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Ohio—A Model Fluoridation Campaign for State or Community
REPORTS OF COUNCILS AND BUREAUS Ohio-a model fluoridation campaign for state or community Council on Dental Health Council on Legislation
departm ent, was rejected by a legislative review com m ittee, and was subm itted instead to the legis lature. T he law has w ithstood legislative and legal threats.
F luoridation decision-m aking is m oving from the local to the state level. This requires intensifying the education and coordinating the support which are necessary in any fluoridation cam paign; but the focus of the educational effort is narrow ed to a small audience, the legislators, and the m ajor su p p o rt is m ustered from state level agencies. O f the seven states which have enacted fluori dation laws so far, O hio m ounted one o f the m ost com prehensive cam paigns to follow the long and im pressive effort that resulted in the precedentsetting first law in C onnecticut. O hio’s exam ple can b e follow ed a t th e state or the local level.
■ M innesota: E nacted in 1967, this law required fluoridation o f all m unicipal w ater supplies by Jan 1, 1970. As o f Jan 22, 1970, 306 com m unities were fluoridated, 204 had plans approved, and about 130 small com m unities (with a total popu lation o f 72,000) had taken no action. A bout 85% o f the state’s population had fluoridation when the law was enacted.
First flu o rid a tio n laws
■ Illinois: A 1966 law applying to all w ater su p plies had two 1968 deadlines. A n estim ated 1,400 w ater systems were affected, although almost 80 % of the state’s population already had con trolled or natural fluoridation. Full im plem enta tion o f the law has been delayed because o f the num ber o f w ater systems and the sm all size o f many. Legal action to block the law failed.
T hese are the precedents for the 1969 O hio law. ■ Connecticut: T h e first fluoridation law enact ed in 1965 has been fully im plem ented for all cities w ith populations exceeding 20,000. T he ac tion was in itiated as a regulation of the state health
A conference on fluoridation in Ohio Governor James A. Rhodes' office brought together (left to right) Al bert Sabin, MD; George P. Schultz, Secretary of Labor; Richard K. Mosbaugh, DDS; Governor Rhodes.
814
■ Delaware: In 1968, D elaw are enacted a law authorizing the state board o f health to order fluo ridation. Because some city councils protested that the law was perm issive rather than m andatory, a ruling upholding the requirem ent was obtained
from the attorney general. The original deadline for action was m oved from 1970 to 1973. D ela w are has very little fluoridation experience: only 5 o f the state’s 45 w ater supplies are fluoridated. ■ Michigan: In 1968, M ichigan enacted the first law th at included a provision for a referendum . T he action started as an adm inistrative ruling. It was m oved to the legislature, w here its passage was hectic. T he original bill was com pletely re w ritten once, am ended three times, voted on by the Senate five tim es and the H ouse twice, and sent to a conference com m ittee which m ade re c om m endations that w ere rejected. T he law re quires all com m unities to take action on fluo rida tion w ithin five years; exem ption is allow ed by local ordinance o r referendum vote. ■ South Dakota: E nacted in 1969, the law ap plies to all com m unities o f 500 or m ore, w ith d ead lines in July 1971 and July 1972. O nly 8 com m u nities in the state have controlled fluoridation al though 91 have naturally fluoridated w ater su p plies. T he law w ould result in fluoridation for 68 additional com m unities. A bill to repeal the law was rejected in the lower H ouse o f the legislature, bu t a bill to require a statew ide referendum is pending.
How far in Ohio? W hen the O hio legislative cam paign started in F eb ru ary 1969, about 4 2 % o f the population was receiving fluoridated water, and the state had a long record o f referendum defeats. A kron had ju st achieved fluoridation after several attem pts during a period o f 15 years. C olum bus and D ayton w ere still w ithout fluoride. T he loss o f m any referendum s can be attributed to the activities of the state’s two ch ief fluorida tion opponents: Jonathan Form an, M D, an aller gist, and M rs. Lucy S. Stevens, age 80, organizer and chairm an o f the O hio P ure W ater A ssociation. M rs. Stevens is noted for her long-running series o f new spaper ads and as a developer and distrib u to r of antifluoridation literature. ■ Broad organizational base: T he O hio legisla tive cam paign had two im portant characteristics th at m ay be responsible for its success: the m uster ing o f b road organizational support and the de velopm ent o f docum entary m aterial for the infor m ation o f the legislators, the press, and the public.
T he cam paign was initiated and organized by the O hio Citizens C om m ittee for Fluoridation, which employed a public relations m an as execu tive director. T he com m ittee consisted of an im pressive coalition o f state organizations and indi viduals favoring statew ide fluoridation action. H ealth organizations represented included the state associations o f dentists, physicians, osteo paths, health com m issioners, optom etrists, nurses, pharm acists, dental hygienists, dental assistants, veterinarians, and the O hio State U niversity C ol lege of M edicine. O ther state organizations includ ed the U nited A uto W orkers, the T rucking A sso ciation, PTA , Jaycees, C ham ber of Com m erce, U rban League, Society o f Professional Engineers, and the A m erican W ater W orks A ssociation. T he com m ittee had three chairm en who re p re sented three o f the m ajor interests. A lbert Sabin, M D , Cincinnati, developer o f the Sabin antipolio vaccine, represented the health and scientific com m unity; M r. J. W illiam H enderson, president of Buckeye (steel) International of Colum bus, rep re sented the industrial com m unity; and M r. F rank W. King, president of the O hio A F L -C IO and form er state senate m inority leader, represented organized labor. Initiative for organizing the com m ittee cam e from the Ohio D ental A ssociation com m ittee on statew ide fluoridation, headed by R ichard K. M osbaugh of C incinnati, p ast O D A president and chairm an of the A D A C ouncil on Legislation. A $10 assessment o f each active m em ber o f O D A raised a total o f $37,500 to finance the com m ittee and cam paign. T hroughout the cam paign, the role o f the O D A was to provide the scientific inform ation and docu m entation with the legislative efforts carried out by the citizens com m ittee. ■ Documenting fluoridation: T he principal doc um entary product o f the O D A was Facts on Fluo ridation, a lengthy com pilation o f general infor m ation on fluoridation th at em phasized experi ence in O hio. Included w ere statistics on caries re ductions in Toledo, Cleveland, and Youngstown. A vailable in Cleveland was one o f the m ost th o r ough surveys ever done on the effects of fluorida tion on the teeth o f schoolchildren. T he docum ent also included the legal background o f fluoridation in O hio. T he publication answ ered the question, “ Why fluoridate w ater?” as follows: We owe it to our children and to the future of our state to see that as many people in this state as pos REPORTS OF COUNCILS AND BUREAUS « 8 1 5
Facts and figures on fluoridation were presented to the Ohio House health and welfare committee by Richard K. Mosbaugh, DDS, chair man, Ohio Dental Association com mittee on fluoridation.
sible receive the proven benefits of water fluorida tion. In the face of the volumes of medical evidence of the effectiveness of controlled fluoridation, it is almost criminal to deprive children of this benefit. We not only give children the benefit of better den tal health, we save ourselves, as parents, higher den tal bills. We save money for all taxpayers by giving better teeth to those children who must depend on public funds for needed dental care.
Facts on Fluoridation was published in the Ohio Dental Journal and was included in a k it o f fluo ridation m aterials p rep ared by the C itizens C om m ittee. A lso included in the k it w ere an A D A publication, the policy statem ent o f the A m erican M edical A ssociation, and som e local editorials calling for fluoridation action. T he kit was d is tributed w ith a b rief cover letter signed by the three cochairm en. ■ Economic benefits: T he fluoridation bill drew strong labor-m anagem ent support as well as en dorsem ent o f the state health and w elfare d e p a rt m ents. As the cause o r the result o f this, consider able inform ation was released to em phasize the econom ic benefits o f fluoridation. Position papers docum ented potential savings for dental insurance program s and publicly funded care program s such as M edicaid. D ocum enting the savings in dental treatm ent needs and dental bills, the com m ittee drew on local experience. T h e T oledo D ental Society estim ated th at fluo ridation in th at city resulted in a saving of at least $29.08 a year p er child, based on curren t fees. 816 ■ JADA, Vol. 80, April 1970
T he total saving in dental bills for second and third grade children was estim ated to be $481,093. H ad T oledo not been fluoridated, R ichard D raheim estim ated, parents w ould have dental bills of at least $53 p er year, assum ing th at the children re ceived adequate dental care. F o r H ead Start dental program s, the O hio State D ental C are C orporation reported th at the aver age cost per child in fluoridated areas ranged from a low o f $18.87 in one m etropolitan T oledo area to a high o f $28.12 in another. A verage costs in nonfluoridated areas ranged from a high of $90 in T rotw ood to a low o f $33.99 in Lancaster. C om m unity action program s providing dental care for children up to age 18 in fluoride-deficient areas averaged $103.66 per case in Knox and $91.63 in Belm ont County. It was reported also that in 1968, O h io ’s M edi caid program paid $4 m illion for dental care for recipients o f A id to D ependent C hildren. A bout 7 0 % o f this dental care, funded by taxpayers, was provided to children. The citizens com m ittee esti m ated th at fluoridation could reduce the costs o f care for children by 30% to 4 0 % w ithin five years and by 60 % in ten years. Releasing this inform ation, the citizens com m ittee repeatedly made the point th at economic reasons alone m ake fluoridation a state responsi bility. ■ Passage o f the bill: T he original fluoridation of w ater supplies in all over 5,000 in population. Introduced in F ebruary 1969, it was passed by
bill required com m unities in the Senate a vote o f 23
Discussing the fluoridation bill are Sen Charles J. Carney, Senate m i nority leader; Albert Sabin, MD, cochairman of the Ohio Citizens Committee for Fluoridation; and Richard K. Mosbaugh, DDS, chair man of the Ohio Dental Association’s fluoridation committee.
to 10 in M ay. T he Senate com m ittee h eard p ro p o nents and opponents in five hearings. In the H ouse, the com m ittee on health and w elfare added an am endm ent allow ing a referendum . H ow ever, on the H ouse floor this provision was am ended to require a referendum . This version was then passed by the H ouse 65 to 39. D octor Sabin testified for the C itizens C om m it tee at the H ouse com m ittee hearing. H e called fluoridation “ one m ore step in reducing illness and bringing relief o f m isery.” H e term ed the m ea sure “effective, safe and practical” and added that today m ost opposition is based on personal re a sons. D octor Sabin said th at he was not an ex p ert on fluoridation, but he based his faith on the com petence o f experts who have judged the m ea sure safe and effective. D octor M osbaugh, representing O D A , p resent ed the facts and figures on fluoridation and d e scribed legislative actions in other states. W hen the Senate refused to concur in the H ouse am endm ent, th e bill w ent to a conference com m ittee w here a com prom ise was w orked out which provided th at a referendum petition could be filed during a 120-day p eriod after the law went into effect and th at a special election could be held not sooner than 90 days n o r later than 120 days after the p etition was filed. T he petition would have to be signed by n o t less than 10% of the electors served by the w ater supply in each political sub di vision that voted for governor in the 1967 general election. In political subdivisions where only some of the electors are served by the w ater supply, only those electors who sign a form provided by
the board o f elections indicating th a t they are served by the w ater supply would be eligible to vote on the issue. The Senate accepted the conference com m ittee’s rep o rt by a vote of 19 to 10. The first try for H ouse acceptance failed, b u t lacked a constitu tional m ajority. T he second attem pt resulted in a 50 to 32 vote for the bill. In the final version signed by the governor, the bill requires fluoridation o f all w ater supplies serving 5,000 or m ore persons, with a deadline of Jan 1, 1971, for w ater systems serving 20,000 or m ore and Jan 1, 1972, for those serving b e tween 5,000 and 20,000. T he state health d ep art m ent will reim burse the com m unity for the p u r chase and installation o f equipm ent. A bout 35 w ater systems serving m ore than 2 0,000 people will be affected by the first deadline and about 100 systems by the second deadline. ■ O pposition rearguard action: As experienced in other states, in the period since enactm ent o f the law, various attem pts have been m ade to overthrow it or block its im plem entation. Suits to test its con stitutionality have been filed by two residents o f C anton and by 151 residents and an an tifluorida tion com m ittee in C incinnati. U nder the law, opponents had until M arch 12 to file referendum petitions and referendum s m ust be held by July 10. A fter th at date, all com m uni ties that have not ruled against fluoridation by referendum or ordinance m ust fluoridate by the ap p ro p riate deadlines.
REPORTS OF COUNCILS AND BUREAUS ■ 817
departm ent, was rejected by a legislative review com m ittee, and was subm itted instead to the legis lature. T he law has w ithstood legislative and legal threats.
F luoridation decision-m aking is m oving from the local to the state level. This requires intensifying the education and coordinating the support which are necessary in any fluoridation cam paign; but the focus of the educational effort is narrow ed to a small audience, the legislators, and the m ajor su p p o rt is m ustered from state level agencies. O f the seven states which have enacted fluori dation laws so far, O hio m ounted one o f the m ost com prehensive cam paigns to follow the long and im pressive effort that resulted in the precedentsetting first law in C onnecticut. O hio’s exam ple can b e follow ed a t th e state or the local level.
■ M innesota: E nacted in 1967, this law required fluoridation o f all m unicipal w ater supplies by Jan 1, 1970. As o f Jan 22, 1970, 306 com m unities were fluoridated, 204 had plans approved, and about 130 small com m unities (with a total popu lation o f 72,000) had taken no action. A bout 85% o f the state’s population had fluoridation when the law was enacted.
First flu o rid a tio n laws
■ Illinois: A 1966 law applying to all w ater su p plies had two 1968 deadlines. A n estim ated 1,400 w ater systems were affected, although almost 80 % of the state’s population already had con trolled or natural fluoridation. Full im plem enta tion o f the law has been delayed because o f the num ber o f w ater systems and the sm all size o f many. Legal action to block the law failed.
T hese are the precedents for the 1969 O hio law. ■ Connecticut: T h e first fluoridation law enact ed in 1965 has been fully im plem ented for all cities w ith populations exceeding 20,000. T he ac tion was in itiated as a regulation of the state health
A conference on fluoridation in Ohio Governor James A. Rhodes' office brought together (left to right) Al bert Sabin, MD; George P. Schultz, Secretary of Labor; Richard K. Mosbaugh, DDS; Governor Rhodes.
814
■ Delaware: In 1968, D elaw are enacted a law authorizing the state board o f health to order fluo ridation. Because some city councils protested that the law was perm issive rather than m andatory, a ruling upholding the requirem ent was obtained
from the attorney general. The original deadline for action was m oved from 1970 to 1973. D ela w are has very little fluoridation experience: only 5 o f the state’s 45 w ater supplies are fluoridated. ■ Michigan: In 1968, M ichigan enacted the first law th at included a provision for a referendum . T he action started as an adm inistrative ruling. It was m oved to the legislature, w here its passage was hectic. T he original bill was com pletely re w ritten once, am ended three times, voted on by the Senate five tim es and the H ouse twice, and sent to a conference com m ittee which m ade re c om m endations that w ere rejected. T he law re quires all com m unities to take action on fluo rida tion w ithin five years; exem ption is allow ed by local ordinance o r referendum vote. ■ South Dakota: E nacted in 1969, the law ap plies to all com m unities o f 500 or m ore, w ith d ead lines in July 1971 and July 1972. O nly 8 com m u nities in the state have controlled fluoridation al though 91 have naturally fluoridated w ater su p plies. T he law w ould result in fluoridation for 68 additional com m unities. A bill to repeal the law was rejected in the lower H ouse o f the legislature, bu t a bill to require a statew ide referendum is pending.
How far in Ohio? W hen the O hio legislative cam paign started in F eb ru ary 1969, about 4 2 % o f the population was receiving fluoridated water, and the state had a long record o f referendum defeats. A kron had ju st achieved fluoridation after several attem pts during a period o f 15 years. C olum bus and D ayton w ere still w ithout fluoride. T he loss o f m any referendum s can be attributed to the activities of the state’s two ch ief fluorida tion opponents: Jonathan Form an, M D, an aller gist, and M rs. Lucy S. Stevens, age 80, organizer and chairm an o f the O hio P ure W ater A ssociation. M rs. Stevens is noted for her long-running series o f new spaper ads and as a developer and distrib u to r of antifluoridation literature. ■ Broad organizational base: T he O hio legisla tive cam paign had two im portant characteristics th at m ay be responsible for its success: the m uster ing o f b road organizational support and the de velopm ent o f docum entary m aterial for the infor m ation o f the legislators, the press, and the public.
T he cam paign was initiated and organized by the O hio Citizens C om m ittee for Fluoridation, which employed a public relations m an as execu tive director. T he com m ittee consisted of an im pressive coalition o f state organizations and indi viduals favoring statew ide fluoridation action. H ealth organizations represented included the state associations o f dentists, physicians, osteo paths, health com m issioners, optom etrists, nurses, pharm acists, dental hygienists, dental assistants, veterinarians, and the O hio State U niversity C ol lege of M edicine. O ther state organizations includ ed the U nited A uto W orkers, the T rucking A sso ciation, PTA , Jaycees, C ham ber of Com m erce, U rban League, Society o f Professional Engineers, and the A m erican W ater W orks A ssociation. T he com m ittee had three chairm en who re p re sented three o f the m ajor interests. A lbert Sabin, M D , Cincinnati, developer o f the Sabin antipolio vaccine, represented the health and scientific com m unity; M r. J. W illiam H enderson, president of Buckeye (steel) International of Colum bus, rep re sented the industrial com m unity; and M r. F rank W. King, president of the O hio A F L -C IO and form er state senate m inority leader, represented organized labor. Initiative for organizing the com m ittee cam e from the Ohio D ental A ssociation com m ittee on statew ide fluoridation, headed by R ichard K. M osbaugh of C incinnati, p ast O D A president and chairm an of the A D A C ouncil on Legislation. A $10 assessment o f each active m em ber o f O D A raised a total o f $37,500 to finance the com m ittee and cam paign. T hroughout the cam paign, the role o f the O D A was to provide the scientific inform ation and docu m entation with the legislative efforts carried out by the citizens com m ittee. ■ Documenting fluoridation: T he principal doc um entary product o f the O D A was Facts on Fluo ridation, a lengthy com pilation o f general infor m ation on fluoridation th at em phasized experi ence in O hio. Included w ere statistics on caries re ductions in Toledo, Cleveland, and Youngstown. A vailable in Cleveland was one o f the m ost th o r ough surveys ever done on the effects of fluorida tion on the teeth o f schoolchildren. T he docum ent also included the legal background o f fluoridation in O hio. T he publication answ ered the question, “ Why fluoridate w ater?” as follows: We owe it to our children and to the future of our state to see that as many people in this state as pos REPORTS OF COUNCILS AND BUREAUS « 8 1 5
Facts and figures on fluoridation were presented to the Ohio House health and welfare committee by Richard K. Mosbaugh, DDS, chair man, Ohio Dental Association com mittee on fluoridation.
sible receive the proven benefits of water fluorida tion. In the face of the volumes of medical evidence of the effectiveness of controlled fluoridation, it is almost criminal to deprive children of this benefit. We not only give children the benefit of better den tal health, we save ourselves, as parents, higher den tal bills. We save money for all taxpayers by giving better teeth to those children who must depend on public funds for needed dental care.
Facts on Fluoridation was published in the Ohio Dental Journal and was included in a k it o f fluo ridation m aterials p rep ared by the C itizens C om m ittee. A lso included in the k it w ere an A D A publication, the policy statem ent o f the A m erican M edical A ssociation, and som e local editorials calling for fluoridation action. T he kit was d is tributed w ith a b rief cover letter signed by the three cochairm en. ■ Economic benefits: T he fluoridation bill drew strong labor-m anagem ent support as well as en dorsem ent o f the state health and w elfare d e p a rt m ents. As the cause o r the result o f this, consider able inform ation was released to em phasize the econom ic benefits o f fluoridation. Position papers docum ented potential savings for dental insurance program s and publicly funded care program s such as M edicaid. D ocum enting the savings in dental treatm ent needs and dental bills, the com m ittee drew on local experience. T h e T oledo D ental Society estim ated th at fluo ridation in th at city resulted in a saving of at least $29.08 a year p er child, based on curren t fees. 816 ■ JADA, Vol. 80, April 1970
T he total saving in dental bills for second and third grade children was estim ated to be $481,093. H ad T oledo not been fluoridated, R ichard D raheim estim ated, parents w ould have dental bills of at least $53 p er year, assum ing th at the children re ceived adequate dental care. F o r H ead Start dental program s, the O hio State D ental C are C orporation reported th at the aver age cost per child in fluoridated areas ranged from a low o f $18.87 in one m etropolitan T oledo area to a high o f $28.12 in another. A verage costs in nonfluoridated areas ranged from a high of $90 in T rotw ood to a low o f $33.99 in Lancaster. C om m unity action program s providing dental care for children up to age 18 in fluoride-deficient areas averaged $103.66 per case in Knox and $91.63 in Belm ont County. It was reported also that in 1968, O h io ’s M edi caid program paid $4 m illion for dental care for recipients o f A id to D ependent C hildren. A bout 7 0 % o f this dental care, funded by taxpayers, was provided to children. The citizens com m ittee esti m ated th at fluoridation could reduce the costs o f care for children by 30% to 4 0 % w ithin five years and by 60 % in ten years. Releasing this inform ation, the citizens com m ittee repeatedly made the point th at economic reasons alone m ake fluoridation a state responsi bility. ■ Passage o f the bill: T he original fluoridation of w ater supplies in all over 5,000 in population. Introduced in F ebruary 1969, it was passed by
bill required com m unities in the Senate a vote o f 23
Discussing the fluoridation bill are Sen Charles J. Carney, Senate m i nority leader; Albert Sabin, MD, cochairman of the Ohio Citizens Committee for Fluoridation; and Richard K. Mosbaugh, DDS, chair man of the Ohio Dental Association’s fluoridation committee.
to 10 in M ay. T he Senate com m ittee h eard p ro p o nents and opponents in five hearings. In the H ouse, the com m ittee on health and w elfare added an am endm ent allow ing a referendum . H ow ever, on the H ouse floor this provision was am ended to require a referendum . This version was then passed by the H ouse 65 to 39. D octor Sabin testified for the C itizens C om m it tee at the H ouse com m ittee hearing. H e called fluoridation “ one m ore step in reducing illness and bringing relief o f m isery.” H e term ed the m ea sure “effective, safe and practical” and added that today m ost opposition is based on personal re a sons. D octor Sabin said th at he was not an ex p ert on fluoridation, but he based his faith on the com petence o f experts who have judged the m ea sure safe and effective. D octor M osbaugh, representing O D A , p resent ed the facts and figures on fluoridation and d e scribed legislative actions in other states. W hen the Senate refused to concur in the H ouse am endm ent, th e bill w ent to a conference com m ittee w here a com prom ise was w orked out which provided th at a referendum petition could be filed during a 120-day p eriod after the law went into effect and th at a special election could be held not sooner than 90 days n o r later than 120 days after the p etition was filed. T he petition would have to be signed by n o t less than 10% of the electors served by the w ater supply in each political sub di vision that voted for governor in the 1967 general election. In political subdivisions where only some of the electors are served by the w ater supply, only those electors who sign a form provided by
the board o f elections indicating th a t they are served by the w ater supply would be eligible to vote on the issue. The Senate accepted the conference com m ittee’s rep o rt by a vote of 19 to 10. The first try for H ouse acceptance failed, b u t lacked a constitu tional m ajority. T he second attem pt resulted in a 50 to 32 vote for the bill. In the final version signed by the governor, the bill requires fluoridation o f all w ater supplies serving 5,000 or m ore persons, with a deadline of Jan 1, 1971, for w ater systems serving 20,000 or m ore and Jan 1, 1972, for those serving b e tween 5,000 and 20,000. T he state health d ep art m ent will reim burse the com m unity for the p u r chase and installation o f equipm ent. A bout 35 w ater systems serving m ore than 2 0,000 people will be affected by the first deadline and about 100 systems by the second deadline. ■ O pposition rearguard action: As experienced in other states, in the period since enactm ent o f the law, various attem pts have been m ade to overthrow it or block its im plem entation. Suits to test its con stitutionality have been filed by two residents o f C anton and by 151 residents and an an tifluorida tion com m ittee in C incinnati. U nder the law, opponents had until M arch 12 to file referendum petitions and referendum s m ust be held by July 10. A fter th at date, all com m uni ties that have not ruled against fluoridation by referendum or ordinance m ust fluoridate by the ap p ro p riate deadlines.
REPORTS OF COUNCILS AND BUREAUS ■ 817