Letters to the Editor
(Included below are the letters published in the Chemical & Engineering News, in response to its Review article on Fluoridation (August 1, 1988). The review stimulated a tremendous amount of feedback - with letters published in the Journal up through April of the following year. Most of the feedback was complimentary, with much appreciation for the Journal's effort to conduct an objective analysis of the issue. To read the full article, visit: http://www.slweb.org/hileman.html)
Fluoridation of Water (10/10/88)
SIR: I congratulate you and your staff, particularly
Bette Hileman, on the special report "Fluoridation of Water"
(C&EN, Aug. 1, page 26). The article is, to me, a manifestation of
the ultimate essence of what the American Chemical Society can be at its
very best. The article addresses within the specifics of fluoridation
a number of fundamental issues that confront and confound scientists and
the public alike in endeavors to resolve societal issues involving science
and technology. It is a case study that displays fundamental issues that
I and many others endeavor to address in general terms. Some of these
* The distinction between a goal (to improve dental health) and a technological mechanism (fluoridation of water) to pursue that goal.
* The potential for misadventure (unbalanced research programs, selective use of data, biased analyses of data, sequestering of data, restriction of publication, and misdirection of research funds in general) of designing research programs to support a specific political position on a technological option as compared to designing research programs to further the attainment of a goal.
* The potential conflict of roles of an individual as a scientist (an expert) and as an advocate of a technological option related to the field of expertise.
* The role of value judgments in the selection and implementation of a technological option (mechanism) to address a societal issue.
The report has not been written as a case study, but the elements of a case study are there.
Anna J. Harrison
Mount Holyoke College
SIR: In the special report on fluoridation of
water, the author says, "For 43 years, there seems to have been no
middle ground between the two points of view [for and against fluoridation].
She also quotes a Natural Resources Defense Council attorney, "Neither
side has given the other one rational moment."
This is the equal-time approach favored by television commentators to attract viewers to programs where science is confronted by opponents, such as programs on biotechnology or on creationism. Equal time for what? Unfortunately, anti fluoridationists, like other detractors of science, are unrestrained by adherence to veracity, so that science loses ground. The allegation that sponsors of fluoridation have not given their opponents one rational moment is quite false.
I, and many others, have tried for many years to rebut -rationally - factual misrepresentation by antifluoridationists. For example, in 1980, they made a statement in an official pamphlet sent to all Oakland, Calif., area voters, that the National Academy of Sciences (NAS) stated that "fluoride is not an essential nutrient, therefore deficiency is impossible." At my instigation, this statement was declared untrue by the president of NAS. Actually, NAS, in "Recommended Daily Allowances" (1980) said, "Fluorine can be considered an essential element for the growing organism on the basis of its proven beneficial effects on dental health .... The Food and Nutrition Board recommends fluoridation of public water supplies where it is needed because of low natural fluoride levels."
The deplorable special report contains many questionable statements against fluoridation that need a lengthy rebuttal.
Thomas H. Jukes
University of California, Berkeley
SIR: I was disappointed and dismayed by your
recent article and editorial on the fluoridation of water. This biased
and misleading review in my professional journal is very disturbing.
Although it can be argued that there are two sides to any scientific question, it is totally inappropriate to emphasize an essentially discredited position, especially when the great majority of these antifluoride data has been questioned by peer review. The length of the article (17 pages) and the complete distortion in the quality, quantity, and sophistication of the scientific data do great disservice to the American Chemical Society and cast grave doubt on your scientific judgment.
There is no conspiracy to withhold the truth about fluoridation, because there is no scientific case to support the antifluoridation position-a case that is based largely on philosophical and emotional issues.
This article, not peer-reviewed, should not be permitted to suggest in any manner that it reflects the position of ACS. Action must be taken immediately to rectify the appearance that this is an ACS official position.
The dental associations should be commended for their support of fluoridation, despite the political and economic pressures that they have experienced. Despite the economic impact that fluoride has had on the dental profession, it has continued to actively support its research and its use.
Our society has been used as a political vehicle in the support of a highly emotional issue, and I believe the journal should make a public apology to the numerous national organizations that it has slandered
Conrad A. Naleway Director,
Department of Chemistry
American Dental Association
Editor's Note: The Aug. I C&EN article on the fluoridation of water was reviewed by eight experts in the field prior to publication. In addition to information obtained from a large number of interviews, the C&EN article is based on material presented in papers published in peer-reviewed scientific journals; policy papers prepared by scientists, public health officials, regulators, and others; and material presented in reviews of fluoridation by the National Academy of Sciences and other credible institutions. None of the hundreds of news and feature articles written by C&EN staff members every year represent the position of the American Chemical Society. Every Editor's Page carries a disclaimer to the same effect. ACS has taken no position on the fluoridation of water.
SIR: Your special report on fluoridation of water
provides a much needed reexamination of a remarkably persistent controversy.
It is interesting to see how the absence of data has permitted both anti-
and pro- fluoridationists to claim that adding that little ion to water
supplies is a health bane or boon.
Hopefully, Bette Hileman's perceptive and even-handed article will spur the National Institute of Dental Research and other agencies to sponsor studies that will settle, once and for all, the many issues for which conclusive evidence is currently lacking.
Michael F. Jacobson
Center for Science in the Public Interest
SIR: Since the publication of your article on
fluoridation, we have renewed our request to the New York State Health
Department for the participation of our scientists in the review/ revision
process of the fluoridation issue presently under way by the department.
We have full confidence in our scientists who are ready to participate,
not as adversaries but as professionals, in the pursuit for scientific
truth. We are hoping that your article will stimulate the type of constructive
dialogue and debate that has, been lacking for so long.
Your article rightly noted some important examples of how vital data on fluoride's adverse effects are withheld from the public. We know of other such examples. Most telling is the result of a survey of physicians reported in Modern Medicine (March 15-30, 1981): "many (physicians) reported being insufficiently informed about the adverse effects of fluoride."
Your article mentioned the World Health Organization (WHO) eliminating all negative data on fluoride in its task group report. WHO's failure to produce proof of its claims of safety goes back to 1969. It had published a report stating that numerous studies have shown no ill effects that could be attributed to fluoridation, but it could not cite any of these studies when the Swedish government medical board asked for them.
Fluoridation, at the usually recommended 1 ppm has been well documented to be harmful-even in research funded by proponents of fluoridation. For example, children in fluoridated Newburgh were found to have a greater incidence of low hemoglobin anemia and cortical bone defects than in the unfluoridated control city of Kingston ("Newburgh-Kingston Pediatric Findings After Ten Years," JADA, March 1956, page 296). Medical followup studies promised by Dr. Ast, director of the Newburgh-Kingston experiment, have never been done. This is typical of the shortsighted tunnel vision of fluoridation's proponents. They rarely check for medical problems while assessing the alleged dental benefits.
Both "Physicians Desk Reference" and "U.S. Pharmacopoeia" report a variety of side effects from fluoride and are now cautioning about the growing concern of total fluoride intake of the individual, which has risen sharply.
Dental fluorosis is the outward sign of fluoride intoxication. Fluoride intoxication leads to acceleration of the loss of bone mass and brittle bone. As the evidence of dental and skeletal fluorosis in our children mounts throughout the U.S., I am reminded of my father, a country doctor, who came away from a cancer convention in Chicago in 1949, telling us about the smokers' lungs he saw. It took the government some 25 years to acknowledge a harm my father saw and understood in one day. No, people do not appear to be dying in the streets from fluoride, and no, the ingestion of one glass of fluoridated water will not kill anyone. But we have found that the chronic ingestion of cigarette smoke-day after day, week after week, and year after year-has people dying in the streets, even though one cigarette did not kill them. And we are equally upset with the knowledge that the chronic ingestion of fluoride in our water, food, and air, day after day, week after week, and year after year soon will create the associated illnesses to have people dying in the streets, even though one glass of water didn't kill them.
Please keep up your investigative pressure.
Paul Stephen Beeber
President and General Counsel
N.Y. State Coalition Opposed to Fluoridation Inc.
Old Bethpage, N.Y.
SIR: This is to comment on Bette Hileman's article
and Michael Heylin's editorial on fluoridation. Bette Hileman's interesting,
but not unbiased, document contains a refutation of her claims regarding
the inaccuracy of early statistics on protection, in one small sentence.
On page 33, in the inset labeled "Some studies indicate that dental
fluorosis is increasing," near the top of the second paragraph, she
states, "Today, nearly all bottled drinks and canned foods in the
U.S. are processed with fluoridated water."
This is the real key. In the prefluoridation era when the initial Newburgh study and that in its twin unfluoridated city were made as a simple correlation between tooth protection and fluoridation, the correlation was valid. That kind of correlation with the fluoride content of the local drinking water supply has now become essentially meaningless.
On page 30 of the Hileman article is one example: "Tooth decay rates in the U.S., Canada, New Zealand, Australia, and in all countries of Western Europe have declined greatly during the past 40 years." This is in spite of zero fluoridation of public water supplies in Austria, Belgium, Denmark, France, Greece, Italy, the Netherlands, Norway, Portugal, Sweden, and West Germany. On page 31 is another example: "Robert L. Glass of Forsyth Dental Center, Boston, noted that in 1965, after more than 20 years of fluoridation, counts of decayed, missing, and filled permanent teeth for Grand Rapids, Mich., and Newburgh, N.Y., were only minimally different from the average for the entire U.S., which was then about 33% fluoridated. Because he had expected nonfluoridated areas to have higher decay rates than Continued on page 48
fluoridated ones, and to therefore raise the average for the entire U.S., he concluded that the U.S. average had not been determined correctly." Another example is, "Other recent reports indicate that fluoridated areas have lower decay rates than unfluoridated areas, but by much less than the alleged 50 to 60% difference."
What would you expect, if the average person's consumption is possibly 50% or more in the form of food and drink processed with fluoridated water? And is it really so mysterious that in all the developed countries cited, the incidence of dental caries has decreased markedly, even in areas where the public water is not fluoridated, an average of 50% in the U.S. since 1970? It seems that the original prediction of a 50 to 60% decrease in dental caries as a result of fluoridation is on target! After all, U.S.-produced soft drinks travel everywhere. The flawed correlations are those based on postfluoridation statistics, not those based on the original Newburgh study!
From now on, anybody trying to establish a meaningful correlation between dental caries protection and fluoride intake will have to measure correctly the total personal fluoride intake, rather than assume that it is represented by the fluoride level in the local public water supply-a daunting challenge.
SIR: At the risk of being called a dogmatic profluoridationist,
I found the recent article on the topic, although informative, to be nonetheless
biased and in some cases inaccurate. To illustrate, I quote from page
39: "The 1983 edition of the 'Physicians Desk Reference' states:
'In hypersensitive individuals, fluorides occasionally cause skin eruptions,
such as atopic dermatitis, eczema, or urticaria. Gastric distress, headache,
and weakness have also been reported. These hypersensitivity reactions
usually disappear promptly after discontinuation of the fluoride.' (This
information was omitted from later editions of the reference.)"
The alleged deletion implies an attempt to minimize the possible adverse effects of fluoride. However, the 1988 edition of the Physicians Desk Reference (PDR) still contains the exact same statement for at least one fluoride-containing product (page 2086). Furthermore, some manufacturers of other fluoride-containing preparations include the following statement under the "Adverse Reactions" section in the PDR: "Allergic rash and other idiosyncrasies have been rarely reported."
Other examples of irrelevant information could be cited. For example, what is a picture of men crippled from lifelong ingestion of toxic amounts of fluoride doing in an article entitled "Fluoridation of Water"? At least for balance the decayed teeth of a child who has not had the benefit of fluoride could have been included.
David B. Roll
Professor of Medicinal Chemistry
University of Utah
SIR: I would like to thank you for publishing
the article entitled "Fluoridation of Water."
It has been difficult to obtain information regarding the harmful effects of water fluoridation. You provided a carefully balanced, scientific presentation that fully covered the many facets of this issue.
I commend you for making this information available in your very complete and well-researched report.
Alexis T. Bell
Chairman and Professor of
University of California, Berkeley
SIR: If you want to prevent industry from releasing
into the environment chemicals whose potentially harmful effects are not
fully understood you are an environmentalist (and may well be a liberal).
But (editorial on fluoridation in the Aug. 1 issue of C&EN), if you want to prevent the government from doing the same thing, you help to create an "unhealthy atmosphere" that "stifle(s) rational discussion of the science involved ... based largely on an extreme rightwing philosophy of freedom of individual choice." Have I got this straight?
Editor Michael Heylin supports "rational discussion," no doubt.
Gerard R. Dobson
Professor of Chemistry
University of North Texas
SIR: You and the author, Bette Hileman, are to
be commended for tackling the difficult subject of fluoridation in your
Aug. I issue and for doing it so well. You are absolutely correct in pointing
out that the traditional norms of scientific inquiry seem to have been
abrogated in the fluoridation debate. In carrying out our own investigation,
the National Federation of Federal Employees Local 2050, which represents
the professionals at Environmental Protection Agency headquarters, found
the scientific documentation for the latest drinking water standard to
be unsupportable. We have not taken a stand for or against fluoridation,
but we have taken a stand against abuse of the scientific process. EPA
management's approach to setting a drinking water standard for fluoride
appears to us to be a clear case of such abuse, and a Congressional inquiry
seems to be in order.
EPA professionals have a clear right to operate in a professionally ethical environment. As a result of the fluoride case, NFFE has proposed a code of professional ethics to EPA management to prevent a repetition of this abuse. At this writing, EPA management is refusing to negotiate this proposal, which speaks volumes about their interest in the subject.
My only criticism of your report is your suggestion that the issue of whether to fluoridate or not "can't be made purely on the basis of scientific evidence." This may be true if the risks are slight. But, if the information that has been suppressed can be verified, the risks may indeed be great and make the "choice" on fluoridation a rather academic exercise.
Robert J. Carton
NFFE Local 2050
SIR: Thank you for presenting a balanced report
on the fluoridation controversy. Now we shall see if this very important
information is relayed to the public by the general news media. Certainly
they have a responsibility, in the public interest, to cover both sides
of this issue, as you have done. This has rarely happened since fluoridation
began over 40 years ago because most editors seem to have accepted, without
question, the official pronouncement that the issue is closed, it is nondebatable,
and all who oppose it are part of a misinformed, emotional minority. This,
in effect, is science by bureaucratic decree-an intolerable situation
in a free society.
Among early critics was the late Benjamin Nesin, former director of laboratories, New York City Department of Water Supply, who warned, "Never in the history of water supply has a substance with so much unfavorable evidence been seriously considered for introduction into the potable water of communities." We firmly believe the case against fluoridation is so compelling that after the facts are all on the table and there has been free and open discussion of the matter, this bitter controversy will end and fluoridation will go the way of the swine flu vaccine, thalidomide, DES, and other major medical misjudgments.
M. K. Sapora
Fluoridation of water (10/17/88)
SIR: Judging by accounts in the popular press (for example, the Aug. 23 Christian Science Monitor; the Aug. 14 issue of the Oakland, Calif., Sunday Tribune; and the Aug. 16 Chicago Sun-Times), C&EN has scored a real winner in associate editor Bette Hileman's special report on water fluoridation. In it she has given convincing evidence that the controversy is much more serious and complex than most people probably realize. As one who has been examining this subject closely since 1964, when I first became aware of adverse health effects that can result from 1-ppm fluoride in drinking water (see "Fluoridation: The Great Dilemma," Coronado Press, 1978), 1 can well appreciate the difficulties and pressures the author must have encountered in preparing her report,
Without question, Hileman has done a superb job of presenting vital key information on both sides of this knotty issue. Because fluoridation directly affects the health of millions of people, publication of this report and your editorial about it clearly reveal your genuine concern, not only for preserving the integrity of science and improving the public image of chemistry, but also for recognizing the impact, both potential and actual, of such an application of chemistry on the lives of people.
In this connection, it is instructive to compare Hileman's treatment of fluoridation with what your former distinguished senior editor, Howard J. Sanders, wrote a few years ago about it in his special report on advances in the prevention of tooth decay (C&EN, Feb. 25, 1980, page 30). There: although in less detail, many of the same controversial aspects of fluoridation were considered as in the Hileman article. For his report, Sanders won first prize in the magazine division of the American Dental Association's 1980 Science Writers Award competition (C&EN, Oct. 27, 1980, page 44). Will a similar award be given to Hileman for an equally impressive and deserving report?
Albert W. Burgstahler
Professor of Chemistry
University of Kansas, Lawrence
SIR: I have been much involved in problems of
fluoridation of water and dentifrices more than 40 years. Thus your extensive
focus on fluoridation in the Aug. I issue of C&EN impels me to respond.
This is a propitious time for the focus because it marks the 50th anniversary
year of the trustworthy published conclusion by H. T. Dean of the U.S.
Public Health Service in 1938 that most probably fluoride in the drinking
water reduces the incidence of dental caries. The plethora of evidence
since that time has proved beyond any doubt that Dean was correct.
The cover of C&EN appropriately dramatizes fluoridation, and your editorial helps in illuminating the present situation. However, the extensive review by associate editor Bette Hileman does not adequately reflect the degree of validity in the findings and conclusions of different investigators and the many persons, professional organizations, and others who have made claims and expressed opinions. Some of the published research and the deliberations of various groups are indeed clearly responsible and highly credible, and some are quite the opposite. In essence, in the long review measures of soundness of the findings, claims, and conclusions are inadequate, thus contributing to misconceptions rather than the promotion of better understanding.
I do not agree with the article in its unqualified acceptance of claims of critics of fluoridation that "research has not adequately answered most of the critical questions about potential risks." Such an unequivocal appraisal distorts the facts and naturally confuses the public whenever it is confronted with an important issue such as a referendum on fluoridation of the public water supply or the use by individuals of fluoridated dentifrices or other forms of self-application. Distorted understanding can be very harmful.
Also, the article somewhat distorts the purposes of many investigators of fluoride in relation to health. This is through implications or assertions that they have sought to prove desired relationships. For example, it is stated, "Proponents also are trying to show that fluoride can be used to alleviate the symptoms of osteoporosis." Professional researchers of merit seek to find relationships and explain facts. The objective is not to prove but to advance knowledge.
Another example of some distortion is the assertion that "profluoridation statements almost always claim that all risks have been fully investigated and found to be groundless." This may be applicable to the assertions of some superficially informed profluoridationists, but really soundly trained persons know that scarcely anything is "fully (exhaustively) investigated." The significant fact is that much good research has been done and the conclusion is clear that risks must be very small and unimportant in relation to the established large benefits of fluoridation.
Although the article is especially long it would have contributed much to better understanding had there been more attention given to the well-confirmed research on which water fluoridation and its safety is based.
Actually, the dominant issue on fluoridation concerns questions of individual rights. In a civilized society some compromises are necessary for the common good. As I wrote in a publication more than 20 years ago, "The argument that fluoridation is a significant infringement on individual freedom is no more valid than asserting that milk should not have vitamin D added to it or that niacin should not be added to bread. Where can a person buy a carton of milk or a loaf of bread that has not been enriched with these valuable nutrients?" The dependence of the public on such foods and the public policy on food enrichment impinges on personal freedom. Who would insist on the return of such freedom?
In dealing with fluoridation this is, of course, ultimately for the public to decide. It requires honest and informed decision making and the help of responsible representatives. But in reference to your editorial, responsibility for "caution and dispassion" is as much needed in the camps of opponents as in the "scientific and health communities" where fluoridation is advocated. Pseudoscience, extremism, and distortion of facts are intolerable regardless of the ways in which they are used, or by whomever they are used.
Whether or not it is worth noting, I enjoy carrying a 50-year membership card in ACS.
Harry G. Day
Professor Emeritus of Chemistry
SIR: Your article, "Fluoridation of Water:
Questions About Health Risks and Benefits Remain After More Than 40 Years"
(C&EN Aug. 1, page 26), is appreciated by those of us who have been
trying to enlighten others that the whole story has not been told, and
that there is good reason for concern. By presenting both sides, you have
given your readers the opportunity to make a meaningful judgment.
The Public Health Service pamphlet, "Water Fluoridation: Nature's Way To Prevent Tooth Decay," that appears on the first page of your article bears commenting. This is a frequent argument by profluoridationists, that fluoride occurs in nature and therefore is beneficial. Yet no one would claim that lead, mercury, and radium, which are also found in nature, are beneficial. Also, the fluoride used in artificially fluoridated water supplies comes from industry as a waste product, usually from phosphate fertilizer. The Environmental Protection Agency (EPA) stated that fluoridation is "an ideal environmental solution to a long-standing problem." Thus, EPA's "solution" is the deliberate addition of fluoride-polluting chemicals to all the water we use for drinking, for cooking, and in all the foods and beverages processed with the fluoridated water. Our idea of natural and nature's way is to reduce tooth decay through proper diet and nutrition, sound selection of food, reduction in sweets and sugar-containing foods, and proper oral hygiene.
Fluoridation is depicted as a safe and simple
procedure. A 119-page publication by the Centers for Disease Control (CDC),
Oct. 1985, entitled, "Water Fluoridation: a Manual for Engineers
and Technicians," is filled with cautions and instructions. Not so
safe. Not so simple.
You pointed out Grand Rapids, Mich., as one of the first cities to be fluoridated as part of an experiment in 1945. It should be known that Grand Rapids is one of the growing number of places that has had overfeeds and accidents, due to machinery breakdown or human error (Grand Rapids Press, July 26, 1984). It never seems to be discussed in profluoridation circles - we would assume in order to preserve the undeserved image of fluoridation as safe, beneficial measure. There are dozens of other documented accidents, overfeeds, spills, leaks, and mishaps, which have caused illness, hospitalization, and even fatality. (Marin County in California; Harbor Springs, Mich; Stanley County in North Carolina; Annapolis, Md.; Los Lunas, N.M.; Potsdam, Saratoga Springs, and most recently, Schenectady, N.Y.; and many more.)
Although our primary concern is chronic fluoride toxicity from day-to-day ingestion on a long-term-basis, this is still another risk, from machinery breakdown or human error, that people in fluoridated communities are forced to take.
Since our New York State Health Department has been undertaking a reassessment of fluoridation, at the request of the Governor, our organization, Merrick Environmental Committee, wrote to David Axelrod, Health Commissioner, on April 29, 1988, and asked for "...your scientific studies or specific scientific references, which supports your position that fluoridation is safe and effective at the 1-ppm level added to fluoridated water supplies."
While most health authorities and their endorsing agencies try to calm people with blanket assurances and claims of safety, Axelrod's reply of May 26, 1988, is significant: "The potential for adverse effects associated with fluoridation depend on a large number of factors, including the total amount of ingested fluoride, as well as the physiological state of the individuals."
Evelyn Hannan, Chairman
Merrick Environmental Committee
SIR: Thank you for presenting a comprehensive view of the fluoridation issue being debated in our public health agencies. It is interesting that while both proponents and opponents have a basis for their for convictions, they can neither listen effectively nor agree upon actions that will resolve specific points in dispute with independent results. All public policies implemented through zealous action without consensus suffer from this problem.
You state that everyone agrees dental caries should be eliminated and you imply that everyone agrees that no one should be injured by the method chosen to reduce dental caries. thus the only question remaining is whether fluoride addition to drinking water meets these goals and at what level. It seems that the unwillingness of both sides to be proven wrong is the only impediment to resolution of this debate. Meanwhile everyone is frustrated.
You have painted a balanced and explicit picture
of the problem. It was fun to read and ponder. I do not know which side
is right, but I am sure the issue needs to be resolved in an open forum
where decisions flow from the facts.
William A Coniglio, Biologist
Fluoridation of water (10/24/88)
SIR: I wish to compliment you and Bette Hileman for the very comprehensive coverage of water fluoridation (C&EN, Aug. 1, page 26), and I appreciate the objectivity of her writings. As I have been in the fray for more than 40 years as a practicing dentist, I saw then how the profession and the government agencies jumped the gun on its approval, especially when so many foreign countries declined to institute such a questionable program.
As you implied in your editorial, anyone who criticized or posed a threat to the program was immediately shot down and vilified by men in high places. In fact, what started out as an exciting scientific experiment became a political-economic football.
Now almost 40 years later, a very remarkable thing is taking place. Prestigious dental clinics are reporting not only dramatic drops in dental decay rates in their studies, but the very embarrassing finding that nonfluoridated towns were showing equal if not better checkups than the fluoridated ones.
The World Health Organization also is reporting that many nonfluoridated countries were outperforming the fluoridated ones in the reduction of dental caries.
Because of the alarming realization of a fluoride overkill through our food chains and fluoride products foisted on the public, many warning statements are being made by these same profluoridation people.
Quoting Dennis H. Leverett of the Eastman Dental Clinic of Rochester, "The fluoride content of ready-to-drink fruit juices increased 5 to 20 times when fluoridated water was used in the processing.. . . An increase of dental fluorosis is indeed the case in fluoride-exposed infants... the optimum concentration of fluoride in community water supplies needs to be reassessed."
Also, to quote A. S. Gray in the Aug. 1 issue of Journal of the Canadian Dental Association, "A review of current findings in British Columbia and other localities indicates that decay rates are drastically falling in nonfluoridated areas. The current statements of our profession in support of fluoridation do not appear to take these changes into consideration. It is timely for our profession to take the lead in deciding what is scientifically appropriate to tell communities considering fluoridation installation."
When proponents of fluoridation send out warning signals such as these, it is about time that all dentists readjust to the facts, and stop trying to support an untenable position. We must remember that the decay rates are down and it is time to turn off the fluoridation faucet.
Herbert H. Robinson, D.D.S.
St. Petersburg, Fla.
SIR: We recently read your special report on
fluoridation. We congratulate you and the author of this report, Bette
Hileman, on your willingness to dispassionately question the benefits
Your article will no doubt incur the National Institute of Dental Research's wrath. Defenders of the conventional wisdom persist even when empirical evidence indicates they should change their position. NIDR still states that school-based fluoride mouth rinsing is an effective and inexpensive method for preventing tooth decay in children despite the National Preventive Dentistry Demonstration Project (NPDDP) and other recent . studies clearly showing that NIDR grossly overestimated the benefits it ascribed to this procedure and greatly underestimated its costs.
The centerpiece of NIDR's evidence for the rinse's effectiveness is a 17-site demonstration project. That project used a cross-sectional rather than a longitudinal control group. Thus, the benefits NIDR attributed to the rinse were probably really due to the national decline in decay that occurred while its study was under way (a decrease that is well documented in other NIDR reports). The NPDDP also would have incorrectly as cribed large benefits to the rinse had it based its estimate of this procedure's effectiveness on comparisons with the study's cross-sectional control groups.
NPDDP results do support NIDR's position that water fluoridation is a relatively safe, inexpensive, and effective method of preventing tooth decay in children. However, there are many questions about the utility of this measure that NIDR seems unwilling to address. For example, NIDR repeatedly refuses to present the difference in decay levels between fluoridated and nonfluoridated communities in the reports of its national surveys. And, it has not examined the long-term benefits of water fluoridation using standard cost accounting procedures.
NIDR is the primary noncommercial source of funding of studies on preventive measures. Most dental researchers are not really independent of NIDR's influence. Moreover, as a condition of many of its grants, NIDR, rather than the grantees, conducts the statistical analyses of the data. And, NIDR's official requests for proposals to conduct studies of preventive measures have specifically encouraged grantees to select communities in which the children have especially high decay levels, which in turn is likely to lead to inflated estimates of the typical benefits that will be derived from these measures.
In summary, don't be put off if NIDR and its followers object to your article, and don't treat their positions as gospel. They and their findings are not so objective or so scientifically sound as they might like you and others to believe. And, your impartial questioning of the conventional wisdom may help to bring about the types of independent research and changes that are truly needed in this field.
Stephen P. Klein
Robert M. Bell
Santa Monica, Calif.
SIR: Bette Hileman and C&EN have performed
a major public service with the publication of the cover story on the
fluoridation controversy. The article will certainly provoke much controversy
of its own, and may in fact elicit some bitter attacks from those (on
either side of the issue) who disagree with some facts it contains or
dispute the author's perspective. As one of the experts interviewed for
the story, I knew it was in preparation, of course; but I was nevertheless
very impressed with the breadth of scope, the thoroughness, and the objectivity
of Hileman's analysis.
There is no one correct view of fluoridation, just as most essentially political issues have no objectively right and wrong sides. Citizens confronted with such issues need an independent, critical analysis of the facts and arguments one that examines whether what the advocates claim is true is really true, Your report has gone a long way toward meeting that need on fluoridation. Unfortunately, the press, which we count on to provide such analysis on so many issues, has not lived up to its responsibility on fluoridation. Media in this country have generally deferred to the authority of the active proponents, accepting their view that there is no scientific controversy over fluoridation, and that opposition comes only from the lunatic fringe. As much as your report demonstrates that this has never been the case, it still requires a great deal of courage to say so.
In the weeks since your report appeared, your judgment, motives, competence, and ethics have probably been called into question by a variety of zealots. Those who cannot win this debate on its merits have long used intimidation to silence views they don't like. Keep your chin up. Your report is the most important and best done analysis of this controversy by the scientific press that I have seen in 20 years of study of public policy disputes. Hileman, you, and all others involved in its production deserve genuine congratulations.
Edward Groth III
Mount Vernon, N.Y.
Fluoridation of water (10/31/88)
SIR: The special report on fluoridation (C&EN, Aug. 1, page 25), although meticulously researched and documented, will doubtless raise the hackles of the promoters of this environmentally dubious mode of combating dental caries. We gave our own child fluoride tablets and withheld refined sugar from his diet, a combination that occurs to me as a sane and better targeted approach to the problem of tooth decay.
According to some estimates, about a third of the total quantity of fluoride that must be removed from crude phosphate ore, prior to its application as fertilizer, is disposed of in public water systems. An additional third is sent to industry, and the remainder is stored as toxic waste.
A few years ago, when I signed a ballot argument against fluoridation of the Berkeley water supply, a local ardent profluoridationist called for my expulsion from the American Society of Biological Chemists and requested that the chancellor at this institution direct a reprimand to me. Although both requests were denied, these tactics seem designed to intimidate. They are typical of the maneuvers of one segment of the profluoridationist lobby. They certainly do little to enhance the quality of debate and the diversity of opinion we wish to hear expressed on an important issue of public policy.
J. B. Neilands
Professor of Biochemistry
University of California, Berkeley
SIR: I have been very impressed with the fair
and valuable presentation of this complex topic of fluoride. I think it
is especially important that clinical work on the use of fluoride seems
to confirm that it is contraindicated in therapy of osteoporosis.
Robert E. Buckley, M.D.
SIR: C&EN is to be congratulated for its
objective special report on fluorides, fluoridation, and health. Author
Bette Hileman has obviously consulted an extensive body of scientific
literature and interviewed many authorities on both sides of the fence.
The resulting work must have been carefully refereed by experts, for everything
in the article is virtually indisputable and accurate. What she has covered
cries out for further discussion, but of the many fascinating points she
has raised, I will focus on only one.
Proponents of fluoridation are quoted as claiming that it "costs only 20 to 50 cents per person per year" to fluoridate water supplies. This contention is another of many falsehoods perpetuated in the name of this pseudoscience. In fact, the real costs of fluoridation are so enormous that they cannot even be estimated with reasonable accuracy. The famous, but much-maligned physician, the late George Waldbott, who in the last 27 years of his distinguished medical career saw about 500 patients with fluoride illness, had some hard data regarding the real costs to persons sensitive to fluoride. One patient spent more than $7000 for illness caused by fluoridated water before consulting him. Another patient, in a notarized statement dated March 20, 1980 (a copy of which I own), has given details of costs of $9,390.09, not including bills paid by Blue Cross or the lifetime expenses of buying distilled water to drink.
That document describes a horrifying list of medical problems beginning after 1967, when Detroit's water began to be fluoridated, that were unsuccessfully but expensively treated until Waldbott correctly diagnosed fluoride poisoning from fluoridated water, By carefully avoiding fluoridated water, the patient began to return to a reasonably healthy condition: "Using distilled water for all my drinking and cooking has made a great improvement in the way I feel, but some of the damage fluoride has done to my body will never completely go away."
I personally spend more than $600 each year for distilled water for my family's needs, as do many thousands of other Americans. Someone should calculate for nonmathematicians the real cost of fluoridation when at least an estimated 1% [see Feltman, R., Kosel, G., J. Dent. Med., 16, 190 (1961)]-and probably more like 10 to 20%-of our fluoridated population suffers ill effects of one sort or another from fluoride. How do we calculate the misery, suffering, missed days of work, deaths, and medical costs of all who are made ill by fluoridation? A bottom-line, very rough estimate at a cost of, say, only half of $10,000 (from the above example for 10 to 15 years) for only 1% of 130 million people who regularly ingest fluoridated water comes to $6.5 billion. How ridiculous, therefore, to talk of 20 to 50 cents per person per year!
H. Lewis McKinney
Professor of History
of Biology and Medicine
University of Kansas, Lawrence
SIR: I'm a freelance writer, concerned not only
with the integrity of our media but also with our environment. For these
two reasons I was stunned to find in your publication the article on fluoridation.
The piece is the first one I have seen in recent years that was written without an obvious bias in favor of fluoridating water. Seldom are fluoridation articles balanced to the point of giving the views of opponents of the water programs. You are to be congratulated and I'm looking forward to more articles that give both sides of an issue.
SIR: We wish to express our great appreciation
for the special report you published on the subject of water fluoridation
by Bette Hileman. At last we have a thorough, objective account of a very
important public issue in a major publication for all the world to see.
Public decisions are supposedly made by an informed electorate, but when public officials decide what's good for us and don't reassess their actions in the light of new data, then it's time to give this information directly to the public.
What is of particular value for your readers and the public is the chronicling of the censorship in supposedly scientific journals of any data that might undermine the profl~oridation policy of the various public health agencies.
Again thank you for a job extremely well done and a valuable public service to boot.
Lorna J. Hancock, President
Health Action Network Society
Burnaby, British Columbia, Canada
SIR: You are to be commended for publishing the
excellent article on fluoridation of water by Bette Hileman.
It is about time that a journal of stature pointed out the harmful effects of drinking water containing 1 ppm of fluoride, and also questioned the efficacy of such a treatment to reduce dental caries.
I have a Ph.D. in chemistry and am an emeritus member of the American Chemical Society. In 1973, when I accepted a position in a fluoridated area, I discovered I was sensitive to fluoride. I suffered flulike symptoms and was unable to work for several months. My recovery was rapid when I stopped drinking the fluoridated water.
As a chemist, I was curious as to whether it was fluoride or some other element causing my problem, so I submitted to a double-blind test to determine if my body could identify water that contained fluoride. I was given six one-week supplies of distilled water, some of which contained I ppm of fluoride. My body was able to identify the two samples that contained the fluoride. Because the local water supply is now fluoridated, I must distill all my cooking and drinking water.
Keep up the good work!
DeLoss E. Winkler
Fluoridation of water (10/31/88)
SIR: Congratulations on your in-dep,th article on fluoridation (C&EN, Aug. 1, page 26). It was extremely well researched and presented a balanced view of the pros and cons of fluoridation.
I became aware of the problems with fluoridation in 1974 when Rockland County in New York State began to debate the issue of fluoridating its water supplies. Being influenced by the late George Waldbott's book, "A Struggle with Titans," I and a few other professionals, along with a growing number of lay supporters, argued against fluoridation with representatives from the leading professional organizations that supported it. Eventually, the county legislature strongly defeated the proposed legislation to fluoridate Rockland's water supply and to this day we remain free of fluoridation.
It is indeed laudable for a publication of C&EN's stature to come out with such a truthful and unbiased report when the prevailing view among most of the professional community has been so biased and one-sided for fluoridation.
Again, let me salute you and the author for your courage in seeking and writing the truth.
Michael B. Schachter, M.D.
SIR: I read with considerable interest the article
on the fluoridation of water. Seldom have I seen such a balanced presentation
of the facts. It is not only responsible journalism but also an opening
of the assumptively closed record that has presumed the lack of risk for
fluoride on the basis of shaky evidence. It seems that this is an ever
increasing pattern displayed by the regulatory community.
The absence of demonstrable acute deleterious effects in the human population provides no prediction of longterm safety. Apparently not only is fluoride of questionable efficacy in the prevention of dental caries, it may also be implicated in the promotion of longterm health effects such as osteoporosis and osteoarthritis in sensitive members of the population.
I commend your foresight in an all too-rare public airing of a health issue that is apparently overlooked.
Rufus Morison, Ecologist
SIR: Thank you for a well-researched and objective
report on the fluoride question. It has certainly helped me understand
the controversy around an issue that should be getting far broader and
more balanced exposure. Bette Hileman's work will be a major reference
from this point on, I'm sure.
I'd like to think there will be a followup sometime in the future to keep us abreast of new findings and political outcomes.
Again, thank you for your professionalism.
SIR: Please accept my belated congratulations
for the courage and perception to publish the enlightening article by
Bette Hileman on fluoridation of water.
I helped wage the battle against fluoridation several years ago in Winsted, Conn., and am aware of the pressures applied by the forces of "Medi-Business" to perpetuate their unconscionable profits with ill-conceived and unfounded pseudo-scientific data.
I admire your actions, and you should rest assured that I will gladly support your intrepid efforts to air the truth about this revolting attempt to pollute our environment and intoxicate our population.
Richard N. Filinson, M.D.
SIR: Fluoride has been a confusing issue to me
for a long time and still remains so despite the wonderful article that
you have published. I remain confused as to how much fluoride my patients
are actually getting. How much fluoride is there in the food chain and
how much fluoride are they actually ingesting from their water supply?
I know some physicians who advise their patients who are trying to reduce
their weight and reduce their appetite by increasing their fluid intake
to use nonfluoride water for that reason. Some patients will take two
to three quarts of water at the instructions of their doctors, and the
amount of fluoride may be excessive for them when you add the amount of
fluoride in the food chain.
In any case, I am most thankful to you for having published such a wide-ranging objective article that reports on all the different points of view. I think your article is certainly one that should be circulated widely in the medical world.
Gerson Jacobs, M.D.
Fluoridation of water (11/28/88)
SIR: I must say that the article on fluoridation by Bette Hileman (C&EN, Aug. I, page 26) implies rather different conclusions than I have drawn, based on careful study of the data and the issues.
The author has accurately reported that the fluoridation of community water supplies has engendered highly emotional responses from a minority of the population and broad-based support from health professionals. Support has been based on the ability of fluoride to increase the resistance of teeth to decay, thus helping to prevent disease. There is abundant scientific evidence for the beneficial effects of fluoride dating back half a century and confirmed in numerous studies including very recent reports. With the improvements in oral health that have occurred, the amount of disease prevented by fluoridated drinking water today may be less than 50 years ago. Still, the fact remains that those who have had lifelong access to fluoridated drinking water experience less dental decay, on average, than those who have not had such access.
Historically, opposition to fluoridation has been based largely on constitutional issues and on a myriad of purported health concerns. The constitutional issues have been fully dealt with by a number of state supreme courts that have upheld fluoridation as legal and appropriate. The U.S. Supreme Court on several occasions has determined that there is no basis for a review of the state court decisions.
In terms of purported health concerns, there is much evidence to indicate that there is no scientific basis for concern and no credible evidence of harm that would justify abandonment of fluoridation as a valued public health measure. As Surgeon General, I have directed two scientific reviews of the effect of naturally occurring fluorides on human health. Although these studies were not targeted at the practice of community water fluoridation per se, it is clear from the evidence that at the level of fluoride that is recommended for community water systems, dental decay is significantly reduced and no deleterious side effects are experienced.
Hileman may have intended to present the issues in a neutral light, but she misses her mark. Little attention is accorded the massive amount of evidence that has documented the effectiveness and safety of fluoridation and thus the great public health benefits that have occurred at little cost to the taxpayer. Much emphasis is placed on allegations of harm, all of which have been substantively dealt with by scientific experts, the courts, and regulatory bodies at the state and national levels. The use of boldface headings, accusatory language such as "Health risks: more questions than answers" and "Promoters' style has fueled fluoridation controversy," and the use of photos of apparently crippled individuals from other parts of the world as an example of what fluoride could ostensibly cause in the U.S. fall below the standards of credibility and veracity and in no way could be viewed as objective journalism.
It is rare that there is total consensus about any issue that is brought before the public or, indeed, in science. However, general public debate is not the most appropriate forum for pursuing scientific truth. Scientific research and review by qualified experts can point to the best choices of health-promotion and disease-prevention measures, based on existing evidence. For methodological and other reasons such as random variation, the results of scientific investigations can never be expected to be 100% consistent. Yet with water fluoridation, the beneficial results have been markedly significant, consistent, and reproducible.
For my part, I will continue to support community water fluoridation and recommend it to communities as an effective public health measure. I will continue to encourage scientific inquiry into the role of fluorides in human health. And I will continue to review dispassionately the scientific evidence relevant to these considerations. I would encourage others to do the same.
C. Everett Koop, M.D.
Editor's note: Surgeon General Koop's comments about the credibility, veracity, and objectivity of the C&EN article should be assessed in the light of questions raised by numerous scientifically qualified individuals and organizations about the fluoridation of drinking water supplies. These questions are largely concerned with present understanding of the impacts of fluoride on human health and with ambiguities over the efficacy of fluoridation as a tooth decay preventative in children.
The discussion of health risks in the C&EN article covers only topics that have been examined in detail by credible and responsible scientific organizations such as the National Academy of Sciences and the National Research Council of Canada. Like the C&EN article, reports from these groups do not advocate that fluoridation be discontinued. Also like C&EN, they examine what is known, and not known, about' relationships between fluoride in drinking water and dental fluorosis, skeletal fluorosis, the welfare of renal patients, hypersensitivity, enzyme effects, mutagenicity, birth defects, and cancer. These reports recommend specific research projects in these areas.
The panel appointed by Surgeon General Koop to investigate the nondental health effects of fluoride identified several potential health risk areas in which research is inadequate. In its final report in 1983, the panel emphasized the lack of information relative to "the effect of supraoptimal fluoride intake on bone marrow turnover in children and the relationship of moderate to severe dental fluorosis to skeletal development." The panel recommended that the "Public Health Service and the Environmental Protection Agency join to enlarge the body of information relative to skeletal maturation and growth in children ingesting more than the recommended daily intake of fluoride." To date this has not happened.
Tooth decay in children has declined substantially in developed countries over the past 40 years. In one of their few areas of agreement, proponents and opponents of fluoridation generally acknowledge that decay reductions have occurred in both fluoridated and unfluoridated areas. Studies to date have not been able to determine unambiguously the relative contributions to this dental health improvement from artificial fluoridation and from other factors. These factors include the use of fluoridated water in processed foods, the use of fluoride-containing toothpastes and mouth rinses, improved oral hygiene and dental care, improved diet, and changes in the immune status.
There has been such a reduction in caries in children in Western Europe, where only about 1% of the population uses fluoridated water supplies. The concept of artificial fluoridation has not been embraced by most European public, health, and scientific authorities. They have rejected it for a variety of reasons, including uncertainties over health effects and legal considerations.
To date, U.S. courts have determined that fluoridation raises no constitutional issues. However, in two of four recent U.S. court cases dealing with the health aspects of fluoridation, judges ruled that fluoridation is a health hazard. These findings were overturned by higher courts, which ruled that courts do not have jurisdiction over fluoridation, regardless of health considerations.
Surgeon General Koop's commitment "to continue to review dispassionately" scientific evidence relevant to fluoridation is in line with the highly credible manner in which he has handled other' public health issues. However, it contrasts with his attack on the integrity and professionalism of a science journalist who has %written, in a nonalarmist way, of the issues surrounding fluoridation in an article based extensively on the dispassionate analyses of scientists and advisory panels at NAS, the Public Health Service, the Environmental Protection Agency, and other such organizations.
SIR: I read with interest the article on fluoridation.
The approach taken in the article was balanced, and provided insight into
a health problem that apparently required attention.
Although I am not an expert on fluoridation, I have been involved as a regulatory scientist at the Food & Drug Administration and the Environmental Protection Agency. It is important that scientific issues, such as water fluoridation, that affect the environment and public health be examined using all available information, not select data. Further, it is important to factor in inf ormation gaps when reaching a regulatory decision. These sorts of considerations may not have been built into the regulation of water fluoridation. [C&EN] should be praised for questioning the scientific and policy underpinnings of the current fluoride regulations.
Philip G. Sayre
Health & Environmental Division
Office of Toxic Substances
Environmental Protection Agency
SIR: The history of fluoridation is characterized
by even worse science than was revealed by Bette Hileman's landmark feature
a~ticle. In the course of helping the supervision of John Colquhoun's
doctoral thesis, I realized that one of the main tests cited in dentistry
textbooks and elsewhere had been thoroughly unsatisfactory. Colquhoun
and I recounted the details in Ecologist [16(6) (1986); 17(2/3)
(1987)]. This experiment had two main defects.
One, the control city, Napier, was abandoned early in the experiment. Such partial records as survive from Napier indicate that the filling rates were dropping, if anything, faster there than in nearby fluoridated Hastings.
Two, the state dental practitioners in the study region, but nowhere else, were ordered-as was not publicly reported-to refrain from filling tiny defects as they had been doing in accordance with the criteria of their training. It is therefore no wonder, nor probably any result of inhibition of actual tooth decay, that lower filling rates were reported.
The experiment was, in these two crucial ways, rigged. I find it highly significant that its apologists have never responded with any published rejoinder to these criticisms.
Tooth decay has declined over the past couple of decades by a very welcome factor of two in wealthy countries that keep such records. But, as Diesendorf's milestone review in Nature (July 10, 1986) showed, this decline is not detectably connected with fluoridation. The mysterious decline has been closely similar in states of Australia; in cities such as Christchurch, New Zealand; and in countries such as Denmark, where fluoridation has never been permitted.
Fluoridation indisputably causes dental fluorosis (which your article did not well illustrate). In view of the worrying hints of other harm, as well as the financial costs, the fact that it doesn't work doesn't inhibit tooth decay-makes fluoridation an anachronistic mistake that should be promptly abandoned.
I. R. B. Mann
Senior Lecturer in Environmental Studies
University of Auckland, New Zealand
Fluoridation of water (1/23/89)
SIR: I commend your excellent special report (C&EN, Aug. 1, 1988, page 26) entitled "Fluoridation of Water," by Bette Hileman. It is an unusual report, for, unlike the great majority of articles on this subject, it eschews opinion and hearsay and strives to present the facts.
The report mentions that there are charges that adverse information about the effects of fluoridation has been suppressed and, in regard to its efficacy, it says, "In fact, some research suggests little or no reduction at all" in dental caries. I support those statements.
It should be of great concern to those the efficacy of fluoridation in reducing dental caries that was provided by the four main trials in Grand Rapids, Newburgh, Evanston, and Brantford. That monograph [Sutton, P. R. N., "Fluoridation: Errors and Omissions in Fluoridation Trials," Melbourne University Press, Melbourne (1959)] pointed out numerous scientific shortcomings in those four crucial trials.
So great was the intolerance of officials to any criticisms of fluoridation, that Cambridge University Press was approached in an attempt to prevent the distribution of the monograph in the U.S., and the printer's type of the first edition at Melbourne University Press was destroyed without authority, thus almost succeeding in preventing the printing of a second edition.
Another edition is in the advanced stages of preparation. This will reprint the original monograph and add new material, including a section on the scientific status of the 124 more recent studies that are said to demonstrate the efficacy of fluoridation.
In 1984, the most recent World Health Organization (WHO) book on this subject, "Environmental Health Criteria for Fluorine and Fluorides," was written by a 10-member task group. These scientists gave as their reference and apparently accepted, without investigation, the data displayed in a poster by J. J. Murray and A. J. Rugg-Gunn at the 26th European Organization for Caries Research Congress in 1979, They stated that "120 fluoridation studies from all continents showed a reduction in caries in the range of 50 to 75% for permanent teeth." These data obviously came from the same source as those in a table in a well-known book by the authors of that poster [Murray, J. J., Rugg-Gunn, A. J., "Fluorides in Caries Prevention," 2nd Ed., Wright, Bristol (1982)], which listed 128 studies.
In 23 of these, the data from the deciduous and the permanent teeth were listed separately-as 46 studies. Two studies that included data from more than one town were listed as six studies, and in seven cases reports in different years from the same study were listed as 14 studies. Therefore, more than a third of the studies were recorded more than once by Murray and Rugg-Gunn to give the fictitious total of 128 studies.
The most important aim of fluoridation is to decrease dental caries in the permanent teeth. Contrary to the statement in that WHO book, 20 studies listed did not present any data for those teeth.
This leaves 74 studies for permanent teeth, but most of these were of very poor scientific quality. One did not refer to fluoridated water, two were anonymous, three were personal communications, and eight were essentially progress reports. Fourteen were not published in a journal, but were short communications in newsletters and bulletins issued by state health departments. These obvious deficiencies, not mentioned by this WHO task group, were revealed by merely reading the reference and a table in the book by Murray and Rugg-Gunn.
Four of the remaining 46 studies were the original, main trials, all of which were mentioned prominently in this WHO book, although, for 29 years, they have been known to be very faulty. Sixteen of the remaining studies were short reports in state dental newsletters and journals.
A further disturbing fact in the table by Murray and Rugg-Gunn that lists the studies, is that one column, with 128 entries, is headed, "Nonfluoridated community caries experience," implying that each of the 128 studies listed had a control. This was not the case.
Even in the remaining 26 studies-now less than a quarter of the 120 mentioned by this WHO task group-almost every study did not attempt to use a control or used one that was obviously unsatisfactory.
None of these studies were designed to estimate examiner error or to eliminate examiner bias.
It should be of great concern to those who prize the integrity of science that an international committee of WHO scientists can produce a publication that grossly exaggerates the extent of data and does not investigate its quality.
Philip R. N. Sutton
Former Senior Lecturer in
University of Melbourne
SIR: The review article by Bette Hileman and
subsequent correspondence have been of much interest to me and to your
readers. Articles like Hileman's serve well to stimulate interest and
point out the gaps in our knowledge. I suggest, however, that the letters
in the Nov. 28 issue of C&EN provide a point at which to postpone
temporarily further publication of letters on this subject.
The pros and cons of fluoridation that I have followed over the past 40 years appear to be a mix of science, pseudoscience, and emotion. The several months of letters to the editor recently printed in C&EN seem to be representative of these approaches. Negative letters that present opinions based on inadequate and questionable studies serve to confuse or mislead those of us who are not privy to complete and reliable data. I suggest, on the other hand, that positive letters, to be convincing, would need to include much more data and require more space than C&EN would care to use.
The time has come for the development and use of definitive guidelines for public health that are based upon the recommendations of properly appointed and convened panels of experts. We should by now have assembled enough data to develop definitive recommendations. If not, we should be able to devise the final studies that are necessary to complete the database. If, indeed, fluoridation of public water supplies is the answer to dental health, future decisions to maintain or expand application of this principle must be based upon solid science. To proceed with flawed or incomplete data gives ammunition to the opposition who has used the overwhelming advantage of public doubt to win its arguments.
Adrian Hainline Jr.
Fluoridation of water (1/30/89)
SIR: In his defense of water fluoridation, Surgeon General C. Everett Koop (C&EN, Nov. 28, 1988, page 2) claims that "those who have had lifelong access to fluoridated drinking water experience less dental decay, on average, than those who have not had such access."
This is not true in Australia or New Zealand. For instance, primary schoolchildren in the Australian state of Queensland, which is onlv 5% fluoridat~d, have levels of tooth ~ecay that are ~qual to or less than those in primary ;schoolchildren in the extensively fluo-idated states of South Australia, West~rn Australia, and Victoria [Nature, 322, [25 (1986)]. Similarly, John Colquhoun, :he former chairman of the New Zeal.and Fluoridation Promotion Commit~ee, has shown that children resident in ~he unfluoridated city of Christchurch, New Zealand, have equal or less decay than children in all the other major cities of New Zealand, which are fluoridated [Community Health Studies, 12, 85 (1987)].
The response to these facts by the Australian Minister for Community Services and Health (our Member of Parliament who is responsible for health) has been to infer incorrectly that the Australian and New Zealand studies did not take into account the place of residence of the children. On the contrary, essentially all the schoolchildren were residents of the Australian state or New Zealand city in which they were examined. Moreover, it can be readily shown from demographic statistics that a large majority of primary schoolchildren, who are residents of an Australian state or a major New Zealand city, have also been lifelong residents of that city or state.
The proponents have overstated the benefits of fluoridation. Moreover, there is now clear evidence from animal experiments and the levels of fluoride in the enamel of human teeth that there is no systemic benefit from fluoride. In other words, any (small) reduction in tooth decay from drinking fluoridated water is obtained from the direct effect of fluoride passing over the teeth. The same benefit would be obtained by gargling with 1 ppm fluoridated water and then spitting the solution out. It is likely that the regular use of fluoride toothpaste, with 1000 times the fluoride concentration of fluoridated drinking water, is much more effective.
The lack of systemic benefit also implies that there can be no benefit in the exposure of children to fluoride before the teeth erupt, and so Surgeon General Koop's emphasis on "lifelong access to fluoridated water" is unnecessary. This has been confirmed with animal experiments, which are much more carefully controlled and executed than the qua~i experiments on human populations.
To be realistic, very few surgeons general or ministers for health have time to study particular health issues such as fluoridation. They take advice from "objective scientific experts," who often have conflicts of interest. In the case of fluoridation, these advisers are often bureaucrats who have been saying for decades that fluoridation is safe and effective, and cannot now reconsider their stances without losing credibility and status; dental researchers who have built their careers on the uses of fluorides; scientists who receive funding through dental health or nutrition foundations from the sugary food industry, a major cause of tooth decay. (Fluoridation encourages people to imagine that they and their children can eat these "foods" safely.)
An excellent political science analysis of the role of the state, professionals, and industry in promoting fluoridation is given in Wendy Varney's book, "Fluoride in Australia: a Case To Answer [Hale & Iremonger, Sydney (1986)].
The advisers with vested interests often draft the letters promoting fluoridation that are signed by surgeons general and ministers. So it is hardly surprising that Koop's letter suggests that such issues should be left to these "experts." But one former Australian Minister for Health, Douglas Everingham, was himself an expert on fluoridation. Before being elected to Parliament, he had studied the fluoridation issue in depth and had concluded that fluoridation should be discontinued. As minister in the early 1970s, he continually asked his department for evidence that fluoridation was effective and safe, but never succeeded in obtaining much more than the usual propaganda. His department obstructed his efforts to get the issue reexamined, and political pressures were brought to bear to make him drop the issue. In retirement he is still opposed to fluoridation.
As Bette Hileman has mentioned, and J. B. Neilands (C&EN, Oct. 31,1988, page 3) has testified, scientists, physicians, and dentists who raise awkward questions for fluoridation are sometimes suppressed by the promoters. In 1985, while employed as a principal research scientist in the Australian Commonwealth Scientific and Industrial Research Organization (CSIRO), I expressed my doubts about the alleged enormous benefits of fluoridation in a paper I delivered at a national science congress. The Australian Dental Association wrote to the chairman of CSIRO and to the Minister for Science, attempting to have my work suppressed or repudiated. In this case the profluoridationists were unsuccessful.
Currently, an unpublished covert critique of my paper, "The Mystery of Declining Tooth Decay" [Nature, 322, 125 (1986)], written by a senior member of the Australian Dental Association, is apparently being circulated to health departme~ts, politicians, and newspaper editors in several countries, including the U.S. Recently an overseas newspaper editor sent me a copy, and it was immediately clear that the critique was easily answered and was of such a low scientific standard that it would be very difficult to publish, except perhaps in certain dental journals. I think that the object of such a covert critique is not to encourage open scientific debate, but instead to create the false impression in the minds of politicians, editors, and bureaucrats that serious questions raised in a refereed paper published in a major international scientific journal have been answered. Further specific examples of suppression of dissidents in the fluoridation issue have been documented recently by Brian Martin [Social Studies of Science, 18, 331 (1988)].
Contrary to Surgeon General Koop, I believe that in a democratic society it is essential to permit, and indeed to encourage, open public debate on issues at the interface of science and society. Such debate is needed in the general scientific literature, in the media, and in the community at large. In this way issues that are simultaneously scientific, political, and ethical can be removed to some extent from the control of narrow technical experts with vested interests. This applies to many issues, such as the risks and benefits of pesticides, medical drugs, nuclear energy, and nuclear weapons. Technical experts have roles to play, but as servants of the community rather than as its masters.
Human Sciences Program
Australian National University, Canberra
Fluoridation of water (2/27/89)
SIR; This letter is in response to Betty Hileman's excellent article on the issue of fluoridation (C&EN, Aug. 1, 1988, page 26) and the recent letter to the editor authored by Surgeon General C. Everett Koop (C&EN, Nov. 28, 1988, page 2). The Surgeon General claims to have based his decision on a "careful study of the data," and states that "in terms of purported health concerns, there is much evidence to indicate that there is no scientific basis for concern and no credible evidence of harm that would justify abandonment of fluoridation."
I became interested in artificial fluoridation in the late 1950s when I was in graduate school at the University of Washington, and the city of Seattle voted against it. I wondered why a population would vote against such a positive benefit when the authorities had furnished them an abundance of factual material. One point made by the opposition to this measure was that there were questions about its safety. My interest aroused, I went to Chemical Abstracts and did a literature search in the area of the chronic toxicity associated with long-term fluoride ingestion. I was extremely surprised to find that there was only one full paper dealing with the effects of long-term fluoride ingestion involving experimental animals under controlled conditions, and at that time, of recent origin [Taylor, A., Dental Digest, 60, 170 (1954)]. The conclusion was less than reassuring. On a diet having a low fluoride content and water fluoridated at 1 ppm (controls 0 ppm), the average life span of the experimental animals was shortened an average of 9% over that of the controls! I have not seen published reports refuting these results. I wrote to Taylor and learned that he had notified the public health authorities when preliminary experiments indicated potential harm. These officials criticized his experiment, whereupon he carried out the full experiment with their suggested modifications. At the conclusion of the experiment, the published results were as noted above. Public health materials and statements on fluoridation to this day either ignore Taylor's research or mention only his preliminary experiments and their shortcomings, declare them flawed and therefore invalid.
At the time this research was done, the necessity of carrying out long-term tests to determine chronic toxicity for ingested substances was not fully appreciated. Indeed, food colors were just being subjected to this type of testing at the time, and subsequently, a number that had been considered safe and consumed by the public for years were found to fail in chronic toxicity tests and were decertified. The life-shortening aspect of life-long fluoride ingestion identified by Taylor has not been thoroughly investigated, and this effect needs to be verified with other animal species. Were fluoridation to be proposed today, it would need to pass both acute and ~chronic toxicity studies. Acute toxicity studies alone are no longer considered adequate when large segments of the population are exposed to ingested additives.
Like Surgeon General Koop, I too feel that I have made a careful study of the fluoridation research data; however, in contrast to his opinion, I think there is a valid scientific basis for concern about the safety of fluoridation. I am in wholehearted agreement that the research arena is the place to settle questions of scientific merit. The problem, as exemplified by the treatment of Taylor's work, however, is a blind spot that those promoting fluoridation have in accepting results not in support of their public policy pronouncements.
Robert Roy Kintner
Sioux Falls, S.D.
SIR: U.S. Surgeon General C. Everett Koop asserted
there is "abundant scientific evidence for the beneficial effects
of fluoride," but offered no explanation for the increasing scientific
evidence that suggests there is little, if any, benefit.
When I was a public health official in New Zealand's largest city, data became available to me that revealed that more children were free of dental decay in nonfluoridated areas than in fluoridated ones. I found that the situation was the same in other areas of my country. These data were collected for the entire population of 12- to 13-year-old children receiving their final treatment in the school dental service (which serves 98% of the total child population of my country, up to that age). The information would not have been released had I not published it (in spite of efforts to suppress it, as described on page 36 of Bette Hileman's report, C&EN, Aug. 1, 1988).
Data collected over a 50-year period on the entire population of new fiveyear-old patients in the school dental service, together with earlier and recent published data, showed that the decline in dental decay started well before the introduction of water fluoridation and other uses of fluoride. Research in New Zealand reports significant improvements in diet over that period, in spite of continued high sugar consumption. Better general nutrition, rather than fluoride, could be responsible for the decline in tooth decay.
The above information has been published in peer-reviewed journals [for example, Community Health Studies, 11, 85 (1987); and 12, 187 (1988)] and is supported by peer-reviewed published data from Australia, Europe, and North America. In general, total child population data do not support various child sample studies that claim to show a benefit from 1 ppm fluoridated water.
On the other hand, various studies show that the prevalence and severity of dental fluorosis, the disturbance of tooth formation that is an undeniable side effect of fluoridation, is much higher in fluoridated areas than had been predicted. Quite disfiguring fluorosis (not just the "barely noticeable" kind proponents talk about) can be found in fluoridated cities such as Auckland, but not in nonfluoridated areas except in children who were given fluoride supplements during the period of tooth formation. It seems probable that other adverse effects of fluoridation have also been underestimated.
My colleague 1. R. B. Mann (C&EN, Nov. 28, 1988, page 3) has described the discovery-from documents obtained under a law that makes government department files available for perusal that the results of our country's first fluoridation trial were contrived by inexcusable methods. I have, since my retirement, researched the history of fluoridation and have found grave flaws in the other early fluoridation trials, which are not apparent from textbook accounts of them.
Recent studies are no better than the early ones. A prime example is the British "Anglesey" study, which is claimed to show that fluoridation still works. My summary critique of that study (Nature, Nov. 27, 1986) explained why its claimed "strictly blind conditions" were worthless: A fluoridated semirural island was compared with a nonfluoridated "control." The control, chosen years after the study commenced, was a mainland urban area that one would expect to have a higher caries rate. There had been no prefluoridation comparison of the test and control groups. No rebuttal followed in the columns of Nature. One still cannot find a single properly controlled blind fluoridation trial in which the test and control populations were similar and were chosen randomly.
I have had to conclude that the "abundant" evidence referred to by Koop is high in quantity but low in quality and that the benefit from fluoride in drinking water was, at best, exaggerated.
Former Principal Dental Officer
Department of Health
Auckland, New Zealand
Fluoridation of water (3/27/89)
SIR: Surgeon General C. Everett Koop has asserted there is "no credible evidence of harm that would justify abandonment of fluoridation" (C&EN, Nov. 28, 1988, page 2). Just what kind of evidence he would find convincing is not clear, but he certainly did not offer any scientific grounds to reject unrefuted published findings of clinically demonstrated adverse health effects from fluoridated drinking water, as reported by Bette Hileman in her article on fluoridation (C&EN, Aug. 1, 1988, page 26).
My late husband, George L. Waldbott, M.D., who was nationally and internationally recognized for his extensive research on allergic-type hypersensitivities, devoted more than 25 years to the investigation of toxic effects of fluoride. He proved unequivocally, and other physicians have fully confirmed his findings, that fluoride added to drinking water at the officially recommended concentration of 1 ppm causes serious poisoning in sensitive individuals. In certain instances he conducted blind and even double-blind tests as recommended to him on April 2,1958, by the editor of the Journal of the American Med~cal Association to provide definitive evidence that the illness was specifically Due to fluoride and not to anything else.
His numerous peer-reviewed reports :)f toxic effects from fluoride in drinking water and other sources have appeared in recognized scientific medical journals starting in 1955. From that time until his death in July 1982, he published more than 80 papers on this subject in various U.S., foreign, and international journals, including the American Medical Association's Archives of Environmental Health, American Journal of Clinical Nutrition, Acta Medica Scandinavica, and International Archives of Allergy & Applied Immunology. In March 1980, his article, "Fluoridation: a Clinician's Experience," which presented case histories of the preskeletal phase of fluoride intoxication, appeared in the Southern Medical Journal. Subsequently, he also presented a number of additional reports.
Again, the fact remains that his various clinical findings of ill effects from I ppm fluoride in drinking water, as described on page 39 in the Hileman article, have not been refuted, nor have they been shown to be due to any other cause. Under these circumstances, objectively speaking, there certainly is "credible evidence of harm" from fluoridation. Tragically for those who suffer these ill effects, this evidence continues to be ignored or dismissed by promoting health officials.
Edith M. Waldbott
Fluoridation of water (4/17/89)
Sir: The letter by Surgeon General C. Everett Koop on fluoridation of water (C&EN, Nov. 28,1988, page 2) and subsequent letters to the editor illustrate the apparent flexibility of the scientific method in connection with a political goal. The letters accurately point out the need for more stringent criteria, more open discussion among scientists concerning the quality of the scientific data, as well as the limitations of the scientific method before conclusions reach the popular media and political leaders. Perhaps the best example of public policy built on a foundation of emotion and political goals rather than rigorous science is that of environmental tobacco smoke and the alleged health effects on the nonsmoker. Since the Surgeon General's report of the health consequences of involuntary smoking, which concluded that "involuntary smoking is a cause of disease including lung cancer in health of nonsmokers" (which was not adequately supported by the evidence presented in the body of the report), the statistically estimated death toll attributed to environmental tobacco smoke set forth in published reports has escalated from 5000 [Environ. Int., 11, 3 (1985)] to 46,000 [Environ. Int., 14, 249 (1988)). Although these reports were peer reviewed, they suffer from many of the limitations cited in the article by Alvan R. Feinstein in Science (242, 1-757 (1988)] regarding the need for improved methods in epidemiology.
The unsubstantiated number of 46,000 deaths attributed to environmental tobacco smoke appears to conflict with recent articles in C&EN that describe the prevalence of volatile organic chemicals in our workplace [Dec. 5, 1988, page 23] and the extent of radon [Feb. 6, page 7] in our homes. Probably, the most embarrassing issue concerning this article was that it was criticized by a syndicated columnist, who pointed out & obvious limitations of drawing conclusions from data generated from disease rates from nonsmoking women married to smoking men and the confines of low-risk epidemiology.
In the absence of rigorous scientific criteria, modern science has developed into a convenient vehicle for manipulation of public perception. Environmental tobacco smoke, food ingredient oils (palm and coconut), and pesticides all share the common element of a special interest group generating fear and emotion to influence the public, which is unable to evaluate the accuracy or validity of the methods. As scientists, we should assume the responsibility to police the standards of scientific papers that reach the media by demanding a more stringent peer review process and a willingness to challenge methodologically flawed science whether or not it feeds popular prejudices. The scientific method should not include double standards. Scientists who have immediate access to media and policymakers; should maintain the highest level of scientific integrity. Perhaps the ideal criteria should be: Would a Ph.D. candidate be able to successfully defend a headline-grabbing claim in front of a thesis committee?
Ironically, if scientists do not voluntarily poli~e our own peers, Congress, which has recently demonstrated an interest in fraud (C&EN, Feb. 20, page 5), will certainly fill the void.
Thomas J. Borelli
Mt. Vernon, N.Y.
Read Chemical & Engineering News' "Fluoridation of Water" at http://www.slweb.org/hileman.html