708 Journal of Public Health Dentistry

The Public’s Oral Health and the Dental Research Community-Participant or Observer?

Ernest Newbrun, DMD, PhD Division of Oral Biology. HSW-604 School of Dentistry University of California at San Francisco San Francisco. CA 94143-0512

Abstract Dental researchers may sometimes find them-

selves called upon to enter the public arena to promote or defend measures to improve the pub- lic’s oral health. It is important, therefore, to keep up-to-date information at hand to supply to news media, public officials, and others, and to be aware of the opportunities and the pitfalls involved in communicating with the public.

Key Words: water fluoridation, news media, public health

Introduction There is no doubt of the need for a coalition

among groups interested in maintaining and im- proving the public’s oral health. Public health den- tists usually have considerable expertise in fields such as epidemiology, statistics, designing and conducting experimental clinical trials, testing the costbenefit of dental procedures, and interacting with civic and community leaders and school offi- cials. They often lack depth, however, in the bio- logical sciences. Conversely, biological scientists prefer the atmosphere of the research laboratory, symposium, or conference to the rough-and-tum- ble political arena or the community health clinic, and generally shun involvement in public health issues. As Dr. E. M. Mrak, former chancellor of the University of California at Davis, has written, “Sci- entists, generally speaking, are not prepared to step up and do battle; normally, they take refuge in the need to do research rather than in pointing out calculated risks.”

Clearly we need each other. The biological re- search scientist, the dentist in private practice, and the public health dentist must collaborate to im- prove the public’s oral health.

Involvement of the Research Community The American Association for Dental Research

(AADR) has recognized both the need for and the responsibility of the research community to work in the public arena to improve the nation’s oral health. It has established a Science Information Committee whose responsibility it is to expand the distribution and transfer of research findings to

health care providers, thereby expediting the appli- cation of new knowledge. It is hoped that this com- mittee will facilitate AADRs interacting with groups outside of dental research, such as sociolo- gists, economists, and behavioral scientists. AADR also has formed a National Affairs Committee whose prime function appears to be to lobby for continued and increasing support for dental re- search. This is a role foreign to many scientists who in the past have been reluctant to write or phone legislators, but it is a necessary activity if dental research is to survive as a viable part of the academ- ic community. In 1983 the AADR embarked on a Spokesperson Training Program in collaboration with the ADA’s Bureau of Communications. Its purpose is to improve the quantity and quality of communication between the dental research com- munity and the media. Selected dental investiga- tors, teachers, and clinicians are being trained to communicate skillfully in interview situations and public speaking. The National Institute of Dental Research has also recognized its responsibility to ensure that dental research findings are applied by the profession, and recently established a Section on Health Promotion and Science Transfer. The reactors to this article will expand on the section’s function and responsibilities.

Fluoridation-A Continuing Public Health Issue Requiring Scientific and Public Health Involvement

First, I sincerely believe that the research scientist or dentist in academia must willingly serve as a spokesperson before the public on oral health mat- ters in which we have specific expertise. A prime example is topical fluorides and water fluoridation, which are the cornerstones of any comprehensive caries prevention program. Second, it behooves us to keep abreast of the literature on these topics, even when they are not currently a matter of debate or concern in the public arena. Not only do we need to keep informed in this field, but also I have found it valuable to maintain a comprehensive file of re- prints and news releases so that I can quickly and easily check the accuracy of any public statements made concerning fluoridation. Third, it is also im- portant to recognize that no one individual can

Vol. 45, No. 4, Fall 1985 209

“If one were to ask me why a scientist or researcher should become involved in an issue that is not one of scientific controversy but rather of politics, the only answer I can give is simply because we have to.”

keep up on every aspect of the fluoridation issue. When necessary, we must know with whom to consult about fluoridation. Currently, such sources of information nationally are Mr. John Small, infor- mational specialist on fluorides and health, Nation- al Institute of Dental Research, Bethesda, Mary- land; Ms. Lisa Watson, director of Fluoridation and Preventive Dentistry Activities, American Dental Association, Chicago, Illinois; and Dr. Stephen Corbin, Dental Disease Prevention Activity, Center for Disease Control, Atlanta, Georgia.

Shakespeare (1) wrote: Be not afraid of greatness: Some men are born great Some achieve greatness and some have greatness thrust upon them.

The fluoridation issue often requires that the sci- entist (oral biologist) play an active and public role, not merely as passive sources of information and references, but also as public advocates. In doing so, they may sometimes find, not greatness, but certainly public exposure-via press, radio, and television-thrust upon them, a situation that most researchers avoid and even spurn. Nevertheless, antifluoridationists are persistent, often appearing where they are least expected and at the most in- convenient of times. Last year I returned from La- bor Day weekend ready to prepare for our fall quar- ter classes when I opened the Sari Francisco Cliroriicle (2) to read on the front page that the then president of the Board of Supervisors, Wendy Nelder, had called for an investigation into fluoridation of San Francisco’s drinking water, claiming that fluorida- tion was ineffective in preventing tooth decay, that fluoride is a toxic waste product of the aluminum industry, and that fluoridation may be linked to various diseases such as acquired immune deficien- cy syndrome (AIDS), cancer, arthritis, and bone disease (hunchback problems).

As I read these statements, I knew that they would cause a furor and that I would have to be- come involved. A review of the sequence of events during the subsequent two weeks may be helpful to others faced with such a predicament; perhaps we can all learn a lesson from my experience.

Fluoridation and the Media The morning after Supervisor Nelder’s call for a

hearing on water fluoridation by the Board of Su- pervisors, I arrived at work and was called to a meeting with Dean John Greene; Dr. Sam Wycoff; and Mr. Andy Evangelista, representing News and Public Information Services; all at the University of

California San Francisco. Mr. Evangelista had al- ready been contacted by press and radio concern- ing the statements of Supervisor Nelder and had been asked for a response. We decided to call for a press conference at 12:30 pm that afternoon and to have in attendance Dr. Jay Levy, a physician and virologist who was in the forefront of AIDS re- search. News and Information Services contacted TV and the press to invite them to this conference. I meanwhile returned a call from the Sarr Francisco Examiner and spoke at length with a staff writer, Mr. Richard Harris, who was preparing his story for an 11 am deadline, as the afternoon paper would be on the stands by 3 pm that day. Fortu- nately, I was able to retrieve quickly from my file the CDC response on the fluoridationiAIDS issue and respond to the reporter’s questions on AIDS as well as other points, such as the efficacy in reduc- ing decay, toxicity of fluoride, and safety of water fluoridation. No sooner had I put down the phone than I received a call from the science editor of the San Francisco Chronicle, David Perlman, who was preparing a story for the next morning’s edition. Again it was important that I could answer his questions succinctly, honestly, and with scientific accuracy. This call was followed by another from Ms. Abby Cohn, medical writer for the Sari fuse Mercury, asking similar questions. Ms. Cohn had already spoken with Supervisor Nelder and told me that the supervisor had not consulted with any- one in AIDS research or dental research, or with the San Francisco Dental or Medical Societies before making her public statements. The artides that fol- lowed in the evening (3) and the next morning’s papers (4,5), as well as an editorial (6), a cartoon (7), and a news analysis (8), were all strongly in sup- port of water fluoridation, with headlines such as ”Fluoride, AIDS experts scoff at Nelder’s idea,” ”No support offered for fluoride probe,” “Health professionals discredit theory linking AIDS, fluo- ride,” “No evidence linking fluoride to disease, UCSF experts say,” ”Wendy Nelder‘s in deep wa- ter,” ”Nelder’s fluoride remarks may have been too much.” In fact, political commentators stated that Supervisor Nelder had raised apprehension about her judgment and may have seriously damaged her prospects of running for mayor (8).

These events convinced me of the importance of maintaining good rapport with the Fourth Estate and keeping up with the facts on fluoridation. They also demonstrated that time often does not permit preparation of a standard news release when edi- tors face deadlines and want their information im- mediately. Subsequently I phoned these reporters

210 Journal of Public Health Dent i \ t ry

to compliment them on their fair and accurate re- porting of the facts.

By the time of the press conference, I barely had time to draft a response to the supervisor’s state- ments because of the continuous telephone calls from the press. The local ABC and NBC television reporters who attended our conference focused pri- marily on the AIDS/fluoridation claim on the eve- ning news. I also went to the NBC studio for a brief interview for the 5 pm news show. The following day CBS came to do a fluoridation story interview. As with the press, so also the TV coverage was strongly in favor of water fluoridation and critical of Supervisor Nelder’s undocumented claims. One channel in particular questioned her statements that the medical community was not well informed about fluoridation.

”‘forewarned is forearmed’ goes the saying; but when, as in this case, there is no warning, the only remedy is to be always prepared.”

In responding to the press, TV, and radio, it was extremely useful to be able to refer quickly to the CDC release on fluoride and AIDS (9) and provide these media with direct quotations and photocop- ies of the CDC response. If I had had to wait as much as 24 hours to receive a copy from Atlanta, we would have lost momentum. CDC does provide a flip chart that contains many helpful card sum- maries answering many of the antifluoridation ar- guments. It is a good start, but it is the responsibil- ity of every one of us, both as dental scientists and as dental public health officials, to be prepared for attacks on what we consider proven and safe dental public health measures. ”Forewarned is fore- armed” goes the saying; but when, as in this case, there is no warning, the onlv remedy is to be al- ways prepared.

Following closely on the heels of the press and TV coverage came calls from various local radio stations. These calls began in my office on the after- noon that the storv broke and continued the next day, starting as early as 6:30 am at my home. Most of the radio reporters asked if I would object to being taped directly on the telephone, and then proceeded to record my remarks and to broadcast them shortlv thereafter. Again, for the most part, these interviews were largely favorable; the report- ers were incredulous at the supervisor’s remarks and afforded me the opportunity oi responding.

One incident with KCBS radio is worth mention- ing, however, as it was a situation to be avoided. I was phoned by the station and invited to appear on their ”Newsmagazine” program to respond to Su- pervisor Nelder’s remarks and to answer any phone-in questions. I agreed to come to the station

because they stated it was against their policy to have guests responding by telephone. On my arriv- al I realized that I had been brought there on a subterfuge and that in fact the hostess had also invited an antifluoridation physician, Dr. John Lee, who has a long history as an outspoken opponent. When I protested to the hostess of the talk show that I had been brought to the station under false pretenses, she told me to take it or leave it. Had I been aware of the hostess’s plans in advance I would have refused to debate, as it is my policy not to give credibility to antifluoridationists. Because the station had already alerted listeners to phone in at 1 pm I was loathe to let John Lee alone answer their questions. I reluctantly agreed to stay. Next I learned that Supervisor Nelder would be allowed to make an opening statement by telephone to the station, which she did without interruption for about four minutes. After further breaks for news and traffic reports John Lee made an opening state- ment, by which time it was 1:22 pm and the pro- gram was scheduled to last 45 minutes. When I protested to the hostess that as yet I had not had an opportunity to speak, she told me that ”she had had enough of my (expletive deleted) complaints.” When I finally had an opportunity to go on the air I was naturally quite upset, but managed to sup- press my anger temporarily and stay cool. I subse- quently learned that this is a common trick of the trade by talk-show hosts to embarrass and anger their guests and thereby provide more excitement for the program.

Because of the negative press and general media coverage, I anticipated that Supervisor Nelder would drop the fluoridation issue and the whole matter would soon be forgotten. I could not have been more wrong. The press had described Super- visor Nelder as capricious, paranoid, and preoccu- pied with personal security (8). Rather than let the fluoridation issue die down, she agreed to appear on the ABC morning program six days after her initial outburst. Dr. Paul Volberding, head of Medi- cal Oncology and an AIDS expert at the San Fran- cisco General Hospital, and I were invited to partic- ipate with Supervisor Nelder on the program. In this case the host was clearly sympathetic to water fluoridation, but again the supervisor was allowed to make an opening statement without interrup- tion. Then, when we appeared, we were ques- tioned by the host and interrupted by Supervisor Nelder, who made many of the usual antifluoride allegations, claiming that the media were not pub- lishing all the information that the public needs to know, that fluoridation of the water influences oth- er diseases such a s cancer, and that reducing cavi- ties only benefits children, not adults. Viewers were told that most countries, such as Sweden, the Netherlands, Canada, Spain, and Yugoslavia, had stopped fluoridation. In addition, she cited the Johnson and Johnson study (sic, actually the Na- tional Preventive Dentistry Demonstration Pro-

Vol. 45, No. 4. Fall 1985

gram funded by the Robert Wood Johnson Founda- tion, directed by Dr. H. Bohannan) as showing that fluoridation did not reduce cavities.

In planning for this TV program I was able to review Nelder’s earlier TV statements, since our university subscribes to a video monitoring service. On the advice of Dean John Greene I had decided not to give credibility to her allegations on the health hazards of fluoridation but to emphasize the positive dental benefits and let Dr. Volberding deal with the AIDS argument. Although 1 had carefully prepared an opening statement, the host did not allow me to complete it, preferring to keep a discus- sion going. Supervisor Nelder dismissed my com- ments concerning the dental benefits by stating that she was more concerned with the whole per- son and I was only interested in teeth, as after all I was ”only a dentist.” The host allowed her to make a final closing remark, and the net effect was that she sowed the seeds of doubt. I believe that anti- fluoridationists benefited. Perhaps the most impor- tant lesson from the radio talk show and the TV program is that the ground rules concerning the format and time allocation must be clearly spelled out in advance. Antifluoridationists should not be a t an advantage simply because they are public figures.

“The biological research scientist, the dentist in private practice, and the public health dentist must collaborate to improve the public’s oral health.”

Whether or not to participate in radio or TV talk shows or debates on fluoridation poses a real di- lemma for the dental researcher. Such a forum is not intended to advance scientific knowledge in a spirit of free enquiry. The antifluoridationist’s goal is to create fear and raise doubts in the public’s mind, irrespective of any factual basis. If one at- tempts to answer such arguments, one is in effect giving some credence to claims that do not merit serious consideration. Alternatively, by refusing to appear on such programs, there is always the risk of permitting antifluoridationists free rein, as they never turn down an opportunity of free publicity.

The same week an informational meeting had been arranged between Supervisor Nelder and Dr. Mervyn Silverman, at that time city health director. He was accompanied by Dr. Korman, then presi- dent of the San Francisco Dental Society, and Dr. Warren Winkelstein, School of Public Health at the University of California at Berkeley. Dr. John Greene, dean of the UCSF School of Dentistry, and I were also invited to attend. I had a previous en- gagement, but advised Dr. Greene that I thought no good would come of the meeting as Supervisor

Nelder had accepted unquestioningly the antifluor- idation line. ”Oh my prophetic soul,” my hunch was correct (10). To this meeting in City Hall, Nelder had also invited Drs. John Yiamouyiannis, John Lee, Jeff Reinhardt, and a reporter, who sub- sequently wrote an article critical of water fluorida- tion in a neighborhood newspaper (11).

I personally had decided that Supervisor Nelder was a lost cause and that I could better spend my time providing information on the safety and effica- cy of water fluoridation to other supervisors. We assembled a package that included the Coizswner Reporfs articles on fluoridation (12); the CDC re- leases on fluorides and cancer (13), and fluorides and AIDS (9); and my own news release in re- sponse to Nelder’s statements. My news release summarized the efficacy of fluoride in reducing car- ies, explained that toxicity was a question of dos- age-that one ppm fluoride was not toxic-and stated that there was no evidence that an optimal concentration of fluoride in drinking water im- paired general health or was a cause of AIDS, can- cer, arthritis, or bone disease..This package, togeth- er with a covering letter offering to answer any questions or supply any information, was sent to each of the other supervisors.

Other Involvement In addition to involvement with the media, there

are many other avenues of working to ensure that fluoridation is maintained or instituted. In this case I also have interacted with engineers and staff of the city water department, with physicians in the city health department, and especially with my professional colleagues in the San Francisco Dental Society. We have formed an ad hoc Profluoridation Committee, chaired by the president of the San Francisco Dental Society, which includes dentists with political contacts at City Hall. In the event that a specific motion is put before the Board of Supervi- sors concerning fluoridation, we are ready to visit individual supervisors and respond with whatever action is necessary. All of this activity requires a commitment, a willingness to devote time to meet- ings, phone calls, and more meetings. We have recognized that this is a problem that will not sim- ply go away; in fact, Supervisor Nelder has vowed, despite ridicule, to intensify her fight to ban fluori- dation in our city (14). In a speech to the Safe Water Coalition, an antifluoride group, she outlined three approaches: (a) to submit a formal request to the city’s health director to respond to the health issue; (b) to explore a referendum, presumably by initia- tive petition; and (c) to explore the litigation route (15). Of course Supervisor Nelder has the support of John Yiamouyiannis, director of the Center for Health Action, who wants to mount “a massive public education campaign,” and has decided to make San Francisco the arena to defeat and remove fluoridation (16). No one in the dental research community, or any other health profession, can

Journal of Public Health Dentistry

afford to sit idly by while this proven, effective, safe, and inexpensive measure is under attack.

Summary and Conclusions Although I have detailed here the specific issue

of fighting to save water fluoridation in one com- munity, there are broader implications. First, oppo- nents of fluoridation are aggressively attacking this public health measure in many other communities throughout the US and elsewhere. Second, the events described illustrate the role of a dental re- searcher as a participant, working with other health professionals to improve the public’s oral health. Obviously, my personal bias is that persons in the dental research community have a social and civic responsibility to participate actively in promoting the public’s oral health, and not be merelv passive observers. Unfortunately, not all of my colleagues, either in dental research or in clinical dentistry, share this view, particularly if it requires working on fluoridation referenda or hearings. In academia, although we get credit for these activities under the broad rubric of community service, it brings in very little else, neither grants nor other monies that pay for our research, our staff, our supplies, or our travel. It usurps our work and private time and it subjects us to harassment, insults, and grief. If one were to ask me why a scientist or researcher should become involved in an issue that is not one of scien- tific controversy, but rather of politics, the only answer I can give is simply because we have to.

Acknowledgments The author appreciates the careful editorial assis-

tance of Ms. E. Leash in preparing this manuscript.

References 1. Shakespeare W. Tiveltth Night, Act 11, V 158. 2. Hsu E. San Fransisco Supervisor seeks probe of AIDS, fluori-

dation. San Francisco Chronicle 1984 Sept. 5. 3 . Farrell D, Harris RF. Fluoridating the city’s water. Supeni-

sor says new e\,idence links i t to AIDS: Lvants hearing. San Francisco Evaminer 1984 Sept. 5.

4. Colin A . New AIDS furor. SupenGor’s fluoride theory leaves experts incredulous. San Jose Mercuy 1984 Sept 6.

5. Pcrlman D. Fluoride, AIDS experts scoff at Nelder’s ideas. San Francisco Chronicle 1984 Sept 6.

h. Anonymous. \Vrndy Selder‘s in deep w‘iter. Editorial. San Francisco Chronicle 1984 Sept 7.

7 . Meyer. Cartoon: Fluoride causes AIDS! It contaminates pre- cious body fluids!! And for cavities it’s useless!!! San Francis- co Chronicle 1984 Sept 7.

8. Hsu E, Liebert L. News analysis. Nelder’s “fluoride” re- marks may have been too much. San Francisco Chronicle 1984 Sept 8.

9. Anonymous. The fluoride/AIDS allegation. Dental Disease Prevention Activity. Center for Disease Control. FL-123, Jan 1984.

10. Shakespeare W. Hamlet, Act 1, V 40. 11. Kelly J. Fluoride advocate has few answers. San Francisco

12. Anonymous. Fluoridation. Consumer Reports 1978; 43:392- 7, 480-2.

13. Anonymous. No association between fluoridation and can- cer. Dental Disease Prevention Activity. FL-120, June 1982.

14. Burress C. Nelder ready to ask for ban on fluoride. San Francisco Chronicle 1984 Oct 22.

15. Ginsburg M. Nelder warns 100 seniors of fluoride dangers. San Francisco Examiner 1984 Oct 22.

16. Yiamouyiannis J. San Francisco board president may seek fluoride ban. Update CHA 1984 Aug Sept Oct.

Progress 1984 Sept 16.

Postscript Since this talk was presented at the Symposium

of the American Public Health Association, Dental Health Section, on November 4, 1984, much has happened concerning water fluoridation in San Francisco. Supervisor Nelder, true to her word, has continued her fight to stop communal water fluori- dation. She has spoken to numerous Democratic clubs and neighborhood organizations and written articles against fluoridation in various local papers. Those activities culminated in a unanimous deci- sion by the Rules and Legislation Committee on July 8, 1985, to recommend to the full Board of Supervisors that there be a city referendum on whether to continue fluoridation at the time of the November 1985 elections. After vigorous informa- tional lobbying and letter writing in support of fluo- ridation by dental, medical, and other health pro- fessionals; a unanimous vote for fluoridation by the city Health Commission; and an unequivocal re- port strongly recommending that fluoridation be continued from the new director of the San Francis- co Department of Public Health, Dr. David Werde- gar, and his professional staff, the Board of Su- pervisors rejected the proposed referendum by a 5 to 3 vote (August 5, 1985). Undoubtedly, this is not the end of the story; the antifluoridationists need 7,332 signatures to force a ballot by initiative peti- tion. The fight to keep fluoridation continues in San Francisco.

-EN