by Paul Connett
The Issue Examined
Water fluoridation is the deliberate addition of a fluoride compound to the public water supply for the purpose of reducing tooth decay. It can come as a shock to find that the chemicals used to fluoridate the water are not pharmaceutical grade, like those used in fluoridated toothpaste and other dental products, but are mainly hazardous waste products of the phosphate fertilizer industry (chapter 3). An even greater shock is to find that while many agencies promote the practice of water fluoridation in the United States, no federal agency accepts responsibility for it (see chapter 4).
Currently, over 180 million Americans and about another 200 million people worldwide are drinking artificially fluoridated water. In the United States and several other fluoridating countries, the so-called optimal concentration of fluoride is 1 milligram per liter, or 1 part per million (ppm; it actually ranges from 0. 7 to 1. 2 ppm, depending on average ambient temperatures).
Proponents claim that 1 ppm is an extremely small concentration and could not possibly cause any harm. In fact, however, it is not at all small for a substance of fluoride’s known toxicity; it is 25–250 times more than the range of concentrations of fluoride found in mother’s milk (chapter 12). This means that a bottle-fed baby in a fluoridated community is getting up to 250 times more fluoride than a breast-fed baby (chapters 1 and 12). Meanwhile, according to the U. S. Centers for Disease Control and Prevention (CDC), 2 32 percent of children in the U. S. have a condition called dental fluorosis, a mottling or discoloration of the tooth enamel caused by excessive exposure to fluoride before the secondary teeth have erupted (see chapter 11).
One of the surprises for independent reviewers of this issue is that the scientific evidence that fluoridation works to reduce tooth decay is actually very weak (see chapters 6–8). According to World Health Organization statistics, 3 rates of tooth decay in twelve-year-olds have been coming down as fast in non-fluoridated countries as in fluoridated ones (chapters 5 and 6). Meanwhile, the scientific evidence indicating that fluoridation may be causing harm gets stronger with each passing year (see chapter 10–19).
A Little History
Fluoridation trials began in 1945, but in 1950, before any trials had been completed, and before any comprehensive health studies had been published, the practice was endorsed by the Public Health Service (PHS). Endorsements from the American Dental Association (ADA), the American Public Health Association (APHA), the American Medical Association (AMA), and others quickly followed but still without any solid scientific information to judge the efficacy and safety of the practice. We dub this abandonment of the normal procedures for determining the safety and efficacy of a medical practice “The Great Fluoridation Gamble” (see chapters 9 and 10).
Endorsements versus Science
Since 1950, endorsements have been routinely used to promote fluoridation. Citizens have been lured into accepting water fluoridation on the basis of “authority, ” not on the basis of any substantial scientific evidence of effectiveness or safety. Because that authority includes the PHS (now the DHHS), as well as professional dental and medical bodies, the endorsements have proved very effective in distracting attention from the absence of rigorous, well-designed, and controlled studies. From a scientific point of view, such a superficial approach to a serious issue is unusual. From a public relations point of view, however, endorsements have proved to be a very effective tool in the promotion of fluoridation for over fifty years. We examine the techniques used in the promotion of water fluoridation in more detail in chapter 23.
Another aspect of the inadequate scientific approach to fluoridation is how poorly potential health effects have been investigated and fluoride exposure monitored. Even the most basic studies have not been attempted (see chapter 22).
From time to time the governments of fluoridating countries have set up panels to review the safety and effectiveness of fluoridation, but by virtue of the selective makeup of these panels, their conclusions are frequently little more than rubber stamps for a long-entrenched government policy (see chapter 24). A notable exception to the self-serving reports is the review by the U. S. National Research Council (NRC) of the National Academies (formerly the National Academy of Science), 4 which we discuss below (see the section “The NRC Review” and chapter 14).
Why This Book Is Necessary Now
Some may wonder why we have written this book now. It may appear that fluoridation is a peripheral issue compared with the major economic, environmental, and political threats facing our planet today. That is true, but we would argue that, unlike those many other problems, this one is as easy to end as turning off a spigot, if the political will can be found. Only a complete change of attitude can generate such political will, however, and only a sober assessment of scientific reality is likely to shift the prevailing attitude.
Another reason for writing now is that promoters of fluoridation seem to be becoming increasingly aggressive in their activities, pressing for mandatory statewide fluoridation in the U. S. A. , Canada, and Australia and passing laws to indemnify water providers against legal liabilities in the UK.
Finally, the recent publication of the NRC review—the first scientific review relevant to fluoridation that is both comprehensive and impartial—was a landmark. 5 Promoters of fluoridation have argued on specious grounds that the review is not, in fact, relevant to fluoridation. We intend to set the record straight on that point.
The NRC Review
The comprehensive review by the U. S. National Research Council of the National Academies, published in 2006, was carried out in response to a request from the Office of Drinking Water of the United States Environmental Protection Agency (EPA) to consider whether the EPA’s safe drinking water level for fluoride, currently 4 ppm, needed to be changed. The NRC review contained 507 pages and approximately 1, 100 citations to the primary literature. 6 For most scientific opponents of fluoridation, this review looked like the final victory in the long battle to expose the health dangers inherent in this practice, and, from the point of view of a former risk assessment specialist at the EPA, it was. 7 However, the agencies that continue to promote this program (e. g. , the CDC and the ADA) are extremely influential, and with the help of a largely acquiescent media, they have managed to convince many decision makers—erroneously—that the NRC report can be ignored in discussions about fluoridation. Even the supposedly unbiased book The Fluoride Wars seems to have bought into this view. It scarcely mentions the review, which (along with other aspects of the book) throws the authors’ claim of impartiality into serious doubt.
The NRC panel concluded that the current EPA safe drinking water standard of 4 ppm was not protective of health and recommended that the EPA Office of Drinking Water perform a health risk assessment to determine a new MCLG (maximum contaminant level goal) for fluoride. 8 As of July 2010 (over four years after the NRC review was published), that had not been done.
In this book we review many of the findings of the NRC report (see chapters 15–19), along with those of some more recent scientific studies, so that these important health issues, and their vital relevance to the practice of water fluoridation, do not remain hidden either from the lay public or from open-minded professionals.
We do not believe that we are overstating the seriousness of the possible downside of fluoridation: People with impaired kidney function accumulate more fluoride in their bones and are more vulnerable to its toxic effects on those tissues and possibly others (chapter 19); some young men may be losing their lives to a fatal bone cancer because of this practice (chapter 18); millions of citizens may be having their bones weakened (chapter 17) and their thyroid function lowered (chapter 16); millions of infants may be having their mental development subtly impaired (chapter 15); and many adults may be suffering from a series of common complaints—from arthritic symptoms to tiredness not relieved by sleep to gastrointestinal problems—that could be reversed if the fluoride was removed (chapter 13).
Note the word �
��may. ” We do not claim that all these harms have been conclusively proven. What we can say, however, is that much existing information points clearly to a variety of serious risks inherent in the fluoridation program. We argue that these risks are far too high when we are considering the mass medication of millions of people, the more so since the benefits are now seen to be so small and achievable by other means in dozens of non-fluoridating countries.
Reliance on the ADA and the CDC
The vast majority of rank-and-file proponents of water fluoridation have received little encouragement to read the scientific literature concerning either fluoride’s toxicity or the efficacy of fluoridation. They, as well as the media, rely on pro-fluoridation pronouncements from the ADA and the CDC. For example, nearly every day someone, somewhere is quoting the CDC’s claim that “fluoridation is one of the top ten public health achievements of the 20th century, ”9, 10 without realizing that that agency is fundamentally biased on the issue. In essence, on the issue of fluoridation, the CDC’s Oral Health Division behaves like an adjunct of the ADA. Indeed, the two bodies often work together on their fluoridation promotional activities—at taxpayers’ expense (see chapter 4).
Bias
In the following pages, we concentrate on arguments against fluoridation, basing them clearly on the existing scientific data, while attempting to acknowledge weaknesses and recognize the existence of counterarguments. We make no apology for our bias; it is a necessary corrective and counterbalance to the contrary bias and obfuscation seen in the many pro-fluoridation statements that have appeared.
The Promoters’ Motivations
Because the pro-fluoridation case is so unsatisfactory scientifically, we have been forced to address some of the possible motivations behind the continued push to fluoridate the water of more towns and states in the United States and other fluoridated countries (see chapter 26). We have been tempted to paddle into rough waters here (who of us really knows what motivates others?) because it is so puzzling to witness the efforts of proponents to step up the fluoridation of more and more water supplies, even as the evidence for the effectiveness and safety of this program gets less and less convincing. If this evidence is so weak, what can explain the continued zealous promotion of fluoridation?
Risk
What is important to remember is that we are talking about mass medication, not a drug that is prescribed after due consultation for an individual. A risk of harm estimated at say 1 in 10, 000 may be considered entirely acceptable in the latter case; in fact, we accept far higher risks of undesirable side effects if we are seriously ill. But if we are giving a drug to nearly 400 million people worldwide, that risk of 1 in 10, 000 translates into 40, 000 cases of harm from one cause. The risks for some harms due to fluoridation are probably much higher. For example, 1 in 100 may be hypersensitive to fluoride (see chapter 13).
So proponents and opponents carry different burdens of proof. Proponents need to have conclusive proof of substantial benefit and very strong evidence for an extraordinarily low risk of harm (they have neither). For opponents, on the other hand, it should suffice to show that there is an identifiable risk of serious harm; conclusive evidence is not necessary. Even small risks are indefensible when deliberately imposed on a large population. This may seem like common sense, but it seems to elude proponents of fluoridation, who continue to talk about small risks as if they were acceptable and to insist that opponents provide conclusive proof (chapter 21).
This distinction lies at the very heart of the fluoridation dispute and comes up again and again. It is the touchstone. Proponents say that unless there is direct and conclusive evidence that fluoridation, as opposed to fluoride, harms anyone, then it is all right to carry on fluoridating. They are zealous in trying to dismiss any relevant evidence as having methodological flaws and claiming that it is “junk science”11 or doesn’t meet “normal scientific standards. ”12 Opponents say that this demand for absolute scientific proof violates the precautionary principle, and the violation is extreme.
Even proponents of fluoridation do not deny that high levels of fluoride cause harm. In fact, millions of people living in areas of India and China with moderate to high levels of fluoride levels in their drinking water have suffered serious health consequences. Therefore, the onus is on the proponents to demonstrate that there is an adequate margin of safety between the doses that cause harm and the huge range of doses that may be experienced by those drinking uncontrolled amounts of fluoridated water and at the same time receiving unknown amounts of fluoride from other sources. Moreover, such a margin of safety should be large enough to protect everyone in society, not just the average person. Those who need protecting include the very young, the very old, those with poor nutrition, those in poor health, and those with impaired kidney function. Proponents have not demonstrated this. Worse, they seldom even address this key issue. We examine this further in chapter 20.
No Debate?
For many years proponents have tried to insulate themselves from discussion and from the obligation to investigate by claiming that “there is no debate” on fluoridation. 13 They argue that the evidence for fluoridation’s benefits and lack of harm is so clear that it is not worth bothering with a handful of “ill-informed” critics. Such a simplistic (and conveniently self-serving) view is easily rebutted. It is long past time that proponents began to engage in this debate in a serious, transparent, and scientific manner.
As Thomas Huxley said, “Many a beautiful theory was killed by an ugly fact. ” As far as fluoridation is concerned, there are many ugly facts; they are revealed in the pages of this book.
ABBREVIATIONS
Organizations
AAAS American Association for the Advancement of Science
ACSH American Council on Science and Health
ADA American Dental Association
Alcoa Aluminum Company of America
AMA American Medical Association
BFS British Fluoridation Society
CDC Centers for Disease Control and Prevention (US)
DHHS Department of Health and Human Services (US)
EPA Environmental Protection Agency (US)
FDA Food and Drug Administration (US)
IPCS International Programme on Chemical Safety
JADA Journal of the American Dental Association
JAMA Journal of the American Medical Association
NAS National Academy of Sciences (US)
NCI National Cancer Institute (US)
NHMRC National Health and Medical Research Council (Australia)
NIH National Institutes of Health (US)
NID(C)R National Institute of Dental (and Craniofacial) Research
NRC National Research Council (US)
NSF National Sanitation Foundation International (US)
NTP National Toxicology Program (US)
NYDOH New York State Department of Health (US)
PHS Public Health Service (US)
SEER Surveillance, Epidemiology and End Results (US)
Technical terms
AMP Adenosine monophosphate
DMFS Decayed Missing and Filled Surfaces in the secondary teeth
DMFT Decayed Missing and Filled secondary Teeth
IRIS Integrated Risk Information System (EPA, US)
LOAEL Lowest Observable Adverse Effect Level
MCL Maximum Contaminant Level
MCLG Maximum Contaminant Level Goal
ppb parts per billion
ppm parts per million
T3 Triiodothyronine
T4 Thyroxin
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PART ONE •
Ethical and General
Arguments against
Fluoridation
In chapter 1, we examine aspects of fluoridation that make it a very poor medical practice. This discussion includes the “alpha and omega” argument against fluoridation—namely, that government does not have the right to force individuals to take a medication against their wishes. We
show that this idea, which many citizens believe intuitively, is actually sanctified in a European convention and in modern medical ethics.
In chapter 2, we further argue that water fluoridation, even if it were a sound medical practice, is not an efficient or appropriate way to achieve the desired end.
In chapter 3, we examine the nature of the chemicals used in the fluoridation program. The shock to many is to find that these chemicals are not pharmaceutical grade, as used in dental products, but hazardous waste derived largely from the phosphate fertilizer industry.
In chapter 4, we examine just who is in charge of the American fluoridation program. We ask who ultimately has responsibility if harm is demonstrated. The answer to this question will probably shock the reader as much as it did us.
In chapter 5, we examine the experimental nature of the fluoridation program. Even after sixty years of the program there have been no rigorous studies demonstrating it’s effectiveness, and many unanswered questions remain over health risks. Most countries do not fluoridate their water, yet their children’s teeth are no worse than the teeth of children in fluoridated countries.
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1 •
Poor Medical Practice
At a public meeting held on October 17, 2009, in Yellow Springs, Ohio, a community that was considering halting its fluoridation program, Paul Connett gave a twenty-minute presentation on the scientific arguments against the practice. After a county health commissioner and local dentist responded, a woman in the audience said, “Whether this practice is safe or not, or beneficial or not, I want freedom of choice. It is my right to choose what substances I put into my body, not some governmental agency’s. ”
This woman echoed what many opponents of fluoridation have believed and articulated for over sixty years: Government has no right to force anyone to take a medicine. Thus, while in the effort to end this practice worldwide it is helpful to provide scientific evidence that the program is neither effective nor safe, this commonsense position remains the crux of the argument against fluoridation.