Bread and Flour Regulations (Folic Acid) Bill [HL]

Lord Rooker Excerpts

Friday 8th July 2016 Lords Chamber

Moved by

[Lord Rooker]

That the Bill be now read a second time.

[Lord Rooker (Lab)]

My Lords, my Bill concerns a measure of preventative medicine designed to reduce the number of children born with a lifelong serious disability and reduce the high level of terminations of affected pregnancies following antenatal screening and diagnosis. Some may think the number is small. We are talking about approximately 1,000 pregnancies per year in the UK, of which 80% are terminated. We can do something about this, and in my view we should act.

In 1991, UK research by a Medical Research Council team discovered that a deficiency of vitamin B9, folic acid, is the cause of neural tube defects. The defect is that, just after conception, the neural tube does not close as it should. This leads to defects of the brain, spine and spinal cord leading to spina bifida and other serious, lifelong disabilities. The neural tube closes at 27 days, which for most women is before they know they are pregnant.

In all health matters, it is wise for Parliament and government to take expert advice. Following the 1991 ground-breaking UK research, in 2000 the then Committee on Medical Aspects of Food and Nutrition Policy gave advice to government to improve the blood folate status of the UK population through the mandatory fortification of flour with vitamin B9, folic acid. This advice was repeated by the Scientific Advisory Committee on Nutrition in 2006 and in 2009. The Food Standards Agency gave similar advice in 2007 and 2009.

Further research was requested by one or more of the Chief Medical Officers, and it was conducted by various scientists. Several aspects were looked at, including a possible male colon cancer rise due to folic fortification, but a peer-reviewed study of 50,000 cases published in 2013 found no evidence. The National Diet and Nutrition Survey was requested in particular to check the blood folate levels in the whole population, especially among women of child-bearing age. This took some years and the results were published in March 2015. The results showed that the blood folate levels for UK women are below the WHO thresholds.

By October 2015, the Scientific Advisory Committee on Nutrition had collated all the latest evidence, and on 20 October wrote to all four Health Ministers in England, Scotland, Wales and Northern Ireland. Its eight-paragraph letter alerted Ministers to the recent information, the WHO studies, evidence from the USA and the blood folate levels, as well as concerns that the UK food industry was actually reducing amounts of voluntary folic acid in its products. In summary, the letter repeated the advice of 2006 to go for the mandatory fortification of flour.

My Bill would effectively put that advice into legislation. Drafting a Bill like this was easy. As the UK already fortifies flour on health grounds, vitamin B9, folic acid, can simply be added to the list.

To date, the policy in the UK has been that women planning pregnancy should take folic supplements. Health is of course a devolved matter, but there are two problems here. First, the UK has the second-highest number of unplanned pregnancies after the USA. Secondly, the use of supplements is in decline. Taking supplements after becoming aware of pregnancy is too late, as this will be after 27 days. A preventative medicine strategy to cut the numbers of affected pregnancies has to take these facts into account. It cannot be that 80% of terminations after the 20-week scan is a preventative strategy.

Recent peer-reviewed research published in February 2014 by a team led by Sir Nicholas Wald, the leader of the 1991 Medical Research Council study, showed that in a 10-year study of 500,000 women in the UK the policy of advice regarding supplementation was not working. The study showed a decline in women taking supplements from 40% in 1999-2001 to 28% in 2011-12. It showed that women under the age of 20 were five times less likely to take folic supplements than women aged 30 and over. Even among women who had previously had a neural tube defect pregnancy, only half were taking supplements. The conclusion was stark: the current government policy was,

“failing and has led to health inequalities”.

On average, 69% of women of child-bearing age are not taking supplements. Half the pregnancies are unplanned. It cannot be right there is no proper strategy.

In my view, saying that it is individual responsibility is unacceptable. Department of Health officials have been known to say that terminations after the 20-week scan identifies the defect are how the issue is managed, and have stated that dealing with neural tube defects via folic fortification is “not a vote winner”. This was told to a public meeting in Parliament last year, and the Minister is aware of the source.

Based on the 1991 UK research, over 80 countries have introduced the mandatory fortification of white bread flour with folic acid, vitamin B9. There is abundant evidence of efficacy and no suggestion of any harm. It reduces the abnormality by up to 50%, though I have seen some research giving an even higher figure than this. The USA mandated the fortification of flour in 1998, based on the 1991 UK research. Recent American published research showed a significant reduction in neural tube defect births there, and they have a Folic Acid Awareness Week. There has been a large saving in America both in human misery and public expenditure. The US expenditure saving on averted medical costs alone for surviving babies is put at $600 million. It spends $4 million on fortification.

No country which has introduced fortification has reversed the decision. The various countries that have introduced it include America, Australia, Iran, Chile, Iraq, Canada and Saudi Arabia. In July 2015, a report on preventable spina bifida in Europe reached the conclusion that Europe has an epidemic of spina bifida compared to countries that apply mandatory fortification. The prevalence of neural tube defects per 100,000 births in the UK, Denmark, France and Germany is in general twice the level in the United States of America, where flour has been fortified for nearly 20 years.

There is a need for a strategy on neural tube defects rather than a campaign for fortification. It is not mass medication, as only white bread flour has ever been involved, so the argument about mass medication does not apply. Research galore has shown no ill effects on the male population. The principle of flour fortification in the United Kingdom is not at stake. The UK has fortified flour on health grounds since World War II with four substances: two vitamins and two chemicals. That was last reviewed in 2013 and a decision to continue that was made by the coalition Government. Industry pays for the fortification, by the way, so it is not a question of public expenditure. People will say that the numbers are not huge, but they are bound to grow as supplement-taking declines and as industry reduces voluntary fortification.

I am in favour of a woman’s right to choose, but I reject the Department of Health view on managing neural tube defects by termination. That is quite unacceptable. The human tragedy, much of which could be avoided by a science-led policy, should be the reason for a push on policy change. There are too many terminations, and too many babies are born with a serious lifelong disability. Mandation is needed to reduce this human distress and misery, to save lives by avoiding terminations, and to prevent lifelong disability and significant public health costs.

During the many times I have raised this matter over the last few years, I have never used any real-life examples, because the science tells the story. However, yesterday I found a letter from a colleague, who is absent from the House at present due to poor health. Although we knew each other for many years before we joined your Lordships’ House, they have never mentioned their family history to me. Our colleague’s letter said that before our colleague was born,

“my parents lost three children to spina bifida: one was still-born, one lived for a year and another for 6 weeks. The grief caused by these deaths cast a very long shadow over my parents’ lives and indeed over my own—I felt an obligation to live for the three of them. The point is that this degree of suffering is largely avoidable by measures like your proposal”.

We have the means, not for a complete cure but vastly to decrease this harm and misery. I cannot see how we can stand by and do nothing when we have the chance to reduce the human misery caused by neural tube defects. I beg to move.

--- Later in debate ---

[Lord Rooker]

My Lords, I do not propose to make a windup speech, but I thank all colleagues who have spoken—I am very grateful. I am grateful to the Minister as well, because we have had a little more time today than we get in Question Time exchanges. I understand where he is coming from. I do not accept it, but at least he has put things on the record about the philosophy argument that will be useful for the future.

It is a bit like somebody in South America at the moment finding a real cure for the Zika virus and not using it. We are standing by with a 100% cure and not using it. I used the example of the United States of America. They do not just do fortification, they have a disability child awareness month and a folic acid awareness week as well—we do not even do that; that is refused as well in Parliamentary Answers—that is voluntary, but they see the benefit of it. Basically, you are on your own, girls. That is a summation of where we are. The Government refuse to accept the fact that half of pregnancies are unplanned. Despite any pre-conception advice, half of pregnancies are unplanned. People will not be listening. That is one of the problems.

I tried to keep my speech devoid of all the scientific quotes, but the issue about the industry is important. I fully accept that the advice to industry from the Scientific Advisory Committee on Nutrition on mandatory fortification was, “Be careful what you do voluntarily”. Since its warning letter last October, industry has taken steps to reduce its voluntary folic acid fortification on the basis that the advice of 2006 would be implemented at some time—that is, there would be mandatory fortification. We have a problem. The industry is reducing voluntary fortification and we are not introducing mandatory fortification, so the position will be even worse. The blood levels will be even lower as a result. That is a cause for concern and I have not heard a solution to it.

I also avoided any reference to devolution. The English Government, for whom the Minister speaks—he does not claim to speak for anyone else—could well be faced, in the next couple of years, because these things take a while, with Scotland, Wales and Northern Ireland legislating for white bread flour fortification. The mills are in the wrong place when one looks at the borders. Industry wants a UK solution. As I said, during the general election, I wasted time knocking on doors, but I also spent time with Sir Nicholas Wald and Sir Colin Blakemore visiting the supplement manufacturers and others. It is quite clear that they want a UK-wide solution.

In September, the Cabinet Secretary for Health and Sport in Scotland and the Chief Medical Officer in Scotland had a meeting with myself, Sir Nicholas Wald and Sir Colin Blakemore to listen to the argument. They do not have all the solutions, and do not profess to have all the answers. Scientists do ask the question, which is why, when I left the Food Standards Agency, I said I would pursue this. The independent scientists were saying on this and on other issues that Government never pronounce about the advice. In this case, the Government have pronounced; they said no. I fully accept that; there is no doubt about that any more. We know where we stand, but I am not going away, and I beg to move the Bill be read a second time.

Bill read a second time and committed to a Committee of the Whole House.