…Three historical cases of major technological innovations whose benefits and risks were the subject of heated public controversy are examined, in search of lessons that may suggest a path toward consensus in the biotechnology debate. In each of the cases-water fluoridation, nuclear power and pesticides-proponents of the technology gathered scientific evidence that they believed established that the innovations were safe. In each case, the federal government was heavily involved in oversight, safety regulation, and in the first two cases, active promotion of the technology. Supporters of the technologies employed a variety of communications strategies, ranging from massive “educational” campaigns (e.g., “Our Friend The Atom”) to vituperative ad hominem attacks on leading opponents. None of these strategies succeeded in achieving broad societal acceptance of the technologies. Fluoridation today is opposed as vigorously by activist groups as it was when first introduced around 1950, it has not been universally adopted even in the U.S., and it has been rejected in most other countries. . . .
1. Fluoridation. In the 1930s, studies of mottled dental enamel in parts of the Midwest and western United States found that fluoride in the water caused the problem. Further research found that people with mottled teeth had fewer cavities, and dental researchers soon proposed adding fluoride to water supplies to reduce tooth decay. Experimental fluoridation trials began in three communities in 1945. But enthusiastic proponents of the idea could not wait for more scientific evidence. They mounted an intensive lobbying campaign, and in 1950 persuaded the U.S. Public Health Service (PHS), which had done or sponsored most of the research up to that point, to endorse fluoridation and urge local communities to adopt it. The PHS and a few state dental officials then began vigorously promoting fluoridation of community water supplies nationwide.(10,11,12,13)
If advocates of fluoridation had expected the PHS endorsement to persuade the public to accept fluoridation, they were rudely disappointed. Virulent public opposition cropped up in communities where fluoridation was being considered.(14) In retrospect, it is not hard to understand why. The scientific case for fluoridation was much weaker than it looked to supporters of the idea. The experimental trials had not run their course, and there had been no significant studies examining the long-term health of people in communities with naturally fluoridated water.(15) Those who favored fluoridation had focused very narrowly on demonstrating its benefits, and had essentially taken its safety as a given. Fluoride is in fact quite toxic (it was once widely used as an insecticide and a rodenticide). Exposure via drinking water, at levels not much higher than what was proposed for fluoridation, had been associated in numerous published studies, beginning around 1940, with serious adverse skeletal and neuromuscular effects, in India and other countries.(16,17) Opposition to fluoridation initially came from scientists concerned about the lack of good evidence on possible health risks. Non-scientific concerns also loomed large: The pro-fluoridation activists had given no serious thought to the rights of individuals to choose whether or not to take the risks of ingesting fluoride, and seemed insensitive to the complex ethical questions raised by adding something beneficial but toxic to the public water supply.(18,19)
When controversy exploded and pro-fluoridationists had no good answers for questions raised by opponents, fluoridation took a political beating. At the local level, opponents demanded referenda on fluoridation, and usually defeated the measure. Congress held hearings in 1952 and recommended that the PHS pursue a “go-slow” policy.(20,21) One option for advocates of new technologies-asking government to regulate the product, and certify its safety-was unavailable in this case. The government (the PHS) was the leading sponsor of fluoridation, had already decided it was safe, and did not consider the risks an open question.(22) The pro-fluoridationists seemed insensitive to the perception on many citizens’ part that because the PHS was a strong advocate of fluoridation’s benefits, it could not be an unbiased assessor of its risks.
Faced with such unexpected and strong opposition, the pro-fluoridation side hardened its stance. Leading PHS dental researchers lobbied every leading scientific organization, to gain endorsements of fluoridation.(23,24) They cast fluoridation as a product of scientific progress under siege from anti-scientific forces, and rallied the scientific community in political support of the measure.(25) They carried out a few studies looking for possible adverse effects of fluoridation; the studies were poorly designed and inconclusive, by today’s standards, but they found no convincing evidence of harm.(26) The PHS declared the issues closed, the debate over.(27,28) The studies were roundly criticized as inadequate and biased by leading opponents of the day,(29,30) but fluoridation advocates rapidly took the stance that there was no longer any scientific doubt that fluoridation was safe and effective.(31,32) Their political strategy was simply to steamroll the opposition, to insist that opponents had no basis for any valid objections. They focused on political campaigning, not on research; in fact, research all but halted, as it was politically inexpedient for the PHS to be studying questions they had already declared adequately answered.(33,34)
The pro-fluoridation movement adopted a hostile attack posture toward opponents. They characterized opponent leaders, regardless of scientific credentials (and many were either research scientists or physicians), as cranks and crackpots.(35) They aggressively used guilt-by-association, spreading images like the right-wing lunatic General Jack D. Ripper in “Dr. Strangelove,” to discredit the very idea of opposition to fluoridation. They used slick public relations campaigns, avoided scientific discourse, sought to solidify political support for fluoridation in the scientific professions, and to energize local health leaders to fight to win referenda.(36)
Did these tactics work? In some limited ways. Few respectable scientists voiced doubts about fluoridation, once proponents had reinforced public perceptions that opposition to fluoridation was a “crackpot” cause.(37) Those who did openly oppose fluoridation were often subjected to personal attacks and professional reprisals.(38) For decades, mainstream scientific journals would reject for publication any paper that did not articulate a strictly pro-fluoridation position on risk and benefit questions.(39,40,41) The strategy of waging political war against the opposition also helped recruit zealous pro-fluoridation leaders, to engage opponents in local skirmishes.
But the tactics pursued in support of fluoridation also had serious counterproductive effects. By recruiting scientific bodies as political endorsers and refusing to debate the scientific issues, proponents substituted dogmatism for open-mindedness and weakened their own scientific credibility. Their scorched-earth attacks on their opponents further polarized the debate, redoubled the determination of the antis, and made them appear to be the underdogs. Far from silencing the opposition, these attacks both increased public sympathy for the anti-fluoridation position and drove anti leaders toward more extreme positions.(42)
Fifty years after it began, the fluoridation debate persists largely unchanged. Despite half a century of official approval and promotion, only about 60 percent of American public water supplies are fluoridated.(43) When local health officials propose fluoridation, grass-roots opposition almost always crops up, and fluoridation still goes down to defeat more often than not. Risk issues much like those raised 50 years ago, with the sophistication added by decades of public debate of environmental health hazards, are raised today, and the science backing up those concerns is accessible on the internet.(44) Outside the United States, most other countries have rejected fluoridation, choosing other effective strategies for combating tooth decay.(45)
In short, the fluoridation model is hardly one the biotechnology industry would want to emulate today. Endorsements by prestigious scientific bodies and “clean bills of health” issued by expert committees from which competent critics were systematically excluded have limited persuasive value; their biases are obvious, and they don’t address the issues that often concern the public. While biotechnology advocates may occasionally feel the urge to sweep aside risk issues and crush their critics with propaganda and ad hominem attacks, all that approach really accomplished for the pro-fluoridation movement was to create an entrenched, undying opposition that limited adoption. Fluoridation advocates have never managed to persuade the public to accept the idea solely on its merits.
10. McNeil, D.R. (1957), The Fight for Fluoridation. New York: Oxford University Press.
11. Exner, F.B. and G.L. Waldbott with J. Rorty (ed.) (1957), The American Fluoridation Experiment. New York: The Devin-Adair Company.
12. Wollan, M. (1968), Controlling the Potential Hazards of Government-Sponsored Technology. George Washington Law Review 36(5): 1105-1137.
13. Groth, E. (1973), Two Issues of Science and Public Policy: Air Pollution Control in the San Francisco Bay Area, and Fluoridation of Community Water Supplies. Ph.D. Dissertation, Department of Biological Sciences, Stanford University, May 1973.
14. McNeil, op. cit. (Note 10). The book is a history of fluoridation proponents’ early struggles to overcome public opposition, told from the pro-fluoridation perspective.
15. Wollan, op. cit (Note 12), pp. 1128-29.
16. Groth, op. cit, (Note 13) reviews the literature, as do Exner et al., op. cit. (Note 11).
17. Waldbott, G.L., A,W. Burgstahler and H.L. McKinney (1978), Fluoridation: The Great Dilemma. Lawrence, KS: Coronado Press.
18. Wollan, op. cit, (Note 12), p. 1129.
19. Martin, B. (1991), Scientific Knowledge in Controversy: The Social Dynamics of the Fluoridation Debate. Albany, NY: State University of New York Press. Ethical and legal issues raised by fluoridation are explored at pp. 30-34.
20. Wollan, op. cit. (note 12), pp. 1128-1130.
21. McNeil, op. cit. (Note 10), pp. 145-154.
22. Wollan, op. cit. (Note 12), pp. 1131-1133.
23. Wollan, op. cit. (Note 12), p. 1131. Groth, op. cit. (Note 13) and McNeil, op. cit (Note 10) also reviewed the PHS lobbying campaign to gain endorsements.
24. McClure, F.J. (1970), Water Fluoridation: The Search and The Victory. Bethesda, MD: National Institute of Dental Research. Chapter 14 details the endorsements.
25. McNeil, op. cit (Note 10); McClure, op. cit (Note 24).
26. See McClure, op. cit. (Note 24) for a summary of these studies, many of which he authored or co-authored; see Groth, op. cit. (Note 13) for a more critical review.
27. The PHS began referring to fluoridation risk issues as “not debatable;” see Wollan, op. cit. (Note 12), p. 1133.
28. Pro-fluoridation scientists also refused to debate the evidence on risks and benefits in public with scientists critical of fluoridation. Panel discussions at major scientific meetings were set up to present only the pro-fluoridation perspective. Invitations to debate the evidence with opponents in communities where referenda were pending were rarely accepted. The effort by pro-fluoridation advocates to avoid public debate of the scientific issues has been documented in detail by Waldbott et al., op. cit. (Note 17) and Martin, op. cit. (Note 19).
29. Exner et al., op. cit. (Note 11) presented a detailed and incisive scientific critique in 1957. Waldbott et al., op. cit. (Note 17) updated the critique in the 1970s.
30. Groth, op. cit. (Note 13) reviewed the original studies and found most of Exner et al.’s criticisms valid.
31. Wollan, op. cit. (Note 12) and McNeil, op. cit. (Note 10) document both the stance taken by the pro-fluoridationists and the political context that gave rise to it.
32. McClure’s book (Note 24) embodies the one-sided, closed-minded attitude towards the scientific evidence held by the PHS researchers.
33. Wollan, op. cit., discusses the PHS attitude toward research after 1950.
34. The American Dental Association, an early recruit to the pro-fluoridation effort, put out special issues of its Journal devoted entirely to promoting fluoridation. Articles included advice on organizing a local campaign, discrediting opponents, publicity and other political strategic issues.
35. Martin, op. cit. (Note 19), details how pro-fluoridation leaders made attacks on the credibility of opponents a keystone of their campaign. For examples of the kinds of information used to discredit anti leaders, see American Dental Association (1965), Comments on the Opponents of Fluoridation. Journal of the American Dental Assn. 71:1155-1183.
36. McNeil, op. cit. (Note 10); Exner et al., op. cit. (Note 11).
37. Waldbott et al., op. cit. (Note 17), pp. 316-352.
38. Martin, op. cit. (Note 19) details numerous examples of professional reprisals taken against scientists who questioned fluoridation publicly (pp. 92-114).
39. Waldbott, a Detroit, MI, allergist who reported what he believed to be idiosyncratic reactions on the part of patients hyper-intolerant of fluoride, had difficulty publishing his reports in U.S. journals. He details several of the rejections-and the explicitly political reasons given for them-in Waldbott et al., op. cit. (Note 17), pp. 333-335.
40. Martin, op. cit. (Note 19), also explores the difficulty anti-fluoridation scientists have had in getting their views published in mainstream journals (pp. 97-99).
41. I myself had three manuscripts based on my doctoral dissertation (Note 13) rejected by U.S. public health journals in the 1970s. My reviews of the evidence on risks and benefits of fluoridation were sent to anonymous pro-fluoridation referees, who found them “biased.” One editor advised that he wished to do nothing that might offer anti-fluoridationists any political leverage. Unlike Waldbott, who was an active political anti-fluoridation leader, I was politically outside the fray; my interest was exploring the interplay between political controversy and interpretations of scientific data. My papers were still rejected by several leading American journals in the 1970s, I believe because of a pervasive bias in favor of defending and promoting fluoridation.
42. Groth, E. (1991), The Fluoridation Controversy: Which Side Is Science On? A Commentary, in Martin, op. cit. (Note 19), pp. 169-192.
43. Martin, op. cit. (Note 19) reports that as of 1990, 121 million out of 212 million Americans served by public water supplies were drinking fluoridated water. The figure has held more or less steady at this level since about 1970 and probably has not changed appreciably since Martin’s report.
44. For example, the Fluoride Action Network, an international coalition of organizations opposed to fluoridation, maintains a web site at http://www.fluoridealert.org.
45. Martin, op. cit. (Note 19), Appendix, Fluoridation around the world (pp. 193-217).