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

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.