The Big Mac Index says one thing about SA. The new fluoride toothpaste index says different.

  • The WHO says fluoride toothpaste is an essential medicine because of its value in preventing cavities in teeth.
  • European scientists investigated how affordable fluoride toothpaste is around the world.
  • SA came 19th out of 78 countries they examined, meaning fluoride toothpaste is relatively unaffordable.
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The Big Mac Index tells us the rand is undervalued but it doesn’t tell us how fast food affects our health.

Now scientists have come up with a global index which plugs part of that knowledge gap – and it’s not great news for South Africans and their dental health.

The fluoride toothpaste affordability index was developed after the World Health Organisation decided the product is so good at preventing dental cavities that it should be on its model list of essential medicines. These are formulations “intended to be available in functioning health systems at all times … at prices individuals and health systems can afford”.

The European scientists, who published their new index on Wednesday in PLOS One, tested affordability by comparing the cost of fluoride toothpaste with the estimated daily wage of the lowest-paid unskilled government workers – a benchmark recommended by the WHO.

They came up with an index of 78 countries and found SA had the 19th most expensive fluoride toothpaste. 

The local cleaner or labourer they had in mind needs to work for 1.38 days to be able to buy a 182.5g tube, they say. That compares with 11.8 days in Benin – the country with the most unaffordable toothpaste – and 0.028 days in New Zealand, which tops the index.

Lesley Vorster, whose 2019 doctoral thesis in the University of the Western Cape dental faculty analysed the economics of the toothpaste industry, says the outcome confirms her findings and is bad news for the nation’s dental health because fluoride is the scientifically accepted gold standard in cavity prevention.

Her concerns are amplified by the results of a 2020 study at Stellenbosch University which found that two-thirds of a Capetonian population had high levels of decayed, missing, and filled teeth.

The Big Mac Index was invented by The Economist magazine in 1986 as “a lighthearted guide to whether currencies are at their ‘correct’ level”.

The Economist says it is based on the theory that “in the long run exchange rates should move towards the rate that would equalise the prices of an identical basket of goods and services (in this case, a burger) in any two countries”.

It has become a global standard, and the latest edition in July implied an exchange rate of R7.75 to the dollar, when the actual rate was R17.04. (The rand has since weakened to R18.25.)

A Big Mac contains about 9g of sugar, which is a quarter of a man’s recommended daily intake and a third of a woman’s, and this provides the link between the two indices because high sugar consumption is one of the root causes of dental cavities. The damage sugar causes is compounded by poor oral hygiene and limited access to fluoride toothpaste, the European scientists say, and the three factors combine to make tooth decay one of the world’s most prevalent lifestyle, or noncommunicable, diseases.

That is why government regulations on the price of medical products should be amended to make fluoride toothpaste as cheap and accessible as possible, they say.

Vorster told Business Insider this is in line with the policy recommendations in her thesis, but she says another vital step is the addition of fluoride toothpaste to SA’s essential medicines list. 

The WHO move “gives oral health professionals a very strong platform from which to advocate for inclusion of fluoridated toothpaste on SA’s national essential medicines list and standard treatment guidelines. This has not yet been achieved,” she said.

For now, the list has no suggestion for how to prevent dental cavities, saying only: “To be managed by a dentist or dental therapist.” 

Generic competition, high-volume production, and support for local production could lower toothpaste prices, according to the World Trade Organisation.

Community, school and workplace programmes should provide free fluoride toothpaste, say the European scientists, and they call for the elimination or reduction of VAT on the product  a recommendation also made by Vorster.

“Any reduction in VAT or other tariffs would be beneficial for fluoride toothpaste due to the regressive nature of such levies affecting poorer households more than richer households,” they say.

“Finally, profit margins for toothpaste products along the production and logistics chains are significant. Packaging and marketing have a large share in production costs, which leads to a low-price segment of unbranded products sold by large retailers.”

The researchers say the WHO decision to make fluoride toothpaste an essential health product provides a “unique and pertinent opportunity to address [its] affordability.” In her 2019 thesis, Vorster called for the establishment of a Central Toothpaste Fund to subsidise fluoride toothpaste, and estimated the cost at R131.45m if it benefited everyone living in poverty.

Over time, reduced demand for “costly therapeutic and restorative dental services” may even produce a saving, she said, even though it was hard to put a figure on the cost of inadequate access to fluoride toothpaste.

Researchers calculated in 2015 that treating cavities only in under-12s in the Western Cape would cost around R1bn. “In general, caries (cavities) and untreated caries pose a significant challenge that disproportionately affects the poor, in terms of individual morbidity and macroeconomically due to diminished productivity, increased reliance on government income support and greater healthcare expenditure,” said Vorster in her thesis.

“A recent study has shown that 12% of international productivity loss due to dental disease could be ascribed to untreated caries. Consequently, for all stakeholders it is imperative that dental caries be prevented.”


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