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Fluoridation Conflict: A History and Conceptual Synthesis
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Fluoridation conflict: a history and conceptual synthesis Richard J. Hastreiter, DDS, MPH
A fram ew ork of literatu re re v ie w and analysis is presen ted to discuss the history and controversy of community w a ter fluoridation.
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A he developm ent of com m unity water fluoridation as a public health m easure is an event w ith few p arallels in eith er dental-m edical or sociopolitical history. From a dental science perspective, the in vestigative history of w ater fluoridation is one of em pirical observation, reasoning, and research that exem plifies the scien tific m ethod. However, as a lesson in sociopolitical interaction, the failure to achieve universal w ater fluoridation is a dem o n stratio n of h u m a n ity ’s ten u o u s ability to apply the know ledge of proved, cost-effective disease prevention to ev eryone’s benefit.
The historical epidem iology of fluoridation The events culm inating in the im plem en tation of w ater fluoridation as a public h e a lth m easure began in th e w estern United States during the first decade of the 20th century. In 1908, at the annual m eeting of the Colorado Dental Associa tion, McKay presented his investigation of a “brow n sta in ” tooth enam el “ at rophy” that occurred in over 80% of the native inhabitants of Colorado Springs. His investigations determ ined that the only difference betw een th e C olorado Springs population and that of the nearest im m une area was that Colorado Springs received its w ater supply from the Pikes Peak w atershed. Other populations in the U nited States and Europe w ith this dys tr o p h ic m o ttle d e n a m e l w e re a lso studied. The condition affected only na tive inhabitants, and the only teeth not m ottled w ere those that had calcified be 486 ■ JADA, Vol. 106, A pril 1983
fore the person came to live in the area.1'4 In 1928, the US Public Health Service (U SPH S) c o m m issio n e d M cK ay a n d Kempf (USPHS epidemiologist) to survey conditions at Bauxite, Ark. Their findings a g ain p o in te d to the d rin k in g w ater source as a common cause, but standard w ater analyses did n o t determ ine the c a u sa l ag en t. H ow ever, in 1930 th e ALCOA laboratories in New Kensington, Pa, w ith instructions to look for rare ele m e n ts , p e rfo rm e d a s p e c tro g r a p h ic analysis of w ater obtained from deep wells at Bauxite. This more definitive test show ed that a fluoride ion concentration of 13.7 p a rts p er m illio n (ppm ) w as p re se n t in the B auxite w ater su p p ly . Analyses were then performed in other areas w h e re m o ttled enam el (d e n ta l fluorosis) was endemic. A positive corre lation was found between the ppm of flu oride in the w ater supply and the degree of endem ic fluorosis in the dentition of native inhabitants.1'4 In addition to fluorosis, it was gradu ally recognized that a high w ater fluoride content was also associated w ith a lower prevalence of dental caries. From 1931 to 1942, epidem iologic studies were con ducted to determ ine the relationship be tw een the water fluoride concentration, dental fluorosis, and dental caries. These investigations culm inated in a two-year dental survey of 7,000 schoolchildren in 21 US cities that was conducted by Dean2 and his associates. In 1942, their report concluded that the optimum w ater fluo ride content that maximized caries resis tan ce w ith a m inim um of u n e sth e tic fluorosis was 1 ppm of fluoride to w ater (1
mg of fluoride per liter of w ater).1'4 By b u ild in g on D ean’s work, su b seq u en t studies by Galagan and others dem on strated that the optim um fluoride concen tration is dependent on the annual aver age m axim um daily air tem perature and varies from 0.7 to 1.2 ppm in the continental U nited States.5'7 As a result of this and sim ilar research, it was postulated th at the adjustm ent of fluoride deficient public w ater supplies to the optim um fluoride level could become one of those unique examples of prim ary prevention that could be m ade available at low cost, w ith little inconvenience, and w ithout hazard to health. Between 1944 and 1947, research studies began in eight cities in the United States and Canada that ad justed local w ater supplies from subop tim um to optim um fluoride concentra tions. Data from these cities dem onstrated that caries prevalence decreased by as m uch as 65% in individuals consum ing optim ally fluoridated w ater from birth.3,7 These positive findings resulted in the expansive im plem entation of com m unity w ater fluoridation during the late 1940s and 1950s. However, in the 1960s and 1970s, although increm ents of the US p o p u latio n w ere still being ad ded to those d rinking flu o rid ated w ater, the adoption of fluoridation by new com m unities slowed considerably. In 1982, the US Centers for Disease Control esti m ated that approxim ately 123 m illion people (67% of those p erso n s in th e United States with public water supplies) had access to fluoridated water w ith fluoride ion concentrations betw een 0.7 to 1.2 ppm . These data indicate that, because of technical, econom ic, or sociopolitical constraints, many people are still not re ceiving the dental caries prevention bene fits of fluoridated water. Of these constraints to fluoridation, the sociopolitical factors have consistently been the most resistant to change.
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The traditional and current m anner of community decision m aking defines the ground rules within which fluoridation is considered.
The sociopolitical fluoridation controversy The origins of the sociopolitical conroversy surrounding com m unity water :lu o rid atio n in th e U n ited States are raceable to a small city in central W is consin. In 1945, the W isconsin Dental As sociation and the W isconsin Board of health passed resolutions encouraging water fluoridation. A favorable report on :he caries reduction effects of fluoridation .n Sheboygan, Wis, w hich h ad fluoriiated in 1946, was announced in 1948. As i result of the persistent drive of four prom inent W isconsin dentists, a large proportion of the urban population of i/Visconsin w as liv in g in flu o rid a te d com m unities by 1949. However, orga nized vociferous opposition to fluoridaiion soon appeared. The first large-scale Fluoridation referendum confrontation and defeat occurred in Stevens Point, Wis, in September 1950. This type of ac rimonious political debate became typi cal of w hat was to develop in other W is consin com m unities an d th e n spread throughout the U nited States.3 The three major objections to fluorida tion that were first effectively articulated in Stevens Point and that persist to this day are: first, that fluoridation is ineffec tive in reducing dental caries; second, that fluoridation is basically harm ful to the hum an system; and third, that fluori dation, applied as a public health m ea sure, deprives individuals of free choice by forcing them to accept m edication against their will. The allegations that fluoridation is ineffective and detrim en tal to hum an health have been refuted rep e a te d ly by p r o p e r ly d e s ig n e d epidemiologic studies that use accepted analytical, statistical m ethods, and that are conducted among populations con sum ing both naturally and artificially fluoridated water. The contention that fluoridation is an abridgem ent of the rights of the individual is an exam ple of the age-old societal tension betw een the common good and personal liberty. Deci sions of the US Suprem e Court and state
s u p re m e c o u r ts (Ja c o b se n vs M as sachusetts, 1905,8 De Aryan vs Butler, 1952,9 Chapman vs Shreveport, 1954,10 and Schuringa vs City of Chicago, 196411) have upheld and reiterated the right of the majority to promote the general welfare through disease control programs. A lth o u g h re se a rc h h a s re p e a te d ly d e m o n s tr a te d , a n d m o st c o n s u m e r groups and virtually all national and in ternational health organizations recog nize fluoridation’s effectiveness, safety, and cost benefit, the small groups oppos ing fluoridation have often succeeded in thw arting its im plem entation. How can an antifluoridation movement, w hich has never been very large, produce such con troversy and negative results against such overwhelm ing evidence? Public health o ffic ia ls a n d so c ia l s c ie n tis ts have studied the dynamics of the fluoridation controversy and form ulated hypotheses to explain the cause and nature of the con flict.
Formulation of hypotheses to explain sociopolitical conflict The first description of a fluoridation con flict appeared in 1953 w hen B um s12 pub lished a report on the w ater fluoridation c o n tro v e rsy in W illia m sto w n , M ass. Many other descriptive case histories fol lowed. The first system atic study of a fluoridation confrontation was the Mausn e r s ’13 a n a ly s is of an o p in io n p o ll taken in Northampton, Mass, during a fluo rid atio n referendum cam paign in 1955. A major finding of this research was that the strength of the antifluoridation position evolved from three major factors: antifluoridationist argum ents are simple and easy to follow (and their weaknesses are difficult for the layman to grasp); anti fluoridationist arguments are based on w idely held cultural mores—individual rig h ts, fear of the u n k n o w n , fear of poison, and fear of bodily harm (they strike responsive chords in m any people); and an tiflu o rid atio n ist argum ents are based on the tendency to perceive the w orld as menacing.
The alienation hypothesis
In 1958, through information gathered from interviews with 22 antifluoridation opinion leaders, Green14 concluded that “ . . . fluoridation has become an issue be cause it mirrors in miniature the ideolog ical uneasiness of those who feel them selves alienated from the direction of American society.” Simmel, who inter viewed voters (probability samples) in two cities in northeastern United States, reported that opposition to fluoridation was concentrated in groups that have a sense of economic, prestige, and political deprivation.15,16 At approximately the same time, Gamson undertook the study of a Cambridge, Mass, fluoridation re ferendum by analyzing voting records and interviewing 141 registered voters in one precinct on election day.15,16 From an examination of these voting records, he discovered that voters opposing fluorida tion were older, of lower socioeconomic standing, and scored high on measures of anomie and political ineffectiveness. He concluded that the lives of many who op posed fluoridation seemed to focus on a status deprivation, lack of attachments, powerlessness, and alienation.17 A socioeconomic differentiation of fluoridation referendum voting patterns appeared to support four major conclu sions: there was a higher percent of voter turnout in middle and higher income groups; high and middle income voters strongly favored fluoridation (80% and 66%, respectively); low er econom ic groups voted 65% against fluoridation; and despite a lower percent of voter turn out in the low economic group, their votes were decisive in determining the outcome because of their greater num bers.18 Further analysis of voting patterns seemed to characterize the antifluoridatio n is ts ac co rd in g to d em o g ra p h ic variables—they were older, without chil dren younger than 12 years, of lower in comes, of lower middle and lower class occupations, and had attained lower edu cation levels (many had not finished high school).13,19 23 Linn,24 in a study of the H astreiter : FLUORIDATION CONFLICT ■ 487
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1969 G reenw ich, Conn, and Berkeley, Calif, fluoridation referenda, continued to report that . . those who say they do not feel w ithin the mainstream of society te n d m ore th a n o th ers to be a g a in st fluoridation.” A description of the opera tio n of th is flu o rid a tio n co n tro v ersy A lienation Hypothesis was best given by Green:25 . . . the direction of change has accelerated tow ards an increasing density of im personal organizations, a rem oval of the sources of pow er from intim ate view, and a tow eringly c o m p le x s o c ia l o rd e r th a t m ay b e c o m prehended only in outline, if at all. . . .O pposi tion to fluoridation mirrors such a m o o d .. . . Fluoridation is tagged w ith a contem pt for in dividuality, and is emblematic of an ultim ate a im to s m o th e r p e r s o n a l id e n t it y in a hom ogenous mass. O pposition to fluoridation is an act of moral resistance.
In the latter part of the 1960s, however, other social scien tists p resen ted two major points of contention that cast doubt on the validity of the A lienation H ypoth esis. First, the survey data research sam ples from w hich Gamson developed the A lienation H ypothesis were sm all and probably biased and, second, there was the strong tendency of these social psy chologists to project the apparently alien ated attitudes of antifluoridationist lead ers to all people who voted against fluori dation.26 F orm ulated in the 1950s and early 1960s, during a period of fascination w ith the effect of alienation, anomie, and the mass society in the aftermath of Nazism and the strength of the Soviet Union, the A lienation Hypothesis seems at times to be a period-bound sim plification of a complex interactional process. And yet this explanation has merit beyond the in adequate data from w hich it was gener ated. I am proposing a reinterpretation of the A lienation Hypothesis to emphasize the explanation originally proposed by Green, w hich Gamson chose not to accen tuate. The m ajor c o n trib u tio n of the A lien atio n H ypothesis lies n o t in its analysis of voting behavior patterns (at tributing fluoridation defeats to a ground swell of alienated hum anity) but in an ex planation for the generation and m ainte nance of antifluoridationist leadership. Research has been lim ited, but em pirical observation of antifluoridation leaders suggests that they are individuals w ho are m arginal to the social, psychologic, polit ic a l, a n d p ro fe s s io n a l m a in s tre a m . A n t i f l u o r i d a t i o n i s t tr a c ts , b o o k s , speeches, and debates present a spectrum of id e a s ra n g in g from ru g g e d in d i vidualism to fanaticism, and whose one com m on elem ent is this alienation—a separation from contem porary social, political, and scientific thought. Further behavioral research is m ost surely in d i cated but, em pirically, the A lienation 488 ■ JADA, Vol. 106, A pril 1983
consequently fewer fluoridation adop tions. Conversely, community political power structures that limited citizen in volvement and emphasized administra tive initiative (fluoridation decisions by mayors, health officer, city councils or The com m unity p o w er structure boards of health, for example) had the op hypothesis posite effect.27 In response to the perceived deficiencies Smith’s28 study provides additional in of the A lie n a tio n H y p o th esis, and sights into the structural political, social, through the funding of the United States and economic variables that may have an Public Health Service (which was becom impact on fluoridation considerations. ing increasingly alarmed by the rise in His findings on the centralization of au fluoridation defeats), a team of social sci thority add further confirmation to the entists from the University of Chicago27 Community Power Structure Hypothesis. undertook a new study of the dynamics of However, his analysis of the effects of community complexity and social inte gration should be regarded as tentative until they are replicated in additional studies using community samples drawn from other areas of the United States. Hypothesis would appear to serve as a reasonable explanation, and as an exper imental framework within which to study the role of antifluoridationist leadership.
The confusion hypothesis
the fluoridation issue in 1968. Whereas the advocates of the Alienation Hypothe sis had only focused on voter reaction in fluoridation referenda, Crain and as sociates investigated the entire array of water fluoridation adoption procedures, because they realized that most cities that adopted fluoridation had done so by ad ministrative action rather than by public vote. By analyzing the number of com munity decision-making variables, they concluded that the form of the decision making process, as expressed in govern mental structure and political power, had a critical influence on the probability of successful fluoridation adoption. They presented a fluoridation controversy Community Power Structure Hypothesis as the explanation for the interplay of forces determining the outcome of fluori dation considerations. Their research in dicated that governmental structures and decision-making mechanisms that al lowed greater citizen participation in the formulation of public policy tended to produce more fluoridation referenda and
A lthough Crain and associates27 pro vided a structural framework explanation for fluoridation controversy, the Com munity Power Structure Hypothesis still failed to generate an explanation for the defeat of fluoridation at the polls. Social scientists were still perplexed by this consistent negative voter reaction to fluoridation. Unsatisfied with the Alien ation and Community Power Structure Hypotheses, they searched for clues to other explanations. Enlightening glimp ses into the American knowledge of and attitude toward fluoridation continued to be provided by public opinion research (Table). From opinion surveys such as those listed in the Table,29 and from sur veys conducted during fluoridation re ferenda, the complexity of the socio psychologic and political interactions in the fluoridation controversy becam e more apparent. “ Three facts appeared pertinent to for m ulating a hypothesis to account for negative voter response in fluoridation referenda. First, opinion polls consis tently showed a favorable public attitude toward fluoridation at the beginning of any referendum contest. But, in spite of this initial support, approximately 60% of fluoridation referenda were rejected. In addition, where fluoridation was eventu ally approved in a referendum, the mar gin of success was much narrower than the percentage of polling favorability with which it had begun the campaign. The second fact, pivotal to explaining voting behavior in fluoridation referenda, was that, on more careful examination of precinct voting records, a bicurvilinear pattern of voter support for fluoridation emerged. These more detailed and exten sive analyses discerned not a continuing increase of support for fluoridation with a rise in education, social status, and eco
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have to create questions about possible fluoridation risks, making it appear as National Opinion Research Center* though the fluoridation controversy is a Attitudes 1959 1965 1966 1968 1972 1977 dispute among conflicting health profes 51 Very desirable/desirable 65 72 71 77 70 sionals. The voter is thus confused. The 12 14 13 11 13 Very undesirable/undesirable 10 fluoridation referendum provides a reso Unconcerned/don’t know 17 39 23 15 15 12 lution for this confusion dilemma of the ‘ Percent of those w h o h ave heard o f fluoridation. cross-pressured voter—fluoridation can tP ercent of all persons surveyed. be postponed by the voter who is assured by the fact that further study and experi mentation should occur elsewhere.23,32 The Confusion Hypothesis also helped nomic class, but a three-stage differentia he knows he has picked up at the (office). He to explain the bicurvilinear voting pat tion based on age, education, and familial talks to a neighbor, who advances an unfamil terns seen in fluoridation referenda. It did com p ositio n . Referenda support for iar argument . . . (against) the proposal. (He) fluoridation was generated primarily cannot counter . . . (it and therefore). . . incor this by relating the level of education to porates the argument. The next time he h as. . . voting behavior. Precinct voting records from two segments of the voting popula contact with the issue he finds himself con indicated that people w ith a college edu tion: college-educated persons aged 21 to fused. He knows arguments on both sides.33 ■ cation and those with low educational 35 years who had children younger than The key variable in the traditional in competency were most likely to favor 12 years, and unskilled persons with little fluoridation, whereas voters of a midformal education. In contrast, much of the terpretation of this model, which deter educational level were more likely to be an tiflu orid ation support cam e from mines the voter's reaction to confusion, is fluoridation opponents. College-trained that the issue is not individually signifi white-collar workers aged 40 to 50, and persons are generally cognizant of scien from persons who had attained a medium cant, and it requires too much effort to re tific principles and methods, and aware level of education, usually high school concile and choose between opposing ar guments. As a consequence, the indi of new scientific developments. Voters of equivalency.30 the lowest educational levels are usually The third fact pertinent to developing a vidual decides not to vote. However, the most misinformed about science and cur hypothesis to explain voter response was Confusion Hypothesis is based on a mod rent events. The least educated individu ification in this key model variable. The the discernment of fluoridation campaign als therefore favored fluoridation because dynamics. During referenda contests, im m ed iacy and m e a n in g fu ln e ss of they were not aware of its controversial fluoridation to the voters changes the radical fluoridation opponents usually aspects and often mistook it for chlorina cited imaginary dangers such as loss of reaction to confusion, and not only do the tion. The college-educated persons gen voters not stay away from the polls, but freedom, Down’s Syndrome, heart dis erally favored fluoridation because they ease, and cancer in a never-ending bar they turn out in larger than expected either com prehended scientific argu numbers27 and vote against fluoridation. rage of accusation. As soon as one charge How does this confusion generate a no ments, or recognized legitimate scientific was disproved another was presented, ad authorities, and deferred to them. On the infinitum. Voters unfamiliar with com vote? Sapolsky postulated that this re other hand, voters with mid-educational plex epidem iologic statistic m ethods sulted from the confusion generated dur levels, the majority of voters in most re ing referendum campaigns when voters were unable to assess the claim s and ferenda, w ere su ffic ie n tly aw are of counterclaims. Many voters, therefore, are exposed to both profluoridation and fluoridation to perceive conflicting opin antifluoridation information. The typical were able to base their referendum deci ions, but were not knowledgeable enough sion only on the advice of the group that nature of the campaign sensitizes voters to rationally weigh the evidence them to the toxicologic problems associated was most successful in gaining their trust selves. They were also often unable to during the fluoridation campaign. As with massive fluoride dosages and to the re co g n ize le g itim a te sc ie n tific a u m y th ic a l d a n g e rs e n v is io n e d by early as 1955, opinion poll research con thorities. Confused by the fluoridation cluded that, “. . . a layman, not being antifluoridationists. In addition, there are debate through which they perceived a always a few health professionals who trained to evaluate (health) authorities, potential risk, the voters opted for the generally must commit an act of faith in express the antifluoridationist sentiment; status quo—a negative vote on fluorida and the general public is often unable to choosing among conflicting (fluorida tion.32 tion) points of view .”31 Subsequent re judge whether these health professional antifluoridationists are legitimate fluori search findings have continued to rein Conclusion force faith and trust as being fundamental dation experts or persons of marginal status in their professions w ith little to the acceptance of water fluoridation know ledge of factual epidem iologic A review of the fluoridation social sci proposals.31 ence literature indicates that few recent Using this information from opinion f l u o r i d a t i o n i n f o r m a t i o n . A ls o , attempts have been made to present this p o lls, voting records, and cam paign antifluoridationists often organize or re research as a holistic body of knowl dynamics, Sapolsky32 formulated the ceive (or both) the support of marginal edge.34,35 However, to profitably use this fluoridation controversy Confusion Hy p r o f e s s io n a l o r g a n iz a tio n s w ith information, it must be understood and pothesis as an explanation for fluorida im pressive-sounding names; and the applied from an integrated perspective tion referenda voting behavior. In my public has a difficult time distinguishing that can be presented through a concep opinion, the theoretical basis of the Con them from legitimate scientific groups. tual synthesis of the three major hypothe fusion Hypothesis is derived from the P rofluoridation and antiflu o rid atio n ses that have been discussed. political science behavioral model of the health professionals are perceived by the Within this context the Community public as scientists with validity. Con cross-pressured voter: sequently, voters do not have to accept P ow er S tru c tu re H y p o th esis is th e The individual circulates in two distinct social a n tiflu o rid a tio n ist arg u m en ts for a gatekeeper to the fluoridation conflict environments that are at cross-purposes with process. The traditional and current regard to the referendum issue. . . . Initially, he fluoridation referendum to be lost. (Only manner of community decision making doesn’t know much about the issue but has a 8% of the voters actually believe the defines the ground rules within which slight to moderate stand (for) the referendum charge that fluoridation poisons a public fluoridation is considered. The implica proposal. What very few negative arguments water supply.) Antifluoridationists only T able ■ Attitudes toward fluoridation.
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The failure to achieve universal w ater fluoridation is a demonstration of hum anity’s tenuous ability to apply the knowledge of proved, cost-effective disease prevention to everyone’s benefit. tions of this fact are clear because odds are against the success of a fluoridation referendum,27,36'39 whereas the chance for fluoridation adoption increases signifi cantly as the propensity for centralized decision-making is strengthened. Fluori dation proponents, therefore, must assess the community power structure and de velop plans to deal with its contingencies before initiating any attempt to imple ment fluoridation. The Alienation Hypothesis elucidates patterns of antifluoridationist leadership selection and action. With few excep tions, it would appear that antifluorida tionist leaders possess true believer40 p sy ch o lo g ic o rien ta tio n s. To them , fluoridation is not an issue to be decided on the basis of the weight of scientific inquiry. By behavioral inclination they are u n w a v e rin g ly co m m itted to an a n tiflu o rid a tio n is t id eology. T h eir perceptions of the world are selectively interpreted to reinforce this commit ment. This perceptual mechanism ac counts for their zealous dedication to the antifluoridation cause unfettered by the overw helm ing body of positive ep i dem iologic fluoridation data. Collec tively, this process results in the devel opment of a small cadre of antifluoridation crusaders who are ready to combat the villainy that fluoridation represents to them. The Confusion Hypothesis provides explanations for fluoridation public opin ion dynamics and voting behavior. The major operational conclusion is that the fluoridation referendum campaign is not a process involving the objective presen tation of information through which vot ers make a rational choice based on the weight of evidence. Rather, because most voters do not understand the nuances of epidemiologic analysis, political philos ophy, and legal precedent around which the fluoridation controversy revolves, the referendum becomes an emotional politi cal process through which the group that wins the faith and trust of the voting majority emerges the victor. Profluorida tion voter confidence can be engendered by displaying a comprehensive, in-depth command of the issues, and accentuating the positive aspects of fluoridation in an em pathetic, reassuring manner. Con versely, a fluoridation referendum debate should be avoided if possible as it usually focuses on negative fluoridation allega tions and raises the level of voter anxiety 490 ■ JADA, Vol. 106, April 1983
and distrust. Since 1953, 30 years of social science research in fluoridation has generated a w ealth of inform ation. But ad d itio n al w ork is still necessary. In-depth analyses of the generation, m aintenance, and ac tivities of the antifluoridationist leader ship are needed. In addition, investiga tions into the operation of the A lienation and Confusion Hypothesis in executive, legislative, and judicial fluoridation de cision making should be of crucial inter est. But regardless of the area investi gated, the major error of the past m ust be elim in a te d . F lu o rid a tio n c o n flic t r e search, rather than being pursued from a single perceptual framework, m u st be analyzed from a m ultidim ensional per spective. Only by using a broad spectrum of behavioral social science analyses can the complex process of fluoridation con flict be conceptualized and ameliorated.
__________________________ Dr. Hastreiter is deputy chief, section of environ m ental and chronic disease epidem iology, depart m ent of health and social services, D ivision of Health, 1 W W ilson St, Box 309, M adison, Wis, 53701. A d dress requests for reprints to Dr. Hastreiter. 1. McKay, F.S. Fluorine and m ottled enamel. In Gies, W.J., ed. Fluorine in dental public health. New York, NY Institute of Clinical Oral Pathology, 1945, pp 10-17. 2. Dean, H.T. On the epidemiology of fluorine and dental caries. In Gies, W.J., ed. Fluorine in dental pub lic health. New York, NY Institute of Clinical Oral Pathology, 1945, pp 19-30. 3. McNeil, D.R., The fight for fluoridation. New York, Oxford University Press, 1957, p p 3-43,85-107. 4. McClure, F.J. Water fluoridation: the search and the victory. US Departm ent of Health, Education, and Welfare, National Institutes of Health. Bethesda, Md, US Government Printing Office, 1970, pp 7-29, 57108. 5. Galagan, D.J., and Lamson, G.G. Climate and en dem ic fluorosis. Public Health Rep 68:497-508,1953. 6. Galagan, D.J., and others. Climate and fluid in take. Public Health Rep 72:484-490,1957. 7. Galagan, D.J., and Vermillion, J.R. Determ ining optim um fluid concentrations. Public Health Rep 72:491-493,109-111,117,1957. 8. Jacobson vs M assachusetts, 197 US 11, 25 (1905). 9. DeAryan vs Butler, 119 Cal A pp 2d 674,260 P2d 98(1953), cert denied, 347 US 1012 (1954). 10. Chapman vs City of Shreveport, 225 La 859, 74 So 2d 142,146 (1954), app dism d, 348 US 892 (1954). 11. Schuringa vs City of Chicago, 30 111 2d 504,198 NE2d 326 (1964), cert denied, 379 US 964 (1965). 12. Bums, J.M. The crazy politics of fluorine. New Republic 128:14-15,1953. 13. M ausner, B., and M ausner, J. A study of the anti-scientific attitude. Scientific Am erican 192:3539,1955. 14. Green, A.L. The ideology of anti-fluoridation partisans. Social Science Program, Harvard School of
Public Health, 17(4):2, 3, docum ent 11-A, (1961). 15. Sim m el, A.G. A sig n p o st for resea rch on fluoridation conflicts: the concept of relative depriva tion. J Social Issues 17(4):26-36,1961. 16. Gamson, W.A. The fluoridation dialogue: is it s idealogical conflict? Public O pinion Q 25:533, 534, 527, 528, 1961. 17. Gamson, W.A. Social science aspects of fluori dation: a supplement. H ealth Ed J 24:136,1965. 18. MacRae, P.; Castaldi, C.R.; and Zacherl, W. Dental H ealth socio-economic level, interest response to polio vaccination program and voting in a fluorida tion plebiscite. J Dent Res 43(suppl):899,1964. 19. Green, A.L., and Briggs, J. Fluoridation in Mas sachusetts: a statistical com parison of com m unities. Working Document 8, Social Science Program, Har vard School of Public Health, 1957. 20. Helson, R.M., and M atthews, D.R. The North am pton fluoridation referendum : a case study of local politics and voting behavior. Sm ith College, 1959. 21. Plant, T.F. Analysis of voting behavior on a fluoridation referendum. Public O pinion Q 23:213233,1959. 22. Taylor, G.F.; M uzro, M.S.; and Fuqua, J.B. Fluoridation study in a California com m unity. Politi cal Science Department, Stanford University, 1956. 23. Silverstein, S.J.; Wycoff, S.J.; and Newbrun, E. Sociological, economical, and legal aspects of fluori dation. In Newbrun, E., ed. Fluorides and dental caries. Springfield, 111, Charles C Thomas, 1975, pp 82, 85-86. 24. Linn, E.L. An appraisal of sociological research on the public’s attitudes toward fluoridation. J Pub Health Dent 29:44,1969. 25. Green, A.L. The ideology of anti-fluoridation leaders. J Social Issues 17(4):25,1961. 26. Sapolsky, H.M. Science, voters and the fluori dation controversy. Science 162:430-431,1968. 27. Crain, R.L.; Katz, E.; and Rosthal, D.B. The poli tics of com m unity conflict: the fluoridation decision. Indianapolis, Bobbs-Merrill Co, 1969, pp v, vi, xii, 75, 235, 91-121, 227, 228. 28. Smith, R.A. Comm unity structural characteris tics and the adaption of fluoridation. Am J Pub H ealth 71:24-30, 1981. 29. Schwab, R.J. A n analysis of attitudes tow ard fluoridation: 1972. 101st A nnual M eeting of Am eri can Public Health Association, Dental Health Section, San Francisco, 1973. 30. Kegeles, S.S. Contributions of the social sci ences to fluoridation. JADA 65(5):667-672,1962. 31. Linn, E.L. Effect of com m unity leaders an d or ganizations on public attitudes tow ard fluoridation. J Pub Health Dent 29:108-117,1969. . 32. Sapolsky, H.M. The fluoridation controversy: a n a lte rn a tiv e e x p la n a tio n . P u b lic O p in io n Q 33:244-248,1969. 33. Abelson, R.P., and Berstein, A. A com puter sim ulation m odel of com m unity referendum con troversies. Public O pinion Q 27:114-115,1963. 34. Motz, A.B. The fluoridation issue as studied by social scientists. In Richard, N.D., and Cohen, L.K., eds. Social science and dentistry: a critical bibliogra phy. The Hague, A. Sijthoff, 1977, p p 347-364. 35. Frazier, P.J. A review of social research. J Pub Health Dent 40(3):214-233,1980. 36. Rosenstein, D.I., and Pickles, T. Fighting the latest challenge to fluoridation in Oregon. Public H ealth Rep 93(l):69-72,1978. 37. Dwore, R.B. A case of the 1976 referendum in Utah on fluoridation. Public H ealth Rep 93(l):73-78, 1978. 38. Evans, C.A., and Pickles, T. Statewide antiflu oridation initiatives: a new challenge to health work ers. Am J Pub Health 68(l):59-62,1978. 39. Isman, R. Fluoridation: strategies for success. Am J Pub Health 71(7):717-720,1981. 40. Hoffer, E. The true believer; thoughts on th e na ture of m ass movements. New York, Harper, 1964.
A
Fluoridation conflict: a history and conceptual synthesis Richard J. Hastreiter, DDS, MPH
A fram ew ork of literatu re re v ie w and analysis is presen ted to discuss the history and controversy of community w a ter fluoridation.
T
A he developm ent of com m unity water fluoridation as a public health m easure is an event w ith few p arallels in eith er dental-m edical or sociopolitical history. From a dental science perspective, the in vestigative history of w ater fluoridation is one of em pirical observation, reasoning, and research that exem plifies the scien tific m ethod. However, as a lesson in sociopolitical interaction, the failure to achieve universal w ater fluoridation is a dem o n stratio n of h u m a n ity ’s ten u o u s ability to apply the know ledge of proved, cost-effective disease prevention to ev eryone’s benefit.
The historical epidem iology of fluoridation The events culm inating in the im plem en tation of w ater fluoridation as a public h e a lth m easure began in th e w estern United States during the first decade of the 20th century. In 1908, at the annual m eeting of the Colorado Dental Associa tion, McKay presented his investigation of a “brow n sta in ” tooth enam el “ at rophy” that occurred in over 80% of the native inhabitants of Colorado Springs. His investigations determ ined that the only difference betw een th e C olorado Springs population and that of the nearest im m une area was that Colorado Springs received its w ater supply from the Pikes Peak w atershed. Other populations in the U nited States and Europe w ith this dys tr o p h ic m o ttle d e n a m e l w e re a lso studied. The condition affected only na tive inhabitants, and the only teeth not m ottled w ere those that had calcified be 486 ■ JADA, Vol. 106, A pril 1983
fore the person came to live in the area.1'4 In 1928, the US Public Health Service (U SPH S) c o m m issio n e d M cK ay a n d Kempf (USPHS epidemiologist) to survey conditions at Bauxite, Ark. Their findings a g ain p o in te d to the d rin k in g w ater source as a common cause, but standard w ater analyses did n o t determ ine the c a u sa l ag en t. H ow ever, in 1930 th e ALCOA laboratories in New Kensington, Pa, w ith instructions to look for rare ele m e n ts , p e rfo rm e d a s p e c tro g r a p h ic analysis of w ater obtained from deep wells at Bauxite. This more definitive test show ed that a fluoride ion concentration of 13.7 p a rts p er m illio n (ppm ) w as p re se n t in the B auxite w ater su p p ly . Analyses were then performed in other areas w h e re m o ttled enam el (d e n ta l fluorosis) was endemic. A positive corre lation was found between the ppm of flu oride in the w ater supply and the degree of endem ic fluorosis in the dentition of native inhabitants.1'4 In addition to fluorosis, it was gradu ally recognized that a high w ater fluoride content was also associated w ith a lower prevalence of dental caries. From 1931 to 1942, epidem iologic studies were con ducted to determ ine the relationship be tw een the water fluoride concentration, dental fluorosis, and dental caries. These investigations culm inated in a two-year dental survey of 7,000 schoolchildren in 21 US cities that was conducted by Dean2 and his associates. In 1942, their report concluded that the optimum w ater fluo ride content that maximized caries resis tan ce w ith a m inim um of u n e sth e tic fluorosis was 1 ppm of fluoride to w ater (1
mg of fluoride per liter of w ater).1'4 By b u ild in g on D ean’s work, su b seq u en t studies by Galagan and others dem on strated that the optim um fluoride concen tration is dependent on the annual aver age m axim um daily air tem perature and varies from 0.7 to 1.2 ppm in the continental U nited States.5'7 As a result of this and sim ilar research, it was postulated th at the adjustm ent of fluoride deficient public w ater supplies to the optim um fluoride level could become one of those unique examples of prim ary prevention that could be m ade available at low cost, w ith little inconvenience, and w ithout hazard to health. Between 1944 and 1947, research studies began in eight cities in the United States and Canada that ad justed local w ater supplies from subop tim um to optim um fluoride concentra tions. Data from these cities dem onstrated that caries prevalence decreased by as m uch as 65% in individuals consum ing optim ally fluoridated w ater from birth.3,7 These positive findings resulted in the expansive im plem entation of com m unity w ater fluoridation during the late 1940s and 1950s. However, in the 1960s and 1970s, although increm ents of the US p o p u latio n w ere still being ad ded to those d rinking flu o rid ated w ater, the adoption of fluoridation by new com m unities slowed considerably. In 1982, the US Centers for Disease Control esti m ated that approxim ately 123 m illion people (67% of those p erso n s in th e United States with public water supplies) had access to fluoridated water w ith fluoride ion concentrations betw een 0.7 to 1.2 ppm . These data indicate that, because of technical, econom ic, or sociopolitical constraints, many people are still not re ceiving the dental caries prevention bene fits of fluoridated water. Of these constraints to fluoridation, the sociopolitical factors have consistently been the most resistant to change.
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The traditional and current m anner of community decision m aking defines the ground rules within which fluoridation is considered.
The sociopolitical fluoridation controversy The origins of the sociopolitical conroversy surrounding com m unity water :lu o rid atio n in th e U n ited States are raceable to a small city in central W is consin. In 1945, the W isconsin Dental As sociation and the W isconsin Board of health passed resolutions encouraging water fluoridation. A favorable report on :he caries reduction effects of fluoridation .n Sheboygan, Wis, w hich h ad fluoriiated in 1946, was announced in 1948. As i result of the persistent drive of four prom inent W isconsin dentists, a large proportion of the urban population of i/Visconsin w as liv in g in flu o rid a te d com m unities by 1949. However, orga nized vociferous opposition to fluoridaiion soon appeared. The first large-scale Fluoridation referendum confrontation and defeat occurred in Stevens Point, Wis, in September 1950. This type of ac rimonious political debate became typi cal of w hat was to develop in other W is consin com m unities an d th e n spread throughout the U nited States.3 The three major objections to fluorida tion that were first effectively articulated in Stevens Point and that persist to this day are: first, that fluoridation is ineffec tive in reducing dental caries; second, that fluoridation is basically harm ful to the hum an system; and third, that fluori dation, applied as a public health m ea sure, deprives individuals of free choice by forcing them to accept m edication against their will. The allegations that fluoridation is ineffective and detrim en tal to hum an health have been refuted rep e a te d ly by p r o p e r ly d e s ig n e d epidemiologic studies that use accepted analytical, statistical m ethods, and that are conducted among populations con sum ing both naturally and artificially fluoridated water. The contention that fluoridation is an abridgem ent of the rights of the individual is an exam ple of the age-old societal tension betw een the common good and personal liberty. Deci sions of the US Suprem e Court and state
s u p re m e c o u r ts (Ja c o b se n vs M as sachusetts, 1905,8 De Aryan vs Butler, 1952,9 Chapman vs Shreveport, 1954,10 and Schuringa vs City of Chicago, 196411) have upheld and reiterated the right of the majority to promote the general welfare through disease control programs. A lth o u g h re se a rc h h a s re p e a te d ly d e m o n s tr a te d , a n d m o st c o n s u m e r groups and virtually all national and in ternational health organizations recog nize fluoridation’s effectiveness, safety, and cost benefit, the small groups oppos ing fluoridation have often succeeded in thw arting its im plem entation. How can an antifluoridation movement, w hich has never been very large, produce such con troversy and negative results against such overwhelm ing evidence? Public health o ffic ia ls a n d so c ia l s c ie n tis ts have studied the dynamics of the fluoridation controversy and form ulated hypotheses to explain the cause and nature of the con flict.
Formulation of hypotheses to explain sociopolitical conflict The first description of a fluoridation con flict appeared in 1953 w hen B um s12 pub lished a report on the w ater fluoridation c o n tro v e rsy in W illia m sto w n , M ass. Many other descriptive case histories fol lowed. The first system atic study of a fluoridation confrontation was the Mausn e r s ’13 a n a ly s is of an o p in io n p o ll taken in Northampton, Mass, during a fluo rid atio n referendum cam paign in 1955. A major finding of this research was that the strength of the antifluoridation position evolved from three major factors: antifluoridationist argum ents are simple and easy to follow (and their weaknesses are difficult for the layman to grasp); anti fluoridationist arguments are based on w idely held cultural mores—individual rig h ts, fear of the u n k n o w n , fear of poison, and fear of bodily harm (they strike responsive chords in m any people); and an tiflu o rid atio n ist argum ents are based on the tendency to perceive the w orld as menacing.
The alienation hypothesis
In 1958, through information gathered from interviews with 22 antifluoridation opinion leaders, Green14 concluded that “ . . . fluoridation has become an issue be cause it mirrors in miniature the ideolog ical uneasiness of those who feel them selves alienated from the direction of American society.” Simmel, who inter viewed voters (probability samples) in two cities in northeastern United States, reported that opposition to fluoridation was concentrated in groups that have a sense of economic, prestige, and political deprivation.15,16 At approximately the same time, Gamson undertook the study of a Cambridge, Mass, fluoridation re ferendum by analyzing voting records and interviewing 141 registered voters in one precinct on election day.15,16 From an examination of these voting records, he discovered that voters opposing fluorida tion were older, of lower socioeconomic standing, and scored high on measures of anomie and political ineffectiveness. He concluded that the lives of many who op posed fluoridation seemed to focus on a status deprivation, lack of attachments, powerlessness, and alienation.17 A socioeconomic differentiation of fluoridation referendum voting patterns appeared to support four major conclu sions: there was a higher percent of voter turnout in middle and higher income groups; high and middle income voters strongly favored fluoridation (80% and 66%, respectively); low er econom ic groups voted 65% against fluoridation; and despite a lower percent of voter turn out in the low economic group, their votes were decisive in determining the outcome because of their greater num bers.18 Further analysis of voting patterns seemed to characterize the antifluoridatio n is ts ac co rd in g to d em o g ra p h ic variables—they were older, without chil dren younger than 12 years, of lower in comes, of lower middle and lower class occupations, and had attained lower edu cation levels (many had not finished high school).13,19 23 Linn,24 in a study of the H astreiter : FLUORIDATION CONFLICT ■ 487
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1969 G reenw ich, Conn, and Berkeley, Calif, fluoridation referenda, continued to report that . . those who say they do not feel w ithin the mainstream of society te n d m ore th a n o th ers to be a g a in st fluoridation.” A description of the opera tio n of th is flu o rid a tio n co n tro v ersy A lienation Hypothesis was best given by Green:25 . . . the direction of change has accelerated tow ards an increasing density of im personal organizations, a rem oval of the sources of pow er from intim ate view, and a tow eringly c o m p le x s o c ia l o rd e r th a t m ay b e c o m prehended only in outline, if at all. . . .O pposi tion to fluoridation mirrors such a m o o d .. . . Fluoridation is tagged w ith a contem pt for in dividuality, and is emblematic of an ultim ate a im to s m o th e r p e r s o n a l id e n t it y in a hom ogenous mass. O pposition to fluoridation is an act of moral resistance.
In the latter part of the 1960s, however, other social scien tists p resen ted two major points of contention that cast doubt on the validity of the A lienation H ypoth esis. First, the survey data research sam ples from w hich Gamson developed the A lienation H ypothesis were sm all and probably biased and, second, there was the strong tendency of these social psy chologists to project the apparently alien ated attitudes of antifluoridationist lead ers to all people who voted against fluori dation.26 F orm ulated in the 1950s and early 1960s, during a period of fascination w ith the effect of alienation, anomie, and the mass society in the aftermath of Nazism and the strength of the Soviet Union, the A lienation Hypothesis seems at times to be a period-bound sim plification of a complex interactional process. And yet this explanation has merit beyond the in adequate data from w hich it was gener ated. I am proposing a reinterpretation of the A lienation Hypothesis to emphasize the explanation originally proposed by Green, w hich Gamson chose not to accen tuate. The m ajor c o n trib u tio n of the A lien atio n H ypothesis lies n o t in its analysis of voting behavior patterns (at tributing fluoridation defeats to a ground swell of alienated hum anity) but in an ex planation for the generation and m ainte nance of antifluoridationist leadership. Research has been lim ited, but em pirical observation of antifluoridation leaders suggests that they are individuals w ho are m arginal to the social, psychologic, polit ic a l, a n d p ro fe s s io n a l m a in s tre a m . A n t i f l u o r i d a t i o n i s t tr a c ts , b o o k s , speeches, and debates present a spectrum of id e a s ra n g in g from ru g g e d in d i vidualism to fanaticism, and whose one com m on elem ent is this alienation—a separation from contem porary social, political, and scientific thought. Further behavioral research is m ost surely in d i cated but, em pirically, the A lienation 488 ■ JADA, Vol. 106, A pril 1983
consequently fewer fluoridation adop tions. Conversely, community political power structures that limited citizen in volvement and emphasized administra tive initiative (fluoridation decisions by mayors, health officer, city councils or The com m unity p o w er structure boards of health, for example) had the op hypothesis posite effect.27 In response to the perceived deficiencies Smith’s28 study provides additional in of the A lie n a tio n H y p o th esis, and sights into the structural political, social, through the funding of the United States and economic variables that may have an Public Health Service (which was becom impact on fluoridation considerations. ing increasingly alarmed by the rise in His findings on the centralization of au fluoridation defeats), a team of social sci thority add further confirmation to the entists from the University of Chicago27 Community Power Structure Hypothesis. undertook a new study of the dynamics of However, his analysis of the effects of community complexity and social inte gration should be regarded as tentative until they are replicated in additional studies using community samples drawn from other areas of the United States. Hypothesis would appear to serve as a reasonable explanation, and as an exper imental framework within which to study the role of antifluoridationist leadership.
The confusion hypothesis
the fluoridation issue in 1968. Whereas the advocates of the Alienation Hypothe sis had only focused on voter reaction in fluoridation referenda, Crain and as sociates investigated the entire array of water fluoridation adoption procedures, because they realized that most cities that adopted fluoridation had done so by ad ministrative action rather than by public vote. By analyzing the number of com munity decision-making variables, they concluded that the form of the decision making process, as expressed in govern mental structure and political power, had a critical influence on the probability of successful fluoridation adoption. They presented a fluoridation controversy Community Power Structure Hypothesis as the explanation for the interplay of forces determining the outcome of fluori dation considerations. Their research in dicated that governmental structures and decision-making mechanisms that al lowed greater citizen participation in the formulation of public policy tended to produce more fluoridation referenda and
A lthough Crain and associates27 pro vided a structural framework explanation for fluoridation controversy, the Com munity Power Structure Hypothesis still failed to generate an explanation for the defeat of fluoridation at the polls. Social scientists were still perplexed by this consistent negative voter reaction to fluoridation. Unsatisfied with the Alien ation and Community Power Structure Hypotheses, they searched for clues to other explanations. Enlightening glimp ses into the American knowledge of and attitude toward fluoridation continued to be provided by public opinion research (Table). From opinion surveys such as those listed in the Table,29 and from sur veys conducted during fluoridation re ferenda, the complexity of the socio psychologic and political interactions in the fluoridation controversy becam e more apparent. “ Three facts appeared pertinent to for m ulating a hypothesis to account for negative voter response in fluoridation referenda. First, opinion polls consis tently showed a favorable public attitude toward fluoridation at the beginning of any referendum contest. But, in spite of this initial support, approximately 60% of fluoridation referenda were rejected. In addition, where fluoridation was eventu ally approved in a referendum, the mar gin of success was much narrower than the percentage of polling favorability with which it had begun the campaign. The second fact, pivotal to explaining voting behavior in fluoridation referenda, was that, on more careful examination of precinct voting records, a bicurvilinear pattern of voter support for fluoridation emerged. These more detailed and exten sive analyses discerned not a continuing increase of support for fluoridation with a rise in education, social status, and eco
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have to create questions about possible fluoridation risks, making it appear as National Opinion Research Center* though the fluoridation controversy is a Attitudes 1959 1965 1966 1968 1972 1977 dispute among conflicting health profes 51 Very desirable/desirable 65 72 71 77 70 sionals. The voter is thus confused. The 12 14 13 11 13 Very undesirable/undesirable 10 fluoridation referendum provides a reso Unconcerned/don’t know 17 39 23 15 15 12 lution for this confusion dilemma of the ‘ Percent of those w h o h ave heard o f fluoridation. cross-pressured voter—fluoridation can tP ercent of all persons surveyed. be postponed by the voter who is assured by the fact that further study and experi mentation should occur elsewhere.23,32 The Confusion Hypothesis also helped nomic class, but a three-stage differentia he knows he has picked up at the (office). He to explain the bicurvilinear voting pat tion based on age, education, and familial talks to a neighbor, who advances an unfamil terns seen in fluoridation referenda. It did com p ositio n . Referenda support for iar argument . . . (against) the proposal. (He) fluoridation was generated primarily cannot counter . . . (it and therefore). . . incor this by relating the level of education to porates the argument. The next time he h as. . . voting behavior. Precinct voting records from two segments of the voting popula contact with the issue he finds himself con indicated that people w ith a college edu tion: college-educated persons aged 21 to fused. He knows arguments on both sides.33 ■ cation and those with low educational 35 years who had children younger than The key variable in the traditional in competency were most likely to favor 12 years, and unskilled persons with little fluoridation, whereas voters of a midformal education. In contrast, much of the terpretation of this model, which deter educational level were more likely to be an tiflu orid ation support cam e from mines the voter's reaction to confusion, is fluoridation opponents. College-trained that the issue is not individually signifi white-collar workers aged 40 to 50, and persons are generally cognizant of scien from persons who had attained a medium cant, and it requires too much effort to re tific principles and methods, and aware level of education, usually high school concile and choose between opposing ar guments. As a consequence, the indi of new scientific developments. Voters of equivalency.30 the lowest educational levels are usually The third fact pertinent to developing a vidual decides not to vote. However, the most misinformed about science and cur hypothesis to explain voter response was Confusion Hypothesis is based on a mod rent events. The least educated individu ification in this key model variable. The the discernment of fluoridation campaign als therefore favored fluoridation because dynamics. During referenda contests, im m ed iacy and m e a n in g fu ln e ss of they were not aware of its controversial fluoridation to the voters changes the radical fluoridation opponents usually aspects and often mistook it for chlorina cited imaginary dangers such as loss of reaction to confusion, and not only do the tion. The college-educated persons gen voters not stay away from the polls, but freedom, Down’s Syndrome, heart dis erally favored fluoridation because they ease, and cancer in a never-ending bar they turn out in larger than expected either com prehended scientific argu numbers27 and vote against fluoridation. rage of accusation. As soon as one charge How does this confusion generate a no ments, or recognized legitimate scientific was disproved another was presented, ad authorities, and deferred to them. On the infinitum. Voters unfamiliar with com vote? Sapolsky postulated that this re other hand, voters with mid-educational plex epidem iologic statistic m ethods sulted from the confusion generated dur levels, the majority of voters in most re ing referendum campaigns when voters were unable to assess the claim s and ferenda, w ere su ffic ie n tly aw are of counterclaims. Many voters, therefore, are exposed to both profluoridation and fluoridation to perceive conflicting opin antifluoridation information. The typical were able to base their referendum deci ions, but were not knowledgeable enough sion only on the advice of the group that nature of the campaign sensitizes voters to rationally weigh the evidence them to the toxicologic problems associated was most successful in gaining their trust selves. They were also often unable to during the fluoridation campaign. As with massive fluoride dosages and to the re co g n ize le g itim a te sc ie n tific a u m y th ic a l d a n g e rs e n v is io n e d by early as 1955, opinion poll research con thorities. Confused by the fluoridation cluded that, “. . . a layman, not being antifluoridationists. In addition, there are debate through which they perceived a always a few health professionals who trained to evaluate (health) authorities, potential risk, the voters opted for the generally must commit an act of faith in express the antifluoridationist sentiment; status quo—a negative vote on fluorida and the general public is often unable to choosing among conflicting (fluorida tion.32 tion) points of view .”31 Subsequent re judge whether these health professional antifluoridationists are legitimate fluori search findings have continued to rein Conclusion force faith and trust as being fundamental dation experts or persons of marginal status in their professions w ith little to the acceptance of water fluoridation know ledge of factual epidem iologic A review of the fluoridation social sci proposals.31 ence literature indicates that few recent Using this information from opinion f l u o r i d a t i o n i n f o r m a t i o n . A ls o , attempts have been made to present this p o lls, voting records, and cam paign antifluoridationists often organize or re research as a holistic body of knowl dynamics, Sapolsky32 formulated the ceive (or both) the support of marginal edge.34,35 However, to profitably use this fluoridation controversy Confusion Hy p r o f e s s io n a l o r g a n iz a tio n s w ith information, it must be understood and pothesis as an explanation for fluorida im pressive-sounding names; and the applied from an integrated perspective tion referenda voting behavior. In my public has a difficult time distinguishing that can be presented through a concep opinion, the theoretical basis of the Con them from legitimate scientific groups. tual synthesis of the three major hypothe fusion Hypothesis is derived from the P rofluoridation and antiflu o rid atio n ses that have been discussed. political science behavioral model of the health professionals are perceived by the Within this context the Community public as scientists with validity. Con cross-pressured voter: sequently, voters do not have to accept P ow er S tru c tu re H y p o th esis is th e The individual circulates in two distinct social a n tiflu o rid a tio n ist arg u m en ts for a gatekeeper to the fluoridation conflict environments that are at cross-purposes with process. The traditional and current regard to the referendum issue. . . . Initially, he fluoridation referendum to be lost. (Only manner of community decision making doesn’t know much about the issue but has a 8% of the voters actually believe the defines the ground rules within which slight to moderate stand (for) the referendum charge that fluoridation poisons a public fluoridation is considered. The implica proposal. What very few negative arguments water supply.) Antifluoridationists only T able ■ Attitudes toward fluoridation.
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Hastreiter : FLUORIDATION CONFLICT ■ 489
REVIEW ARTICLE
The failure to achieve universal w ater fluoridation is a demonstration of hum anity’s tenuous ability to apply the knowledge of proved, cost-effective disease prevention to everyone’s benefit. tions of this fact are clear because odds are against the success of a fluoridation referendum,27,36'39 whereas the chance for fluoridation adoption increases signifi cantly as the propensity for centralized decision-making is strengthened. Fluori dation proponents, therefore, must assess the community power structure and de velop plans to deal with its contingencies before initiating any attempt to imple ment fluoridation. The Alienation Hypothesis elucidates patterns of antifluoridationist leadership selection and action. With few excep tions, it would appear that antifluorida tionist leaders possess true believer40 p sy ch o lo g ic o rien ta tio n s. To them , fluoridation is not an issue to be decided on the basis of the weight of scientific inquiry. By behavioral inclination they are u n w a v e rin g ly co m m itted to an a n tiflu o rid a tio n is t id eology. T h eir perceptions of the world are selectively interpreted to reinforce this commit ment. This perceptual mechanism ac counts for their zealous dedication to the antifluoridation cause unfettered by the overw helm ing body of positive ep i dem iologic fluoridation data. Collec tively, this process results in the devel opment of a small cadre of antifluoridation crusaders who are ready to combat the villainy that fluoridation represents to them. The Confusion Hypothesis provides explanations for fluoridation public opin ion dynamics and voting behavior. The major operational conclusion is that the fluoridation referendum campaign is not a process involving the objective presen tation of information through which vot ers make a rational choice based on the weight of evidence. Rather, because most voters do not understand the nuances of epidemiologic analysis, political philos ophy, and legal precedent around which the fluoridation controversy revolves, the referendum becomes an emotional politi cal process through which the group that wins the faith and trust of the voting majority emerges the victor. Profluorida tion voter confidence can be engendered by displaying a comprehensive, in-depth command of the issues, and accentuating the positive aspects of fluoridation in an em pathetic, reassuring manner. Con versely, a fluoridation referendum debate should be avoided if possible as it usually focuses on negative fluoridation allega tions and raises the level of voter anxiety 490 ■ JADA, Vol. 106, April 1983
and distrust. Since 1953, 30 years of social science research in fluoridation has generated a w ealth of inform ation. But ad d itio n al w ork is still necessary. In-depth analyses of the generation, m aintenance, and ac tivities of the antifluoridationist leader ship are needed. In addition, investiga tions into the operation of the A lienation and Confusion Hypothesis in executive, legislative, and judicial fluoridation de cision making should be of crucial inter est. But regardless of the area investi gated, the major error of the past m ust be elim in a te d . F lu o rid a tio n c o n flic t r e search, rather than being pursued from a single perceptual framework, m u st be analyzed from a m ultidim ensional per spective. Only by using a broad spectrum of behavioral social science analyses can the complex process of fluoridation con flict be conceptualized and ameliorated.
__________________________ Dr. Hastreiter is deputy chief, section of environ m ental and chronic disease epidem iology, depart m ent of health and social services, D ivision of Health, 1 W W ilson St, Box 309, M adison, Wis, 53701. A d dress requests for reprints to Dr. Hastreiter. 1. McKay, F.S. Fluorine and m ottled enamel. In Gies, W.J., ed. Fluorine in dental public health. New York, NY Institute of Clinical Oral Pathology, 1945, pp 10-17. 2. Dean, H.T. On the epidemiology of fluorine and dental caries. In Gies, W.J., ed. Fluorine in dental pub lic health. New York, NY Institute of Clinical Oral Pathology, 1945, pp 19-30. 3. McNeil, D.R., The fight for fluoridation. New York, Oxford University Press, 1957, p p 3-43,85-107. 4. McClure, F.J. Water fluoridation: the search and the victory. US Departm ent of Health, Education, and Welfare, National Institutes of Health. Bethesda, Md, US Government Printing Office, 1970, pp 7-29, 57108. 5. Galagan, D.J., and Lamson, G.G. Climate and en dem ic fluorosis. Public Health Rep 68:497-508,1953. 6. Galagan, D.J., and others. Climate and fluid in take. Public Health Rep 72:484-490,1957. 7. Galagan, D.J., and Vermillion, J.R. Determ ining optim um fluid concentrations. Public Health Rep 72:491-493,109-111,117,1957. 8. Jacobson vs M assachusetts, 197 US 11, 25 (1905). 9. DeAryan vs Butler, 119 Cal A pp 2d 674,260 P2d 98(1953), cert denied, 347 US 1012 (1954). 10. Chapman vs City of Shreveport, 225 La 859, 74 So 2d 142,146 (1954), app dism d, 348 US 892 (1954). 11. Schuringa vs City of Chicago, 30 111 2d 504,198 NE2d 326 (1964), cert denied, 379 US 964 (1965). 12. Bums, J.M. The crazy politics of fluorine. New Republic 128:14-15,1953. 13. M ausner, B., and M ausner, J. A study of the anti-scientific attitude. Scientific Am erican 192:3539,1955. 14. Green, A.L. The ideology of anti-fluoridation partisans. Social Science Program, Harvard School of
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