by Paul Connett
Bryson suggests that it is these concerns about industrial liabilities that drove the U. S. PHS to endorse fluoridation. He carefully documents meetings between industry, dental interests, and PHS representatives long before the PHS endorsement. For example, he describes a meeting in April 1936 between Charles Kettering, vice president and director of research at General Motors, a delegation from the American Dental Association, and Captain C. T. Messner of the PHS. 154 Bryson also documents the aggressive role that Robert Kehoe, the director of the Kettering Laboratory, played in protecting industries involved in fluoride use, and his close ties with officials in the PHS, matters we explore further in chapter 10. 155
Big Sugar’s Influence
In 1949, in an issue of Sugar Molecule, the scientific director for the Sugar Research Foundation (a lobby for about 130 sugar interests) was quoted as saying that the purpose of the foundation’s research was “to find how tooth decay may be controlled effectively without restriction of sugar intake. ”156
There is no question that the sugar lobby had a huge interest in distracting attention from sugar as a major contributing cause of tooth decay. Whether the lobby had a direct influence on the U. S. PHS’s decision we leave to others to explore.
One thing we know is that the Sugar Research Foundation put a lot of money into the work of Dr. Frederick Stare, chair of the Nutrition Department at Harvard. From the 1940s through the early 1990s, Dr. Stare was one of the most prominent spokespeople on behalf of both sugar interests and water fluoridation (see chapter 26).
Development of the Atomic Bomb
The development of the atomic bomb in the 1940s coincided with the development of fluoridation. Production of the bomb required huge quantities of fluoride to produce the uranium hexafluoride used to separate the fissionable isotope of uranium from the nonfissionable isotope. As indicated above, the chief toxicologist of the Manhattan Project was Harold Hodge. Not only was Hodge involved in studies of fluoride’s toxicity for the Manhattan Project, he was also chair of the committee set up to oversee the important Newburgh-Kingston trial of fluoridation (1945–1955) and tracked the results of medical examinations conducted in that trial. 157
Proponents of fluoridation like to make fun of those who suggest that there might have been ulterior motives behind the rush to instigate fluoridation and often use the word “conspiracy theorist” to conjure up the notion that such people are simply exhibiting paranoia. However, Bryson’s suggestion that industrial and government scientists conspired to put fluoride into the drinking water—(1) to collect low-dose data to be used to combat potential lawsuits brought by farmers and workers on the atomic bomb production line, and (2) to change the image of fluoride from a nasty air pollutant to something so harmless that children could drink it—pales beside the known fact that Hodge and his fellow Manhattan Project researchers, working for the U. S. government, actually did conspire to expose patients to injections of plutonium without their knowledge or permission. 158, 159
The U. S. PHS Endorsement of Fluoridation
The June 1950 issue of the Journal of the American Dental Association was a special issue devoted to the progress of dentistry in “this first half century. ” Under “Advances in Research, ” the epidemiological studies of Henry Trendley Dean were singled out as work that “epidemiologists all over the country know and are proud of. ”160 However, those studies were still missing the crowning finale.
That crowning finale came in the same month of June, but it did not arrive with much fanfare outside the dental community. There were no press conferences, no press releases, or any media coverage. The announcement of the U. S. PHS endorsement of fluoridation was printed as a small item in the ADA newsletter of June 1, 1950. The following statement appeared, referring to a report of “today” by Assistant Surgeon General Bruce D. Forsyth: “As a result of new evidence from its Grand Rapids project, where community water has been fluoridated since January 25, 1945, the Public Health Service, Dr. Forsyth said, has now altered its basic policy regarding fluoridation to read: ‘Using scientific methods and procedures, communities desiring to fluoridate their communal water supplies should be strongly encouraged to do so. ’”161
A few days later the state and territorial dental directors also endorsed water fluoridation. They did this at their annual meeting in Washington, D. C. , June 7–9, 1950.
On the last day of this meeting, the PHS released a renewed statement of its position on fluoridation, which was published in the Journal of the American Dental Association. 162 The American Dental Association and the American Association of Public Health Dentists followed suit at their respective annual meetings a few months later. 163
In this grand finale for dentistry in public health one can find few, if any, words of doubt about possible dangers of fluoridation. Any qualms were forgotten once the U. S. Public Health Service took the ultimate gamble and recommended fluoridation for the whole country—or at least any community that wanted it. We shall see in the next chapter that there was to be no turning back from that position. The die had been cast for the next sixty years.
Summary
As a result of studies on dental mottling, now called dental fluorosis, in the early part of the twentieth century, researchers in 1931 found that the cause of the condition was naturally occurring fluoride in the drinking water. From the outset it was established that this was a systemic effect. We define the Great Fluoridation Gamble as the notion that fluoride could cause that condition without having any other systemic effect on the body.
Whatever the reasons that led the U. S. PHS to endorse fluoridation in 1950, researchers did not have solid evidence to demonstrate either the short-term or the long-term safety of this practice. Not only was safety not demonstrated in anything approaching a comprehensive and scientific study, but also a large number of studies implicating fluoride’s impact on both the bones and the thyroid gland were ignored or downplayed.
It remains an open question whether this was simply a case of zealous dentists winning out over more cautious public health officials, as McNeil suggests, or there were sugar or other industrial or nuclear interests at play, as other commentators have suggested. Either way, the PHS decision was a serious blow to the notion that public health policies should be based on the very best science available and contradicted the Hippocratic admonition “First do no harm. ”
We return to this matter in the next chapter, where we discuss the next phase of the Great Fluoridation Gamble, exploring the investigations of fluoride’s impact on health that took place or were published after the all-important PHS endorsement.
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10 •
The Great Fluoridation Gamble, 1950–
Coauthored by Peter Meiers
As we explained in chapter 9, the Great Fluoridation Gamble was the blind trust that drinking water containing 1 ppm fluoride could damage growing tooth cells without damaging any other tissue in a child’s developing body or causing any damage to adults after a lifetime of exposure to uncontrolled doses. The gamble began tentatively in 1945 with the fluoridation trials and continued with a vengeance in 1950 when the U. S. Public Health Service (PHS) endorsed fluoridation with no trials completed and no comprehensive health studies published. We now examine how the gamble has continued right up to the present day.
PHS Gamble Cemented into Place
The crucial PHS endorsement of the fluoridation of public water systems on June 1, 1950, was swiftly followed by endorsements from many other distinguished authorities and professional bodies, including the American Association of Public Health Dentists (October 29, 1950), the American Dental Association (ADA; October 30–November 2, 1950), the American Public Health Association (APHA; November 1950), and state and territorial health officers (November 1950).
According to Exner and Waldbott, 1 most of those endorsements were orchestrated by a few individuals who held leading positions in several of the organizations. None of the endorsements came with a scientific
review to justify them. They simply represented a follow-the-leader approach to public health and dentistry. What is surprising about the activities of the key players we examine in this chapter was their expressed certainty in the absolute safety of this measure
Prior to 1950, at least lip service was paid to the need to investigate the side effects and possible dangers of drinking fluoridated water. After 1950 even the lip service seems to have evaporated. Very quickly investigation changed to promotion.
Thus, this chapter is more about political science than physical science. We start with Dr. Frank Bull, a fluoridation zealot, and toward the end we discuss the role of Edward Bernays, the father of both public relations and propaganda in the United States.
Frank Bull and the 1951 D. C. Conference
The transcript of the remarkably candid Conference of State Dental Directors in Washington, D. C. , in 1951 (whose participants apparently did not know that a transcript was being made, or suspect that the document would eventually pass into public hands) clearly shows a preoccupation with the promotion of the fluoridation program rather than a discussion of dealing with any doubts about its safety or effectiveness. The following excerpts give an idea of just how candid the comments of Dr. Frank Bull, the Wisconsin state dental director, were.
In response to his own question, “Why should we do a pre-fluoridation survey?” Dr. Bull replied, “Is it to find out if fluoridation works? No. We have already told the public that it works, we can’t go back on that. ”2
Among a few dos and don’ts, Bull tells the U. S. state dental directors, “Don’t use the word ‘artificial’. . . and certainly don’t use the word ‘experimental. ’”3
On toxicity, Bull says, “The question of toxicity. . . Lay off it altogether. Just pass it over, ‘We know there is absolutely no effect other than reducing tooth decay, ’ you say and go on. ”4
On liability, Bull says, “The water department will say, ‘What is our liability in fluoridation?’ Well, we say ‘You are going to look bad if they start suing you because you are not doing it. ’ (Laughter). You pretty nearly have to turn the thing around. If they get you answering questions for them, then they have you on the defensive, and you are like any salesman, you are sort of up against it. ”5
John Knutson and the PHS, 1952
On January 17, 1952, John Knutson, chief of the Dental Health Division for the PHS, gave a presentation to the North Shore District Dental Society in Salem, Massachusetts, which was later reprinted as “The Case for Water Fluoridation” in the May 8, 1952, issue of the New England Journal of Medicine. 6
The rhetoric and argumentation used by Knutson give us a preview of the formula that was to be used again and again over the next fifty-plus years. For example, note his use of endorsements when he said, “It is now more than a year since the American Dental Association put its stamp of approval on water fluoridation as a mass method of reducing the incidence of tooth decay. . . ” and:
Similar endorsements have come from all the other national groups concerned with promoting dental health—the American Public Health Association, the American Association of Public Health Dentists, the American Medical Association, the U. S. Public Health Service and many others. These highly reputable organizations did not give their blessing lightly. They approved fluoridation only after careful study by competent members and consultants, experts with broad scientific knowledge in every phase of fluoride chemistry and toxicology. 7
This is utter nonsense. With the possible exception of the AMA, organizations rushed to endorse fluoridation within weeks or months of the PHS endorsement in 1950. We are not aware of any evidence that any of these bodies reviewed the literature for themselves after the key endorsement by the PHS.
Knutson complained that the fluoridation program in Massachusetts was “moving ahead with the speed of the proverbial snail” and asked, “Why [are] we. . . quibbling, delaying, pigeon holing—in the face of exhaustive research and overwhelming proof?”8
In chapter 9 we illustrate how little research had been done on safety, and what was done hardly constituted “overwhelming proof. ” As far as benefits were concerned, none of the trials had been completed in 1952 at the time Knutson gave this presentation.
Knutson presented the following “facts” on the matter: “An infinitesimal quantity of fluoride compound added to the water supply will reduce tooth decay by as much as two-thirds. . . this protection will. . . carry over to future generations of adults. . . save many millions of dollars in dental bills. . . does not change the color, taste or odor of the water. . . will not harm any living thing or interfere with any industrial process. ” He continued by asserting that behind these facts “lies a mass of proof based on years of painstaking scientific research—because fluoridation is no magic formula concocted overnight. ”9 In chapter 9 we saw that most of these claims were simply not scientifically based.
Referring to the fluoridation trials still in progress, Knutson went on to say, “The purpose of these studies was not to determine whether or not 1. 0 ppm of fluoride in water is a safe amount. We already knew that, simply because millions of Americans have been drinking water containing this amount of natural fluoride all their lives without ill effect. ”10
Acknowledging that fluoride was toxic in excessive amounts, Knutson introduced a calculation that he attributed to McClure: “You would have to drink over 400 gallons of water containing 1. 0 ppm at one sitting to receive a toxic dose. Such a large drink of water might kill you, of course, but water alone would do the job without any help from fluoride. ”11
What Knutson and McClure were doing—and many promoters have done since—was obfuscating the crucial difference between an acute lethal dose and a chronic toxic dose. Knutson also cited a 1951 report from an ad hoc committee of the National Research Council report12 as stating, “The margin between the optimal quantity of fluoride in drinking water which is required for maximal benefit in tooth development, and the amount which produces undesirable physiological effects is sufficiently wide to cause no concern. ”13 But in 1951 there was little science on which to base such a confident statement. In the Great Fluoridation Gamble, Dr. Knutson, as chief dental officer of the PHS, perhaps qualifies as gambler-in-chief.
Nicholas Leone and Bartlett-Cameron, 1954
The first formal U. S. health study—the famous Bartlett-Cameron study—did not appear until two years after Knutson’s comments above and four years after the PHS had endorsed fluoridation. This was perhaps the ultimate example of “locking the barn door after the horse escaped” and, to continue our farmyard metaphors, represented a fairly clear case of the fox guarding the chicken coop.
The name most associated with the Bartlett-Cameron study is that of Nicholas Leone, MD, the director of medical research at the NIDR. However, Leone’s name was not on the study when it was first cited by the Committee on Dental Health of the National Research Council’s Food and Nutrition Board. 14 The committee cited the study as follows:
MB Shimkin, FA Arnold, JW Hawkins, HT Dean: Medical aspects of fluorosis: a survey of 114 individuals using water with 8 parts per million fluoride and of 131 individuals using water with 0. 4 parts per million fluoride. Am. Assoc. Advancement Sci. 1953 (in press).
However, when the study appeared in the 1954 AAAS symposium report, 15 as well as in a Public Health Report, 16 some of the key authors had changed. Dean’s and Hawkins’s names had been dropped, and previously unlisted Nicholas Leone appeared as the lead author. It’s puzzling how the authorship of this crucially important study could have changed within the space of one year. Moreover, Leone seems to have taken on this leading position with practically no background in the matter. From 1951 to 1953 he was working at the National Microbiological Institute. He did not become the chief of medical investigations at the NIDR until March 1, 1953. 17 He really did not have a lot of time to work on this study. The report without his name on it was in press in November 1953, and the report with his name on it appeared in
October 1954.
Bartlett-Cameron Study Details
For a study that was destined to become the core of the argument for fluoridation’s safety, the Bartlett-Cameron study was remarkably small and limited. According to Leone et al. , the study began in 1943 when a team from the PHS examined 116 residents in Bartlett (where the water contained 8 ppm fluoride) and 121 residents in Cameron (where the water contained 0. 4 ppm fluoride), both in Texas. The participants were all white and ranged in age from fifteen to sixty-eight. The basic requirement for inclusion in the study was having fifteen years or more of continuous residence prior to 1943. 18
The 1953 investigation—by an entirely different team—involved tracing as many members of the group studied in 1943 as possible. According to Leone et al. , 71 percent of the 237 participants still resided in Bartlett or Cameron in 1953. Eight percent of the participants had died, and the forty-seven who had moved were traced; thirty-seven of those were reexamined in 1953, and the other ten were interviewed by telephone or mail and their ten-year medical histories obtained. 19
Each participant received a physical examination, blood and urine tests, and X-rays. Leone et al. tabulated the abnormalities in various characteristics observed in Bartlett and Cameron in 1943 and 1953, including dental fluorosis, arthritic changes, blood pressure, bone changes (density, coarse trabeculation, hypertrophy, spurs, osteoporosis), cataracts or lens opacity, thyroid function, cardiovascular system function, hearing (decreased acuity), tumors or cysts, fractures, urinary tract calculi, and gallstones. Their overall conclusion was that “no significant differences between the findings in the two towns were observed, except for a slightly higher rate of cardiovascular abnormalities in Cameron [0. 4 ppm F] and a marked predominance of dental fluorosis in Bartlett [8 ppm F]. ”20