IN January 2016, our previous Public Health Minister announced, with barely a ripple, that Scotland might “go it alone” in preventing some birth defects by adding Vitamin B9 (folic acid) to wheat flour. The rationale is the ability of this measure to prevent Neural Tube Defects (NTDs) and therefore many terminations, miscarriages and children born with disabilities. For more than 20 years, the UK Government and Westminster Parliament have been inert, while 80 other countries have safely and successfully enacted this public health measure. On the surface, little seemed to happen recently. But, as with ducks, there has been serious paddling underneath during the past two years.

In January 2018, UK media proclaimed that new research, led by Professor Sir Nicholas Wald, would be a “game-changer” in the effort to prevent the vast majority of NTDs throughout the UK. His work is the capstone on the high international mound of scientific evidence because it revealed that Vitamin B9 is neither toxic nor risky in any plausible amount. Vitamin B9 can now accurately be described as Vitamin “Benign”; strong benefits with no significant downside.

READ MORE: Scotland ‘must add folic acid to flour to prevent birth defects’

The ironies of the UK’s persistent inaction have become ever more apparent. For example, the foundation stone of international research on the massive preventative effect of sufficient Vitamin B9 at the time of conception was a large random controlled trial (RCT) sponsored by the British Medical Research Council in 1991 – and led by the very same Dr Nicholas Wald. The UK provided the resources for his research and honoured him with a knighthood for this contribution to global health science, but never bothered to take his advice.

There is no principled government argument against mandating the fortification of non-wholemeal flour, since (also ironically) the UK has required routinely adding four ingredients – including two other B vitamins – for half a century! Even ardent ‘nanny state’ opponents have (sensibly) not called for existing fortification to be halted. This reality also invalidates any economic argument against adding Vitamin B9, given that the technology is already in place and the cost of adding folic acid to white flour would be negligible.

However, the human and financial cost of the continuing failure to take this simple step toward primary prevention is much higher than imagined. Very few readers know anyone with either spina bifida or any of the four cephalys that afflict babies born with a neural tube defect, i.e. abnormalities of the brain, spine or spinal cord. However, the economic burden on the public purse of each neural tube defect is very significant; in fact, the cumulative total dramatically exceeds the cost of fortification.

It is still not widely understood that NTDs can result in the adverse pregnancy outcomes with which readers are much more aware – terminations, miscarriages, stillbirths and infant deaths. All of these have a financial cost, too, but they pale in comparison with the human costs to prospective mothers and fathers experiencing the usually preventable consequences of NTDs.

Will Sir Nicholas’ latest research findings actually be game-changing, i.e. the tipping point that finally results in Vitamin B9 (folic acid) joining Vitamin B1 (thiamine) and Vitamin B3 (niacin) in becoming a standard ingredient in the UK’s supply of flour? In a more rational world, it would. But, in this Westminster Parliament, the enactment of this public health measure is by no means assured.

The Scottish Government did not just announce this intention and then disappear. At its behest, Food Standards Scotland was instrumental in another detailed review of the case for, and against, fortification. The Scientific Advisory Committee on Nutrition (SACN) unreservedly endorsed Vitamin B9 fortification in mid-2017. In December 2017, Scotland’s current Public Health Minister – along with her Welsh counterpart – wrote a letter to the UK’s Health Secretary urging Westminster to require the addition of Vitamin B9. To date, there has only been a ‘holding’ response.

One other irony in this story is that the House of Lords actually passed a Members Bill in 2017 favouring folic acid fortification (led by Lord Rooker, a former Chair of the UK’s Food Standards Agency). It was then introduced in the House of Commons by an English MP; only to go down the drain as soon as the Prime Minister called last year’s snap election. It has not yet been reintroduced. Will it now? Instead of acting positively on the new game-changing research, will the UK score an “own goal” by kicking fortification into the long grass yet again? Many questions remain, including why Scotland’s representatives at Westminster have been so quiet and passive (at least publicly) on this issue. It is a campaign on which Scottish and Welsh MPs (on a cross-party basis) should take the lead. Will they?

The need to make prevention a reality, instead of merely an aspiration, is sorely needed in Scotland and, especially, at the UK level. This is a golden opportunity to show we mean it when we say that “an ounce of prevention is better than a pound of cure”.

Everyone agrees it is simpler, cheaper and more efficient for Vitamin B9 fortification to occur now at the UK level. But, what if it doesn’t? Scotland has the legal power, and we believe a moral obligation, to finish what the Scottish Government started two years ago. There are worse outcomes than Scotland having to ‘go it alone’ – such as the shameful human and financial costs of standing idly by as preventable terminations, miscarriages, stillbirths, infant deaths and birth defects are not prevented.

Sir Nicholas deserves the final word: “Withholding a benefit is a harm ... failure to fortify is more than a missed opportunity; it is a tragedy.”

Dr Linda de Caestecker is Director of Public Health for NHS Greater Glasgow & Clyde and Chair of Scotland’s Public Health Network. Dr Jonathan Sher is a Visiting Expert at Edinburgh University’s Scottish Collaboration for Public Health Research and Policy (SCPHRP).