The folate debate - no easy choices

Having stalled for three years and tried to minimise public debate, National is facing a tough decision on whether or not to compel bakers to put folic acid in all our bread. Either way, there's a price to pay

So, the thing about making it mandatory to put folic acid in bread is that it's a choice about choice - you can either have "free choice" or you can save up to 24 kids a year from spina bifida. You can't have both. So which do you choose?

That's the end of this journey, though. Let's begin at the beginning, and to do that I need to start by saying 'I'm no scientist'. I'm just a journalist. So I'm relying on other experts for the science and employing whatever skills and judgment 20-something years of journalism have afforded me. So away we go...

What's the issue? Three years ago New Zealand was poised to follow Australia (and Canada, the US and 70 other countries, although none in Europe) and put folic acid in all non-organic New Zealand bread; it was to be mandatory. Then Food Safety Minister Kate Wilkinson went on Q+A and got herself in a tangle.

It was Labour who'd committed New Zealand to the folic course, under our joint food safety regulations with Australia. The likes of Annette King and Steve Chadwick were big fans of the health gains they thought would eventuate -- that is, fewer kids getting spina bifida and other neural tube defects. National, as a centre-right party founded on principles of individual choice, had reservations, but didn't want to upset any apple carts with the Australians and felt obliged to honour the previous government's commitments.

But at that point new research had suggested possible links between increased folic acid intake and cancer. Britain and Ireland had delayed their plans to make folic acid in bread mandatory while it was reviewed. Wilkinson ended up saying that she didn't want to do it, couldn't guarantee it was safe ("the science is light"), but had to do it and would review it soon after introducing it.

It was a mess. So a week later John Key - in the first instance of what has become a bit of a pattern with this government - stepped in to clean up. He announced a deferral until May 2012.

So, with a slight delay, here we are.

A working group has been negotiating this since 2009 and, although you'd hardly know it, is in the midst of public consultation. Indeed, that consultation ends in just a week.

You'd think that a major public health policy change would warrant a major public debate. The "stakeholders" involved seem to think otherwise. Try as we might to get them to discuss this on Q+A, they preferred to stick to their "rules of engagement", which amounted to, well, no public debates. It seems they want to build consensus and the like. To be fair to them, it stems from a reasonable fear that the public may get unnecessarily hysterical about the issue. My read is that the doctors are concerned people will hear "mass medication" and panic, while the businesses are afraid people will stop buying their bread.

But it still sounds a heck of a lot like stitching things up behind closed doors. That's woefully disrespectful of you and me.

Ultimately, the only way to deal with an ill-informed public is to inform them, not shut them out. If those of who eat bread aren't "stakeholders", then I don't know who are.

In the end we were able to get some pros and cons to air. But it's fraught. Certainly the science community here in New Zealand seems largely pro-mandatory fortification. Bakers' groups and Food & Grocery Council are opposed.

The latter are using the research of Emeritus Prof. David Smith, formerly of Oxford University, who claims the link between increased folic acid and cancer is real. He says his thinking is mainstream and properly cautious; the trade-off isn't worth it. In this country, Sir Peter Gluckman, the Paediatrics Society and others say he's talking hokum and is "completely" wrong. Their message: It is safe. Full stop.

What's more, since bread was fortified in the US, cancer rates have fallen and there may be a link to the falling number of deaths by stroke.

I can't go much further on the science without leaving the shores of my usefulness far behind, but there are a couple of underlying points worth exploring.

First, our rate of neural tube defects (NTDs) has been falling at much the same rate as it has in the US, where their bread is fortified. All agree on that. So is our improving nutrition and good rates of folic acid amongst women fixing this without the need for mandatory fortification?

To some extent. NTDs have roughly halved since voluntary fortification began in 2009. But Dr Andrew Marshall of the Paediatric Society reckons another 24 kids could be saved from those defects every year if it was made mandatory.

So it seems to come down to this: Do you believe there's a cancer risk or not? Most of the science suggests there's no risk; that which does suggest a possible risk says it's "borderline".That risk, as I understand it, is that it may stimulate existing cancer cells in a few sub-groups of the population. No-one's saying it will "give" you cancer.

Everyone has to come to their own conclusions as to who they believe on that front.

But what seems to upset most people about this is the lack of choice. How dare my right to choose not to eat consume folic acid be removed? And how dare the government decide what goes in my food?

To which I'd reply, they already do. We have food standards up the wazoo. But to be fair, this is an additive, something extra. And people are rightly skeptical.

Then again, what if it was Vitamin C? Would people feel as fearful of a more familiar vitamin? In other words, is choice the issue or does it really come back to risk?

Many say, why not just put it in some bread and leave the rest (as we do now)? Why not educate pregnant women? Why not target it more? If only it were that easy.

Because here's the nub: That won't work for those 24 kids. Or put another way, those kids who can be saved from NTDs by folic acid later in pregnancy are already being saved.

The reality is that many women get pregnant without planning to -- especially those who are young, can't afford many GP visits for "education" and are most resistant to public health campaigns. Even those planning a pregnancy might take a long time to strike oil. And for folic acid to work for those extra 24 kids each year, their mums have to be taking it before they get pregnant.

By the time a woman has found she's pregnant -- typically some weeks after conception - those defects are already there. It's too late to folate, you might say.

So by my reckoning it comes down to an uncomfortable choice. You either protect that free choice or you protect those children. You can't have both.

Still reckon you could run the country better? It's a rotten choice, really, but one we have to make as a country in a matter of days.