Here’s what happened when Israel removed fluoride from tap water

Ilana Decker, who moved from Israel to New York three years ago, says she doesn’t agree often with Robert F. Kennedy, Jr. Arguing, as he does, that the government should not make health mandates, she said, makes her “sound like an anti-vaxxer, which I’m not.”

But there is one issue, she said, where she and Kennedy do line up: The man whom Donald Trump has picked as the next secretary of health and human services has publicly floated ending the decades-long policy of encouraging cities to inject fluoride into the American water supply.

Decker supports the change — and she’s speaking from personal experience: Her former home, Israel, stopped fluoridating its water a decade ago.

“I hate to align with RFK Jr. in any way, shape, or form, but I really do agree that it should not be in the water,” she said. Citing concerns about the risk to children, she even switched her 4-year-old to fluoride-free toothpaste, though she didn’t rule out its use fully.

“I have a deep distrust in the government taking away individual health choices ‘for our own good,’” Decker said. “I can use toothpaste with fluoride, but I can’t decide to not drink the water coming out of my faucet.”

The nomination of Kennedy, an anti-vaccine activist and harsh critic of government health agencies, has cast a spotlight on debates over the role the government should play in public health — and over the degree to which mounting distrust in science should guide policy-making.

Fluoridation offers a case study in those debates. According to the U.S. Centers for Disease Control and Prevention, fluoridation in water has been shown to reduce cavities in children and adults by about 25% over a lifetime, with the organization dubbing it “one of the 10 great public health achievements of the 20th century.”

Critics of fluoridation point to studies showing that very high levels of the mineral — beyond what is normally present in fluoridated water — are associated with developmental problems in children; they also cite an array of conspiracy theories, including that the government is seeking to control citizens through fluoride use.

Kennedy has called fluoride “an industrial waste” and “dangerous neurotoxin” and said that he would seek to end fluoridation on “day one” after taking office. (Water is managed locally, so the federal government can only advise and incentivize changes.) As with vaccines, he has said the use of fluoride should be up to individuals, not the government.

“I think fluoride is on its way out,” he said on NBC News shortly after Trump’s election last month. “I think the faster that it goes out, the better.”

Those same debates lay at the root of the decision in 2013 by Israel’s health minister to end water fluoridation. Now, Israel’s policy change could act as a case study for how defluoridation could affect Americans. And the discourse is ongoing, with Israeli public health experts and some parents agitating for fluoride to be reinserted in the water — citing worsening dental outcomes for children — at the very moment when the United States may move in the opposite direction.

“The success of water fluoridation serves as a beacon for public health in general, and by extension, opposition to it should serve as a warning,” said Shlomo Zusman, who served as Israel’s chief dental officer for over two decades and was a vocal critic of the 2014 policy change.

He said modern water purification methods mean that fluoridation is far from the only way the modern water supply is altered. In addition, he noted that because 75% of Israel’s potable water is desalinated, it has no natural fluoride levels at all.

“The idea that water without added fluoride is ‘natural,’ as if it comes straight from a spring, is mistaken – there’s no such thing, it’s all manipulated,” he said. Referring to a story in the Bible, he added, “The days of Rachel pumping water from the well are long gone.”

Israel began mandating fluoridation in nearly all municipalities decades ago, following the first local American fluoridation efforts. An Israeli Health Ministry webpage calls fluoridation “the most efficient, safest, simplest, cheapest, and most equal measure, by a significant margin, among all methods for preventing dental diseases in the general public.”

But in 2013, the health minister, Yael German, pledged to stop requiring fluoridation the following year, citing unnamed doctors who she said had personally told her that fluoridation presents risks to pregnant women, people with thyroid problems and the elderly. Like Kennedy and his followers, she also cited the importance of individual choice.

“All things considered, and balancing all the interests, I feel that continued massive fluoridation of 100% of the water was an incorrect act,” German wrote to an association of pediatricians that was one of several groups to publicly oppose her plan. “And many even believe it infringes on fundamental rights and freedom of choice.”

The government that succeeded German’s term in office pledged to reintroduce fluoride — prompting legal action from German — but it has not been mandated again in Israel.

Since discontinuing fluoride in tap water, Israeli dentists have observed a significant rise in children’s cavities and have urged its reinstatement, even as some parents remain firmly against the idea.

A study published in September found a significant increase in dental restorations and crowns among Israeli children ages 3 to 5, attributing the rise to fluoride’s absence. The researchers, from the Hebrew University-Hadassah School of Dental Medicine, concluded that the results provided “further proof of the need to restore community water fluoridation in Israel.”

Another study, published in January 2022, analyzed six years of data from dental clinics affiliated with a national Israeli healthcare network, showing that children ages 3 to 12 required nearly double the number of restorative treatments compared to before fluoridation ended. Researchers emphasized that even Israel’s expansion of free dental care for all children failed to offset the worsening dental health.

With fluoridation the subject of widespread misinformation as well as ongoing research, Israel is not the only place to adjust its approach over time. Juneau, Alaska, saw pediatric dental health worsen after eliminating fluoride in 2007, according to a study that examined the cost and frequency of dental treatment for poor children. So did the Canadian city of Calgary, which recorded higher rates of cavity-related treatments under general anesthesia among children after it stopped adding fluoride to its water in 2011. Calgary has now decided to resume fluoridation. But dozens of municipalities across the United States have moved away from fluoride use in recent years, including some whose voters made the choice on Election Day last month.

Most of Europe, meanwhile, has either dropped fluoridation or never introduced it in drinking water. Many of those countries offer fluoridated salt and milk, mitigating the potential costs of not including the mineral in water.

Not everyone in Israel is convinced that reintroducing fluoride is a good idea. In one Israeli mothers’ group on Facebook, several women posited that the country’s cavity epidemic has less to do with the absence of fluoride in water and more to do with poor hygiene habits and children’s consumption of sweets and sugary snacks.

“Kids subsisting on white bread and chocolate spread isn’t helping,” wrote one, naming a popular Israeli snack.

Another, who identified herself as a teacher with 25 years of experience, agreed that there has been a significant decline in nutrition.

“I can say with 100% certainty that children’s diets have deteriorated immensely and it just so happens to coincide with the removal of fluoride,” she said.

Several cited a recent study from the National Institutes of Health’s National Toxicology Program that suggests that high levels of fluoride exposure may be linked to lower IQ in children. The report does not question the dental health benefits of fluoride.

The program reviewed more than 500 studies over nearly a decade and concluded with “moderate confidence” that fluoride exposure at concentrations above 1.5 parts per million is associated with reduced cognitive development in children. But the study, which drew criticism from the American Academy of Pediatrics, also noted that that number was far above the recommended fluoride level in U.S. drinking water of 0.7 parts per million.

Another study from May of this year found that prenatal exposure to fluoride was linked to behavioral problems, with children of mothers in areas with higher fluoride concentrations showing symptoms of autism, anxiety and other disorders by age 3, though the authors stopped short of establishing causation.

Zusman dismissed many of the concerns about health risks as a fad.

“There was a time when they claimed fluoridation caused hip fractures, then cancer, and later stunted growth in boys” caused by osteosarcoma, he said. “Now the fashion is ADHD and IQ, so they blame fluoridation on that.”

He said that just like parents who oppose fluoridation, the issue is personal to him, too.

“Believe me, if there were serious, professional studies showing harm, I’d be the first to say, stop fluoridating the water,” he said. “I have eight grandchildren to think of.”