examples of what a challenge might be given on the websites and on TV highlight the broad canvas of possibilities, from environmental and social to economically focused.

The public consultation is important — it will engage the public in having greater ownership of their investment in the science system, and help both them and the policy maker understand how important science is to our national future. But the consultation with the research community is equally important. We need to identify where the best in our research community spanning across institutions and disciplines can coalesce on some well defined strategic questions where a concerted research effort could have major impact on our economy, environment or social capital. There is no point engaging in wishful or fanciful thinking — we are a small country and we must build on what we are good at. This is not the place to pretend we can build something out of nothing, whereas by better linking up and filling identified capacity or capability gaps science could make a substantial difference.

Beyond the identification of the challenges themselves and their funding, this exercise will have long echoes in influencing how one thinks about the future of the New Zealand science system and the impact and value proposition of public investment in science. It will influence thinking about how science priorities are determined.

I will be chairing the expert panel that will assess the challenges and make a recommendation to Cabinet as to which of them will be funded. We will be looking for research proposals that will truly advance New Zealand’s economy, environment and/or society. I hope there is broad engagement — please look at the websites for further information. There are separate sites for the public and for research providers and research users.

The National Science Challenges exercise is a very important opportunity for New Zealand and the science system; it must not be squandered.

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To quote the authors, “A more robust system of linking the scientific community to the government is clearly needed. That is not just to prepare for the next national emergencies. In fact, science in a broad range of fields is deeply built into the everyday operation of today’s government. Science-based policy-making has grown ever more important in recent years, in parallel with the dramatic increase in the complexity and uncertainty of the ways in which science and technology interact with society and economy at the local, national, and global levels.”

They point out that the failure for scientific advice to be independent harms public trust in science-based experts, and with this they note a major erosion of trust in Japan. They highlight the efforts a number of countries such as the UK have made in recent years to improve the protocols surrounding the use of independent advice, and in New Zealand such concern was reflected in my own appointment. Japan is now looking to strengthen its own approach including the appointment of Science Advisor(s) to their Prime Minister.

The Japan Science and Technology Agency’s Centre for Research and Development Strategy has developed 10 principles for guiding government-science relations and they are worth reflecting on. These Japanese points parallel the advice I have provided and the work program that my office is undertaking.

The authors note that independent high quality scientific advice is essential to policy formation, but that there are situations when other considerations may over-ride that advice. They also point out the need for the underlying science advice to be balanced, and the need to acknowledge the limits of knowledge. Equally important is how governments respond to that advice.

To quote again, “It (Government) must not approach scientific advice with any preconception, distort scientific knowledge when making it public, or intentionally add wrong interpretations when using advice in policy-making. The government should explain how scientific advice was considered when drawing up policy. It is especially important for the government to explain the rationales when making policy decisions that are in conflict with the scientific advice obtained.”

The issue of how to create effective links between science and policy are complex, and different jurisdictions are approaching this in different ways. But the general need to do so is becoming increasingly well understood in a world where many of the challenges being collectively faced will rely on science and technology for solutions – even though this has the potential to create tensions with political processes.

Increasing dialogue on how to best accommodate this issue is occurring between national academies, science advisors and advisory councils. The authors put it well in saying “that (dialogue) is exactly what is needed now, as we have entered the age of intense, intricate interaction between science, technology, and the globalized society.”

In keeping with these imperatives, earlier this week the APEC leaders endorsed the proposal that the member State’s science advisors meet next year for the first time to promote dialogue. New Zealand and Indonesia will co-chair the meeting – I suspect such matters will be present on the agenda.

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