Day: February 14, 2017
Zbigniew L. Olkowski -genealogia
...dokument ten pochodzi z Archiwum Glownego Akt Dawnych w Warszawie z ksiag sadowych - przasnyskie ziemskie wieczyste. 1788, PZW, sygn.32, k.187; #Kazimierz Olkowski, syn +Józefa de Niesułowo, zapisuje Zofii Bobińskiej, córce Konrada i +Antoniny z Chodkowskich, pannie, przyszłej swej żonie 500 złp. na swych dobrach. Czyli matka Antoniego Olkowskiego zmarlego w 1849 r. w Krasnosielcu byla z domu Bobinska. Jej ojciec Konrad Bobinski zenil sie dwa razy. Najpierw okolo 1760 r. z Antonina Chodkowska, corka Grzegorza Chodkowskiego i Zofii z Biedrzyckich, a wnuczka Fabiana Chodkowskiego i Marianny z Chodkowskich. A nastepnie, po owdowieniu, w 1780 r. w Krasnosielcu z Teresa Olkowska, rodzona siostra Kazimierza Olkowskiego!
Scientific knowledge in controversy: the social dynamics of the fluoridation debate
Scientific knowledge in controversy: the social dynamics of the fluoridation debate Brian Martin with a commentary by Edward Groth III Published in 1991 by State University of New York Press, Albany The version here differs from the published version in a number of details of expression, a different format, different page numbering (151 instead of 274 pages) and omission of the index. Contents 1. Introduction 1 2. Arguments 9 3. Coherent viewpoints 27 4. The struggle over credibility 40 5. Professional attack 66 6. A corporate connection? 84 7. Making a decision 94 8. Studying the controversy 106 The fluoridation controversy: which side is science on? by Edward Groth III 122 Appendix: Fluoridation around the world 137 Acknowledgments Albert Burgstahler, Edith Waldbott, and many others (too numerous to mention) plied me with valuable information through correspondence. Gay Antonopoulos obtained copies of many publications for me through interlibrary loans. I thank the individuals listed in chapter 3 for their generosity in being interviewed. Discussions with Mark Diesendorf and Evelleen Richards provided me with insights. I received a large number of valuable corrections and comments on the earlier drafts from Albert Burgstahler, Brian Burt, John Colquhoun, Mark Diesendorf, Edward Groth III, Michael A. Lennon, Pam Scott, John Small, Donald Taves, and several anonymous reviewers. I especially thank Edward Groth III for his mammoth correspondence and for writing the commentary.
The 1 August 1988 issue of Chemical & Engineering News contained an article that caused a sensation in the long-running controversy over fluoridation. “Fluoridation of Water,” a special report written by associate editor Bette Hileman,1 surveyed the arguments both for and against the measure. Fluoridation is the addition of the element fluorine — called “fluoride” when in an ionized form — to public water supplies as a measure to help prevent tooth decay in children. Hileman’s article outlined the standard view that fluoridation greatly reduces tooth decay, but also presented criticisms of this view. It described evidence both for and against claims that fluoridation may be involved in health problems, such as kidney disease, hypersensitive reactions, and cancer. It also recounted some of the methods used in the ardent promotion of fluoridation. Hileman had not been involved in the fluoridation debate that has raged for decades. In writing the article, she studied the issue and consulted both supporters and opponents of fluoridation. The ideas in her article were not new, and most of the evidence had been canvassed repeatedly in other forums. Why, then, did it cause such an impact? The reason is that never before had such a major scientific publication presented both sides to the debate in such an extensive treatment. In particular, never before in recent decades had a major professional association, such as the American Chemical Society, publisher of Chemical & Engineering News, given the scientific criticisms of fluoridation such credibility.2 In the English-speaking countries at least, fluoridation has long been virtually untouchable for “serious scientists.” Opponents of fluoridation have been categorized as cranks, usually right-wing, and akin to those who think the earth is flat.3 In most dental, medical, and scientific journals, the arguments against
fluoridation are given little space and little credence. The Chemical & Engineering News article represented a dramatic contrast to the usual dismissal of antifluoridation views. The article generated news stories around the country and overseas, and led to a large volume of correspondence in later issues. Not surprisingly, opponents of fluoridation were delighted with the article; supporters were dismayed. More significantly, many correspondents congratulated Bette Hileman and Chemical & Engineering News for raising both sides of the issue for public discussion. A BRIEF HISTORY The use of fluoride to prevent tooth decay was promoted by various individuals in Europe in the 1800s.4 But the key events on the road to fluoridation occurred later and in the United States. Frederick McKay, a dentist, first noticed staining of teeth in his Colorado patients in 1901. The colors ranged from white, yellow, and brown to black. In serious cases, there was also pitting of the enamel. Unlike most others who had noticed this mottling, McKay was intrigued by it and, over the next three decades, he pursued its origins. He noticed that, whereas people who had lived in a particular community from birth had stained teeth, newcomers to the district did not. Further investigation convinced McKay that water supplies were responsible. It was not until 1931 that chemical analysis provided an answer to what was causing the discoloration: fluoride. H. V. Churchill, chief chemist at the Aluminum Company of America, supervised tests on water samples and, with McKay’s help, established a connection between fluoride in drinking water and mottled teeth. At about the same time, researchers M. C. Smith, E. M. Lantz, and H.
V. Smith in Arizona were able to produce mottling in the teeth of rats by feeding them fluoride. Also in the same year, H. Velu reported the fluoride-mottling link based on work in Morocco and Tunisia. McKay had long observed that mottled teeth, although unsightly, seemed to be more resistant to decay. Discovery of the fluoride connection finally stimulated the United States Public Health Service (USPHS) to investigate the issue. Led by H. Trendley Dean, USPHS scientists (mainly dentists) carried out surveys of decay in towns with different fluoride levels and also carried out experiments with animals. A range of levels of fluoride led to the severe mottling observed by McKay and others. Severe mottling was widespread at five parts per million (ppm) and above, but less common at lower concentration.5 Investigators looked to see whether there was a concentration that avoided most mottling while providing the benefits of reduced tooth decay. The level judged to be optimal in this regard was 1.0 ppm. Only a small fraction of water supplies have high levels of fluoride naturally. Most have less than 0.2 ppm, a concentration too small to provide much impact on decay. In 1939, it was first proposed to add fluoride to waters that naturally have low fluoride levels. Fluoride would be added to bring the concentration to about 1.0 ppm. The proposal struck a chord with a small number of dentists and public health officials in the United States who began campaigning vigorously for fluoridation. Many others were more cautious, including national health administrators and USPHS scientists who were still studying the dental effects of fluoride. In 1945, the first of a number of trials was begun. In these studies, two cities with similar characteristics were selected. Both had low natural levels of fluoride in the water. One city had fluoride added to its water supply, while the other’s water remained unfluoridated. Rates of tooth decay in the cities were monitored by periodic examination of children’s teeth. The first study involved Grand Rapids, Michigan, where water was fluoridated in
1945. The water supply in control city, Muskegon, also in Michigan, remained unfluoridated. In the same year and in New York State, Newburgh’s water was fluoridated, while Kingston served as the control. Other important early studies involved fluoridation of the water supplies in Evanston, Illinois, and Brantford, Ontario. Oak Park, Illinois, and Sarnia, Ontario, served as the respective controls. At the time, it was thought that fluoride acted by being incorporated into the growing enamel of children’s teeth. Hence, it would take quite a few years to see the full effect of fluoridation. The trials were planned to last ten or fifteen years. But after only a few years, the reported reductions in tooth decay were quite striking. The proponents of fluoridation — in particular, a few enthusiastic advocates such as Wisconsin dentist John G. Frisch and Wisconsin dental administrator Francis Bull — were impatient with delay. Their lobbying was aimed especially at administrators in the USPHS, the most influential body in the public health field. H. Trendley Dean, whose work helped lay the ground for fluoridation, was not a supporter of rapid implementation, preferring to wait for the full results of the fluoridation trials. Along with others, his view was influential in maintaining the USPHS’s cautious stand throughout the 1940s. The high-pressure tactics of Frisch, Bull, and others eventually won out. The top administrators of the USPHS apparently overruled Dean,6 and, in 1950, the USPHS endorsed fluoridation. Shortly afterward, two key professional bodies — the American Dental Association (ADA) and the American Medical Association (AMA) — also expressed support. In the United States, however, decisions concerning public water supplies are made at the level of states, cities, or towns. The USPHS endorsement did not force any community to fluoridate, but it did provide vital authoritative backing for local individuals and groups that pushed for it. The endorsements by the USPHS, ADA, and AMA were based on the claim that
fluoridation resulted in massive reductions in tooth decay, typically quoted as 50 to 60 percent, with no associated health risks, and at little cost to the community. At the time, dental decay was widespread, and many dentists felt unable to cope with it. Many people had all their teeth removed at an early age due to decay. In this environment, fluoridation was an attractive proposition. During the 1950s, a large number of communities moved to fluoridate their waters. But almost as soon as the push for fluoridation began in the 1940s, a vocal and persistent opposition arose. In many communities where fluoridation was proposed, there were local individuals and groups that claimed that it was dangerous. The opponents typically claimed that it caused certain health problems in some people, and that it was ”compulsory mass medication” and, therefore, unethical as well as an abuse of government power. This basic configuration of proponents and opponents has persisted from the 1940s until today. The arguments on each side have remained essentially the same. The proponents assert that fluoridation massively reduces tooth decay rates, has no proven adverse consequences for health (except negligible mottling of teeth, which is only of cosmetic concern), and is the cheapest and most effective way of getting fluoride to all members of the population. The opponents say that the benefits are overrated, that there are a variety of proven or possible adverse health consequences (including skeletal fluorosis, intolerance reactions, and cancer), and that fluoridation is unethical because it is compulsory medication with an uncontrolled individual dosage. Although the arguments have remained much the same, the fortunes of fluoridation have waxed and waned. The population drinking fluoridated water in the United States greatly expanded during the 1950s, but the opposition caused local reverses and stopped many proposals. Since the 1960s, the fraction of the U.S. population served by water supplies with added fluoride has increased only gradually, and now hovers at about one half.7
From the United States, the message about fluoridation was sent around the industrialized world. Dental and medical authorities, after investigation, usually endorsed the measure. In several countries — especially Australia, Canada, Ireland, and New Zealand — the pattern has been similar to that of the United States: there has been widespread adoption of fluoridation in the face of strenuous opposition. On the other hand, in Britain, only one in ten people drinks fluoridated water. In continental Western Europe, the measure was greeted even more cautiously by government bodies, and fluoridation is found in only a few localities. Only in the Netherlands did a sizable fraction of the population ever receive fluoridated water, and that program was terminated in the 1970s. By contrast, several Eastern European governments have introduced fluoridation on a more substantial scale, although it is far from universal. In nonindustrialized societies, fluoridation is not usually a feasible proposition. In some countries, tooth decay was not much of a problem as long as the diet remained sufficiently traditional. But as the diet became Westernized, with large amounts of refined and sugary foods, tooth decay became a serious problem. The main obstacle to fluoridation in nonindustrialized countries is a lack of centralized public water supplies. Often, water is obtained from private wells not suitable for fluoridation.
Table 1 Percentage of the population served by water supplies with added fluoride, in selected countries in the late 1980s. For details see the appendix. 66 Australia 0* Austria 0 Belgium 21 Brazil 36 Canada 10 Chile 21 Czechoslovakia 0 Denmark 10 Fiji 2 Finland 0 France 20 East Germany 0 West Germany 0 Greece 0 India 0 Iran 66 Ireland 20 Israel 0 Japan 0 Lebanon 0 Netherlands 50 New Zealand 0 Norway 7 Papua New Guinea 0* Philippines 3 Poland 0* Portugal 0 Romania 100 Singapore 0 South Africa 15? Soviet Union 0 Sweden 3 Switzerland 0 Thailand 0 Turkey 9 United Kingdom 49 United States 0 Zimbabwe * Greater than zero but less than 0.5 percent.
The proponent case has had no dramatic developments since 1950. The early promoters of fluoridation — including prominent figures such as H. Trendley Dean, John G. Frisch, and Francis Bull — have been followed by many others, such as Frank J. McClure, Ernest Newbrun, Herschel S. Horowitz, and Brian Burt. Other countries have their own lists of prominent proponents, including Douglas Jackson, John J. Murray, and Andrew J. RuggGunn in Britain, and Noel Martin, Lloyd Carr, and Graham Craig in Australia. The proponents refer to an accumulating body of data supporting the efficacy of fluoride in preventing tooth decay. They have also produced critiques on claims of hazards. Compared to the proponents, it is easier to single out scientist opponents around the world. George Waldbott was undoubtedly the most prestigious opponent in the United States from the 1950s until his death in 1982. Others have been Frederick Exner, Albert Burgstahler, and John Lee. These critics have concentrated on the health hazards of fluoridation, including allergic and intolerance reactions. In the mid 1970s, John Yiamouyiannis and Dean Burk joined the debate when they made dramatic claims about a link between fluoridation and cancer, and, since then, this issue has been a continuing and contentious one. Yiamouyiannis is the most prominent scientist opponent in the United States today. Another side to the opponents’ case is a critique of the evidence that fluoridation enormously reduces tooth decay. Waldbott, Exner, and others introduced this point, but the earliest comprehensive critique was presented by Philip Sutton, an Australian dental researcher, in 1959. In the 1980s, the critique of the size of benefits was taken up by John Colquhoun in New Zealand; Mark Diesendorf, Australia; John Yiamouyiannis, United States; and Rudolf Ziegelbecker, Austria. These individuals rank among the world’s leading scientist opponents of fluoridation.8 The fluoridation debate has been such a bitter one that it is virtually impossible to say anything on the topic that cannot be questioned by one side or the other, or both.
This applies to the history of fluoridation as much as to anything else. The abbreviated account I have given is largely the picture as presented by the proponents of fluoridation.9 Some opponents have emphasized other events in the history, and given a different complexion to the whole account. I will have occasion to return to some events that have been the subject of debate. Suffice it to say that the selection of historical events as significant and the interpretation of motives are influenced by the stance of those making the selections and interpretations. ANALYZING THE FLUORIDATION CONTROVERSY The confrontation between expert proponents and opponents of fluoridation is a central focus in this book. By contrast, most social scientists have treated fluoridation as scientifically beyond dispute and have ignored natural scientists who are opponents. These social scientists have focused on the popular opposition to fluoridation and tried to explain it by factors such as ignorance, political conservatism, alienation, and confusion. This approach exempts the scientific aspects of fluoridation from scrutiny. The resulting analyses of the controversy are one-sided, usually serving the proponents by implicitly denigrating the opponents. To analyze the fluoridation controversy, I prefer to use instead what can be characterized as a power picture of science.10 Instead of treating science solely as a search for truth, science is analyzed like other social activities such as advertising or transportation. In this picture, science is something people do that serves some interests in society more than others, especially the interests of scientists themselves and other groups with money and power enough to fund research and apply results. Power is involved in all aspects of the practice of science, even in the daily processes by which scientists make decisions about what is valid knowledge. What is counted as knowledge depends on getting agreement from
other scientists, and this may involve funding, status, or persuasive ability. Fluoridation is a good topic for examining the dynamics of science and power because the opposition, while far from entirely successful, has not been totally submerged. The profluoridationists have been largely successful in maintaining their views as dominant among key groups in English-speaking countries, and this helps reveal the processes by which orthodoxy is established and perpetuated. But this insight is made possible by the persistence of a minority opposition, which ensures that the exercise of power in science is, to some extent, brought out into the open. Furthermore, the issue has been a public one, and this means that many of the arguments for and against fluoridation have been spelled out with exceptional clarity. Internal disputes within the scientific community about theories of chemical catalysis, for example, do not generate very much accessible material for analysis. Finally, fluoridation combines technical, political, and ethical dimensions in a potent mixture. In using the power picture of science to analyze fluoridation, I employ a variety of concepts and approaches. One is the idea of a “resource” or “tool.” Various elements — including slogans, claims of scientific knowledge, publications (Hileman’s article, for example), professional prestige, authoritative endorsements, community organizations, governments, and the mass media — have been used as resources in the struggle over fluoridation. Another important concept is interest. For example, scientists have an interest in obtaining publishable results, establishing a good reputation, and having a good job. Corporate executives have an interest in increasing sales and profits, and also in protecting their executive status and privileges. The idea of “social structure” or “social institution” is also valuable. For example, capitalism is a way of organizing work based on private property and the purchase of labor power. This results in patterned sets of
relationships between people, such as the employer-employee relationship. Rather than try to analyze fluoridation by using a single unified theoretical picture, I prefer to approach it at a series of different levels, using the concepts already mentioned where appropriate. I have selected parts of the controversy that highlight the interacting roles of knowledge and power. Chapters 2 through 6 can be seen as a series of examinations of the fluoridation debate, each showing the exercise of power on a successively larger scale. Each chapter reveals a power dynamic that casts a different light on the preceding chapters. In chapter 2, I examine the arguments raised by scientists who support or oppose fluoridation in relation to benefits, risks, individual rights, and decision making. This can be considered to be an analysis at the level of intellectual debate, although, even here, the role played by other factors can be observed. In detailing the arguments, chapter 2 also sets the stage for the later analysis. Proponents and opponents line up in an almost completely predictable fashion on the entire range of arguments, from science to ethics. Chapter 3 probes this remarkable coherency of viewpoints, which can be explained as a product of the polarizing nature of the fluoridation debate itself: the partisans develop their coherent views in order to make a solid case in the rough and tumble of public debates and campaigns. This analysis at the level of social psychology suggests that the scientific arguments outlined in chapter 2 have been shaped, directly or indirectly, by the requirements of public fluoridation debates. Chapter 4 turns to the struggle for credibility, which involves obtaining authoritative backing and attacking the credibility of those on the other side. This means going far beyond attacking the credibility of scientific statements, which would constitute part of an intellectual dispute. Rather, the attack is on the credibility of individuals as scientists and as honest, sensible, and upstanding citizens. This is a level involving every possible use of rhetoric against the reputations of individuals as a tool in a struggle for authority. The
existence of systematic attempts to undermine the credibility of individuals as people — rather than the credibility of their arguments, and to gain support on the basis of authority — shows the limitations of dealing only with arguments and views as in chapters 2 and 3. Another exercise of power has been control over publication, research funding, and professional accreditation. In all these areas there are examples of the overt use of the power of the dental profession against antifluoridationists. Chapter 5 examines this side of the controversy by placing it in the context of the dental profession’s support for fluoridation. This analysis at the level of professional power shows that the debate over scientific knowledge about fluoridation has involved more than language. It is not solely an intellectual dispute, nor a verbal duel for authority and credibility, as treated in chapters 2 to 4. Rather, the material basis for scientific communication, scientific research, and professional advancement — namely, publications, research grants, and accreditation — have been used as tools in the struggle. Moving beyond a focus on individual researchers and partisans, chapter 6 looks at the role of industrial corporations whose interests may have shaped the context of the fluoridation debate. This analysis, at the level of corporate power, suggests that the issue of fluoridation might not have arisen in the form that it took — or even become an issue at all — had the historical configuration of corporate interests and the dental profession been different. Proceeding through chapters 2 to 6, the focus changes from the exercise of power at the level of individuals and arguments to the role of power at the large scale of social structures. All levels are required for a full picture. The large-scale, structural perspectives provide the context for detailed disputation; without these wider contexts, the debate might be imagined to be proceeding on the basis of fact and logic alone. But the structural perspectives do not tell the story by themselves. Rather, they provide a framework for and an influence on debate. Even so, only a
detailed examination can tell what arguments are actually developed and deployed. In chapter 7, I attempt to draw out some implications of the analysis. How should the debate be resolved? Can the debate be resolved? In retrospect, how could the proponents and the opponents have improved their strategies? I conclude that there is no simple answer to any of these questions. In confronting the fluoridation debate, one also confronts — implicitly or explicitly — basic issues about the organization of society. A basic theme in my analysis is that it is impossible to separate the scientific and power dimensions of the fluoridation issue. In order to assess the scientific work on fluoridation, it is necessary to understand the wider social context — the careers of key individuals, the commitment of the USPHS and the ADA, and the potential of corporate support or hostility. All of these can influence what scientific research is done or not done, the predisposition of researchers to obtain particular types of results, and the assessment of contrary findings. The body of research relating to fluoridation and the common evaluations made of it cannot be separated from the wider power dimensions of the controversy. Conversely, it is impossible to understand fully the power dimensions of the controversy without assessing the scientific issues. The common view that fluoridation is scientifically beyond question, as well as the minority view that it is scientifically indefensible, eliminate the possibility of understanding how scientific knowledge claims are embedded in power struggles. Assessing the struggles over scientific knowledge is essential to a full understanding of wider power dimensions. It is not my task in this analysis to either support or oppose fluoridation. So far as I am concerned, that is a side issue. My interest is in the analysis of scientific knowledge as it is used and shaped in the course of a bitter public dispute. In developing my analysis, I have benefited greatly from a handful of writers who have analyzed the issue without assuming that fluoridation is scientifically correct.11 Chapter 8 deals with the social analysis of the fluoridation controversy. I briefly describe
standard approaches in previous studies, contrast my own approach with them, and defend my formal agnosticism about fluoridation. I also recount a potential difficulty encountered by those studying contemporary controversies: the involvement of the researcher, reluctant or otherwise, directly in the controversy. In this book I present one way of looking at the issue of fluoridation. It is certainly not the only way. It is my hope that, in selecting some perspectives not often given attention previously, some will see this issue in a new light. When I circulated the first draft of this book to a range of individuals for comment, I also invited them to write responses to my text. Edward Groth III took up this offer, and I am greatly pleased to have his insightful essay as part of this book. It deals with how to assess the scientific evidence on fluoridation. It is highly appropriate that Groth’s views should be represented here, since his pioneering work on the fluoridation controversy has received insufficient attention.12 NOTES 1. Bette Hileman, “Fluoridation of Water,” Chemical & Engineering News, vol. 66, no. 31 (1 August 1988): 26-42. 2. Stated in each issue of Chemical & Engineering News is the disclaimer that the American Chemical Society “assumes no responsibility for the statements and opinions advanced by the contributors to its publications.” Nevertheless, the views expressed are given considerable legitimacy by their very publication. 3. In a special issue of the Journal of the American Dental Association on fluoridation, the introduction likened antifluoridationists to those who opposed fire and the wheel, who believed the earth is flat, who opposed the automobile, who opposed anesthesia, and who opposed blood transfusions, vaccination, immunization, Pasteurization, and chlorination. “Fluoridation is Here to Stay,” Journal of
the American Dental Association, vol. 65, no. 5 (November 1962): 578-580. 4. Kai Hunstadbraten, “Fluoride in Caries Prophylaxis at the Turn of the Century,” Bulletin of the History of Dentistry, vol. 30, no. 2 (October 1982): 117-120. 5. One part per million fluoride means one milligram of fluoride in each liter of water. 6. Michael Wollan, “Controlling the Potential Hazards of Government-Sponsored Technology,” George Washington Law Review, vol. 36, no. 5 (July 1968): 1105-1137, at 1128. 7. This figure understates the extent of fluoridation of public water supplies, because many of the 50 percent who drink unfluoridated water do not use public water supplies but instead obtain water from wells and other sources. Furthermore, some waters are naturally fluoridated and do not count as having added fluoride. 8. In referring to leading scientist supporters or opponents of fluoridation, I use the term scientist loosely to include doctors and dentists who are familiar with scientific research on fluoridation. 9. Notably, Donald R. McNeil, The Fight for Fluoridation, New York: Oxford University Press (1957). 10. My approach to the fluoridation controversy is elaborated and placed in context in chapter 8. 11. John Colquhoun, Education and Fluoridation in New Zealand: An Historical Study, Ph.D. thesis, University of Auckland (1987); Edward Groth III, Two Issues of Science and Public Policy: Air Pollution Control in the San Francisco Bay Area and Fluoridation of Community Water Supplies, Ph.D. dissertation, Stanford University (1973); Edward Groth III, “Science and the Fluoridation Controversy,” Chemistry, vol. 49, no. 4 (May 1976): 5-9; Allan Mazur, The Dynamics of Technical Controversy, Washington, D.C.: Communications Press (1981); Wendy Varney, Fluoride in Australia: A Case to Answer, Sydney: Hale and Iremonger (1986);
and Wollan, op. cit. Some of the explicitly antifluoridation literature is also valuable here, notably George L. Waldbott in collaboration with Albert W. Burgstahler and H. Lewis McKinney, Fluoridation: The Great Dilemma, Lawrence, Kans.: Coronado Press (1978). 12. Chapter 8 was written after Groth’s commentary was completed, hence my remarks in chapter 8 on his contribution. Groth gave me comments on a draft of chapter 8, but preferred to leave his own essay unaltered.
The aim in fluoridation is to adjust the concentration of fluoride in public water supplies to the optimal level for dental health. The main beneficiaries are children up to the age of twelve or perhaps as old as sixteen. Benefits for adults are less certain. The higher the concentration of fluoride in the water, the greater is the preventive effect against dental caries, commonly known as tooth decay. But as McKay discovered back in 1901, if the concentration is too high, staining and, in severe cases, pitting occurs. The optimal concentration of fluoride — considered to be about 1.0 parts per million (ppm) — prevents tooth decay as much as possible without causing much mottling. In hotter climates where people drink more water, the concentration of fluoride is set lower, perhaps to 0.7 ppm. In cooler climates where people drink less water, the concentration is set higher, such as 1.2 ppm. Fluoridation is not intended to provide a controlled dosage but rather to mimic naturally fluoridated water supplies which, as shown by H. Trendley Dean’s studies in the 1930s, result in less tooth decay throughout the community. People who drink one liter of water with 1.0 ppm fluoride swallow exactly one milligram of fluoride. But different people drink different volumes of water. Some, such as laborers and athletes, may drink several liters per day. Others may drink only milk or fruit juice and obtain no fluoride from the water supply. So, whereas the concentration of fluoride in the water can be specified and controlled, the dosage of fluoride to any individual is uncontrolled. The most obvious way to ensure a precise dosage of fluoride is to take a tablet. Fluoride tablets have been advocated and used widely, especially in regions where water is not fluoridated or where there is no public water supply. The biggest problem with fluoride tablets is that most people find it a chore to
take them. Children are expected to take them daily for the first 12 or so years of their life, and experiments show that few parents are able to instill the required habit. By comparison, it requires no will power to reap the benefits of water fluoridation. Simply by virtue of drinking water, most people will obtain fluoride. This means that individuals who never go to a dentist, or those who have decay-producing diets due to poverty, ignorance, or preference, still obtain the benefits of fluoride. Admittedly, some children obtain less than the amount of fluoride specified as optimal. But water fluoridation still provides a wider cross section of benefits than do fluoride tablets, since more people drink some water than would persist in taking tablets. Most promoters of fluoride to prevent tooth decay prefer water fluoridation over other methods of obtaining fluoride — so much so that the word “fluoridation” is normally taken to mean addition of fluoride to public water supplies. Water fluoridation gets to a larger fraction of the public and is also thought to be more effective than other approaches. It is also quite inexpensive on a per-capita basis, even when one considers that large volumes of fluoridated water are used in industry, to water lawns, and for other purposes. Only a tiny fraction of the water supply is actually consumed. THE CASE FOR FLUORIDATION The strength of the arguments in favor of fluoridation rests on the widely experienced pain of tooth decay, plus the claim that decay will be dramatically reduced by fluoridation without any effort, harm, or much expense. A large segment of the population has experienced toothaches or seen their effects on family or friends. This set of experiences provides a powerful motivation to seek a way of reducing or eliminating this pain. Dentists
in particular witness the problem regularly and this helps explain why so many of them support fluoridation. Fluoridation promises a solution that seems miraculous. Simply by adding a tiny concentration of a tasteless element to the water supply, tooth decay is supposed to be reduced by one-half or even more. A limitation of the basic argument for fluoridation is that it only promises to prevent tooth decay. That doesn’t help someone with a toothache now. If a fluoride tablet could positively cure decay, it would be much easier to sell. A quick cure is something that can be observed by anybody (although the cause of the cure may be debatable). Prevention is altogether harder to document and, therefore, harder to sell. In their arguments for fluoridation, proponents most commonly refer to numerous scientific studies. The classic trials in Grand Rapids and Muskegon, Michigan; Newburgh and Kingston, New York; and other communities were designed to compare populations drinking fluoridated water against those drinking unfluoridated water. The researchers found that decay rates were greatly reduced in the fluoridated communities. For example, John J. Murray and Andrew J. Rugg-Gunn refer to these studies in their authoritative book Fluorides in Caries Prevention. They conclude, “the strength of the experimental proof of the caries-inhibitory property of fluoride drinking water lies … in the fact that the three American studies, carried out by different investigators in different parts of the country, reached similar conclusions: addition of 1 ppm fluoride in the drinking water reduced caries experience by approximately 50 per cent.”1 In surveying ninety-five studies from twenty countries on the effectiveness of fluoridation, Murray and Rugg-Gunn state that “The modal [most common] percentage caries reduction is 40-50 per cent for deciduous teeth and 50-60 per cent for permanent teeth — this is in agreement with the oft-quoted statement that ‘water fluoridation reduces dental decay by half.’”2 In a briefer discussion of key clinical trials, prominent dental researcher Ernest Newbrun
states that “the conclusion that fluoride is effective in reducing dental caries prevalence is based not only on clinical diagnosis of carious lesions but also on blind clinical and radiological examination of children and on strictly objective criteria such as missing permanent first molars.”3 Similarly, Wesley O. Young, David F. StriffIer, and Brian A. Burt, in a dental textbook, state that “Fluoridation is the most effective and efficient means of reducing dental caries on a community-wide basis. It reduces caries prevalence by 50 to 60 percent in the permanent dentition among children born and reared in a fluoridated community.”4 These types of scientific findings are easy to use for promotional purposes. The results are presented typically to dentists, doctors, politicians, and the general public in the form of statements such as “More than 50 years of research and practical experience have proved beyond a reasonable doubt that fluoridation is effective in preventing tooth decay. Hundreds of studies have demonstrated reductions in tooth decay of 60-70% in communities with either natural or controlled fluoridation.”5 Many antifluoridationists have left unchallenged the research results showing reductions in tooth decay by fluoridation. There are several reasons for this. First, there are many studies showing such reductions, as well as numerous studies of the microscopic processes in the mouth that explain how reductions can occur. It is hard to counter such a preponderance of research. Second, most of those who have done research on the effect of fluoridation on tooth decay have been supporters of fluoridation. There have been few inside this group of researchers to take up the antifluoridation cause. Finally, the arguments about health risks and individual rights are much more powerful tools for opposing fluoridation. QUESTIONING THE BENEFITS Nevertheless, there have been some criticisms of the claims for large benefits from fluoridation. The first thorough critique was by Philip R. N. Sutton, then a senior research fellow at
the University of Melbourne Dental School. Sutton’s monograph, Fluoridation: Errors and Omissions in Experimental Trials, was published in 1959 by Melbourne University Press. Sutton examined the five classic fluoridation trials, of which the comparison between Grand Rapids and Muskegon was the first. He began by stating that these trials constituted “the main experimental evidence which has led to the introduction of this process [fluoridation] as a public health measure.”6 Sutton’s work is a critique of the claims for massive benefits from fluoridation. He proceeds by scrutinizing the central research papers and exposing methodological flaws in them. For example, he points out the problem of examiner bias: if the dental examiners who count the number of decayed, missing, and filled teeth in children know whether a particular child is from the fluoridated or the unfluoridated community, this may unconsciously affect their evaluation. (Sutton points out elsewhere that assessment of whether a cavity is present depends on whether a dentist’s probe encounters hard or soft material in the tooth, a process involving a distinct evaluative element. Counting missing and filled teeth is a less contentious process.) Sutton suggests that a proper blind procedure would involve bringing children from both fluoridated and unfluoridated communities to the examiners in such a way that they would not know which children were which. Because this was not done in any of the classic studies, they are all open to the criticism that examiners unconsciously found what they wanted or expected to find. Sutton raises a large number of points in regard to the classic studies, including lack of sufficient baseline statistics prior to fluoridation, variations in sampling methods, examiner variability, and sampling error. In the Grand Rapids study, the results were limited by the fact that the control city, Muskegon, was fluoridated in 1951, six years after the beginning of the study. The power of Sutton’s critique is that it exposes the “soft underbelly” of scientific research, namely that scientists do not do
everything the way they are supposed to in theory. But this does not in itself automatically lead to the conclusion that fluoridation doesn’t work. A piece of research can come up with a valid conclusion even though the methods used are less than perfect. Sutton himself did not carry out a proper controlled study of fluoridation. Nor did he prove that the studies he examined came to the wrong conclusion. He made a lesser claim: that the scientific methods used in the classic studies were inadequate, and, hence, these studies are not a good basis for proceeding with fluoridation. His assumption is that the onus of proof should lie with those promoting fluoridation to conclusively demonstrate its benefits. After Sutton’s monograph was published, the president of the Australian Dental Association sent copies to the scientists who had been in charge of the classic studies. As a result, several reviews were published, mainly in the Australian Dental Journal. In the second edition of his monograph, published in 1960, Sutton included four reviews and his replies to them.7 Several of the reviewers deal with technical points, either defending the studies against Sutton’s criticism or criticizing Sutton’s account. For example, Sutton had said that, in two of the control or unfluoridated cities, there were significant changes in tooth decay rates. This was contrary to the reports of the studies claiming that these rates had stayed about the same.8 R. M. Grainger takes this up in one of fifteen specific points in his review. He said the important thing was that, in the control cities, the changes noted by Sutton “were upward trends or mere fluctuations” compared to the fluoridated city of Brantford where the change was “a highly significant continual downward trend.”9 Replying to Grainger, Sutton notes that the chance that fluctuations would be as great as noted was 1 in 370 and therefore these changes were significant rather than “mere fluctuations.” Sutton also points out that the “highly significant continual downward trend” in decay rates in Brantford appeared only in children aged twelve to
fourteen, and therefore Grainger’s claim of a continual downward trend in Brantford is incorrect and misleading.10 This example is one of the more readily understandable points of technical disagreement between Sutton and his critics. It illustrates the small details involved. This technical attack and counterattack can be interpreted as a battle for credibility, in which showing even tiny mistakes in the other side’s argument is important since it reflects on the soundness of their case. If the first basic response to Sutton was to challenge him on technical points, the second response was to question whether his argument was relevant to fluoridation at all. Donald Galagan, the assistant chief of the Division of Dental Public Health, United States Public Health Service, made this point strongly. It is an important argument, used ever since by profluoridationists. Galagan argues that the scientific basis of fluoridation had been solidly established before any of the classic control studies. The benefits of fluoride were shown by examination of children who drank naturally fluoridated water. “The fact is that the projects at Brantford, Grand Rapids, Newburgh and Evanston were designed primarily to evaluate the technical, financial and administrative problems associated with the controlled addition of fluorides to a municipal water supply, and, secondarily, to demonstrate the effectiveness of the procedure to the profession and the public.”11 The basis of Sutton’s monograph was the claim that “proposals to fluoridate domestic water are almost entirely based” on the results of experimental trials in these four cities.12 Arguably, one reason why studies of naturally fluoridated communities cannot be used to draw ironclad conclusions about artificially fluoridated communities is that most waters that have high natural levels of fluoride also have high levels of other minerals such as calcium and magnesium, and also contain trace elements such as strontium and boron. It is difficult to rule out that the high mineral content of so-called hard water, which is usually associated with high natural fluoride
levels, may contribute to the resistance of teeth to decay. The controlled studies were exactly the sort of test required to determine whether added fluoride alone, without the other elements, would reduce tooth decay. Sutton’s reply to Galagan does not rely so much on this sort of logic (which was implicit in Sutton’s analysis) as on quotations from key researchers involved in the classic trials themselves. For example, he quotes one group of researchers involved in one of the two Brantford studies as saying in 1951, “It was recognized that fluorine in the public water supply was not a proven method for the prevention of dental caries, and that it might take ten years to prove or disprove its preventive value.”13 Through a series of quotations, Sutton attempts to show that, at the time, the controlled studies were seen as tests of the effectiveness of artificial fluoridation against tooth decay. In this way, Sutton asserts the relevance of his critique of methods used in those studies. It is important to note that what is ostensibly a technical dispute about scientific experimentation actually involves a dispute about history: the history of fluoridation. Sutton interprets the history as one in which the controlled studies of matched communities were seen as a crucial test of the effectiveness of fluoridation. Many of the proponents of fluoridation interpret the history as one in which fluoridation was established scientifically in the 1930s through studies of naturally fluoridated communities and through animal studies, and in which the controlled studies of matched communities were demonstrations of the effectiveness of fluoridation. A related response to Sutton is to point out that scientific understanding of the mechanism by which fluoride prevents tooth decay has changed. In the 1940s and 1950s, it was accepted that fluoride needed to be incorporated into the enamel of growing teeth. But in recent decades, the topical or surface effect of fluoride has been assessed to be of equal or greater significance. Fluoride in the saliva is thought to inhibit decay, for example, by promoting remineralization at the surface of the tooth. The classical studies and Sutton’s
critique do not allow for the topical effect of fluoride in drinking water, which could reduce tooth decay quickly. Although Sutton’s criticisms were met with a vehement response in the reviews published in 1960, little debate on this topic was carried out thereafter. Sutton did not pursue his challenge, and antifluoridationists, while sometimes citing his views, did not take them up as a central plank in their campaigning. The intricate technical points involved are not the best type of material for public campaigning. For their part, the proponents have assumed that the effectiveness of fluoridation has been established. Few texts or review papers on fluoride and tooth decay even mention the existence of a critique by Sutton or anyone else.14 This situation changed only in the 1980s when John Colquhoun, Mark Diesendorf, and Rudolf Ziegelbecker published critiques of the effectiveness of fluoridation. Diesendorf’s approach is similar to Sutton’s. He examines studies claiming to show that fluoridation reduces tooth decay to determine whether they conform to a rigorous methodological ideal in which a control is used, baseline data are available, examinations of cavity rates are carried out in a blind fashion, and there are no confounding factors. Even though there have been dozens of studies — almost all of them showing a reduction in tooth decay associated with fluoridation — Diesendorf argues that few, if any, are satisfactory statistically.15 Diesendorf has injected two important points into the fluoridation debate. First, he quotes studies and data showing significant declines in tooth decay in unfluoridated regions. Second, he quotes studies and data showing continued declines in tooth decay in fluoridated regions, long after the maximum effects should have been obtained. For example, seven-year-old children should obtain maximum benefits if their water supply has been fluoridated for seven years or more (although benefits may well occur in less than seven years). For a community fluoridated for twenty years, tooth decay rates for seven-year-olds should be stable for the last thirteen years, unless other factors are operat
ing. Diesendorf refers to studies showing continued declines in tooth decay long after the maximum benefits from fluoridation should have occurred. Diesendorf’s argument is that fluoridation has never been conclusively demonstrated to be effective, and that other factors — such as changes in diet, immunity, and dental hygiene — are likely to be involved in declines in tooth decay. Profluoridationists assume that fluoridation has long since been shown to reduce tooth decay. They see Diesendorf’s criticisms as irrelevant, just as they dismissed Sutton’s contentions of a quarter of a century earlier. They respond to the observed declines in tooth decay in unfluoridated regions by suggesting the importance of fluoride tablets, fluoride toothpastes, and topical fluoride treatments by dentists. Also, they reject the import of Diesendorf’s criticisms of many of the studies. Although there may be some methodological shortcomings in some studies, these do not by themselves show that fluoridation is not effective. Diesendorf and Colquhoun16 focused their criticisms on the controlled trials of fluoridation. As noted before, many proponents treat these trials as demonstrations, and consider the studies of naturally fluoridated communities in the 1930s and 1940s to be definitive proof of the effectiveness of fluoridation in preventing tooth decay. Yet these classic studies have also been criticized by antifluoridationists from the 1950s on.17 Rudolf Ziegelbecker, in an oftencited 1981 paper, claimed that the classic work by H. Trendley Dean on the relationship between natural fluoride levels in public water supplies and the average rate of tooth decay in children relied on selecting a biased sample of twenty-one data points from the many hundreds available to him.18 Ziegelbecker’s analysis has, in turn, been criticized as incorrect.19 The criticisms of fluoridation trials by Sutton, Diesendorf, Colquhoun, and Ziegelbecker are one way in which opponents can try to undermine the case for fluoridation. This approach has the strength of challenging the scientific basis for fluoridation, but, by the
same token, the disadvantage of turning the issue into a very technical debate. Arguments about the significance of figures for decayed, missing, and filled teeth in twelve-year-olds in Newburgh or Sarnia in 1950 are hardly the sort of thing to excite the public or even galvanize dentists. NEITHER NECESSARY NOR SUFFICIENT Another approach used to criticize fluoridation is more accessible. The argument here is to say that fluoride is neither necessary nor sufficient for good teeth. The terms “necessary” and “sufficient” are used here as in formal logic. If fluoride is not necessary, that means that a person can have good teeth without fluoride. This is a counter to the claim by proponents that fluoride is a missing ingredient in human nutrition and that fluoridation is essentially the “topping up” of water supplies to what nature would normally supply as optimal. Opponents argue that many people did — and still do — have excellent teeth although their drinking water contains almost no fluoride and although they obtain no extra fluoride through toothpaste or other nondietary sources. (There are traces of fluoride in most foods, so, in practice, a completely fluoridefree diet is virtually impossible.) The new conventional wisdom is that fluoride has a greater effect in the mouth, at the surface of the teeth, than it does incorporated into the growing teeth as a result of swallowing it. As noted, this knowledge has been used by proponents to explain rapid improvements in decay rates in the trials of fluoridation. But it also provides a new argument for antifluoridationists. Why drink fluoridated water? Why not just rinse out one’s mouth with fluoridated water, gaining most of the benefits, and then spit it out, avoiding most of the risks?20 This can be seen as a modification of the argument that fluoride is not necessary for good teeth. It accepts that fluoride may be helpful in the mouth but, to obtain most of the benefits, it is not necessary to swallow it. The other part of the argument is that fluoridation is not sufficient to prevent tooth
decay because some people have many cavities in spite of drinking fluoridated water. The opponents’ argument is that tooth decay is not caused by a lack of fluoride, but rather by poor diet, in particular eating refined sugary foods. Those populations with excellent teeth in spite of little fluoride are ones whose diets are largely unprocessed and contain a preponderance of grains, fresh vegetables, and fruits. Those populations with many decayed teeth in spite of fluoridation typically eat highly processed foods containing considerable amounts of sugar. The brushing of teeth and practicing oral hygiene in general may also be relevant in this context. Some opponents of fluoridation argue that it is better to address the ultimate cause of tooth decay, namely diet, with avoiding sugary foods as the main emphasis. They also point to the dietary role of other minerals besides fluoride in building strong teeth. These include calcium, of course, plus phosphorous, strontium, vanadium, and molybdenum.21 Poor diet can also have consequences for dental health by affecting the gums. Periodontal disease is a more serious problem than decay, especially in adults. This means of criticizing fluoridation does not impress the proponents, especially dentists. Some of them have been pushing for better diet for many decades. Typically the proponents simply say something like this: “We agree that sugary foods are a primary cause of tooth decay. But, in spite of major campaigns, most people will not change their diets — they prefer processed and sugary foods. Diet is something we can influence only a little. But we can control fluoride levels in the water supply, and, in this way, do something definitive against tooth decay.”22 When the debate goes in this direction, it is apparent that it is no longer strictly about fluoridation, but deals with preventive dentistry in the broadest sense. In this area, there is actually considerable agreement between the proponents and opponents of fluoridation: both support better diet. But this has never been a basis for establishing harmonious relations. The opponents in particular have emphasized criticism of
fluoridation rather than positive alternatives. For example, in The American Fluoridation Experiment, the most authoritative book critical of fluoridation published in the 1950s, only a few of the more than two hundred pages are devoted to criticism of the claims about benefits of fluoridation, and fewer still deal with alternatives.23 HEALTH RISKS Overall, the debate about the existence and size of benefits from fluoridation has been a sideline to the main arena, the risks involved. The debate here is straightforward. The opponents claim that fluoridation causes serious health problems in a fraction of the population. The proponents deny the existence of any such problems. The apparent simplicity of these issues is part of their attraction. Everyone can understand a statement that fluoridation causes poisoning or cancer, or the claim that fluoridation is entirely safe. Statistical nuances do not intrude so obviously. Yet, in practice, the debate about hazards involves just as many scientific complexities as the debate about benefits. There are many claims made about the adverse effects of fluoridation on human health. I will concentrate only on effects considered to be the most important by prominent critics of fluoridation who are scientists, such as Albert Burgstahler, Dean Burk, Frederick Exner, John Lee, George Waldbott, and John Yiamouyiannis.24 Three key areas are chronic fluoride toxicity, intolerance reactions, and genetic effects. Because these and other topics have received exhaustive treatments, only a few examples will be used to illustrate the ways in which the debate has proceeded. “Chronic fluoride toxicity” refers to toxic effects caused by a long period of exposure to low levels of fluoride. Many fluoride compounds are poisonous. For example, a dosage of several grams of sodium fluoride can cause death in human adults. The effects from large doses are called “acute effects.”25 Because fluoridation involves the ingestion of
tiny amounts of fluoride over many years, it is the possible long-term or chronic effects that are of greatest concern. Opponents refer to mottling of teeth as a sign of chronic toxicity. They consider that it reflects an excessive intake of fluoride that may also be affecting other organs or functions of the body. Proponents see mottling as only a cosmetic problem with no health implications. The different interpretations of mottling are representative of different approaches to the issue of toxicity. At least both sides agree that mottling does occur. The only other consequence of fluoride on which there is much agreement is skeletal fluorosis, a bone disease caused by excessive fluoride intake that, in serious cases, can cause crippling deformities. It is agreed that skeletal fluorosis is found in some high-fluoride regions in India and several other countries, typically with 2.0 ppm to 10.0 ppm fluoride in the water. Occupational exposure to high levels of fluoride is also linked to skeletal fluorosis. Opponents say that 1.0 ppm of fluoride in water can be enough to cause symptoms of skeletal fluorosis in some people. They point out that, in India and other countries with welldocumented incidents of skeletal fluorosis, there are many more severe cases when the fluoride level in drinking water is very high at 5.0 to 10.0 ppm. But there are also some cases seen even at fluoride levels of 1.0 ppm or lower. Also of concern to opponents are subtle changes in the skeleton due to fluoride, which occur prior to the clinical symptoms of skeletal fluorosis. Proponents say, to the contrary, that the margin between 1.0 ppm and the concentration required to cause skeletal fluorosis is sufficient. This divergence of opinion is possible because there have been very few reported cases of skeletal fluorosis in Western countries. Other factors, in addition to fluoride, may contribute to the high levels of skeletal fluorosis in some parts of India. The opponents argue that the margin between the 1.0 ppm concentration used for fluoridation and the somewhat larger concentrations usually required to cause overt skeletal
fluorosis and other symptoms of chronic fluoride toxicity is simply not great enough. They consider that a small fraction of the population may be experiencing some forms of chronic fluoride toxicity. The proponents argue that there is no evidence in Western countries that fluoridation contributes to skeletal fluorosis. As one report puts it, “In non-tropical countries there has been no report of clinically symptomatic skeletal fluorosis in areas with drinking water less than 4 mg/litre [4.0 ppm].”26 “Nontropical countries” eliminates the evidence from India. “Clinically symptomatic skeletal fluorosis” excludes toxic effects that do not show up as overt or clinical symptoms. The 4.0 ppm figure puts fluoridation’s 1.0 ppm in the safe range. (Despite its qualifications, the foregoing statement can still be challenged. There are some reported cases of skeletal fluorosis in the United States and other “non-tropical countries” that contradict it.27 To be more accurate, the statement would have to exclude cases where other factors contribute to skeletal fluorosis, such as kidney failure and excessive thirst.) Each side puts the onus of proof on the other. The proponents cite a scarcity of reports of “clinically symptomatic skeletal fluorosis” as a refutation of the danger. In other words, it is up to the opponents to come up with studies showing significant effects at water fluoridation’s level of 1.0 ppm. The opponents, on the other hand, claim that the margin of safety is too small, leaving it to the proponents to demonstrate that 1.0 ppm does not cause problems for at least some people. This divergent interpretation of evidence reflects a theme in the debate that goes back to the original studies. What constitutes a sufficient examination of the health consequences of fluoridation? The proponents repeatedly assert that there is no evidence of risk from fluoride at the dosages involved with water fluoridation. Newbrun summarizes some of the early investigations showing the safety of fluoridation. “Very thorough medical examinations of the children accompanied both the Newburgh–
Kingston and the Grand Rapids–Muskegon fluoridation studies. No significant differences in health or in growth and development were found between children in study and control cities. The Newburgh examination was very detailed and included tonsillectomy rates, height and weight, onset of menstruation, bone density by X-ray examination of hands and knees, skeletal maturation, hemoglobin level, erythrocyte count, leukocyte count, urinalysis, and skin moisture, texture, color, and eruptions. The conclusion of this long-term pediatric study was that, aside from the reduction in caries, there was no indication of any systemic effects, adverse or otherwise, from the use of fluoridated water.”28 A typical overall conclusion is that of Murray and Rugg-Gunn. “The effect of water fluoridation on general health has been thoroughly investigated in a series of population studies. There is no evidence that the consumption of water containing approximately 1 ppm F (in a temperate climate) is associated with any harmful effect.”29 One way to challenge these findings is to demonstrate individuals who react adversely to fluoridation. If only a small fraction of individuals react this way, the effect may not readily show up in statistical studies of populations, especially if the adverse reaction can result from other causes as well as fluoride. For many years, the leading U.S. scientist opponent of fluoridation was George L. Waldbott, an allergist and researcher who campaigned against the measure from the mid- 1950s until his death in 1982. Waldbott published many articles in which he documented adverse reactions by particular individuals to fluoride, often in amounts associated with water fluoridation.30 Supporters of fluoridation — with a few exceptions31 — have ignored or dismissed Waldbott’s findings. For example, H. C. Hodge in his “Evaluation of some objections to water fluoridation,” says “Reports of ‘fluoride allergy’ have come principally from the late Doctor George Waldbott.” After describing one of Waldbott’s cases, Hodge comments, “Competent immunologists do not
accept Waldbott’s case histories as evidence that fluoride allergy exists.” Hodge then quotes the executive committee of the American Academy of Allergy, which stated, in 1971, “There is no evidence of allergy or intolerance to fluorides as used in fluoridation of community water supplies.”32 Hodge does not refute Waldbott’s extensive evidence, but uses an argument from authority. Certainly the executive committee of the American Academy of Allergy provided no scientific refutation of Waldbott’s findings. Furthermore, Waldbott interpreted most of his cases in terms of intolerance reactions, not allergy as implied by Hodge. At least Hodge did go to the trouble of briefly describing Waldbott’s findings. In Murray and Rugg-Gunn’s key book Fluorides in Caries Prevention, Waldbott’s studies are not mentioned at all.33 This is the more common pattern.34 One of the arguments used against claims of fluoride toxicity in individuals is that studies must be double blind: that is, the reaction of the “subject” to drinking water or tablets should be investigated using an experimental procedure in which neither the investigator nor the subject knows which samples contain fluoride and which do not. This is important, since knowledge on the part of investigators or subjects could result in false responses. An example would be if subjects reacted physically simply on being told they had ingested fluoride. If the subject reacts to a placebo (no fluoride), this shows the lack of a physical basis for the reaction. Many of Waldbott’s patients who showed reactions to fluoride were not tested in blind conditions. This allows critics to be skeptical. But some of his patients were tested in blind conditions. Some of Waldbott’s critics also suggest that his claims have not received independent verification.35 Admittedly, Waldbott did not allow outsiders access to his files on his patients, making it impossible for his unpublished documentation to be inspected or his patients to be tested by other doctors.36 But there have been quite a number of other blind
and double-blind studies that provide support for Waldbott.37 The profluoridationists seem to demand a high standard of proof before they will accept claims about the effects of fluoridated water on individuals. Even if particular individuals react adversely to small administered dosages of fluoride, this does not show that fluoride in water at 1.0 ppm causes the same effect. They note that fluoride is widespread in the environment — for example, it is contained in many foods — and therefore tracing adverse reactions to the fluoride in water supplies is difficult. The profluoridationists seem to require a set of definitive experiments, but few of them make clear what these definitive experiments would be.38 The antifluoridationsts see the studies by Waldbott and others as showing that fluoridation cannot be judged safe. They put the burden of proof on the other side. They say that profluoridationists have not conducted careful double-blind trials in an attempt to determine whether water fluoridation is causing intolerance or other adverse reactions. The relevance of double-blind trials depends on what assumption is made about the onus of proof. The profluoridationists argue that such trials are necessary to avoid bias by those who may have falsely accused fluoridation of causing problems. The antifluoridationists argue that documented cases of allergy, intolerance reactions, or hypersensitivity are strong evidence against fluoridation until it can be proved that fluoridation is not responsible. Remember that Sutton, in criticizing the classic fluoridation trials, pointed to the lack of blind examinations of children’s teeth; in the case of intolerance reactions, it is the proponents who complain about the lack of definitive double-blind trials. Within the medical research community, clinical randomized double-blind trials are commonly considered to be the ultimate scientific arbiter of the objective effects of a substance on humans. But such trials are not the end of the matter. Any given trial and result can be criticized and dismissed in various ways, such as by alleging shortcomings in methods used, by suggesting that the
researchers are biased, by reinterpreting the findings, or by rejecting the results as incompatible with standard findings or theories.39 Clinical double-blind trials certainly have not been treated as definitive in establishing allergic, intolerance, or hypersensitivity reactions to fluoride at the level involved in water fluoridation. Another area of contention is mutations and cancer, which can be called genetic effects. There have been several claims, all rejected by supporters of fluoridation, that fluoride is responsible for genetic effects. In the 1950s, Alfred Taylor at the University of Texas reported that cancer-prone mice drinking fluoridated water developed tumors at an earlier age than mice drinking distilled water. Ionel F. Rapaport at the University of Wisconsin in the 1950s concluded that fluoride was associated with the birth defect called mongolism, or Down’s Syndrome. Ever since the 1970s, Dean Burk and John Yiamouyiannis have claimed that fluoridation is linked to increased cancer death rates in U.S. cities.40 The response to the claims by Burk and Yiamouyiannis illustrates the way the issue of genetic effects has been dealt with. Burk and Yiamouyiannis collected figures on cancer death rates in a series of large U.S. cities, both fluoridated and unfluoridated. They claimed that the cancer death rates averaged over the group of cities were the same before fluoridation but diverged afterwards, with the fluoridated group showing a 20-percent greater cancer death rate. According to Burk and Yiamouyiannis, fluoridation appears to be responsible for many thousands of extra deaths in the United States. Unlike the issue of allergic and intolerance reactions in which individual patients can be tested, the controversy over cancer and fluoride is concerned mainly with statistics. Critics of Burk and Yiamouyiannis have said that they did not make corrections for the distribution of the population by age and sex. Alternative analyses of the cancer death rate statistics were carried out, showing no correlation with fluoridation.41
Burk and Yiamouyiannis countered by saying that, contrary to their critics, they had corrected for age and sex. They criticized a contrary study by saying that it had omitted 90 percent of the data. The proponents argued, in turn, that Burk and Yiamouyiannis had not corrected their data sufficiently. As in every other area of the dispute, entirely different interpretations of evidence have been made, with no concessions to the other side. The argument about genetic effects also takes place at the level of mechanisms. The antifluoridationists cite laboratory studies showing that fluoride can cause mutations in tissue cultures of human cells at low concentrations. Mutagens are often carcinogens or cocarcinogens. In other words, these studies suggest that a plausible mechanism exists by which water fluoridation could be associated with cancer and genetic defects. The profluoridationists counter by criticizing the relevance of the laboratory studies of mutagenic effects. They say that the concentrations of fluoride in the experiments are too high, or that they do not replicate the effect of fluoride in water supplies. There is a curious inversion of stances in the way the debate on benefits and the debate on genetic effects has proceeded. In the case of the benefits, the proponents bring forward statistical evidence of declines in tooth decay backed by experimental work showing the microscopic processes by which fluoride can inhibit decay. The opponents have challenged this position by criticizing the statistical studies on methodological grounds, while setting the experimental work aside as irrelevant unless effects can conclusively be shown for populations. Quite the opposite set of stances is taken on genetic effects (although often by different figures in the debate). The opponents Burk and Yiamouyiannis bring forward statistical evidence of increases in cancer death rates backed by experimental work showing the microscopic processes by which fluoride can induce mutations. The proponents have challenged this position by criticizing the validity of the statistical studies, while setting the experimental work aside as irrelevant
unless effects can conclusively be shown for populations.42 The critics of the benefits, such as Sutton and Diesendorf, believe that the evidence of risks is sufficiently strong to warrant questioning about fluoridation. Therefore, unless fluoridation can be conclusively proven to be as effective as claimed, it cannot be justified. Their implicit conclusions about risks provide a basis for their assumption about the burden of proof on the benefits. The proponents adopt an opposite perspective. So far as they are concerned, the existence of risks has not been demonstrated. Therefore criticisms of the benefits must be conclusively proved before fluoridation can be rejected. Also, they believe that the effectiveness of fluoridation has been proved beyond any doubt, in which case a high standard of proof about hazards is required before rejecting fluoridation and its benefits. INDIVIDUAL RIGHTS Along with arguments about risks of fluoridation, the other staple argument in the antifluoridation case concerns individual rights. Once fluoride is introduced into the public water supply, it is very difficult to avoid ingesting it. Filters are available, but they are not cheap and, if not replaced regularly, can lead to sudden big doses of fluoride. In effect, most people are forced to have fluoride whether they need it or want it. Those who are toothless or who work in fluoride-contaminated occupations (such as aluminum smelting) drink the fluoridated water just the same as the children whose teeth are to be protected. The individual-rights argument has been a vital one, especially in the United States where the ideology of individualism is powerful. It is an ethical and political objection, but it cannot be separated easily from what are called scientific issues. A number of public health measures are compulsory, such as certain vaccinations and isolation of individuals with highly contagious diseases. Opponents argue that these instances do not provide a precedent for fluoridation
because tooth decay is not life-threatening. Proponents then refer to laws requiring the use of seat belts in cars. Sometimes, seat belts can cause death, as in the case of fire or a car falling into water. But, so the argument goes, seat belts save many more lives than they put at risk. Hence, legislation requiring people to wear them is legitimate. Associated with the individual-rights argument is the argument that fluoridation is unethical because the dosage to individuals is not controlled. It depends on how much fluoridated water an individual drinks. To force people to ingest an uncontrolled dosage of a substance to reduce the incidence of a nonlethal disease is seen as unacceptable by opponents. The individual rights argument is powerful because it appeals to the concept of purity — that is, the purity of water.43 Water is seen by many people as something that should be pure and unadulterated especially, perhaps, in an age when colorings, flavorings, preservatives, and the like are added to so many foods and drinks. The obvious and frequent response to this is that public water supplies are not pure but are chemically treated in a number of ways. Chlorination — the process by which chlorine gas is bubbled through water in order to kill bacteria — is the most well-known method of treatment. (Perhaps because the words are similar, chlorination and fluoridation are often confused.) Opponents respond by saying that chlorination is designed to treat the water, whereas fluoridation is designed to treat the person drinking it. These opponents draw analogies with putting contraceptives or sedatives into the water supply — ideas generally considered to be ethically unacceptable — to illustrate the social danger of allowing water supplies to be used for dosing the population. The individual-rights argument also draws strength from the existence of many alternative methods of dispensing fluoride, most of which are voluntary (see table 2.1). For example, adding fluorides to salt or sugar allows the marketing of both fluoridated and unfluori-
dated varieties, and, unlike water fluoridation, offers consumers a choice. Table 2.1 Compulsion and Control over Dosage Associated with Several Ways of Getting Fluoride to People’s Teeth Fluoride vehicle (a) Dosage Compulsion Public water supplies Uncontrolled Compulsory School water supplies Uncontrolled Compulsory for school children Table salt (b) Uncontrolled Voluntary ** Sugar (c) Uncontrolled Voluntary ** Milk Uncontrolled Voluntary ** Topical application by dentist Not ingested* Voluntary ** Toothpaste Not ingested* Voluntary ** Mouthwash Not ingested* Voluntary ** Bottled water Controlled if desired Voluntary ** Tablets Controlled Voluntary ** * Except inadvertently, which does occur. **When parents choose any method to get fluoride to the teeth of their young children, the child is seldom in a position to provide informed consent. (a) For a discussion of different fluoride vehicles see for example J. J. Murray (ed.), Appropriate Use of Fluorides for Human Health, Geneva: World Health Organization (1986). (b) Th. Marthaler, “Practical Aspects of Salt Fluoridation,” Helvetica Odontologica Acta, vol. 27, no. 3 (1983): 39-56, in Schweizer Monatsschrift für Zahnmedizin, vol. 93, no. 12 (1983): 1197-1214. (c) H. Luoma, “Fluoride in Sugar,” International Dental Journal, vol. 35, no. 1 (1985): 43-49.
The individual-rights argument is a powerful one because many people are mobilized by it. In terms of logic alone, it is not automatically a weapon for the antifluoridationists. There are various ways for proponents to reply. One response to the individual-rights argument is to say that water fluoridation is not really compulsory because people can choose to drink unfluoridated bottled water. Fluoridation, in this view, does not force people to drink fluoridated water, but imposes upon them inconvenience and financial costs if they wish to avoid it. An analogy to the financial penalty on those who choose to pay for unfluoridated bottled water is the taxation of childless people to support public schools.44 Another response is to accept the premise that there is some violation of individual rights, but that this must be weighed against the benefits from fluoride. Various analogies are used in this contention. People in a modern society must accede to some constraints on their freedoms in order to serve the general good. People accept that, in driving a car, they must stay on the correct side of the road and stop at stoplights. This may be a violation of “individual rights” to drive where and how one likes, but people accept that such “violations” are necessary for the common good. Proponents are critical of fluoride tablets, table salt, and topical treatments for various reasons, but one important reason is that these methods of dispensing fluoride do not provide benefits to the whole community. An individual’s right not to ingest fluoride may be protected, but it is at the cost of the social rights of people in general to enjoy the benefits of fluoride. Thus, the rights argument is reversed: people should have the right to good teeth through fluoridation, and other approaches besides water fluoridation do not provide this right or benefit to everyone in the population. The conception of “rights” has been the subject of struggle in the fluoridation debate. Although the antifluoridationists have used the rights argument much more than have the proponents, this is not necessarily because the argument over rights by logic alone supports the opponents. It may be because the propo-
nents have kept mainly to the scientific arguments about benefit and risk, an area in which they have a near monopoly on authoritative support. The issue of individual rights and social welfare is more obviously an ethical and political issue, one the opponents can use even if they have relatively few scientists supporting them on the issues of risks and benefits. Another means by which proponents have responded to the individual-rights argument is to say, contrary to the opponents, that fluoridation is replication of a natural process. Instead of seeing fluoridation as “artificial,” water supplies without fluoride are described as depleted. Fluoridation is simply the process of “topping up” water supplies that are “deficient” in fluoride. Large-scale water supplies for urban areas are seen by some profluoridationists as what is artificial, not the presence of fluoride.45 They portray water with fluoride — whether it is added or not — as healthy and natural. (While superficially plausible, I know of no actual studies of the impact of urbanization on fluoride levels to back up this argument.) For their part, antifluoridationists consider water with added fluoride to be unnatural. They also point out that mother’s milk is normally very low in fluoride, even when the mother drinks fluoridated water. Therefore, they say, if nature knows best, fluoride for infants is inappropriate. Thus, each side in the debate has attempted to define the concept of “natural.” This is because the wider community looks favorably on things that are “natural” and “pure.” But whether fluoridated or unfluoridated water is “natural” cannot be determined solely by reference to “nature,” which provides no unambiguous evidence. Instead, the meaning of “natural” becomes an essential part of what the fluoridation controversy has been about. DECISION MAKING A key bone of contention in the fluoridation issue has concerned how decisions should be made about fluoridation of public water supplies. This is overtly a political issue, but
the role of expert knowledge about fluoridation is crucially involved. There are, in principle, a large number of different ways in which decisions about fluoridation could be made. • Experts make a decision based on their assessments of the benefits and risks, and they have the power to implement that decision directly. • Experts make a recommendation to a statutory authority or semiautonomous government organization that, in turn, makes a decision and implements it. • Elected officials make a decision based on hearing evidence and arguments on scientific, ethical, and individual-rights aspects, and implement it. • A commission of inquiry accepts submissions from all interested parties and, on the basis of these, makes a recommendation to elected officials who, in turn, make a decision and implement it. • Elected officials make a decision, based on results of a referendum of the affected population, and implement it. • A binding referendum is held and the result implemented. These are only a few of the possible decisionmaking models. The actual reality of fluoridation decision making is usually much messier. Typically, an elected government — whether national or local — is pressured by profluoridation or antifluoridation groups to either start or stop fluoridating. Various interest groups try to exert their powers. Experts make submissions, government bodies apply pressure, and community groups and individuals write letters to newspapers. The situation becomes further confused by visiting experts, legal challenges, bans by trade unions, advertising campaigns, public meetings, and debates. If the conflicting demands are too sensitive to confront directly, the government may diffuse the responsibility by instituting an inquiry or a referendum. But the result of any formal assessment of opinion — whether an expert’s submission, a public inquiry, or a
referendum — is seldom the final word. There is always room for further contention. The method by which fluoridation decisions are made is crucial to the struggle, and, indeed, part of the struggle has been between proponents and opponents each trying to ensure that the actual decision-making procedure is one that gives them an advantage. Because the proponents have had the support of most of the acknowledged dental experts in the field, they almost always favor a decision-making method that gives these particular experts a key role. For example, most proponents would be happy with governments making decisions based on advice from authoritative bodies of dental researchers. This means that their persuasive efforts could be directed at one specific body of experts. They oppose referendums.46 The opponents have been more successful in generating support among the general public. Therefore they tend to favor decisionmaking methods allowing public participation, such as referendums. Unlike the debate over the benefits and risks of fluoridation, differences involving preferred methods of decision-making are not clearly articulated in most written material about the issue. Proponents often say or imply that fluoridation is a scientific issue — in other words, the decision should be made on scientific grounds alone — but they also realize that they must, nevertheless, wage a political struggle and win the support of the general public as well as politicians. Opponents are suspicious of giving experts too much power, but they are quite willing to call upon their own experts — such as Waldbott or Yiamouyiannis. CONCLUSION The benefits of fluoridation, the risks of fluoridation, individual rights, and decision making: these have been the key areas of the debate. In this chapter, I have presented the arguments as if they are issues of science, logic, and assessment of human welfare by rational means. This is a narrow and inadequate framework from which to analyze
the issue, as later chapters will show. But, even within this framework, it is possible to see that “arguments” do not stand outside society. They rely on a variety of rhetorical devices,47 and are embedded in systems of belief and everyday practices. It is convenient to conceptualize arguments about benefits and risks as “tools” or “resources” that partisans can use to support their cases. For example, the reported results of the classical fluoridation trials have been a powerful resource used by the proponents. The opponents have tried to counter this with methodological criticisms. The opponents have used claims about individual rights as a tool to oppose fluoridation of community water supplies. Proponents have responded with arguments about community welfare and lack of any dangers. Arguably, the prominence of particular lines of argument in the debate has depended on their usefulness in winning over relevant individuals — including dentists, politicians, and members of the public. Scientific details about the benefits of fluoridation have not, in the past, played a major role in the public debate, probably because the technical nature of epidemiological studies is not suited for communication to nonscientists. Issues of individual rights and community welfare are easily comprehended by nonspecialists, and so these have played a prominent role in the debate. In each case, the arguments have been tied to wider constellations of ideas. Individual rights connotes a link to freedom of speech and religion. Community welfare may suggest a link to widely supported amenities such as clean air and national parks. What makes a good argument is not logical coherence or social importance in some abstract sense, but logic and socially relevant realities tied to deeply felt problems and beliefs. It is important to note that an analysis of the arguments about fluoridation, as presented in this chapter, is insufficient to promote understanding of much of the dynamics of the fluoridation controversy. Many questions remain unanswered.
How are different arguments used in relation to each other? What further resources have been used in the struggle over fluoridation? Why have most dental authorities supported fluoridation? Why has the debate been about fluoridation rather than some other facet of dental health? The following chapters will address these questions. NOTES 1. John J. Murray and Andrew J. RuggGunn, Fluorides in Caries Prevention, Bristol: Wright PSG, second edition (1982): 16. 2. Ibid., 67. 3. Ernest Newbrun, “Water Fluoridation and Dietary Fluoride,” in Ernest Newbrun (ed.), Fluorides and Dental Caries, Springfield, Ill.: Charles C. Thomas (Third edition, 1986): 3-32, at 14. 4. Wesley O. Young, David F. Striffler, and Brian A. Burt, “The Prevention and Control of Dental Caries: Fluoridation,” in David F. Striffler, Wesley O. Young, and Brian A. Burt, Dentistry, Dental Practice, and the Community, Philadelphia: W. B. Saunders (Third edition, 1983): 155-200, at 179. 5. Alan M. Slutsky, Sheldon Rovin, and Norma A. Kaplis, “Fluoridation: 100 Questions and Answers,” Stephen Barrett and Sheldon Rovin, eds., The Tooth Robbers: A Pro-Fluoridation Handbook, Phildelphia: George F. Stickley (1980): 44-65, at 48. 6. Philip R. N. Sutton, Fluoridation: Errors and Omissions in Experimental Trials, Melbourne: Melbourne University Press (Second edition, 1960): 5. 7. Ibid., “Part Three: Criticisms and Comments,” 73-129, including reviews by Donald Galagan, by J. R. Blayney and I. N. Hill, by R. M. Grainger (all from the Australian Dental Journal, February 1960), and by J. Ferris Fuller (from the New Zealand Dental Journal, January 1960), with replies from Sutton. See also James M. Dunning, “Biased Criticism of Fluoridation,” Nutrition Reviews, vol. 18, no. 6 (June 1960): 161-165. 8. Sutton, op. cit. (note 6), 45.
9. Ibid., 97. 10. Ibid., 106. 11. Ibid., 75 (emphasis in the original). 12. Ibid., 1. 13. Ibid., 77-78. 14. Sutton’s book is not cited by: P. Adler, “Fluorides and Dental Health,” in Fluorides and Human Health, Geneva: World Health Organization (1970): 323-354; Murray and Rugg-Gunn, op. cit. (note 1); Newbrun, op. cit. (note 3); Royal College of Physicians of London, Fluoride, Teeth and Health, Tunbridge Wells, Kent: Pitman Medical (1976); Young et al., op. cit. (note 4). James Morse Dunning, Principles of Dental Public Health, Cambridge, Mass.: Harvard University Press (1962), appears not to give any reference to Sutton although he had reviewed Sutton’s book not long before (Dunning, 1960, op. cit. (note 7)). A partial exception is Frank J. McClure, Water Fluoridation: The Search and the Victory, Bethesda, Md.: U.S. Department of Health, Education, and Welfare; National Institutes of Health; National Institute of Dental Research (1970): 288, who includes Sutton’s monograph in a list of fluoridation literature but does not discuss it in the text. 15. Mark Diesendorf, “The Mystery of Declining Tooth Decay,” Nature, vol. 322 (10 July 1986): 125-129; Mark Diesendorf, “A Reexamination of Australian Fluoridation Trials,” Search, vol. 17, nos. 10-12 (OctoberDecember 1986): 256-262. 16. John Colquhoun, “Influence of Social Class and Fluoridation on Child Dental Health,” Community Dentistry and Oral Epidemiology, vol. 13 (1985): 37-41; J. Colquhoun, “Fluoridation in New Zealand: New Evidence,” American Laboratory, vol. 17, no. 5 (May 1985): 66-72, and vol. 17, no. 6 (June 1985): 98-109; John Colquhoun and Robert Mann, “The Hastings Fluoridation Experiment: Science or Swindle?,” Ecologist, vol. 16, no. 6 (1986): 243-248, and letter (postscript), vol. 17, no. 2/3 (1987): 125-126; John Colquhoun, “Child Dental Health Differences in New Zealand,” Community
Health Studies, vol. 11, no. 2 (1987): 85-90; John Colquhoun, “Decline in Primary Tooth Decay in New Zealand,” Community Health Studies, vol. 12, no. 2 (1988): 187-191. Colquhoun’s work includes comparison of dental decay in fluoridated and nonfluoridated areas as well as a critique of earlier studies. 17. F. B. Exner and G. L. Waldbott (James Rorty, ed.), The American Fluoridation Experiment, New York: Devin-Adair (1957): 113-116. 18. R. Ziegelbecker, “Fluoridated Water and Teeth,” Fluoride, vol. 14, no. 3 (July 1981): 123-128. 19. H. Busse, E. Bergmann, and K. Bergmann, “Fluoride and Dental Caries: Two Different Statistical Approaches to the Same Data Source,” Statistics in Medicine, vol. 6 (1987): 823-842. 20. I thank Mark Diesendorf for this point. 21. Alfred Aslander, “The Theory of Complete Tooth Nutrition as a Natural and Effective Dental Caries Prophylaxis,” Journal of Applied Nutrition, vol. 17 (1964): 190-204. I thank Albert Burgstahler for bringing this point to my attention. A survey of the effect of minerals on tooth decay is given by M. E. J. Curzon and T. W. Cutress (eds.), Trace Elements and Dental Disease, Boston: Wright/PSG (1983). 22. A less colloquial phrasing is the following from J. J. Murray (ed.) Appropriate Use of Fluorides for Human Health, Geneva: World Health Organization (1986): 116. “The two other principal means of preventing dental caries [besides fluoride] are dietary control and oral hygiene. However, the role and applicability of these two measures in public health are connected with complex behavioural and cultural problems. For this reason, they are not conducive to a rapid improvement in dental health.” 23. Exner and Waldbott, op. cit. 24. Key accounts of a general nature include Albert W. Burgstahler, “Dental and Medical Aspects of Fluoridated Drinking Water,” Transactions of the Kansas Academy of Science, vol. 68, no. 2 (1965): 223-243, and
“Corrigenda and Addenda,” vol. 68, no. 3 (1965): 418; Exner and Waldbott, op. cit.; George L. Waldbott in collaboration with Albert W. Burgstahler and H. Lewis McKinney, Fluoridation: The Great Dilemma, Lawrence, Kans.: Coronado Press (1978); John Yiamouyiannis, Fluoride: The Aging Factor, Delaware, Ohio: Health Action Press (Second edition, 1986). 25. Murray and Rugg-Gunn, op. cit., chapter 13; Waldbott et al., op. cit., chapter 7. 26. National Health and Medical Research Council, Report of the Working Party on Fluorides in the Control of Dental Caries, Canberra: Australian Government Publishing Service (1985): 4. For a similar statement, see Royal College of Physicians of London, op. cit., 38. 27. Waldbott et al., chapter 8. 28. Newbrun, op. cit., 15. As noted by some critics, there were significant differences between the Newburgh and Kingston children on some tests; these have been ignored by proponents such as Newbrun. 29. Murray and Rugg-Gunn, op. cit., 241. 30. Waldbott et al., op. cit., and many references therein, dating from the 1950s. 31. For scientifically sensitive counters to Waldbott’s work (and to other scientific claims of hazards from fluoridation), see Safe Drinking Water Committee, Advisory Center on Toxicology, Assembly of Life Sciences, National Research Council, Drinking Water and Health, Washington, D.C.: National Academy of Sciences (1977): 369-400; Donald R. Taves, “Claims of Harm from Fluoridation,” in Erling Johansen, Donald R. Taves, and Thor O. Olsen (eds.), Continuing Evaluation of the Use of Fluorides, Boulder, Colo.: Westview Press (1979): 295-321. 32. Harold C. Hodge, “Evaluation of some Objections to Water Fluoridation,” in Newbrun, op. cit., 221-255, at 239. For a similarly brief dismissal of Waldbott’s work, see Dunning (1962) op. cit., 347. The report of the Royal College of Physicians of London, op. cit., 62-64, gives more detail on Waldbott’s work, but ends by dismissing it
with reference to the same American Academy of Allergy statement. 33. Murray and Rugg-Gunn, op. cit. 34. For example, Ernest Newbrun, “The Safety of Water Fluoridation,” Journal of the American Dental Association, vol. 94, no. 2 (February 1977): 301-304; Frank A. Smith, “Safety of Water Fluoridation,” Journal of the American Dental Association, vol. 65, no. 5 (November 1962): 598-602; and Young et al., op. cit. 35. For example, Royal College of Physicians of London, op. cit. Hodge, op. cit., 239, by contrast, says “Such anecdotal reports by others have also been presented.” 36. Walbott’s reluctance here may have been due to his bad experience with Hornung, described in chapter 4. 37. G. W. Grimbergen, “A Double Blind Test for Determination of Intolerance to Fluoridated Water,” Fluoride, vol. 7, no. 3 (July 1974): 146-152. See also Reuben Feltman and George Kosel, “Prenatal and Postnatal Ingestion of Fluorides — Fourteen Years of Investigation — Final Report,” Journal of Dental Medicine, vol. 16, no. 4 (October 1961): 190-198; H. T. Petraborg, “Chronic Fluoride Intoxication from Drinking Water,” Fluoride, vol. 7, no. 1 (January 1974): 47-52; H. T. Petraborg, “Hydrofluorosis in the Fluoridated Milwaukee Area,” Fluoride, vol. 10, no. 4 (October 1977): 165-169. See also Lois I. Juncos and James V. Donadio, Jr., “Renal Failure and Fluorosis,” Journal of the American Medical Association, vol. 222, no. 7 (13 November 1972): 783-785; John Lee, “Gilbert’s Disease and Fluoride Intake,” Fluoride, vol. 16, no. 3 (July 1983): 139-145. 38. One exception is Taves, op. cit. 39. Evelleen Richards, “The Politics of Therapeutic Evaluation: The Vitamin C and Cancer Controversy,” Social Studies of Science, vol. 18 (1988): 653-701. 40. For a full account and further references, see Yiamouyiannis, op. cit. See also J. B. Bundock, D. Burk, J. R. Graham, and P. J. Morin, “Fluorides, Water Fluoridation, Cancer
and Genetic Diseases,” Science and Public Policy, vol. 12, no. 1 (February 1985): 36-46. 41. Richard Doll and Leo Kinlen, “Fluoridation of Water and Cancer Mortality in the U.S.A.,” Lancet (18 June 1977): 1300-1302; J. David Erickson, “Mortality in Selected Cities with Fluoridated and Non-Fluoridated Water Supplies,” New England Iournal of Medicine, vol. 298 (18 May 1978): 1112-1116; Robert N. Hoover, Frank W. McKay, and Joseph F. Fraumeni, Jr., “Fluoridated Drinking Water and the Occurrence of Cancer,” Journal of the National Cancer Institute, vol. 57, no. 4 (October 1976): 757-768; Leo Kinlen and Richard Doll, “Fluoridation of Water Supplies and Cancer Mortality. III: A Re-Examination of Mortality in Cities in the USA,” Journal of Epidemiology and Community Health, vol. 35 (1981): 239-244; P. D. Oldham and D. J. Newell, “Fluoridation of Water Supplies and Cancer-A Possible Association?” Applied Statistics, vol. 26, no. 2 (1977): 125-135, and letter, vol. 28, no. 2 (1979): 184; Eugene Rogot, A. Richey Sharrett, Manning Feinleib, and Richard R. Fabsitz, “Trends in Urban Mortality in Relation to Fluoridation Status,” American Journal of Epidemiology, vol. 107, no. 2 (1978): 104-112. 42. Mark Diesendorf, “International Symposium on Fluoridation,” Social Science and Medicine, vol. 27, no. 9 (1988): 1003- 1005. 43. “Water throughout history has been perceived as the stuff which radiates purity.” Ivan Illich, H2O and the Waters of Forgetfulness, London: Marion Boyars (1986): 75-76. Illich deals with the complex cultural role of water. 44. Dunning (1962) op. cit., 372. 45. A concise exposition of this view is given by Lee A. Krimmer in a letter, Journal of the American Dental Association, vol. 88, no. 6 (June 1974): 1241-1242. “For millions of years, man’s water supply was that of running streams, lakes, rivers, wells, and cisterns. All of these forms were soil leaching, enriched with the minerals from the soil they contacted. As cities grew, man established the reservoir water supply. Reservoirs are essentially rain
water collected from short runoffs and devoid of minerals. … God put fluoride into the water and man inadvertently took it out.” 46. For example, P. Jean Frazier, “Priorities to Preserve Fluoride Uses; Rationales and Strategies,” Journal of Public Health Dentistry, vol. 45, no. 3 (Summer 1985): 149- 165, at 162-163; Ruth Roemer, “Water Fluoridation: Public Health Responsibility and the Democratic Process,” American Journal of Public Health and the Nation’s Health, vol. 55, no. 7 (July 1965): 1337-1348, at 1344- 1346. 47. The uses of rhetorical devices in technical arguments on fluoridation and nuclear power are discerningly treated by Allan Mazur, “Disputes Between Experts,” Minerva, vol. 11, no. 2 (April 1973): 243-262, reproduced in Allan Mazur, The Dynamics of Technical Controversy, Washington, D.C.: Communications Press (1981).
Coherent viewpoints
The benefits of fluoridation, the risks of fluoridation, individual rights versus community welfare, decision making about fluoridation — these are four key areas involved in the fluoridation issue. Considering these areas separately, it might seem that there is no necessary connection between conclusions reached on each one. But, when one looks at leading proponents and opponents of fluoridation, they turn out to have remarkably coherent views. That is, they either take positions supporting fluoridation in relation to benefits, risks, individual rights, and decision making, or they take positions opposing fluoridation in all these areas. If these partisans support or oppose fluoridation, they do so on all possible grounds rather than as a balance of advantages and disadvantages. To understand the fluoridation controversy, it is necessary to go beyond an examination of the arguments, such as presented in the previous chapter, which implicitly assumes that evaluations are based solely on scientific evidence, logic, and human welfare. The coherency of viewpoints is an indication of the passionate commitments commonly found on this issue. These commitments, either for or against fluoridation, help explain the nature and style of argumentation on the issue, as well as the behaviors described in following chapters. Coherency of viewpoints is apparent in most of the writings on fluoridation, which are easy to divide into “pro” and “anti” camps. But rather than present a detailed exegesis of written views, I will describe in this chapter my interviews in Australia with leading scientist proponents and opponents of fluoridation. In Australia, as in other English-speaking countries, the fluoridation issue has been a major public controversy for several decades. The National Health and Medical Research Council, an advisory body made up of ad hoc
expert committees, has made recommendations in favor of fluoridation since 1952.1 Following the early recommendations, the idea was studied by dental and health bodies in different parts of the country. Because of Australia’s federal structure, there has never been an attempt to introduce fluoridation nationally. Decisions have been made at the state level and, more frequently, at the level of individual cities and towns. Mainly due to the initiative of individuals, a few Australian towns were fluoridated in the 1950s. Most capital cities have also fluoridated their water supplies, including Canberra (1964), Hobart (1964), Sydney (1968), Perth (1968), Adelaide (1971), Darwin (1972), and Melbourne (1977). The only capital city remaining unfluoridated is Brisbane. Thus, about two-thirds of Australians drink water with added fluoride. The decision-making process involved varied considerably, ranging from administrative decision to extensive political maneuvering and public debate. In most cases, public debate about fluoridation was minimal in any given area in the years after a decision, whether it was pro or con. But the issue is kept on the boil by new proposals to fluoridate various towns, such as Geelong in Victoria in the mid 1980s. Similarly, decisions by the newly established self-government in Canberra in 1989 to stop and then restart fluoridation triggered an enormous public debate. There have been many people involved in the fluoridation issue in Australia, including dentists, politicians, government bureaucrats, and “members of the public.” I set out to examine the views of knowledgeable professionals who have played an important role in the debate, with “professionals” referring mainly to scientists, dentists, and doctors. The number of such individuals who have played an important promotional or oppositional role is quite small, and has been depleted by
deaths. Those interviewed are listed in Table 3.1. Table 3.1 Fluoridation Partisans Interviewed, Plus Their Positions at the Time of Interview Proponents LLOYD CARR, special advisor (Dental), Commonwealth Department of Health, Canberra; and chairman, National Health and Medical Research Council (NHMRC) Working Party on Fluorides in the Control of Dental Caries. GRAHAM CRAIG, associate professor, Department of Preventive Dentistry, University of Sydney; and member, NHMRC Working Party on Fluorides in the Control of Dental Caries. JEAN CURRIE, School Dental Section, Australian Capital Territory Health Authority, Canberra. GERALD DICKINSON, orthodontist, Melbourne; and former chairman, Australian Dental Association (Victorian Branch) Fluoridation Committee. BRUCE LEVANT, dentist, Melbourne; and former chairman, Australian Dental Association (Victorian Branch) Fluoridation Committee. JACK MARTIN, Professor of Medicine, University of Melbourne; and NHMRC Working Party on Fluorides in the Control of Dental Caries. NOEL MARTIN, professor, Department of Preventive Dentistry; and Dean, Faculty of Dentistry, University of Sydney. GAVAN OAKLEY, dentist, Melbourne; and former chairman, Australian Dental Association (Victorian Branch) Fluoridation Committee. ELSDON STOREY, Professor of Child Dental Health, Department of Preventive and Community Dentistry, University of Melbourne. DAVID THORNTON TAYLOR, orthodontist, Canberra; and former chairman, Australian Dental Association (ACT Branch). KEITH TRAYNOR, dentist, Canberra.
Opponents MARK DIESENDORF, Visiting Fellow, Human Sciences Program, Australian National University; and former principal research scientist, Division of Mathematics and Statistics, Commonwealth Scientific and Industrial Research Organization, Canberra. LESLIE KAUFMAN, retired pharmaceutical chemist, Melbourne; and former secretary, Antifluoridation Association of Victoria. JOHN POLYA, retired associate professor, Department of Chemistry, University of Tasmania. GEOFFREY SMITH, dental researcher and consultant with experience in general practice, Melbourne. PHILIP R. N. SUTTON, retired as senior lecturer, School of Dentistry, University of Melbourne; and author of Fluoridation: Errors and Omissions in Experimental Trials. Melbourne: Melbourne University Press (Second edition, 1960). GLEN WALKER, chairman, Antifluoridation Association of Victoria; chairman, Freedom from Fluoridation Federation of Australia; former owner and then chairman of directors of a metal finishing supply company; and author of Fluoridation: Poison on Tap, Melbourne: Glen Walker (1982). (Note that Jack Martin and Noel Martin are not related to the author of this book.) I planned to interview the most important figures in the fluoridation debate in the cities of Canberra and Melbourne, plus those from other localities if convenient. Fluoridation was introduced in Canberra (Australian Capital Territory) in 1964 by administrative decision with little public debate, whereas Melbourne (Victoria) was not fluoridated until 1977 after two decades of political struggle. I hoped to uncover any divergence of opinion due to the divergent political contexts of the introduction of fluoridation in these two cities.2 To select potential interviewees, I initially contacted some well-known figures in the debates as well as state health departments and branches of the Australian Dental Association. At the end of each interview, I asked the
interviewee to name others who were prominent in the debate and who should be interviewed. It soon became apparent that I had attained almost complete coverage of the leading figures in the fluoridation controversy in Canberra and Melbourne. Only two other individuals from these two cities are obvious candidates for the list of opponents: Arthur Amies, the former Dean of the Melbourne University Dental School, now deceased; and Edward Dunlop, a surgeon in Melbourne who declined to be interviewed. Indeed, the short list of opponents whom I interviewed constitutes an almost complete coverage of scientists, dentists, doctors, and other technical workers who have been prominent in the debate in major cities throughout Australia. A similar near-complete coverage of leading proponents in Canberra and Melbourne was obtained. There are no widely recognized leading figures in these cities whom I did not interview; on the other hand, there was a greater number of people recommended to me for interview on the proponent side, but I did not contact every one of them. Because of the long and active struggle over fluoridation in Melbourne, there seems to be a high density of partisans there. Those knowledgeable about campaigns in other states informed me that there were relatively few to contact in Perth, Adelaide, or Brisbane. Of the individuals listed in Table 3.1, only one — David Thornton Taylor — said he did not play an important role in the decision making or debate on fluoridation. Several — most notably Gavan Oakley and Glen Walker — are inveterate campaigners. The interviews were carried out between September 1986 and February 1987. Bruce Levant, Leslie Kausman, and Geoffrey Smith were interviewed by telephone. The others were contacted face-to-face. The interviews lasted for 30 minutes to three hours, with the median length being one hour. Using an interview schedule, I asked questions about the introduction of fluoridation in the relevant state, reasons for fluoridation, assessment of alternatives to water fluoridation, reasons for opposition to fluoridation,
why there is little fluoridation in Europe, and appropriate decision-making procedures concerning fluoridation. COHERENT VIEWPOINTS The viewpoints of every person interviewed were highly coherent, and indeed mobilized, either in total support or total opposition to fluoridation. This included both technical issues (concerning the benefits and risks of fluoridation), as well as ethical and political issues. The proponents were unanimous in crediting fluoridation with massive reductions in tooth decay. While figures on the order of 50 percent reduction are standard in the technical literature, two dental practitioners volunteered that the reduction in decay they had personally observed in children’s teeth would be on the order of 90 percent, if both the number and seriousness of cavities were taken into account. By contrast, only one of the opponents accepted that any reductions had been conclusively shown to be due to water fluoridation. (None ruled out that water fluoridation may have resulted in reductions in tooth decay.) They pointed to flaws in the experimental trials, and also pointed to the decline in tooth decay in unfluoridated cities, such as Brisbane. The opponents argued that there are health hazards from fluoridation, such as intolerance reactions, for at least a small fraction of the population. They said that the possibility that fluoridation increased the cancer death rate could not be ruled out, although, as yet, the evidence was not fully conclusive. In complete contrast, the proponents denied that there was adequate evidence to demonstrate a hazard to a single individual from fluoridation. The studies purporting to show such hazards were dismissed as unsubstantiated, poorly done, or biased. Concessions from these monolithic perspectives were so infrequent that they are worth itemizing. Smith, an opponent, said that an optimal intake of fluoride as a decay preventive has been well established.3 John Polya, another opponent, said that fluoride
may play some useful role in preventing decay, via individual doses for those who are not sensitive. Taylor, a supporter though not a leading proponent, noted that there is only a factor of three between 1 part per million (ppm) of fluoride in water which is optimal and 3 ppm which he said can cause unacceptable mottling of teeth, and that this factor of three is small compared to the usual factor of 100 between recommended use and harmful effects. These were the only conspicuous concessions toward the opposition’s views on benefits and risks raised in all the interviews. One feature of the coherency of the viewpoints of proponents was a total dismissal of alternatives to the policy endorsed. One of my questions was “To what degree and why was water fluoridation promoted in preference to major campaigns for widespread use of fluoride tablets; fluoride in school water supplies; fluoride in table salt; topical applications of fluoride; improved oral hygiene; and better diet?” Almost without exception the proponents dismissed each of these alternatives as impractical, ineffective, or even undesirable. It was said, typically, that fluoride tablets work but few people persist in giving them to their children; that school water supplies do not provide a full coverage and miss preschool children in particular; that excessive intake of salt is undesirable for health reasons; that topical applications are too expensive and do not reach the entire community; that improved oral hygiene is of limited importance for tooth decay although it benefits gums; and that achieving better diet, while desirable, is very unlikely to occur. The reasons stated against these alternatives were not surprising, since objections have been raised to each of them in the literature. What was striking was the total rejection of all alternatives coupled with the total endorsement of water fluoridation. For example, fluoride tablets were rejected as not providing the coverage of the community that water fluoridation offers. But, since some communities reject water fluoridation, it might be thought that tablets would be appropriate in these places, since they avoid
the objection of compulsion. Again, fluoride in table salt avoids compulsion, and has been effectively implemented in Switzerland. Yet, the advantages of the alternatives in overcoming some of the primary objections to fluoridation were never mentioned by proponents. The proponents agreed that strong efforts had been made to improve oral hygiene and diet. There were divergent opinions about whether diet had actually improved, but agreement that little could be done to dramatically alter the decay-producing aspects of Western diets and agreement that fluoridation was still necessary. The actual words used by proponents and opponents to describe their positions are revealing. Studies have shown that scientists typically express different evaluations of evidence and knowledge through the use of different types of language. When claims about knowledge are accepted, they are typically referred to as having been derived from objective examination of material reality. The language used here is called the “constitutive” or “empiricist” repertoire.4 An example would be, “The early studies showed that fluoride in water significantly reduces tooth decay.” When claims about knowledge are challenged, it is common for the human aspects of the claims to be exposed. The language here is called the “contingent” repertoire. For example, “The early investigators selected their figures in a way that favored fluoridation, while, actually, some towns with high fluoride levels had higher decay.” I expected that advocates on each side would use the constitutive repertoire when describing their own positions and the contingent repertoire when describing the other side. As shown in the following paragraphs, this did occur regularly; but, in addition, the contingent repertoire was often used by proponents and opponents in describing views and behavior on both sides. This seems to be a product of the intensely political nature of the debate, which means that the operation of “political” factors is more overt and recognized on both sides.
Most interviewees claimed their stand was based on the scientific evidence, while denying that there was any rational basis for a contrary view. The proponents regularly described the opponents as a fringe minority. Lloyd Carr said that opponents, such as Amies and Sutton, were in the corner of a field, and that credence should be given to those in the center, including the World Health Organization, health authorities, and parliaments. When asked to account for the opposition of particular prominent figures — I specifically mentioned Amies and Dunlop — several proponents simply said they couldn’t understand it and that they never had understood what motivated antifluoridationists. Arthur Amies was the most prominent opponent of fluoridation in Victoria for many years before his death. In view of his position as Dean of the Dental School at the University of Melbourne, both proponents and opponents said that Amies was responsible for greatly delaying the introduction of fluoridation in Melbourne where nearly one-fifth of all Australians live. The frequency and variety of contingent explanations for Amies’ stand were fascinating. It was explained to me by different proponents that Amies’ views were colored by his wife’s diabetes; that he was strongly opposed to dentistry in the United States and saw fluoridation as US in origin; and that he had a philosophical preference for treating the individual rather than using mass treatment.5 By contrast, Kausman and Philip R. N. Sutton, opponents who knew Amies, attributed his opposition to knowledge. Although the participants interviewed always attributed their own stands to knowledge (the constitutive repertoire), most of them were quite open in describing why they had become involved with the topic, and, in most cases, this explanation relied on the contingent repertoire. This difference is understandable in terms of a distinction between arguments for or against fluoridation and reasons for being involved in the debate. The arguments — both for or against — were seen by most interviewees as scientific, whereas involvement in the debate was seen a
political, which legitimately may be described by using the contingent repertoire. Most proponents, without being asked, explained their own support for fluoridation and their involvement in the debate as being a result of their experience with massive decay problems, most commonly in the 1950s and as dentists or dental researchers. The dentists recounted their experiences in extracting numerous teeth — and sometimes the entire dentition — from child after child under general anesthesia, with tears from the child, the parents, and even the dentist. It was their experience of the human suffering of tooth decay that led to their support for a preventive measure. The opponents expressed a much more varied set of motivations. Mark Diesendorf had previously been involved in campaigns on a number of environmental and health issues. Sutton said he became involved after Amies asked him to look at figures on fluoridation trials. Walker had come across fluoride in his metal finishing supply company and found it to be highly dangerous. Contingent explanations came into their own in responses to the question “How do you account for the failure to fluoridate in some other countries, especially in Europe?” Detailed information about the reasons for lack of fluoridation in Europe is not readily available (see appendix), and so this question provided a type of Rorschach ink-blot test on which interviewees could supply speculations about the lack of fluoridation. Two respondents mentioned some sources for their information, which was mostly about Scandinavia. On the other hand, a number of respondents admitted their comments were speculative. Explanations offered by proponents were uniform in insisting that health concerns were not the reason for lack of fluoridation. Political factors — specifically the organized efforts of antifluoridationists — were most commonly mentioned. For example, Carr said that countries have not avoided fluoridation on the basis of health, and therefore, by exclusion, there must be political reasons.
Other reasons suggested were legal obstacles, popular opposition to centralized measures (due to the experience of fascism); the low status of European dental professionals; the use of other methods to prevent tooth decay (such as fortnightly treatment of people showing a tendency towards decay); a lower level of decay; and higher natural levels of fluoride in the water. It was mentioned by a couple of respondents that the parliamentary vote against fluoridation in the Netherlands had immediately followed a claim on television by a US antifluoridationist that fluoride causes cancer.6 In this context Oakley said “It is nothing to do with science — it’s all politics.” This was a common view. Opponents in their explanations gave much more weight to the rational consideration of evidence by European authorities. Kausman said that European countries had been guided by scientific advisors. Walker said that the failure to fluoridate in Europe was because their scientific communities were better educated, more inquiring, and objective. But most opponents put rational considerations in the context of contingent factors. Polya and Diesendorf each suggested that medical and scientific bodies in some countries may have been more cautious, especially of a US-based idea. In describing the introduction of fluoridation in Australia, many of those interviewed had a great deal of information, and both proponents and opponents gave detailed accounts that usually included a strong component of contingent factors. In this chapter, I only give a few examples of how a “fact” raised on one side can be undercut by the other side. Oakley mentioned that a local newspaper had published an antifluoridation article that said there had been a 63 percent increase in hospital admissions for kidney problems, which the author attributed to fluoride.7 Oakley was writing a response; he had checked with the hospital and found that the reason for the so-called increase was that there were more dialysis machines available. In a letter to the Melbourne Age, Elsdon Storey criticized Sutton’s opposition to
fluoridation.8 Storey noted that the judge in the Strathclyde (Scotland) court case on fluoridation had said that Sutton had made no criticism of the important Tiel-Culemborg (Netherlands) study. Sutton and Walker each spontaneously brought up this issue, noting that Sutton, in his testimony, had only been asked whether the Tiel-Culemborg study was an important one. He had replied “yes,” but had not been asked anything further about the study. In other words, he had not been asked whether he had any criticisms, which he did have. To an outsider, these may seem like minor points, not really affecting the major issues at stake. But to those involved, small errors or alleged misrepresentations by the other side reflected the general inadequacy of those against whom they were debating. While a few interviewees recollected the satisfaction of disputing a technical point raised by the other side, the more common experience was the intensely political nature of the debate. This was generally regarded as undesirable, and certainly seen as frustrating by nearly everyone concerned, since they believed that there was a “truth” favoring their position. Gerald Dickinson said he would have respect for opponents if they raised constructive criticisms. But this was not the case, and, eventually, he dropped out of the issue because of the emotionalism involved. Polya was unique in being openly derogatory of nonscientist partisans involved on both sides. He characterized the proponents as having latched onto the idea of fluoridation and then being tied to it with religious fervor, whereas many of the opponents were Luddites, often with fundamentalist connections. Polya thought there was no real science involved in the debate since there was no peer group for scientific argument, and he believed that he had joined a political rather than a scientific debate. It is common in controversial issues for partisans to attempt to associate their causes with favorable images. In this debate, the proponents regularly refer to “controlled fluoridation” — so called because the concen-
tration of fluoride in the water supply is controlled — while opponents refer to “artificial fluoridation,” noting that the dosage of fluoride to people who drink fluoridated water is not controlled. The claim that fluoridation is artificial or unnatural is a staple of the antifluoridation repertoire. What was striking in the interviews was the number of proponents who, without prompting, described water with added fluoride as more natural than its previous unfluoridated state. Graham Craig said that water fluoridation is chosen to mimic nature and to supplement depleted water. Jean Currie said that water reservoirs for urban areas are overpurified compared to natural water supplies, and contended that fluoridation is not really adding anything, but bringing the level up to natural levels. This seemed to be a common perception of fluoridation by proponents, and not just an argument of convenience. The disagreement about what is called “natural” shows that this concept can be challenged as well as struggled for. “Naturalness” does not spring unambiguously from “nature.” Perhaps the most dramatic evidence of the coherency of viewpoints came with views expressed about ethics. The objection to fluoridation that it is a violation of individual rights as compulsory mass medication for a nonlethal disease has been central to the opposition. It shapes the scientific claims of both sides. Proponents regularly deny that there has been a single documented and authenticated case of damage to an individual’s health from water fluoridation. If it were acknowledged that, for example, fluoridation caused harmful effects in even just one of a million people, then this would have to be weighed against benefits in the form of reduced tooth decay. The argument would then become one of health costs versus health benefits. But if there are no health costs, the argument is shifted to a different ground. There is then no apparent reason to object, and opposition seems irrational. Craig, for example, admitted that some value judgments — which he left unspecified — are involved in
the fluoridation issue, but said, concerning the issue of relative risks, that there are no demonstrated risks. Some opponents think the individual-rights argument is so important that they would oppose fluoridation even if there were no health risks. The attitude of proponents to the individual-rights argument is vastly different. Keith Traynor said that fluoridation, like chlorination, is a health measure beneficial to the community, and individuals cannot do anything about it. Oakley took the measured view that liberties are not absolute, and that people should submit to reasonable laws for overall benefit, provided that safety is assured. Dickinson said it is ethical to have fluoridation, noting that when there is widespread disease causing pain and cost, there is a need for community health measures; an appropriate analogy is seat-belt legislation. Thus the rights issue, a key one to most opponents, carried little weight with proponents or was actually turned to their advantage. A key question in the interviews was “What do you think is an appropriate decisionmaking procedure on fluoridation?” Here the views of proponents and opponents diverged again, along lines congruent with their stance on fluoridation. In Australia, the 1968 Tasmanian Royal Commission9 and the 1980 Victorian Committee of Inquiry10 have been the two most important public inquiries into the issue. Both strongly endorsed fluoridation. With some notable exceptions, most overseas commissions and inquiries have also supported fluoridation. Opposition to fluoridation — in the United States, at least — has been more effectively expressed in referendums. When the public has been given an opportunity to express opinions on fluoridation — for example, in public debates involving meetings, petitions, and letters to newspapers — opponents are frequently much more successful than they are in formal inquiries. Without exception, proponents favored paths in which expert bodies played a major role, advising a government that then took action and implemented the specialists’ and experts’ advice. They opposed referendums and were uniformly reluctant to support any
direct public involvement in decision making, except the involvement implicit in the election of representative government. For example, Carr said that government — which is the voice of the people — should decide, and that the government should not make a decision without consulting the experts, such as health authorities, the National Health and Medical Research Council, and university professors. Traynor said there should never be a referendum on a public health issue because the public is not qualified to offer an opinion. Levant opposed referendums but favored a public education campaign before or after the decision to tell the public what had been done and why. The views of proponents on decision making about fluoridation are compatible with their own situations and conclusions. Most expert bodies have favored fluoridation. They (the proponents) favor it, and many of them are the very experts whom they consider should be relied upon to play a major role. The opponents11 supported community participation, usually by referendum, in decision making on fluoridation. Walker said that experts can put their cases to the people before the vote. Polya said that people should be free to choose their own medicine and health, provided that the choice does not disadvantage others. He suggested that, even with support in a referendum, fluoridation should not proceed, drawing the analogy that there should not be a referendum on religion, even though one religion may be best for the community. The opponents still left an important role for science and expert opinion. But, contrary to the proponents, they thought that a full range of experts would not necessarily support fluoridation. For example, Diesendorf saw value in specialists’ knowledge, but opposed a technocratic elite making decisions for the public. He contended that community decision making was necessary since political and ethical issues were involved. Sutton favored referendums in practice, but thought that, in an ideal world, fluoridation would be a scientific issue decided by appropriate scientists, including
statisticians. Smith did not mention referendums, but commented that it is dangerous to legislate to enforce something that is supposed to be a scientific issue. He added that politicians should understand that no scientist has the ultimate truth. The more diverse range of views of the opponents concerning decision making can be interpreted as reflecting two conflicting tendencies. On the one hand, they are likely to favor referendums because this has been an effective way by which fluoridation has been stopped. On the other hand, most of them hesitate to rule out the role of experts, since that is where their own role in the issue lies. Rounding out the picture was the regularity with which both proponents and opponents criticized the decision-making approach favored by the other side. Proponents dismissed referendums, claiming that antifluoridationists would win because it is easy to scare people with allegations about poison and cancer and, anyway, people usually vote “no” in any referendum. Two of the opponents denigrated formal inquiries. Sutton commented that judges are predisposed for judging the law and are not equipped for judging science. He also contended that they rely on the opinions of advisors and witnesses whose credibility depends partly on reputation. Polya said simply that inquiries are set up not for science but to keep people quiet.12 In each case, the decision-making procedure favored by the other side was undermined by using the contingent repertoire. SOURCES OF COHERENCY The views of partisans who are knowledgeable about the technical issues involved in the fluoridation debate show a remarkable coherency that cuts across the common division between scientific and nonscientific issues. The topic may be the benefits of fluoride, the hazards of fluoride, alternatives to water fluoridation, reasons for the lack of fluoridation in Europe, the naturalness of fluoride in water, the ethics of fluoridation, or the most desirable methods of decision making
on technical issues. Regardless, the partisans line up on opposite sides of the fence in a completely predictable fashion. One possible explanation for this coherency of viewpoints is that the partisans held, prior to encountering the fluoridation issue, a set of attitudes about health risks and benefits, ethics, and decision making that they have applied to the fluoridation issue and expressed in the course of the debate. This explanation is both implausible and virtually untestable. Probing this explanation, it may be asked: Why are there no individuals prominent in the debate who have studied the issue carefully and decided that the benefits of fluoridation are large and the hazards are negligible, but have, nevertheless, concluded that, on ethical grounds, the measure should be opposed? Why have no prominent fluoridation partisans found that the benefits are overestimated and the hazards are of concern but, nevertheless, concluded that the benefits outweigh the costs and that the decision should be made via expert committees? If knowledgeable individuals with these or other such mixtures of views do exist, they have not become prominent in the Australian fluoridation debate. In the current and recent social climate — and speaking very generally — concern about the hazards of trace substances is characteristic of environmentalists. Support for individual rights over collective benefits is characteristic of the political right, and support for direct citizen participation in decision making is characteristic of the libertarian left. It seems most unlikely that antifluoridation partisans would have originally come to the issue with this mixture of orientations and that profluoridation partisans would have had precisely the opposite orientations. In short, it is implausible that prior sets of attitudes explain the observed coherency of views. It may be asked: Why not test this point by asking partisans their views on seat-belt legislation, compulsory AIDS testing, nationalized health insurance, and a variety of other issues? The trouble is that for most of the partisans, the issue of fluoridation is much more significant in their lives — in some cases
it is the central social issue — than the other areas to which it might be compared. As a result, personal stands on fluoridation will tend to shape views on related issues, in order to reduce cognitive dissonance.13 For example, views on individual rights linked to the fluoridation issue are more likely to influence views about seat-belt legislation than the reverse process. In order to test whether views on fluoridation reflect prior sets of attitudes, one would have had to examine attitudes on a range of issues prior to an individual’s exposure to the fluoridation debate. This implies examining virtually everyone — in some cases, before the fluoridation debate even arose, since some partisans were involved with the issue from the beginning. Thus, this explanation for coherency of viewpoints is virtually untestable — at least for the case of fluoridation. A more plausible explanation of coherency of viewpoints is the influence of the fluoridation debate itself on the partisans.14 Because there has been an intense public debate on fluoridation, any person with claims to expertise who speaks publicly on the issue comes under strong pressure to support one side or the other. Because most authorities — at least in English-speaking countries — favor fluoridation, any expert who voices even moderate criticism tends to be taken up by opponents as “supporting their cause.” Anyone who conspicuously spurns partisanship is unlikely to find professional or emotional support from either side. This seems likely to create pressures to join one side or the other, or to drop out of the issue. In the camps of both proponents and opponents, there are processes that encourage the coherency of viewpoints. In the fluoridation committees of the Australian Dental Association, the explicit and sole aim is to promote fluoridation. Those actively involved in such committees scour the literature to find relevant evidence and arguments, and, in their speaking engagements, they quickly learn the most effective responses to various questions. Anyone who has debated an issue in public knows that it is difficult to stick to only a portion of the issue, especially the technical
part. Other issues are raised in questions and, if the cause is to be promoted, effective answers must be provided. The intense and all-consuming nature of the campaign for many of those involved is seldom apparent to people on the outside. For activists on both sides,15 there are talks to be given to public meetings, community groups, and the media; enquiries from the public to be answered; letters to write to newspapers; and submissions to make to politicians. Oakley, of the proponents, and Walker, of the opponents, seemed among the most persistent and indefatigable of partisans. Interestingly, each one expressed the view that the activists, on their side, were an embattled few, with little money and insufficient people willing to take an open stand.16 It is precisely this self-image of a small group of partisans making enormous efforts in the face of perceived apathy that helps mold a coherent overall perspective. Some of the scientists involved were not so heavily involved in the day-to-day struggle. Nevertheless, their views were no less coherently organized around the issue, so far as can be seen from the limited sample. With two exceptions, the proponents reported that they had given fluoride tablets to their children. In the exceptions, the community water was fluoridated, and they supplemented this with topical fluoride treatments. Such parental action is likely to solidify belief in the benefits of fluoridation, since it would be difficult to admit to doing the wrong thing for one’s children. By contrast, the opponents had not given fluoride tablets to their children, similarly making it more difficult to admit that they were wrong in their beliefs. Another factor promoting uniformity of viewpoints is the reliance on material from overseas by both proponents and opponents. Certainly, endorsements by dental and medical associations from other countries are regularly cited by proponents, whereas critical work is cited by opponents. But it is not clear how much the use of this material actually influences the coherency of positions. Obviously, not all overseas material is used,
and what is used must be adapted for Australian conditions and audiences. One factor that reflects the coherency phenomenon as well as maintains it is the lack of informal personal contact between proponents and opponents. It would seem that the most regular contact between those on opposite sides occurs during hearings or debates on fluoridation — for example, before local councils. There seems to be little free discussion of the issues. Symptomatic of this is the comment by Sutton that no one in the Melbourne University School of Dentistry approached him to talk about fluoridation during his ten years there, although the school included many supporters of fluoridation, including the prominent proponent Storey. While contact between partisans on opposite sides is uncommon, interaction between those on the same side is frequent and can be intense. Consultation can occur to check facts, prepare arguments, coordinate talks, or compose letters to newspapers and journals, and so forth. It is not surprising that interaction between sympathizers is common. Some of the opponents reported receiving considerable correspondence from around the world. Naturally, most of it is from other opponents.17 In organizing speakers for public meetings, preparing testimony for formal hearings, or arranging publicity material for the media, each side promotes those individuals who are most effective in supporting the overall case. Those with intermediate, complex, or ambivalent positions receive little encouragement to take leading roles. In Edward Groth’s words, there is a “natural selection for extremist leadership.”18 Only those tough enough and committed enough to stand up to abusive attacks and to suppress self-doubts are likely to stay in the campaign. Another factor is the lack of criticism by people on one’s own side. Pro- and antifluoridation scientists have seldom openly criticized the inaccuracies, exaggerations, and simplifications made by activists on their own sides, although they may privately deplore these shortcomings. Usually, they try to maintain scientific integrity by attacking mistakes made
by those on the other side, while presenting their own cases in as persuasive a manner as possible yet compatible with their assessments of the evidence. Peer-group pressure restrains individuals from criticizing others on the same side and thus breaking ranks since, in the context of the controversy, this would, indeed, seem to help the other side — at least in the short term. Does it make sense to analyze separately the views of partisans on science, ethics, and politics? My conclusion, based on interviews with Australian fluoridation partisans, is that it does not. The coherency of viewpoints most plausibly derives from engagement in a public debate on an issue with both scientific and political dimensions. To resist pressures for coherency within the debate would mean not so much individual cognitive dissonance but rather social dissonance — attacks from both sides and pressures to take a stand.19 For the technically knowledgeable partisans discussed in this chapter, it makes little sense to isolate views on the benefits or hazards from opinions on individual rights, because beliefs on the whole array of issues are made coherent by the debate itself. The partisans themselves often distinguish between science and politics, usually in a way that aids their own argument. The distinctions they make can be described as being “socially constructed.” For the purposes of social analysis of partisan viewpoints, it seems much more useful to set aside their usual distinctions between science and politics and to analyze their viewpoints on a whole range of topics. In this way there is less illusion that views are separately formed on the merits of the case, whether in science, ethics, or politics. Rather, what seems to happen is that individuals make a global judgment about fluoridation in the context of the polarized debate. Then, their stance for or against fluoridation promotes a coherency of views on the separate arguments, cutting across the distinction between scientific and nonscientific factors.
FLUORIDATION PARADIGMS? The coherency of viewpoints is compatible with the idea that thought and behavior on the fluoridation issue are guided by two contrary paradigms.20 The concept of “paradigm” here is a liberal adaptation of Thomas Kuhn’s notion of paradigm as a complex of ideas and practices that guides the routine performance of scientific research within specified areas, such as the paradigm of Ptolemaic or earthcentered cosmology that was superseded by the paradigm of Copernican or sun-centered astronomy.21 To speak of two paradigms in a single area is to imply a situation of conflict or crisis. The profluoridation paradigm is basically that water fluoridation is highly beneficial and completely safe and, hence, socially desirable. The antifluoridation paradigm is essentially that fluoridation is harmful to some people, unethical, and possibly not proven to be especially beneficial and, hence, socially undesirable. Using this picture, partisans collect and interpret evidence starting from the presuppositions of their own paradigm, and mobilize arguments to support it. Whether one calls it a paradigm, an exemplar, a world view, or a coherent position, the value of this concept is that one can predict with considerable accuracy the arguments of a partisan by knowing the answer to a single question: “Are you for or against fluoridation?” NOTES Most of the material in this chapter is adapted from Brian Martin, “Coherency of Viewpoints among Fluoridation Partisans,” Metascience, vol. 6, no. 1 (1988): 2-19. 1. Commonwealth Department of Health, Fluoridation of Water, Canberra: Australian Government Publishing Service (1985): 34-41. 2. An excellent account of the politics of fluoridation in Victoria is given by Brian W. Head in “The Fluoridation Controversy in Victoria: Public Policy and Group Politics,”
Australian Journal of Public Administration, vol. 37, no. 3 (September 1978): 257-273. For other states, there are no equivalent accounts although Wendy Varney provides considerable documentation, especially for New South Wales, in Fluoride in Australia: A Case to Answer, Sydney: Hale and Iremonger (1986). Carr described the introduction of fluoridation in Canberra as a process in which the four relevant Commonwealth ministers — Health, Australian Capital Territory, Works, and Attorney-General who are elected parliamentarians with briefs similar to US cabinet members — each took advice from their departments which, in turn, consulted their experts. After discussion in cabinet, the government took a decision. Traynor described the Canberra decision in this way: Traynor was the dentist who treated Harold Holt, the federal Treasurer. The federal president of the Australian Dental Association suggested to Traynor that he raise the question of fluoridation for Canberra with Holt. Via Holt, a visit was arranged between the Minister of Health and Traynor along with Peter Lazar, director of the Dental Health Education and Research Foundation. Later, Lazar and Traynor met with Prime Minister Robert Menzies, who was favorable. (Earlier, they had approached the opposition Australian Labor Party’s spokesperson on health, who was also agreeable.) Shortly afterward, Menzies put the motion for fluoridation in parliament. A somewhat different sequence is given by James Killen in Killen: Inside Australian Politics, Sydney: Methuen Haynes, (1985): 89-90. See also Penelope Layland, “What Happened in 1964 …” Canberra Times (29 September 1989): 9. 3. See, for example, Geoffrey E. Smith, “Is Fluoride a Mutagen?” Science of the Total Environment, vol. 68 (1988): 79-96, at 79. “The success of water fluoridation in combating tooth decay would appear to be well-established.” Since my interview with him, Smith seems to have reevaluated his position on the benefits of fluoridation in the light of recently published critiques. See
Geoffrey E. Smith, “Is Fluoridation a Fraud?” Science of the Total Environment, vol. 76 (1988): 167-184. 4. H. M. Collins and T. J. Pinch, “The Construction of the Paranormal: Nothing Unscientific Is Happening,” Roy Wallis (ed.), On the Margins of Science: The Social Construction of Rejected Knowledge, Keele: University of Keele (1979): 237-269; G. Nigel Gilbert and Michael Mulkay, “Warranting Scientific Belief,” Social Studies of Science, vol. 12 (1982): 383-408; Michael Mulkay and G. Nigel Gilbert, “Accounting for Error: How Scientists Construct Their Social World When They Account for Correct and Incorrect Belief,” Sociology, vol. 16 (1982): 165-183. 5. A proponent whom I didn’t interview told me he had heard it said that Amies was more likely to obtain ego gratification from opposing fluoridation than from scientific work, at which he was mediocre. 6. This account is presented in “Fluoridation: The Cancer Scare,” Consumer Reports, vol. 43, no. 7 (July 1978): 392-396. 7. Patricia Speller, Regional Progress, Melbourne (15 October 1986): 8. 8. E. Storey, letter, The Age, Melbourne (27 September 1986): 12. 9. Malcolm Peter Crisp, Report of the Royal Commissioner into the Fluoridation of Public Water Supplies, Hobart: Government Printer (1968). 10. D. M. Myers, V. D. Plueckhahn, and A. L. G. Rees, Report of the Committee of Inquiry into the Fluoridation of Victorian Water Supplies, Melbourne: Government Printer (1980). 11. Smith, whose comments concerned the role of scientists, is a possible exception. 12. Concerning the Tasmanian and Victorian inquiries, Varney, op. cit., 23, states along this line that “Judging from the circumstances and conduct of both of these inquiries, it is doubtful that their chief purpose was to probe into, and weigh up, the conflicting evidence. Rather they were to convey an image of neutrality and open-mindedness on
the part of the respective governments and so to allay public fears by supposedly having thoroughly investigated the matter prior to government’s final decision.” 13. Leon Festinger, A Theory of Cognitive Dissonance, Stanford: Stanford University Press (1957). 14. The polarization that results from the intense controversies over nuclear power and fluoridation is raised by Allan Mazur, “Disputes Between Experts,” Minerva, vol. 11, no. 2 (April 1973): 243-262, at 258-260, reproduced in Allan Mazur, The Dynamics of Technical Controversy, Washington, D.C.: Communications Press (1981). 15. Books that give a good feel for fluoridation campaigning are: from the proponents’ perspective, Paul Castle, The Politics of Fluoridation: The Campaign for Fluoridation in the West Midlands of England, London: John Libbey (1987); and from the opponents’ perspective, Hans Moolenburgh, Fluoride: The Freedom Fight, Edinburgh: Mainstream (1987). 16. Varney, op. cit., points out that the proponents in Australia are backed by the dental and medical professions, the federal and most state governments, and several major industries. But, from the point of view of profluoridation partisans, this does not translate into volunteers to carry out the dayto-day legwork on the issue. 17. The argument here is compatible with standard ideas in social psychology. See, for example, George Cvetkovich, Steve R. Baumgardner, and Joseph E. Trimble, Social Psychology, New York: Holt, Rinehart and Winston (1984): 176-209; and Kenneth J. Gergen and Mary M. Gergen, Social Psychology, New York: Springer Verlag (Second edition, 1986): 158-191. Attitudes based on direct experience (such as attending meetings, speaking, or writing letters in the fluoridation debate) are more likely to be salient and central to attitude structures, and more likely to cause a reduction in dissonance with related but peripheral attitudes.
18. Edward Groth III, “The Fluoridation Controversy: Some Implications for Science and Public Policy,” unpublished seminar paper presented to the Dental Public Health Program, School of Public Health, University of Michigan (28 March 1980): 65. See also his sections on personalities (57-58) and lack of a clientele for a middle-of-the-road position (65- 66). 19 To my knowledge, Geoffrey Smith is the only one of those interviewed who has been criticized by both proponents and opponents. 20. John Colquhoun has developed this perspective in “Professional Education and the Fluoridation Paradigm,” New Zealand Journal of Educational Studies, vol. 24, no. 2 (1989): 159-173. 21. Thomas S. Kuhn, The Structure of Scientific Revolutions, Chicago: University of Chicago Press (Second edition, 1970).
The struggle over credibility
PART I: ENDORSEMENTS AND DEBATES Only to a limited extent has debate on fluoridation proceeded on the basis of pure discussion of claims about knowledge. Almost always salient has been who has made the claims. If a doctor or dentist makes a statement about tooth decay it is given more credence than exactly the same statement made by a layperson. If a professional body, such as the American Dental Association, makes a statement, it is given more credence than exactly the same statement made by a single dentist or even a group of dentists. Endorsements Authoritative backing has been a key to the debate on fluoridation. In the 1940s in the United States, the most influential relevant bodies — the United States Public Health Service (USPHS), the American Dental Association (ADA), and the American Medical Association (AMA) — had not endorsed fluoridation. The promoters of fluoridation devoted much of their efforts towards convincing the key people in these bodies of the value and need for early endorsement. In the late 1940s, the USPHS adopted a policy of delay: it would not endorse fluoridation on the basis of information then available. This stand by the premier authority provided valuable support for opponents of fluoridation. As historian Donald McNeil said, “Recommendations for delay by the national organizations became potent weapons in the hands of local opponents of fluoridation.”1 The opponents could justify their stand by pointing to caution by the USPHS and the ADA. This added authority, but not extra evidence or arguments, to the opponents’ position. John J. Frisch, Francis Bull, and other leading proponents of fluoridation kept heavy
pressure on the top figures in the USPHS throughout the late 1940s. Finally the USPHS acquiesced. In May 1950, it announced its support for fluoridation. This is generally acknowledged as a turning point in the struggle. With the USPHS taking a stand, the ADA added its support. It, too, had been the subject of intense lobbying and pressure for some years. Although the evidence about the risks and benefits of fluoridation was essentially the same before and after the endorsements by the USPHS, the ADA, and the AMA, the resources available to the proponents and opponents were vastly changed. The opponents, previously able to cite the stands of these organizations to justify their reservations, now had to confront proponents backed by their endorsements. Prior to the endorsements, the proponents were overtly political in their approach. Frisch “was often impatient with his professional colleagues who felt the battle should be waged on a factual and dignified level.”2 He believed that political campaigning methods were needed on this political issue. The intense and unrelenting campaign by Frisch and his colleagues was important in obtaining the endorsements for fluoridation. But, once the endorsements were obtained, the style of the confrontation changed. Now, it was the turn of the opponents to be overtly political while the proponents portrayed themselves as strictly scientific and following the best expert advice. Ever since 1950, the weight of authoritative backing has strongly favored fluoridation. Professional endorsements have been used repeatedly as a prime argument for fluoridation, as is apparent from perusing just about any piece of promotional literature. In this situation, it is the opponents who appear overtly political. In order to promote their case, they have to challenge the “authorities.”
Frank J. McClure’s book Water Fluoridation: The Search and the Victory illustrates the heavy use of endorsements. In the chapter on “Approval,” he quoted some of the early statements for fluoridation made in the 1940s. After outlining the early endorsements by professional organizations in the early 1950s, McClure stated, “Fluoridation has been given official approval by virtually all national and international health and professional organizations”.3 He proceeded to quote statements from ADA, AMA, the American Association for the Advancement of Science (AAAS), the American Federation of Labor and Congress of Industrial Organizations, the American Water Works Association (AWWA), and the American Institute of Nutrition (AIN). He then listed 34 American and 15 British organizations approving fluoridation. He quoted from the Canadian Dental Association (CDA), and quoted “additional statements” from eight individuals or organizations.4 This section of McClure’s book is testimony to the importance he placed on endorsements. Such endorsements often are used as a general recommendation of fluoridation. They serve as shorthand. Instead of giving a detailed account of the arguments for and against the measure, the endorsements are cited as evidence of the conclusion of “those who should know.” This is a usual procedure in many areas of health and technology: professional endorsements of safety are taken to indicate that experts have investigated a product or practice and found it safe. For the opponents of fluoridation, the extensive endorsements are a major stumbling block. There are several ways they have responded. One is to find individuals or groups who openly criticize fluoridation, or who refuse to make endorsements. The work of opponent scientists — such as George Waldbott and John Yiamouyiannis — is repeatedly cited. Another way to criticize endorsements is to try to undermine the process of endorsement itself. One line of argument is that the numerous endorsements do not represent independent evaluations of the important issues. Bodies such as the AIN did not carry
out their own research or comprehensive assessments of the research literature. Instead, most of the endorsements have been made on the basis of earlier endorsements by a few key organizations, in particular the USPHS and the ADA. At best, endorsing bodies relied on advice from a small number of experts, almost all of whom were committed promoters of fluoridation.5 Furthermore, opponents alleged that key promoters applied pressure on professional societies for rapid — and hence, less carefully considered — endorsement. One such promoter was H. Trendley Dean in the case of the AAAS, of which he was a former president.6 The opponents saw a “bandwagon” or “snowballing” process, in which organizations concluded that, if the “real” authorities were for it, it must be all right. Opponents also alleged that some endorsements have been “pushed through” without proper concern for due process, not to mention the arguments. Concerning the endorsement of fluoridation by the World Health Organization in 1969, Waldbott, Albert W. Burgstahler, and H. Lewis McKinney stated that “during the final hours of the session, when only 55 to 60 of the 1,000 delegates from 131 countries were still present, all bills that had not been accepted were collected into one and voted upon, including a statement on fluoridation.”7 (The profluoridationists could complain of a similar lack of due process in some of their defeats, such as the Swedish Parliament’s repeal of the Water Fluoridation Act in November 1971.8 ) There remains the further problem that the World Health Organization has re-endorsed its profluoridation stand, a fact seldom mentioned by antifluoridationists. One response would be to say that it is much easier to re-endorse a stand than to reverse it. While the argument about “snowballing” and contrived endorsements may undercut the persuasiveness of the great number of endorsements, it does not explain away the important early endorsements. The opponents have two lines of attack here. First, they argue that these endorsements were pushed through by a small number of
profluoridation activists, and do not represent the opinion of all the members of the organization. Second, they assert that the endorsements are not based on original research by the endorsing bodies. They are simply statements by groups claiming that the research points to a particular policy. This second line of argument leads to the conclusion that people should be looking at the evidence rather than at endorsements, and this is precisely the approach favored by the opponents. They usually prefer to deal directly in the arguments about benefits, risks, and individual rights, whereas the proponents often refer to endorsements. This difference does not arise because opponents, by the nature of their stand, have some special commitment to informing the public about the actual issues (although some opponents do have a commitment to this). Rather, the opponents cannot use the resource of endorsements because so few prestigious bodies oppose fluoridation. If dental associations opposed fluoridation, most opponents would use endorsements as readily as do the proponents. This is clear from the regular reference by opponents to those few professional bodies that do openly oppose fluoridation. Widespread authoritative endorsement allows some proponents to go a step further and deny that there is any legitimate scientific debate at all. For example, Conrad A. Naleway of the ADA wrote in 1988 that “there is no scientific case to support the antifluoridation position.”9 In denying the existence of scientific debate, proponents are implicitly stating that all knowledgeable people support fluoridation and that anyone who opposes fluoridation must, therefore, be uninformed, politically motivated, or in some other way “unscientific.” In 1978, the magazine Consumer Reports ran a two-part article attacking opponents of fluoridation. The article concluded with the statement that “The simple truth is that there’s no ‘scientific controversy’ over the safety of fluoridation. The practice is safe, economical, and beneficial. The survival of this fake controversy represents, in CU’s [Consumers
Union] opinion, one of the major triumphs of quackery over science in our generation.”10 What is only implication in other statements is spelled out here: there is no scientific debate; therefore, opponents are quacks. It is revealing that the claim that all experts support fluoridation and that there is no scientific debate became routine only after the endorsements by professional bodies in the early 1950s. These endorsements did not change the scientific evidence then available, but they did eliminate a major resource used by the opponents — namely, that authoritative bodies had not endorsed the measure. To Debate or Not to Debate In the struggles over fluoridation, there have been many opportunities for the issues to be debated — for example, in public meetings, in local government meetings, and before community groups. Profluoridationists often have refused to openly debate antifluoridationists in such settings when they consider that debating will hurt their campaign. The reason they give for this is that there are no valid grounds for opposing fluoridation, and, therefore, any debate can only give credibility to the opponents by acknowledging that there is something worthy of debate. Refusing to debate can be interpreted as an attempt by those with a near monopoly on credibility — in this case scientific or professional credibility — to deny any of it to the opponents. In 1952, Charles Eliot Perkins, a biochemist and physiologist opposed to fluoridation, described how proponents refused to appear on a radio forum in Washington, D.C. shortly after the city’s water supply had been fluoridated. Perkins concluded that “The professional proponents of fluoridation, as a rule, refuse to discuss the subject in public meetings or debate fluoridation with anyone who opposes it in public forums.”11 This has remained the pattern ever since. In 1979, the Society for Social Responsibility in Science in Canberra, Australia, organized a debate on fluoridation and cancer between fluoridation supporter Roland Thorp and fluoridation opponent John Yiamouyian
nis. Afterward, Dr. Peter Cooper, chairman of the Australian Capital Territory Cancer Society, wrote an article and letters for the Canberra Times denying any link between fluoridation and cancer, and calling fluoridation a “nonissue.”12 When challenged by Mark Diesendorf to a public scientific debate on the issue, Cooper replied that Disendorf “doth rant and rave, and mightily stir to keep the fluoridation pot aboiling.” Then, he declined to debate.13 Robert Isman, in an often-cited article, “Fluoridation: Strategies for Success,” which was published in 1981 in the American Journal of Public Health, commented: “Several authors have recommended that debates be avoided and I concur with this recommendation. This is little to gain and much to lose from debating an emotional issue like fluoridation. A debate simply serves to give more credibility to fluoridation opponents.”14 Prominent proponent Ernest Newbrun concurs. He says that he normally refuses to debate because “it is my policy not to give credibility to antifluoridationists.”15 In 1985, Michael W. Easley commented similarly in an article “The New Antifluoridationists” in the Journal of Public Health Dentistry. He wrote, “Armed with volumes of scientific literature and lists of endorsements, eager proponents of fluoridation too often are trapped into consenting to public debates on this sociopolitical controversy. Almost nothing can be gained by debating. Regardless of which side is successful in presenting the best argument, the mere fact that the debate even took place conveys to the public that a legitimate scientific controversy exists.”16 This does not mean that the proponents do not campaign at all. They conceptualize the issue as being in two parts: a scientific part and a political part. The scientific part, they believe, consists of scientific findings that contain no basis for opposing fluoridation. This is the foundation for the claim that there is no scientific debate. The political part of the issue arises from the existence of opponents who are motivated for nonscientific reasons. This political opposition must be countered,
and thus many of the proponents counsel the waging of a political struggle for fluoridation. Easley concluded, “Foremost is the need to recognize and accept the realization that fluoridation is no longer strictly a scientific or legal issue, but that it has become predominantly a political issue.”17 Part of the political struggle is the refusal to debate, thereby denying the opponents any credibility.18 Unfortunately for the profluoridationists, refusal to debate can raise problems. Ernest Newbrun commented that “Whether or not to participate in radio or TV talk shows or debates on fluoridation poses a real dilemma for the dental researcher.” Participating in and responding to antifluoridation arguments can give them legitimacy, whereas “by refusing to appear on such programs, there is always the risk of permitting the antifluoridationists free rein.”19 Another problem is that, when supporters of fluoridation refuse an open invitation to debate, this often is seen by citizens as arrogance. As analyzed by Raulet, professionals such as dentists and physicians promoting fluoridation can take either the role of experts or partisans. Many have attempted to fill both roles, and this sometimes leads to difficulties. As experts, they can act as authoritative sources of information but are open to the charge of arrogance in refusing to debate. But if they enter the debate as open promoters, the role of expert knowledge in support of fluoridation is undercut.20 To be an authoritative source of information while not openly promoting fluoridation means taking a low-visibility role. The scientist who publishes technical papers in specialized journals or the dentist who answers questions from patients falls into this category. This stance draws its strength from the image of the objective and socially concerned professional who has no apparent vested interest in a particular course of action. It is precisely from not being openly partisan that the role of the objective professional draws its strength. Ideally (for those who support fluoridation), this would be all that is required to create a climate leading to the implementation of fluoridation.
While this stance is possible for some supporters of fluoridation, it has seldom been adequate to introduce and sustain the measure. The opponents of fluoridation have been open and vociferous in their campaigning. A lowkey stance is not enough to counter such opponents. Consequently, some supporters of fluoridation have had to be openly political as well, and this has included many dentists, doctors, and scientists. Partisans have been involved in lobbying fellow professionals and politicians, speaking at community groups, writing letters to newspapers and journals, writing general interest articles, speaking on radio and television, debating, fundraising, passing out leaflets, and a host of other activities. Dentists, doctors, and scientists supporting fluoridation as partisans can be effective via their activism, but, at the same time, many of them rely on their professional role to give status to their views beyond that of a lay partisan. But their activism can undercut the advantages of professional status to some extent, since many of the methods of campaigning are widely perceived to be incompatible with objectivity. Note that the two roles of expert and partisan are only perceived to be divergent. It is quite possible for an “objective source of information” to be an effective proponent — for example, by publishing scientific papers or teaching dental students in ways which favor a particular conclusion. Likewise, it is possible for an active partisan to be extremely careful with the evidence and arguments, more so than those who are not partisans. In each case, the role of expert and partisan is not inherent in the knowledge or social role, but depends on the interaction of behaviors and beliefs. The social construction of an expert or partisan depends to a great extent on the ways, or lack of ways, in which opponents can attack. For example, it is very difficult for the opponents to criticize those who make contributions only in specialized scientific journals. Such criticism tends to be highly technical — as in the case of Sutton’s critique of the classic fluoridation trials — and, hence, is not very useful for public campaigning. By
contrast, those who make the same points in newspapers or on radio are much more vulnerable to attack. When translated out of the technical context, the same points are subject to criticism in a way that would not be permissible in a scientific journal. It is also important that partisans can be attacked because they are partisans. The opponents can claim, with apparent justification, that fluoridation is not just a scientific matter, but is being promoted because of various vested interests. The partisan promotion of fluoridation — made necessary by the partisan opposition — thus must be masked as much as possible. This is because the rhetoric of promotion sounds incompatible with the language of objective science, and opponents can use this ostensible incompatibility to attack the proponents. Promoting Fluoridation An early and revealing example of this dynamic centers around a talk given by fluoridation proponent Francis Bull in 1951, at the Fourth Annual Conference of State Dental Directors with the USPHS and the Children’s Bureau, in Washington, D.C. Remember that Bull was one of the leading figures behind the push for fluoridation in the 1940s, a push which led to the key endorsements in 1950 and 1951. In his talk titled “Promotion and Application of Water Fluoridation,”21 Bull was essentially telling new supporters how to sell fluoridation. Bull was quite candid in his talk. Unknown to him, there was a stenographer present making a complete record of the proceedings. Later, antifluoridationists obtained a copy, and, ever after, they have been quoting Bull out of context in order to damn the promotion of fluoridation.22 Bull spent considerable time describing how to answer objections to fluoridation. I think the first one [objection] that is brought up is: “Isn’t fluoride the thing that causes mottled enamel or fluorosis? Are you trying to sell us on the idea of putting that sort of thing in the water?” What is
your answer? You have got to have an answer, and it had better be good. You know, in all public health work it seems to be quite easy to take the negative. They have you on the defensive all the time, and you have to be ready with answers. Now, we tell them this, that at one part per million dental fluorosis brings about the most beautiful looking teeth that anyone ever had. And we show them some pictures of such teeth. We don’t try to say that there is no such thing as fluorosis, even at 1.2 parts per million, which we are recommending. But you have got to have an answer. Maybe you have a better one.23 Bull’s comments suggested to many opponents of fluoridation that the proponents were trying to hoodwink people about the problem of fluorosis by calling mottled teeth “beautiful looking teeth.” Waldbott certainly took this view, saying “Bull instructed his colleagues to describe mottled teeth to the public and to the profession as ‘egg-shell white’ and ‘the most beautiful looking teeth that anyone ever had,’ even though these teeth are known to turn brown and brittle in later years.”24 The context of Bull’s talk was his confidence in data showing that fluoridation is highly beneficial and harmless. For Bull, fluoridation, unlike all previous public health measures, “has absolutely no bad connected with it.”25 Therefore, the issue was how to promote it. Language and images are important, and part of this is the language used to describe mottled teeth. Bull continued by dealing with another perception of fluoridation. And, incidentally, we never use the term “artificial fluoridation.” There is something about that term that means a phony. The public associates artificial pearls or artificial this or artificial that with things that are not real or genuine. We call it “controlled fluoridation.”26 To this day, a fairly reliable test of a person’s stance on fluoridation is whether they call it
“controlled” fluoridation, as do the proponents, or “artificial” fluoridation, an expression favored by the opponents. The choice of language is a crucial part of the debate. Bull continued: Incidentally, we never had any “experiments” in Wisconsin. To take a city of 100,000 and say, “We are going to experiment on you, and if you survive we will learn something” — that is kind of rough treatment on the public. In Wisconsin, we set up demonstrations. They weren’t experiments.27 Bull’s advice has been taken up by proponents ever since. Sutton in his critique of the “classic trials” argued that they were experiments. Sutton’s critics argued that fluoridation had already been proved, and that the trials were demonstrations. Here is a case in which Bull’s advice on promoting fluoridation (and that of others) entered into the “scientific” area of disputes over the validity of the trials. The next quote from Bull shows how much difference context makes. … this toxicity question is a difficult one. I can’t give you the answer on it. After all, you know fluoridated water isn’t toxic, but when the other fellow says it is, it is difficult to answer him. I can prove to you we don’t know the answer to that one, because we had a city of 18,000 people which was fluoridating its water for six or eight months. Then a campaign was started by organized opposition on the grounds of toxicity. It ended up in a referendum and they threw out fluoridation. So I would hate to give you any advice on that deal [Laughter]. It’s tough.28 It is easy, and tempting for opponents, to take this statement out of context — especially the part about “this toxicity question is a difficult one. I can’t give you the answer on it” — and conclude that Bull was admitting that the proponents, at least in 1951, didn’t know for sure whether fluoridation might have toxic effects.
But this is not what Bull was saying. He stated, after all, that “you know fluoridated water isn’t toxic.” Bull was concerned about promoting fluoridation, and he was raising the problem that there was no good argument or turn of phrase to counter claims of toxicity. When he said “we don’t know the answer to that one,” he meant that there was no answer that was effective for public campaigning, rather than no answer at all. He was seeking an answer, such as calling mottled teeth “beautiful” or referring to controlled fluoridation. The point is that promotion assumes — or sometimes ignores — the validity of what is to be promoted. In an honest and open talk, a promoter describes the good and bad ways of going about the promotion. But “honest and open talk” is dangerous if it gets into the wrong hands. Bull also said, “Now, why should we do a pre-fluoridation survey? Is it to find out if fluoridation works? No. We have told the public it works, so we can’t go back on that. Then why do we want a pre-fluoridation survey?”29 This quote seems to be the most damning yet. Bull appeared to be saying that the promoters cannot go back on their claims that fluoridation works. But the context gives a different story. Bull advocates making prefluoridation surveys of tooth decay, and says that the fluoridation committee of the state dental society can assist in doing this. After the previously quoted passage, he went on to say that the point of a prefluoridation survey would be to show, later on, the effectiveness of fluoridation in preventing tooth decay as insurance against possible future campaigns to stop fluoridation. Once again, Bull was assuming that fluoridation is a good thing, and was simply presenting his views as to how it could best be promoted. He was advocating prefluoridation surveys as insurance against subsequent attempts to stop fluoridation. In this quote, he was telling others not to fall into the trap of thinking — or saying — that a prefluoridation survey is intended to find out if fluoridation
works. If anyone said that, it could be used against them by opponents. It is clear from this example why statements about how to promote fluoridation are better left out of the public eye, just as the candid discussions of the designers of advertising copy would be damaging to the product concerned. Bull’s talk is part of the large literature on how to promote fluoridation. Annabelle Bender Motz, in a 1971 review article published in a collection entitled Social Sciences and Dentistry, outlined some of the recommendations stemming from this literature.30 First, the community to which fluoridation is to be introduced should be studied closely, noting demographic characteristics, the political system, and so forth — all in an effort to plan an effective strategy. Second, fluoridation should, if possible, be introduced through legislation or administrative action since popular participation, for example through a referendum, often leads to the rejection of fluoridation. Third, if popular involvement cannot be avoided, grassroots support for fluoridation should be developed through community groups and locally influential people. This might involve Rotary clubs, mothers’ groups, health associations, trade unions, and many other organizations. Fourth, “confrontations whether in the form of panel discussions, public debates, or referenda” should be avoided. Here, Motz referred to several social-science studies. For example, “[H.] Nathan and [S.] Scott have shown that confrontations give the antifluoridationists the stamp of legitimacy on a par with that of the recognized community leaders and organizations.”31 Fifth and last, the role of the “health publicist” should be developed. Such people would, for example, use knowledge about a community to plan a program to introduce fluoridation or some other health measure. By being neither a scientist nor a medical practitioner, the “health publicist” may be able to avoid being typecast as an arrogant professional.
The large body of social-science research suggesting how to best promote fluoridation is based on the proponent claims that fluoridation is a scientific issue and that there is no scientifically credible opposition to it. The idea of creation of the “health publicist” assumes that the professional experts will decide what is best for the community, and then this will be “sold” to the community by using the best selling techniques that social science can provide. From the point of view of the opponents — especially those who are scientists — the refusal to debate is a denial of all that is proper. PART II: RESPONDING TO SCIENTIST OPPONENTS Without endorsements by the major professional bodies, the best the opponents have been able to do is cite a few organizations that have opposed fluoridation and a number of individual professionals who are critical of fluoridation. Although the number of these individuals is very small compared to the total number of dentists and doctors formally represented by profluoridation professional bodies, their critical perspectives are vitally important because they challenge what would otherwise appear to be unanimous professional support for fluoridation. The opposition to fluoridation has included a large number of “extremists.” In the 1950s in the United States, the John Birch Society was involved, as were some other right-wing and anticommunist groups. The opposition has also included members of some religious groups — such as Christian Scientists — as well as naturopaths, chiropractors, and others considered by the medical profession to be fringe practitioners or “quacks.” In other words, “reputable” bodies — such as the ADA — supported fluoridation, while “fringe” bodies and individuals opposed it. This, at least, was the picture painted by the proponents. It is a picture quite favorable to the proponents, since it suggests that rational and respectable people support fluoridation, whereas opponents are found only among
“fringe” groups. The rhetoric of many fluoridation opponents often helps to confirm this view. Nonscientists who are opponents frequently sound extreme — but so, also, do some of the scientists. Charles Eliot Perkins in his 1952 booklet The Truth About Water Fluoridation included numerous scientific arguments, but these are interspersed with political commentary with extreme-sounding claims. Perkins concluded that “It is common knowledge that artificial water fluoridation is a technique in mass control through mass medication, which is an integral part of Communist philosophy.”32 Frederick B. Exner, a medical doctor and leading opponent of fluoridation in the 1950s, wrote that, in convincing people that fluoridation is completely safe, “the primary tools have been equivocation and prevarication. Outright lies are rarely used except when so tightly cornered under cross-examination that there is no other way out.”33 Exner referred to the promotion of fluoridation as “an incredible story of chicanery and malfeasance.”34 He attributed fluoridation to a totalitarian philosophy, both in those “who sincerely believe in the Führer principle” and “‘dogooders’ who promote totalitarianism through good-intentions-gone-crosswise.”35 Philip E. Zanfagna, a doctor and coauthor of a book opposing fluoridation published in 1974, wrote that “While the fluoridation travesty is in progress, Americans are ingesting more poisonous fluorides (and other dangerous chemicals) with their food, water and from polluted air than any other people on earth. Related to this consumption, the national incidence of heart attacks, cancer, crippling arthritis, infant deaths, and enzymedeficiency diseases continues to rise.”36 Zanfagna’s coauthor, writer and activist Gladys Caldwell, used more colorful language, describing fluoridation as “the most disastrous and costly consumer fraud of this polluted century. Hundreds of millions of tax dollars have been spent to programme an entire generation to salivate like Pavlov’s dogs when the word fluoridation is mentioned.”37 Glen Walker, a leading Australian antifluoridationist, concluded his long and
vehement book on the topic with the statement that “Yes fluoridation is a hoax!”38 Robert Mick, a New Jersey dentist and researcher, and highly visible opponent, said that “Hitler was a Boy Scout compared with the United States Public Health Service … To be selected by the United States Public Health Service for an experiment is a CRIMINAL CONSPIRACY surpassing acts of those Nazis who were hung for selecting humans for experiments.”39 Other statements similar to these would be easy to list. In each case, undoubtedly, those making the statements would argue that they are being perfectly accurate. But others may be repelled by the intemperate-sounding language, and be drawn to the proponents’ categorization of all opponents as “cranks.” This picture has always been complicated by the presence of some orthodox, mildspoken, and otherwise respectable professionals — dentists, doctors, and scientists — who are critical of fluoridation. While some of them — such as Exner and Mick — on occasion used extreme-sounding language, others, such as Albert Burgstahler and John Colquhoun, have been more restrained. The very existence of such individuals undermines any suggestion of professional unanimity. Proponent Sheldon Rovin recognized the problem: “There are increasing numbers of ‘credentialed opponents’ lurking about in fluoridation matters. One or two dentists or physicians coupled with a few scientists who are opposed to fluoridation can stymie even the best organized and conducted fluoridation campaign.”40 The promoters of fluoridation have responded to these critics in various ways. One response has been to criticize their arguments, as described in chapter 2. But a response of logical and cautious criticism is not always enough to undermine an opponent’s credibility. Further — or different — measures have been taken in many cases. Rovin said, “Ways to neutralize these people are limited. The choices are to ignore them, assail their motivations, or drown them out by enlisting large numbers of dentists and physicians on
behalf of the issue in a manner highly visible to the public. Of these, the third is obviously the best choice.”41 But, quite often, methods other than Rovin’s “best choice” have been used. Ignoring the Critics One potent response has been simply to ignore the critics. Sutton’s detailed criticisms of the classic fluoridation trials are not even mentioned in most discussions of the case for fluoridation. Likewise, Waldbott’s reports of toxic effects of fluoride are not referred to at all in many treatments. Because the critics have been ignored, a number of technical disputes concerning the risks and benefits of fluoridation cannot be said to have been resolved scientifically. There has been no process of engagement with the arguments of the critics, allowing for a continual revision, refinement, and testing of claims. Often the antifluoridation material is simply assumed to be wrong or irrelevant and not worth refuting, and then just ignored. In other cases there is a response at first, as in the initial reviews of Sutton’s 1959 monograph, but no follow-through. Sutton’s second edition of 1960, including replies to his critics, was ignored. This type of response can be successful only when the overwhelming weight of professional credibility and endorsement is on one side. If the critics are ignored, this seems to say that their views are not worth bothering with. So far as most profluoridationists are concerned,42 the issues are closed and dead and not worth raising again. Antifluoridationists prefer a different interpretation. For them, the proponents ignore criticisms because a thorough examination of them might support the claims of the critics. If the opponents can persuade people that this is the real explanation for proponents’ silence, then ignoring the critics can be counterproductive.43
Attacking in General Terms A related approach is to attack the antifluoridationists in general terms, without mentioning any names or sources. For example, Dr. Russell B. Scobie, a pediatrician who “helped pioneer the drive in 1944 to have Newburgh selected for the now classic NewburghKingston Fluoridation Study” and who has given lectures around the world on fluoridation, wrote “the opposition rely on innuendo, half-truths and deliberate untruths to support their position. They never ask for information, although they are always willing to provide instruction. They know the answer with a religious fervor and they are obviously not susceptible to educational efforts.”44 Donald R. McNeil, in a 1969 booklet, Fluoridation: For Your Community and Your State, published by the ADA on how to promote fluoridation, described some of the arguments of the opponents but gave no names or references. He said, “Despite thousands of scientific studies on fluoridation and nearly unanimous agreement by scientists that it is safe, effective and worthwhile, fluoridation remains under attack. Few scientifically proven public health measures have been the object of such falsehood, distortion and deceit.”45 Dental researcher Herschel Horowitz, a leading proponent in the United States, wrote in a mostly technical paper in the British Dental Journal that “It is truly unfortunate that a public health measure with these impressive attributes, on occasion, generates so much public controversy.”46 Horowitz gave no reference to scientists among the critics of fluoridation. Ronald J. Hunt, in an article about fluoridation in small Iowa towns, referred to the arguments of the opponents in only a couple of sentences: “opponents of the measure have found that it is much easier to create confusion and fear than it is to educate people. The fluoridation issue increases in complexity when antifluoridationists cause controversy by continuing to claim that fluoridation causes cancer and has been linked to other diseases, even though these claims have repeatedly been
scientifically refuted.”47 Hunt gave no references to scientific work on either side of the controversy. A book called Appropriate Use of Fluorides for Human Health, published by the World Health Organization in 1986 and edited by J. J. Murray, a leading proponent of fluoridation, includes discussions of implementation of fluoridation, safety, legal aspects, and referendums, plus a mention of “the often misguided opposition to community fluoridation programmes,”48 without giving a single reference to scientific criticisms. A variant of this technique is found in a compilation called Classification and Appraisal of Objections to Fluoridation by Kenneth R. Elwell and Kenneth A. Easlick. More than 100 separate objections are listed, followed by responses including numerous references. What is evident on inspection is that, whereas the profluoridation arguments are well documented, the objections are not. The names of people making the objections are seldom mentioned, and their publications are seldom cited. For example, Alfred Taylor’s research on fluoride and cancer in mice is mentioned, but his publications on this topic are not cited, whereas responses to Taylor’s work are cited. Waldbott is not named but, instead, is alluded to as “a physician.” His publications are not cited.49 Edward Groth III, after examining a wealth of scientific literature on fluoridation, concluded that virtually all sources “are tainted by detectable political bias.” He noted that the bias in antifluoridation reviews of the scientific literature is often overt, whereas in profluoridation sources it can be less obvious. In the latter, “Reports of the effectiveness and safety of fluoridation are extensively discussed, but the numerous studies which have suggested contradictory conclusions, or which contain critiques of the validity of the evidence presented, are often neither quoted nor listed in the bibliography. Such reports may mention allegations of harm from fluoridated water, and attempt to refute such allegations; but in doing so, the specific evidence that supports claims of potential harm is rarely discussed.
This method of not giving the opponents the status of a name or an argument has been used frequently — for example, in numerous editorials and notices in the Journal of the American Dental Association over the years.51 Attacking the other side in unspecific terms can be done by anyone from any position, but it is especially useful for those who have more status, since they avoid giving recognition to the other side. Circulating Unpublished Critiques Another technique for attacking credibility is the unpublished critique. For example, after Mark Diesendorf’s Nature paper was published,52 a critique was written by Australian proponent Graham Craig and circulated to government health departments and editors of newspapers and journals. (Diesendorf eventually obtained a copy.53) Craig’s critique was not designed to be published. In fact, in a cover letter to the editor of Nature, Craig stated that his letter and critique were not for publication.54 This technique avoids putting the criticisms in the open scientific literature where they can, in turn, be criticized. Hence this denies the criticized paper the status of being taken seriously in a prestigious open forum, but profluoridationists are able to use the unpublished critique when preparing responses for local debates. Diesendorf found it difficult to respond to this. He prepared a reply, but it seems unusual to publish in a journal a response to unpublished material. But there was no obvious way to circulate his reply — or even notice of its existence — to all those who would have received the unpublished critique. Another critique of Diesendorf’s Nature paper, by leading British proponents Murray and Andrew Rugg-Gunn, was “issued” by the British Fluoridation Society.55 Again, as the critique did not appear in the open scientific literature, Diesendorf had the same problems in replying. Colquhoun has encountered similar difficulties. After the appearance of his twopart article in American Laboratory,56 a letter
criticizing his research was circulated by the director of the Division of Dental Health’s head office in Wellington, New Zealand. The letter was written by Peter Hunter, principal dental officer for research. It alleged mistakes in Colquhoun’s calculations of decay rates in New Zealand school children. The letter was the basis for a statement circulated to local water supply authorities in New Zealand from the Director-General of Health, stating that Colquhoun’s data contained a serious error in at least one instance. Later, the Centers for Disease Control, part of the USPHS, reproduced the letter as part of one of their publications. At no time was Colquhoun sent a copy of the letter. When Colquhoun found out about the letter, he wrote to the DirectorGeneral of Health asking for access to the data to assess the alleged error, but this was denied.57 An article by Colquhoun and Robert Mann criticizing the study of the effect of fluoridation in Hastings, New Zealand, appeared in the December 1986 issue of The Ecologist.58 The authors claimed that the Hastings results were wrong because the diagnostic criteria for tooth decay were changed in Hastings but not in the control town Napier. In 1988, they obtained by indirect means an unpublished critique of their paper by Peter Hunter and Elsdon Storey. This critique had been circulated to the general manager of the City of Hastings, among others, but not directly to Colquhoun and Mann. They responded by circulating a booklet reprinting the Hunter-Storey critique accompanied by comments of their own in reply.59 The unpublished critique seems to be a common way to attack the credibility of opponents. For example, Ionel Rapaport’s studies of the link between fluoridation and mongoloid births were the subject of a critique by A. L. Russell, who did research supposedly refuting Rapaport. Russell’s research has never been published, but a letter of Russell’s about this research has been widely cited by profluoridationists.60 Edward Groth III’s 1973 doctoral dissertation was seen as critical of fluoridation by many proponents. Leading proponent Ernest
Newbrun wrote an attack on the dissertation which was circulated by the USPHS for years. Groth did not learn of its existence for about ten years.61 In one sense, the unpublished critique is a curious tactic, as the proponents undoubtedly have greater opportunities for publishing in dental journals. The advantage of the unpublished critique is that nothing about the issue being contested appears in dental journals at all, and so the issues are not raised to the status of being worthy of professional debate. Prestigious dental journals generally do not publish antifluoridation articles.62 Nor do they often publish careful refutations of antifluoridation scientific work. Thus the antifluoridation scientists are not given recognition — not even the negative recognition of criticism — in the crucial journals. Responses remain in the domain of unpublished, informally circulated manuscripts. This point was articulated well by leading proponent David B. Ast at the 1951 conference of dental directors where Francis Bull spoke. In commenting on how to respond to an “alleged rumor” about fluoridation and cancer, Ast said: If a refutation is published it will reach a very much larger number of persons. I wonder if it would not be preferable for a refutation to be prepared at the University of Texas and made available to those who make inquiry for it, and for the dental directors to write to the University of Texas for that information. So if the question comes up in their community they will be well heeled with information to answer the question rather than to publicize this rumored information.63 In exceptional cases, the work of opponents has sufficient impact to lead to refutations being published in scientific and dental journals. The claims of Yiamouyiannis and Burk on fluoridation and cancer stimulated replies by several scientists in medical and scientific journals.64 More recently, the studies by Diesendorf and Colquhoun in nondental
Cytochemical response of kidney, liver and nervous system to fluoride ions in drinking water – Zbigniew L. Olkowski
Abstract
Morphological and cytochemical studies on the squirrel monkey have been made after maintaining the sujects on pure distilled water and fluoridated distilled water for 18 months with the objective of determining the effect of fluoride on the activity of some hydrolytic and oxidative enzymes in the kidney, liver and nervous system. Daily water intake by individual animals was measured over the final 10 months of the animal’s exposure to 0,1 and 5 ppm fluoride. Water consumption was considerably higher in the animals on higher fluoride intake. Whereas the nervous system remained totally unaffected by this experimental procedure, the liver showed a slightly enhanced acivity of Krebs citric acid cycle enzymes. The kidneys, however, showed significant cytochemical changes, especially in the animals on 5 ppm fluoride intake in their drinking water. In these animals, the glomeruli showed an increase in the activity of acid phosphatase and the enzymes belonging to the citric acid cycle and the pentose shunt, whereas lactate dehydrogenase, a resentative of the anaerobic glyoclytic pathway, remained unchanged or only slightly changed. These observations suggest that fluoride in concentrations as low as 5 ppm interferes to some extent with the intracellular metabolism of the excretory system.
Article
PROFESSIONAL ATTACK
In this chapter, I present a number of cases in which attempts have been made to stop antifluoridationists from expressing their views, doing research, and practicing dentistry. (1)
The implication of these examples is that the fluoridation debate has used more than rhetorical tools. Various other forms of power have been deployed. It is necessary to realize the extent of this activity in order to understand the dynamics of the fluoridation issue. In particular, assessing the technical disputes over fluoridation requires a simultaneous assessment of the wider exercise of power.
Most of the cases of the sort presented here have been documented by antifluoridationists. Some may be incorrect or overstated. But the number of cases is very large, and they fall into comprehensible patterns. In my study of this phenomenon in other areas, there are always many more cases occurring than end up being documented. (2) So I am convinced that these cases point to an important dynamic in the fluoridation controversy. What the cases actually mean is something to which I will return to later in this chapter.
Some Cases
Dr. John Neilands, professor of biochemistry at the University of California at Berkeley, signed a ballot argument against fluoridation. A local proponent of fluoridation wrote to the chancellor of the university requesting that Neilands be reprimanded, and called for him to be expelled from his professional society. (3)
Ivan H. Northfield, a dentist living in Duluth, Minn., made a speech against fluoridation during a campaign in 1965. As a result, his local dental society suspended his membership for one year, without allowing him to speak in his own defense. (4)
In 1964, a sociology student at a U.S. university carried out a survey of a medical society and found that only half of the respondents favored fluoridation while a third opposed it. George Waldbott reports that “The assistant dean, prompted by the fluoridation chairman, wrote a letter berating the student for allegedly abusing the good name of her school.” Although threat of a legal action by the student forced a retraction of the letter’s allegations, the attack discouraged the student from publishing her data. (5)
While Edward Groth III was a graduate student in biology at Stanford University in the late 1960s, he became interested in the fluoridation issue and, after studying the arguments, wrote a letter to the president of the university suggesting that a ballot argument for the proponents had falsely claimed that there was no evidence of harm. Groth sent copies of his letter to two proponents whom he had interviewed. One of them approached the head of the biology department and vehemently attacked Groth at length, suggesting that he should be expelled from graduate school. But the department head defended Groth. (6)
Dr. Chong W. Chang had done work showing that fluoride interfered with the biochemistry of living tissues. Chang said in a 1972 letter to Waldbott. “I have been associated with six years of basic research on fluoride since my study at the University of California and the USDA [U.S. Department of Agriculture] here. However, in recent years, USDA keep demanding me to do the research area which is not related to fluoride. After careful consideration, I have strongly determined to find some other position where I could continue my research on fluoride.” (7)
Virginia Crawford, a registered nurse living in Detroit, found that she was severely affected by fluoridated water, and became a vocal opponent. In 1964, she stated that many people had threatened that her nursing license would be taken away because of her activities. (8)
According to George Waldbott, in the 1950s “one internist, still practicing in Detroit, received a warning from a member of his hospital staff. Should he continue to publicly oppose fluoridation he would jeopardize his consultant practice, even his hospital staff appointment. He was profoundly distressed. Reluctantly he withdrew. He had no other choice.”
A doctor in Windsor, Ontario who recommended in 1962 to a patient to stop drinking fluoridated water in order to overcome a stomach ailment asked the patient to refrain from revealing his diagnosis to anyone so that his position in the eyes of his colleagues, especially Windsor’s medical officer for health, would not be jeopardized. (10) …
Waldbott said that, whereas many presidents or secretaries of dental or medical societies would privately express concern about fluoridation, to do so openly would mean the end of their careers in these societies. (13)
Carol Farkas, a Canadian researcher who has studied the levels of fluoride in foods and warned that some people may be ingesting too much fluoride, (14) gave a talk on this subject to the Canadian Dental Association’s annual meeting in the 1970s. After the talk, several dentists came forward, asked for her phone number and said they would call. Five of them did so, “saying they agreed with what I had said but couldn’t say so in public because they would get black-balled from the CDA.” (15)
In 1963, Dr. R.J. Berry of Oxford published results of research showing a reduction in the rate of growth of cancer cells in the presence of 0.1 parts per million of fluoride. (16) This sounded good in terms of cancer, but actually pointed to the dangers of fluoride for normal cells. At any rate, Berry decided to abandon further work on fluoride after being criticized and subjected to “veiled threats.” (17)
Hans Moolenburgh, a doctor and leader of the campaign against fluoridation in the Netherlands, reports that he was instructed by a medical official not to write articles against fluoridation. (18) A friend of Moolenburgh’s, named Mien Bulthius, did research for her dissertation on the role of fluoride in inhibiting the activity of the enzyme cholinesterase. A special committee of the Netherlands’ Health Board discussed the dissertation in May 1973. According to the minutes of the meeting, “Mr de Wael remarks [that] he has had a telephone call from Mr Drion (Chief Inspector of Health), who requested that he exert his influence in order to prevent remarks relating to the possible effect of fluoride on humanity from being published in the Bulthius dissertation, as the subject was already receiving to much publicity that it could cause unrest among the population.” (19)
John Polya, associated professor of chemistry at the University of Tasmania, claimed in 1973 that his staff and equipment had been taken away because of his public opposition to fluoridation. (20)
Geoffrey Smith in 1979 worked as a dentist at Proserpine Hospital in Queensland and supervised a dental therapist at a local primary school. He drew attention to the high level of dental fluorosis in children there, and began collecting data on this and on dietary sources of fluoride. He claims that he was officially warned by the Queensland Health Department to cease research and, after media coverage elsewhere in the country, was fired. (21)
Mark Diesendorf worked until 1985 as a principal research scientist at the Commonwealth Scientific and Industrial Research Organization (CSIRO). Officials of the Australian Dental Association wrote letters to the chairman of CSIRO and to the federal Minister for Science and Technology, who was responsible for CSIRO, complaining, for example, that Diesendorf had “mis-used his CSIRO connections to lend weight to his views on subjects outside his expertise,” and requesting the taking of “all necessary steps to ensure [that] this deceptive practice does not continue.” CSIRO defended Diesendorf in correspondence on the grounds that he had made clear that he spoke about fluoridation in his “private capacity.” (22)
In 1986, Mark Donohue, a doctor, wrote a letter to the editor of a regional Australian newspaper, attacking fluoridation. He received a letter from the state medical board informing him that the board had received a complaint about his letter to the editor, that the board had concern that his comments were not in agreement with standard medical views, and that a newspaper was not the most appropriate place to present his views on fluoridation. (23) This is an example of what Waldbott would call a “veiled threat.”
John Colquhoun describes the difficulty of assessing the role of pressure against antifluoridationists in the following manner.
In New Zealand the late R E T Hewat resigned from his position with the Medical Research Council in the same year that he revealed to his colleagues his doubts about the [fluoridation] paradigm. The author knows that he was fulfilling a long-held wish to go farming, but to what extent he was influenced by pressures to make his decision at that particular time, with the Hastings experiment just started, is not known. The minutes of the Dental Association show that some within the profession believed he resigned under pressure. The late Owen Hooton was a respected Auckland dentist, in private practice, who felt bound by conscience to write to the newspaper dissociating himself from support for fluoridation and agreeing with Sir Arthur Amies’ assessment. He was visited by Evan Williams, an officer of the Dental Association, and told that he (Hooton) should desist from such public differences with his colleagues. Hooton promised to reconsider, but after doing so wrote explaining why, in the light of the evidence available to him, he could not change his stance. He added, “The majority of people are against fluoridation. I make that statement on the evidence of the ten referendums held in New Zealand. The methods being used by both the Health Department and the NZDA to force the issue are just repugnant to me.” Hooton resigned from the Association in 1968, and died soon after, saddened by the ostracism he had suffered from most of his colleagues.” (24)
Colquhoun himself experienced direct pressure. After being quoted, in a newspaper article, as warning parents about the danger of their preschool children swallowing fluoride toothpaste, he received a letter from his employer, the Director-General of the New Zealand Health Department. The letter stated that “a staff member who is required to carry out instructions which are abhorrent to him should seek a transfer to another position where this conflict will not exist, or he should resign.” (25)
A colleague of Colquhoun’s made a similar warning in a newspaper, but anonymously, “was visited by a superior officer who had learned her identity and warned that she had committed ‘a dismissable offence’” since she, like Colquhoun, had contradicted the official policy that recommended fluoride toothpaste for all children with teeth, namely two-years six-months and older. (26) In New Zealand in the 1950s, the profluoridationists even arranged for the police to secretly investigate the political affiliations of opponents. (27)
The combination of direct attacks on some public opponents of fluoridation, their fears about loss of grants, and the general labeling of opponents as ignorant and misguided combine to discourage many scientists from doing research or speaking out on the issues. The relative lack of open opposition, in turn, encourages a perception of the “fringe” position of critics.
The direct attacks that occur, plus fears of jeopardizing careers, help to ensure that research projects which may lead to criticism of fluoridation are less often undertaken, and create an atmosphere in which those studies that are carried out are affected by a profluoridation bias. (28) Hence, relatively few articles critical of fluoridation are ever submitted to scholarly journals. Of those that are, there is evidence that it is more than usually difficult to obtain publication.
Mark Diesendorf submitted an article critical of fluoridation to the Australian journal New Doctor. It was rejected because “it might encourage the antifluoridationists.” The editor did not supply the referee’s comments, and would not even write in a letter that the article was rejected. He offered this information only over the telephone. (29)
Sohan L. Manocha, Harold Warner, and Zbignew L. Olkowski submitted a paper about enzyme changes in monkeys who drank fluoridated water to the Journal of Environmental Health. One reviewer wrote that the paper “appears to be written with the intent to discredit the use of fluoridated water for the maintenance of dental health” and wondered, since the safety of fluoridated water had been demonstrated “exhaustively and repeatedly,” whether there was any point in “reviving an issue that has already been resolved.” Another reviewer gave, as a reason for recommending against publication, this statement: “this is a sensitive subject and any publication in this area is subject to interpretation by anti-fluoridation groups. Therefore, any detrimental fluoride effect has to be conclusively proven.” The paper was rejected. The authors were warned by their head of department not to seek publication in any other U.S. journal, since the head had been cautioned by the National Institute of Dental Research that the results would hurt the fluoridation cause. (30)
British scientist R.S. Scorer wrote, “I know of one paper rejected by a prestigious British journal on the grounds that it would cause public alarm if published – it raised the issue of a possible relationship between fluoride and cancer mortality.” (31)
Waldbott, in a court hearing, was asked, “How did it happen that the Journal of the American Medical Association, the Annals of Internal Medicine, the Journal of Gerontology, and the Annals of Allergy turned down your articles on fluoride poisoning?” Since the question enumerated “every single journal that had ever rejected an article of mine,” Waldbott inferred that Public Health Service officials, as editorial consultants, must have advised the editors of these journals to turn down the articles, and that the editors had provided the information that they had done so.” (32)
Albert Schatz, often noted as the codiscoverer of streptomycin, sent three separate letters to the editor of the Journal of the American Dental Association in the 1960s. Apparently because Schatz was a known critic of fluoridation, all three certified letters were refused and returned to Schatz unopened. (33)
On 15 to 17 October 1962, a conference on the toxicology of fluorine was held in Bern, Switzerland. The conference was originally planned for the Netherlands but, due to “opposition from dental interests” there, it was transferred to Bern. “The conference proceedings were to be published as a book. One publisher of medical and dental literature set the text in type, investing some 10,000 Swiss francs, before pulling out. The publisher was allegedly threatened by a boycott from the dental profession, and was offered compensation for dropping the book. (34)
Phillip Sutton reports that after the first edition of his monograph Fluoridation: Errors and Omissions in Experimental Trials was published by Melbourne University Press in 1959, copies were dispatched to the press’s United States agent, Cambridge University Press. The executive director of the Nutrition Foundation, a body funded by the American food industry, wrote to Cambridge University Press, saying “The professional standing of the Cambridge University Press among scientists and educators would seem to preclude publication of such a book by Cambridge University Press.” (35)
Sutton also says that the type of his monograph was, without authorization, melted down soon after publication and had to be reset for the second edition only a year later. At that time, Melbourne University Press normally kept for at least six months. (36)
The Index to Dental Literature, published by the American Dental Association, did not include either the first or the second edition of Sutton’s book. It included negative reviews of the book, but not positive ones. (37)
Not surprisingly, journal editors usually deny any improper behavior on their parts. In 1957, dental editors responded to charges of bias by issuing a resolution which stated that “no dental journal is restrained or has been restrained from being free to publish both sides of all controversial matters.” (38) Of course, it is quite possible for editors to believe that they are unbiased, while bias, as inferred by others, is at the same time, present.
The above cases are examples of attacks on antifluoridationist. (39) I have heard of only one exception to this pattern. The Australian journal Simply Living has published several articles critical of fluoridation. After one of them appeared, Gordon Medcalf, a dentist, submitted a brief reply. The editor rejected it, saying that the views on fluoridation expressed in Medcalf’s article were contrary to the facts as Simply Living understood them. (40)
The attacks against antifluoridationists predictably are documented almost entirely by antifluoridationists themselves. (41) It is not normally considered proper to reject a scientific paper or deny a research grant simply because of a person’s views on fluoridation. Therefore, such cases are not normally publicized by profluoridationists, but are, sometimes, referred to by opponents in order to condemn the methods of the proponents.
Most of the cases have been documented by leading opponents of fluoridation who are scientists rather than, for example, members of citizens’ groups. There are several reasons for this.
First, leading opponents who are scientists attract a disproportionate share of the attacks because it is especially important to proponents to reduce the effectiveness which derives from their greater credibility. If an accountant, bricklayer, or homemaker makes claims about fluoridation, it is easy for dentists, doctors, and scientists to dismiss the claims as coming from uninformed sources. In the public debate, and in many scientific forums, the credibility of a statement relates more to the formal status of the person who makes it rather than to the content of the statement itself. For the purposes of the fluoridation debate, the claims of relevant professionals – especially those who have written and done research in the field – take on an exceptional significance.
Then, too, because most professionals have favored fluoridation, the few public opponents play a special role. If their credibility can be damaged or their activities which hurt fluoridation can be reduced, this can help change the situation from debate – however unbalanced it may be – to unanimous professional support. Therefore, the leading opponents are much more likely to be targeted for attack.
Also, leading opponents are likely to document attacks because they are prominent nodes for communication. People hear them give talks, read their articles, and, as a result, send them further information. These key figures thereby obtain masses of information, some of which they may publish as accounts of attacks on opponents.
Finally, leading opponents are more able to publish accounts of attacks – especially attacks on themselves – because they have little to lose and something to gain by doing this. They are already prominent in their opposition. Others may not want to spend their lives as antifluoridation partisans, but may simply want to continue work as dentists or medical researchers. For such people, to publicize attacks on themselves would be to bring further attention to their activities and perhaps induce further problems. A safer path is often to simply say nothing and avoid arousing the antipathy of fluoridation opponents.
Attacks on opponents probably have the greatest impact on those who are less prominent in the debate. They provide moral lessons in what may happen to those who take up the “wrong stand.”
The normal idea of professional practice holds that measures such as dismissal are taken only against those who are incompetent, unethical, or simply “not good enough.” A decision to reject an article submitted to a professional journal is supposed to take place on the basis of peer review, itself based on scientific or scholarly criteria. Membership in professional societies is normally withdrawn only from those who have severely breached professional ethics. How, then, are the sorts of attacks on antifluoridationists described here to be interpreted?
Some profluoridationists perhaps see continued open opposition to fluoridation as evidence of poor judgment, scientific incompetence, unethical behavior, or worse. The imposition of measures against certain opponents is quite justifiable in this context.
Furthermore, no doubt, some of the cases can be explained (or “explained away”) as exaggerated accounts or paranoid interpretations by people who have “an ax to grind.” But this does not explain the full pattern of attacks.
Most antifluoridationists see the use of professional power against opponents as a violation of professional principles, and as evidence of the unscrupulous behavior of promoters of fluoridation. Opponents of fluoridation frequently raise these cases of “suppression” as showing the political rather than the scientific basis for the promotion of fluoridation. By highlighting discrepancies between the stated norms of scientific behavior and the actual behavior of certain scientists, the opponents use the category of “unjustifiable behavior” as a resource in their struggle.
A middle-of-the-road approach might categorize these examples as unfortunate excesses, not representing proper behavior and possibly being counterproductive for the proponents. But, since the opponents are believed to be wrong and have so little professional credibility, it is not worth making a big fuss about particular cases.
This apparently moderate and balanced view ignores one thing: the organized efforts within the dental profession to denigrate the reputations of antifluoridationists. (42) The dossiers published and distributed by the American Dental Association create a climate of contempt, in which attacks on antifluoridationists become more acceptable. The opponents are, the dossiers suggest, “only cranks anyway.”
In summary, the profluoridationists, through their influence in dental and medical associations, their positions and influence with health authorities – especially the U.S. Public Health Service – and their influence over the editorial policies of journals and publishers, have created a climate in which some zealous promoters use a variety of aggressive techniques to stop the expression of antifluoridation views by professionals. (43)
This point again illustrates the impossibility of assessing the fluoridation issue without a full consideration of the dimension of power. An assessment of the scientific evidence is incomplete without knowledge of what research may have been inhibited from being done in the first place, prevented from being published, or relegated to marginal status by attacks on the credibility of the researchers.
Read more from Brian Martin:
Print 
PDF
Zbigniew L. Olkowski, MD 