[NOTE: The first quarter of this article from SATURDAY REVIEW – which is not reproduced below – covers the findings of a 1965 paper from the journal Archives of Internal Medicine, authored by Dr. Donald Taves of the University of Rochester. In the paper, Taves documented high levels of fluoride in the bones of a woman receiving dialysis treatment. In light of his findings, Taves concluded that more research was necessary to determine if the use of fluoridated water in dialysis systems could damage patients’ bones. Until such research was done, Taves cautioned that ” it would seem prudent to use non-fluoridated dialysate baths for long-term hemodialysis.” The remainder of the SATURDAY REVIEW article – reproduced below – describes the research that was conducted in the aftermath of Taves’ report.]
Among the scientists who attended the Philadelphia meeting at which Taves spoke was a young Canadian, Dr. Gerald Posen. Dr. Posen had studied at Johns Hopkins in Baltimore and had gone from there to Montreal to join the staff of the Montreal General Hospital. There he did clinical research with artificial kidneys. It was commonplace for patients aided by artificial kidneys to be attacked by blood and bone discomforts, but these problems were just as commonly dissipated by supplementing the patient’s supply of calcium, phosphorous, and Vitamin D. The experience at Montreal encouraged Posen to take a bigger assignment and he went to the Ottawa General Hospital in Canada’s capital city to take charge of that institution’s artificial kidney unit. There he encountered much more severe manifestations of the same types of bone problems he had found and successfully combated in Montreal. But he discovered to his dismay that the treatments he had used in Montreal would not work in Ottawa. No matter what massive therapeutic dosages he prescribed, the bone deformation in his artificial kidney patients grew worse instead of better.
Posen went to the meeting of the American Society for Artificial Internal Organs in Philadelphia to learn something helpful in alleviating the suffering of the people in his charge. By chance he sat besides Taves at a dinner party. He told Taves his troubles. Taves asked him whether the possibility of fluoride involvement had been considered. Posen said it had not. Taves asked whether the public drinking water in Montreal was fluoridated. Posen said it was not. Was the public drinking water in Ottawa fluoridated? Posen did not know. The question agitated him so much that he walked to the nearest telephone and called Ottawa. Was Ottawa’s public drinking water fluoridation? Yes, it had been since November 1965.
Posen made an immediate decision. He would set up a definitive experiment to determine what, if any, role fluoride might be playing in the suffering of his artificial kidney patients in Ottawa. He asked Taves whether Taves would make analyses of the blood of the patients. Taves was happy to do so…
His next step was to assure a continuing story of what happened to fluoride from the artificial kidney bath water after the fluoride entered the blood. To do that, he had to match the fluoride concentration in the blood of his patients against the concentration of fluoride in their bones.
He asked Taves to recommend an expert bone analyst. Taves recalled that Dr. L.F. Belanger, of the Department of Histology, University of Ottawa, had reviewed a widely discussed Archives of Environmental Health state-of-the-art report on fluoride pathways to bone [see SR, Jan. 4, 1964]. Posen called for help from Belanger, who referred the challenge to one of the three authors of the state-of-the-art report: John Marier, a chemical analyst associated with Dr. Dyson Rose, an internationally reputed chemist on the staff of the National Research Council of Canada. Marier agreed to analyse bone for Posen if Rose would approve. Rose approved, on the grounds that Posen’s project was an important public service worthy of NRC’s respect. All that remained to make the experiment foolproof was for Posen himself to record his patients’ clinical symptoms in fine detail.
At intervals thereafter, samples of blood went to Taves and samples of bone (mostly biopsied from the iliac crest, the bony vestige at the base of the spine where evolutionists say pre-man once had a tail) to Marier. The samples were identified only by number. Neither Taves nor Marier knew the names or physical conditions of the patients they were observing. Only Posen had the identities and clinical records that fit the numbers.
In the half year that followed the Philadelphia meeting, Posen accumulated enough data to reach several solid conclusions. He incorporated these facts into a paper and took it to Washington, D.C., in November 1968 to read at a meeting of the American Society of Nephrology. Expecting a small audience, he was appalled to find that he had been assigned the biggest conference room available. “I will be deafened by the echoes,” he said. When the time came for him to speak, however, the big room was not only filled but overflowing. Hundreds of kidney specialists were attracted by his subject. Posen did not disappoint them. The facts he recited thoroughly confirmed what Taves had hinted at three years before — fluoridated water should not be used in the dialysis baths of artificial kidneys because of the side effects it wreaks in the bones and perhaps in other parts of the patients’ bodies.
If any account of Posen’s report ever has been published in a newspaper or magazine or on a radio or TV broadcast, SR’s science editor is not aware of it.
The reaction of the medical scientists who applauded Posen’s pronouncements is an instructive commentary on the power of the USPHS fluoridation dogma. Scores of kidney specialists buttonholed him afterward, but not one of them raised the question whether fluoridation of public drinking water ought to be discontinued, or whether proposals for further extension of the practice should be subjected to vigorous scrutiny. The only question they asked was: Where can our hospitals buy dependable filters to remove fluoride from the dialysis baths of our artificial kidney units?
Posen was in fact relieved that no one put the larger question because he didn’t feel he could give an answer, one way or the other, that would stand up under scientific analysis. He went home to Canada, located a fluoride filter manufacturer in the town of Hamilton, Ontario, and ordered a set of de-mineralizers to attach to the dialysis baths of artificial kidneys in the Ottawa General Hospital.
Now one of the archaic principles that governs the practice of modern medicine says no physician is really expected to be better than average. As long as a doctor does what most of his colleagues in his neighborhood do, he is safe from criticism. Improvements in treatments of any kind are therefore slow to achieve acceptance. But once a method or a technique is commonly adopted, inertia acts to hold it in operation far beyond its period of true worth. Nevertheless, so many physicians share an inner compulsion to surpass average performance that medicine is carried forward almost despite of itself, in individual spurts related to each other through an incredibly intricate network of informal feedbacks. Somehow this patchwork system of communication penetrated the silence surrounding the Posen project and placed Posen’s name on the list of speakers for a meeting of the Royal Canadian College of Physicians and Surgeons at Vancouver, British Columbia, late in January 1969. Marier was asked to speak to the Canadian Society for Clinical Investigation, which met at the same time and place. And for the first time since original mention of the problem in a medical journal four years before, the side effects of fluoridated water in the bodies of people whose survival depends on artificial kidneys became news to the daily newspapers.
The Canadian Press correspondent who covered the Vancouver meetings sent CP member editors a dispatch that began:
The artifically-fluoridated water supplies of certain cities may cause unexpected complications in the use of kidney machines to keep alive patients with kidney failure, two Ottawa doctors reported…
Their work in spotting the problem and examining its effects has resulted in a decision in the Ottawa General Hospital not to use the city’s fluoridated water in the kidney-machine treatment.
North American cities are being checked to determine whether other centres with fluoridated water experienced the same complications.
Southern News Services clients got a much longer report from correspondent Bob Cohen which opened with these paragraphs:
The fluoride in city water supplies may be aggravating bone problems in people with diseased kidneys who need to have wastes mechanically filtered from their blood every week.
An Ottawa study which describes the possibility was outlined here… at the annual meeting of the Royal Canadian College of Physicians and Surgeons.
Dr. Gerald Posen, head of the Ottawa General Hospital’s hemodialysis unit, reported that fluorides in the Ottawa water supply apparently have had this aggravating effect.
He and colleague John Marier, an analytical chemist at the National Research Council, are now trying to determine whether other cities with fluoridated water supplies have had the same experience.
As so often happens in the United States when the impact of science on society is involved, the reporters at Vancouver apparently did not attempt to probe beneath the surface of events. Full texts of the Posen and Marier talks may not have been available, but abstracts were, and their authorship citations were explicit. Posen cosigned Marier’s paper, Marier cosigned Posen’s, and both appended the names of Posen’s boss at Ottawa General Hospital, Dr. Z.F. Jaworski (who was then on leave from Ottawa to serve as a consultant at Henry Ford Hospital in Detroit where the public drinking water supply is fluoridated and where allergies and neurological disturbances have been attributed to fluoride for years by Dr. George L. Waldbott) and of Taves, who remained in Rochester during the Vancouver meetings. Had the newsman at Vancouver asked about Tave’s role in Posen’s experiment, they would have discovered what has just been recited here — that Posen’s work was a confirmation of Tave’s findings of 1965, and therefore already on a footing of international significance rather than being a [illegible] to coming significance.
In opening his remarks to the Royal Canadian College of Physicians and Surgeons, Posen mentioned sixteen cases in which artificial kidneys were used at Ottawa General Hospital since 1966. Later, in a long-distance telephone conversation with SR’s science editor, he discussed fourteen of these patients who had “minimal or no detectable bone disease” at the time of treatment with artificial kidneys began. Four of the fourteen died before Posen could learn very much about them. The concentrations of fluoride in the blood of all of the remaining ten patients rose to levels comparable to the levels that cause fluoride-induced bone disease in experimental animals. Alkaline phosphatase, an enzyme that circulates in the blood in amounts proportional to the dissolution of bone in the body, also rose steadily in volume in all ten patients. By the end of a year of dialysis with fluoridated water, the ten patients had all developed bone disease. Nine of the ten complained of pain in their bones. Six were attacked by arthralgias — arthritic-like pains in the joints. Three developed calcific bursitis, a condition in which mineral crystals imbed in the shoulder muscles and saw at them from within. Muscles of five of ten patients became weakened, and in three patients symptoms of irritation of the surface of nerves appeared.
X-rays meanwhile showed knobbly growths on some bones, oversize crystals of mineral inside other bones, and disappearance of minerals from areas beneath the surfaces of still other bones. Progressive X-ray pictures revealed that as the period of dialysis with fluoridated water lengthened, dissolution of bone in all ten patients accelerated. In nine of the ten, the mineral substance of some bones became so depleted that the bones broke spontaneously. For example, ribs cracked under the pressure of breathing.
One of the ten patients died last summer, of causes that Posen says have not been determined although the body was autopsied. X-rays of that patient revealed first an area of bone from which the minerals were disappearing, then an associated fracture of the bone. The post-mortem confirmed occurrence of a metabolic disorder little understood by laymen. This phenomenon arises from the fact that the bones of the body are storehouses of minerals that the body draws upon in time of need. When the bones do not respond readily to the demand, the parathyoid gland sends a hormone through the blood to order the bones to act. If the bones still do not respond, the parathyroid assumes the hormone did not deliver the message. The gland thereupon exerts itself to send more hormones. Overexertion causes the gland to grow beyond its normal size. In the Ottawa patient whose death is under discussion here, the parathyroid gland was oversize. One explanation for the condition could be that the excessive fluoride in the bone had combined with and thus locked up an unusually large amount of calcium. As the parathyroid hormone carried its orders deeper into the bone, underlying calcium moved out in response to the instructions. By that time, the enlarged gland had grown accustomed to crying “give,” and it continued to call after the need for calcium had passed.
Posen characertized the influence of fluoride in his fourteen cases as “a complicating factor; we don’t know enough yet to call it a cause.” Marier, who found among his chemical analyses the highest concentrations of fluoride ever observed in human bone, concurred in the view that results of the experiments to date “make it difficult to pinpoint fluoride involvement. Nevertheless,” he said in his report to the Canadian Society of Clinical Investigation, “we have observed a pattern of bone disease that does not respond to normal therapy, associated with high fluoride levels in [blood] serum and bone which strongly suggest fluoride involvement in this particular form of bone disease.”
Of the nine surviving subjects of the study, four have received natural kidneys transplanted from other persons. Two are using artificial kidneys at home, and three remain in the hospital. “Currently,” Marier told his professional audience in Vancouver, “the Ottawa patients are being dialysed with fluoride-free water, and we hope to report on the follow-up phase in the near future.” Immediately after the switch from fluoridated to unfluoridated water, the condition of the patients improved. To what extent the improvement will continue remains to be seen. Marier wholeheartedly endorsed Posen’s closing statement to the Royal Canadian College of Physicians and Surgeons: “We recommend that fluoridated water not be used for hemodialysis until the role of fluoride in renal osteodystrophy is clarified.”
In its news dispatch concerning the Vancouver meeting, the Canadian Press quoted Posen and Marier as having told a press conference that “their findings have no implications whatever in the use of fluoridated water for drinking in those centers which add the chemical to the water supply as a tooth decay preventive.” Questioned on the point by telephone afterward, Posen accepted responsibility for the statement but conceded he could not document it scientifically, nor, he said, could he document the opposite conclusion that fluoridation of public drinking water evokes side effects on a sufficientlly broad spectrum to justify discontinuance of the fluoridation practice. “I don’t wish to be a party to the fluoridation controversy,” Posen said. “I wish only to continue my research and see where it takes me.”
Marier agreed that Posen alone had made the statement quoted by CP. Marier’s personal position was that Ottawa General Hospital’s experience with fluoridated water in artificial kidneys, plus the Rochester-Seattle experience reported earlier by Taves, plus repeated reports in the medical literature of side effects caused by fluoride in water abroad, have clear implications for exposure to fluoride everywhere in the environment, and that these call for deeper research into the metabolic behavior not only of fluoride but of other trace elements in biology such as phosphate, magnesium, calcium, citrate, and cobalt. As man enters an era of profound concern over the totality of his environment, ignorance of small convergences may frustrate his understanding of larger consequences.
In presenting his observations to the Canadian Society of Clinical Investigation, Marier emphasized that side effects of fluoridated water moving into the body through an artificial kidney are not now being translated into predictions of side effects that will be brought about by fluoridated water taken by mouth. He reminded that the concentration of free ionic fluoride in the blood can be as low as 0.02 ppm, whereas the concentration of fluoride in artificially fluoridated water is 1 ppm. In other words, the amount of fluoride in the bath water of an artificial kidney can be proportionately as much as fifty times the amount of in the blood that the plastic coil of the kidney carries through the bath. The 50-to-1 gradient between the outer and inner sides of the coil membrane drives fluoride across the membrane from the water into the blood until an osmotic equilibrium is reached.
At the 50-to-1 ratio, fluoridated water produced bone disease in ten patients studied at Ottawa General Hospital within a year; in two and a half years, all ten patients were actively sick. As is recalled in Michael Wollan’s brief history of fluoridation beginning on page 56 of this issue of SR, specialists in fluoride chemistry who opposed initiation of fluoridation of public drinking water years ago warned that fluoride was such a subtle enzyme inhibitor that its damaging effects would be a long while in exposing themselves; nevertheless, those specialists — several of them Nobel Prize winners — insisted that the effects would be inexorable. SR’s science editor believes there is now excellent cause to determine whether the protesting Nobelists were right or wrong. If water fluoridated at a concentration of 1 ppm can, by moving through an artificial kidney, cripple the body within a year, it is time to discover whether water fluoridated at a concentration of 1 ppm can reasonably be expected to cripple the bodies of severe kidney disease victims who drink the water daily for ten to twenty or more years.
The question posed in these columns five years ago grows more pertinent with time’s passage: Is fluoride’s effect sufficiently selective? Does it protect the teeth without exacting penalties elsewhere in the body? To repeat a comment made here at that time:
Surely we have learned to respect this question. We have frightening examples from the past to justify it. Radium water was drunk by the glassful, with the approval of some of the most advanced physicians, until someone suddenly discovered that those who were drinking it were slowly disintegrating internally. Sulfa elixir was accepted as a cure-all for a while; when its full effects were realized, the drug laws of the United States were reformed as a consequence. X-rays were performed for every imaginable purpose in the belief that there could be no such thing as too much diagnosis; then the National Academy of Sciences in 1956 reported that X-rays were a greater immediate peril to health and life than any other form of radiation, and the use of X-rays dropped sharply almost overnight. Antibiotics worked wonders against some of man’s toughest competitors among the bacteria; but overuse of antibiotics in a shotgun type of therapy alien to modern medicine brought the removal of the antibiotics division director of the U.S. Food and Drug Administration only a few years back, and today the medical profession exhorts its members continually to guard against the undesirable side effects of antibiotics.
Adequate protection of children’s teeth against decay is not at issue. Such protection can be provided without indiscriminately dosing people of robust and frail health alike with fluoride. To pay out public moneys to fluoridate public drinking water and then pay out public moneys to de-fluoridate water used in hospitals is hardly an exercise inn economy when it is possible to confer fluoride’s tooth decay inhibiting benefits on children who need it simply by adding fluoride pills to drinking water in the children’s homes. USPHS could subsidize purchase and distribution of the pills. According to one of four letters on the subject published last January in Science, journal of the American Association for the Advancement of Science, the pills would cost onlly a fraction of the sums spent in fluoridating the water of a city. To repeat another observation made here five years ago:
A possible danger in the continuing effort of the US Public Health Service to fluoridate public drinking water is that it runs counter to the personal resonsibility of the citizen.
– JOHN LEAR