Achievements of the Seventies: Community and School Fluoridation

234 Journal of Public Health Dentistry

Achievements of the Seventies: Community and School Fluoridation

Ernest Newbrun, BDS, MS, DMD, PhD*

INTRODUCTION Communal water fluoridation is an axiom of caries prevention; it is

effective, f’ inexpensive, I h and nondiscriminatory. Children of both sexes, all races, and all socioeconomic classes benefit thereby, and its dental benefits extend throughout the lifetime of residents of optimally fluoridated communities. ’I The safety of ingesting optimally fluoridated water has been amply documented I ’ ” I-‘’ and is further based on the health of communities where for generations the inhabitants have been drinking water with natural fluoride at a concentration of about one ppm.

Opinion surveys concerning fluoridation were discussed in detail in the preceding paper by Frazier (Table I ) . Suffice it t o say, when fluoridation has been defeated in local elections, it has been because we failed to convince the large number of undecided and uninformed voters of the merits and benefits of communal water fluoridation.

TABLE I

ATTITUDE TOWARD FLUORIDATION

National Opinion Research Center*41 Gallup** qy

1959 1965 1966 1968 1972 1977

Very desirable/ desirable 65 72 71 77 70 51 Very undesirable/ undesirable 12 14 13 I 1 13 10 Unconcerned/ don’t know 23 I5 15 12 17 39

*Percent of those who have heard of fluoridation **Percent of all persons surveyed

ACHIEVEMENTS: AN OVERVIEW During the seventies, fluoridation of water supplies continued to receive the

endorsement of many officials and health-related organizations, including President Carter,X Surgeon General Richmond, Ix the World Health Organization, 5” the American Medical Association, I q the National Nutrition Consortium, 3 3 and the Royal College of Physicians of London,“’to name but a few. Somewhat belatedly our own International Association for Dental Research 2y resolved that it “fully endorses and strongly recommends the practice of water fluoridation for improving the oral health of nations.” Valuable support came from the highly respected Consumers Union,” which concluded that the practice is safe, economical, and beneficial. Responding to what it called the “lies and false claims” made in the attacks on fluoridation, the Consumers Union stated that the survival of this fake

*Professor of Oral Biology, Department of Oral Medicine/ Hospital Dentistry, University of California, San Francisco, CA 94143

Vol. 40, No. 3-Summer, 1980 235

controversy represents ". . . one of the major triumphs of quackery over science in our generation."

In the last decade, 17 million persons have been added to the number drinking optimally adjusted fluoridated water (Table 11). While this progress is commendable, it represents a n increase of only five percent of the population receiving public water supplies. At this rate it would take another 80 years to reach all Americans on public water supplies. Clearly this is a n unacceptably slow rate of progress, a s the Comptroller General of the United States recognized in 1979 when he urged the government to put greater emphasis into promoting fluoridation.4' As a result, federal grants are now available for promoting and meeting the initial costs of fluoridating community water systems. 'I

TABLE I1

U.S. POPULATION SERVED WITH FLUORIDATED WATER

Year 19691 19752 I9793 ~~ ~~

Natural F ( > 0.7 ppm) 8,378,824 10,711,049 11,000,000

Adjusted F (optimal conc) 80,096,860 94,627,294 97,000,000

Total 88,475,684 105,338,343 I08,000,000

% Total Population 43 49 49 ~ ~~

%' Population on public water supply 56 60 61

I Fluoridation census 196947 2 Fluoridation census 197548

Values for 1979 are estimated figures approximated to nearest million

The number of persons served by fluoridated water increased rapidly between 1950 and 1955 (Figure I ) , following the reduction in caries successfully demonstrated in the first five years of controlled fluoridation trials and the subsequent

FIGURE 1

U S . POPULATION SERVED BY NATURAL A N D ADJUSTED FLUORIDATED WATER 1945-79

100 c

3 30 (z

2 20

U. S. population served by communal water supplies with natural fluoride, minimum con-

and optimally adjusted fluoride, 0.7 to 1.1 ppm F depending on climate (-). Data for population living in natural fluoridated communities were not

centration 0.7 ppm F (---------- ),


endorsement of fluoridation by the USPHS and American Dental Association. A second surge took place between 1965 and 1970, when several states passed laws mandating fluoridation of domestic water supplies and when New York City, with a population of 8.5 million, was fluoridated. By comparison, the relatively small growth of water fluoridation during the seventies, less than half that during the fifties and sixties (Table I l l ) , is not unexpected. Some of the reasons will be discussed later. Most populous urban communities have already fluoridated. 20 To reach the remainder of the U.S. population, smaller, and therefore relatively-more-expensive- to-fluoridate (per capita), water supply systems still need to be fluoridated. '" Differ- ent strategies and approaches will be required for these small communities, and will be discussed by Faine subsequently in this symposium. 1h

TABLE Ill

GROWTH OF COMMUNAL WATER FLUORIDATION IN EACH DECADE

- -

Decade

~~ ~~ ~~~

Absolute Increase in Population Served by

.-Idiusred Fluoridated Water

1949-59 1959-69 1969-79

38,565,558 40,468,523 I7.000.000

ACHIEVEMENTS: SPECIFIC COMMUNlTlES This overview does not adequately describe the remarkable successes attained by

many dedicated and hardworking fluoridation protagonists in specific communities. Again 1 must restrict my remarks to a few select examples, in this case of communities or water districts serving in excess of 100,000 persons (Table 1V).

After two unsuccessful attempts to fluoridate Seattle's water supply, fluoridation was victorious in a 1968 referendum by a 57 percent margin. Water fluoridation began in 1970 to benefit almost one million residents of Seattle and King County. A further challenge by opponents was overwhelmingly rejected in a 1973 referendum in which nearly 70 percent of the votes cast favored retaining fluoridation. This success has been attributed to three factors - aggressive door-to-door precinct work by health student volunteers, broad-based community support, and lack of a sizable counter-movement. A subsequent attempt to ban fluoridation of water supplies throughout Washington State was defeated in 1976 by a margin of 65 to 35 percent. This victory can be credited to a successful political campaign, involving a statewide organization, contributions totaling $25,000 from a variety of insurance and health organizations, hiring a public relations communications firm, and establishing an aggressive position through the media, campaign hand-out literature, and door-to- door canvassing. I:

In 1972 voters in the Marin Municipal Water District (comprising most of Marin County, California) approved water fluoridation by a 56 percent margin. This campaign was waged by a citizens' committee including local political, professional,

Vol. 40, No. 3- Summer, 1980 23 7

TABLE IV

IMPLEMENTATION OF WATER FLUORIDATION O F MAJOR COMMUNITlESt

IN THE U S A . SINCE 1969

Community

Lincoln, N E Memphis, TN Seattle/ King County, WA Long Beach, CA Fort Lauderdale, F L Bethlehem, PA Columbus. OH Marin Muni. Dist., C A Greenville, SC Cambridge, M A Jersey City, NJ Albuquerque, NM New Orleans, LA Knoxville, TN *East Bay M.U.D., C A **New Bedford, M A Dayton, OH Greater Boston/ M.D.C., MA Cincinnati, OH Montgomery. A L Shreveport, LA (approved, not implemented) Birmingham, A L (approved, not implemented) *Portland, OR (approved, #t not implemented)

Date Begun

I970 1970 I970 1971 1971 I97 I I973 1973

' 1973 I974 1974 1974 1974 1974 1976 1977 1977 1978 I979 I979

Population

158,500 649,5 80 989,800 353,700 139,590 120,000 539,677 I70,OOO 200,000 100,361 259,790 286,400 593,47 I 177,730

I , I00,100 10 1,700 292,224

1,898,160 412,564 153,343 182,054 276,273 400,000

:Only communities o r water districts with more than 100,000 have been listed *Water fluoridation facing another referendum in 1980

#Editor's note: Disapproved in May 19x0 primary 26.000-22.000 **Fluoridation defeated in 1979 referendum. fluoridation still in effect pending court decision

and business leaders who undertook defined tasks such as solicitations of support, fund raising, speakers bureau and p ~ b l i c i t y . ~ ' Between October 25 and 31, 1977, malfunctioning of an antisiphon valve allowed a transient overfeeding of fluoride in the San Geronimo water treatment plant, that resulted in fluoride levels of 5.4 ppm. Antifluoridationists seized on this issue to force another referendum in 1978. Never- theless, voters approved continued water fluoridation by a 53 percent margin.

A major achievement in 1976 was fluoridation of the East Bay Municipal Utility District, serving I , 100,000 residents of Alameda and Contra Costa Counties, California. This district ranks seventh in size among fluoridated communities. The campaign, hampered by minimal manpower and budget ($27,000), was waged by a dedicated steering committee which included one physician, two county dental health officers, a public health nurse, one lay person, two dental society representatives, one community health worker, one representative of the local Jaycees, and one county supervisor. ~ Based on sound political advice, the campaign guide- lines were:


1. Get maximum visibility during the two weeks before the election 2. Concentrate energies in the low-income areas of the community that would benefit most

3. Keep the campaign message short and simple 4. Refuse any public debate forums for television, radio, or before large groups 5. Keep the public image 100 percent positive; and 6. Emphasize endorsements of prominent local individuals and organizations with which

all segments of the community could identify.

Because of the narrow election victory (50.5 percent for versus 49.5 percent opposed - a one percent margin), antifluoridationists have repeatedly attempted to stop fluoridation, and the district faces another such referendum in 1980.

The saga of the struggle in Boston and surrounding communities, 2 "'extending over more than 12 years and culminating in 1978 with the fluoridation of the water supplies for almost two million people, is most encouraging. The Metropolitan District Commission (MDC) is responsible for the water system serving 33 munici- palities within 15 miles of Boston. Until 1968, progress had been restricted by a law requiring a compulsory fluoridation referendum in each community in Massa- chusetts. The first step to overcoming this barrier was the formation of a Massachusetts Citizen's Committee for Dental Health (MCCDH), which lobbied the legislature and mobilized an extensive postcard-writing campaign to convince the legislators that fluoridation had public support. A bill was passed authoriiing a municipal board of health to order fluoridation upon the advice of the Commis- sioner of Public Health, and a referendum was made optional upon petition by 10 percent of the registered voters.

A regional approach to fluoridation was both politically and economically advantageous. The cost of fluoridating the entire M D C was about one tenth of the sum for installing separate equipment in each community. A Joint Committee for Regional Fluoridation was formed that consisted of representatives from city administration, community organizations, dentistry, law, medicine, public health, health education, and water supply engineering. A working subcommittee then drew up a community profile, surveyed the members of each community board of health, and arranged a regional meeting for local health officials at which factual information concerning fluoridation was presented and experts answered questions. Most questions concerned costs, waterworks, legality, and responsibility for implementation and surveillance. The dental benefits were rarely questioned. By March 1971, 27 of the 32 boards of health had ordered fluoridation and a year later the State Attorney General decided that the M D C must fluoridate. Six years later, fluoridation facilities were in actual operation. The Boston story is an example of persistence, patience, and politicking - all necessary ingredients in a water fluoridation campaign.

from the program

FAILURES: AN OVERVIEW Were we not t o analyze our mistakes and learn from them, we would quite likely

repeat them and fail to achieve our goal of nationwide fluoridation. Some of these failures are inadequate communication and public relations, especially vis-a-vis the media and elected officials. Another problem is that fluoridation campaigns have generally been underfinanced, and dependent mostly on donations from the dental profession rather than third-party insurance carriers who, unlike dentists, have a real financial stake in the outcome. There is no mechanism for preparing, training, and

Vol. 40, No. 3-Summer, 1980 239

educating health professionals and lay persons to assume leadership roles in fluoridation campaigns. Without such preparation of our leaders, the odds are against them, especially now that the opponents have experienced political agitators among them who travel around the country anxious to debate, lecture, and lobby against fluoridation. Some examples may illustrate these points.

In 1972 Hushower, ?8 senior sanitary engineer with the Environmental Protec- tion Agency (EPA), warned: “Too frequently, surveillance of the fluoridation installation after the switch is turned on is quietly neglected.” Large urban fluoridation systems have installed automatic fluoride analyzers as a means of maintaining a constant record of fluoride levels and of activating deviation alarms. SbRegrettably, some small systems have not taken similar precautions. At the close of 1979 the record of safety of fluoridation was marred by an accident in Annapolis, Maryland. Through human error, a storage tank valve was not closed. The result was a fluoride spill that raised fluoride levels t o 35 ppm. The excess fluoride in the water caused the death of a kidney patient undergoing hemodialysis treatment in an outpatient clinic,‘ but this intoxication was the result of excess fluoride entering the patient’s circulatory system through transfer during artificial kidney dialysis, nor the result of drinking fluoridated water. The incident was aggravated by the failure of the clinic to use a deionizer as recommended by the Surgeon General more than 10 years ago,45 and by the patient’s refusal t o obtain hospital treatment after acute toxic symptoms appeared. Had he sought treatment he likely could have been saved. In fact, a case has been recorded of an attempted suicide in which a man ingested 120 g of sodium fluoride (about 24 times a lethal dose) and survived thanks to prompt hospital care and management. ’

This unfortunate sequence of events emphasizes the need for strict controls of both water-treatment systems and hemodialysis procedures and for additional training for water plant operators. Furthermore, this single, isolated event must be viewed in proper perspective. There are more than 7,000 water fluoridation systems in the U.S., supplying over 97 million residents. A record of one fatality in 97 million people compares favorably with other preventive public health procedures such as immunization. Any mistakes in adjusting the concentration of fluoride in the water have usually erred on the side of shortchanging communities. Spot checks by sanitary engineers of the EPA have found that some communities supposedly fluoridating were not, whereas others were, but not at adequate levels. ‘’

Water fluoridation reduces the cost of dental care to residents of fluoridated communities and has a highly favorable benefit/ cost ratio. 3b Surprisingly, dentists’ support of fluoridation has been misinterpreted as serving their own personal economic goals. I h Feldstein, an economist, writes: “Fluoridation reduces the demand for restorations for children . . . allowing dentists to concentrate upon higher fee adult services.. . . Fluoridation, emphasis on good oral health habits, and coverage of children’s preventive services under federal programs should ultimately result in a higher demand for dental care when these children become adults.” These remarks come not from an antifluoridation extremist but from a professor in the School of Public Health and Department of Economics at the University of Michigan.* Ignored are the facts that fewer teeth are lost, fewer restorations required - particularly of the expensive multiple-surface type, and fewer days missed from school or

-

*Editor’s note: Feldstein sought but then ignored the technical advice of his dental public health col- leagues at Michigan. ~ DFS


work. When these cost savings in dental treatment and in personal time for the patient are misrepresented as self-serving to the dentist, we have reached 1984 d ou ble-spea k.

Obviously we must convince critics that support of preventive public health procedures such as fluoridation, immunization, and nutritional education by health professionals is not out of self-interest but out of a commitment to improving the health of patients. Ironically, it has been dental societies and dentists themselves - with no financial gain therefrom - who have been the major contributors, both in money and time, to the fluoridation campaigns. In contrast, the health insurance industry, the only business entity that stands to benefit financially from caries prevention and reduced need for dental services, has not contributed significantly to the effort t o extend water fluoridation.

A surprising attack on fluoridation came on July 18, 1974 from an unexpected source, Jack Anderson, the political columnist in the Washington Posr. He wrote a column, widely syndicated to other newspapers, entitled “A belated look at fluoridation,” questioning its efficacy in caries prevention because the original clinical trials had not been conducted under “blind” conditions. Numerous objective and “blind” measurements demonstrating the effectiveness of water fluoridation exist to refute this criticism. iJ When presented with such data, Anderson never corrected nor retracted his misleading commentary. The lesson from this episode is that it is important to keep national columnists and reporters continuously informed about fluoridation and to establish rapport, so that they know how to validate any stories with informed sources hefore the articles are published. Furthermore. contacts should be established between dental school faculties, dental society officers. USPHS regional dental consultants, and the science editors of local newspapers.

Who are the experts on fluoridation and public relations at the national level‘? Until 1976, the ADA’s Secretary of the Council on Dental Health, Mary Bernhardt, fulfilled this function in Chicago. Regrettably, after she left there was a four-year hiatus before Gordon Schrotenboer was appointed in November 1979 as Director of Fluoridation Activities.* In the Division of Dentistry, USPHS, Cora Leukhart and John Small served this function in Washington, D.C. until 1976, when the fluoridation activities were moved to the Center for Disease Control ( C D C ) in Atlanta and called the Dental Disease Prevention Activity. Cora Leukhart now has retired a s Public Health Advisor and John Small has transferred to the Office of the Director of the NIDR in Bethesda.

Naturally these changes caused disruption, loss of momentum, and lack of continuity in our ability to respond to fluoride issues at a national level. Chrono- logically this disruption coincided with the hiring on June I , 1974 of Dr. John Yiamouyiannis as full-time Science Director of the National Health Federation, (NHF), an organization founded in 1955 with headquarters in Monrovia, California. The N H F is “dedicated to the protection of health freedoms,” emphasizing that the patient should be free to choose alternative forms of health care and that the choice should be free of governmental restriction. ’’ The N H F opposes pasteuri~ation of milk, fluoridation of public water supplies, and immunizations, and promotes Laetrile, K r e b i o ~ e n , megavitamin therapy, naturopathic medicine, chelation

*The position is part-time. #Editor’s note: To CDC‘s credit, considerable ha5 happened to revitalirr CDC‘s F cfforts. See Faine’s

paper which follows later (p. 258-67). -DFS

Vol. 40, No. 3 - Summer. 1980 241

therapy, and a variety of other health care practices. Yiamouyiannis’ prime assign- ment was to “break the back” of efforts t o fluoridate more American communities. “’ The NH F apparently has adequate financial resources and a n organizational structure of national scope. During the past six years the N H F has gained extensive experience in many campaigns and can bring i t t o bear in local communities. The appeal of the antifluoridationists is not limited to members of the NHF, but is based on several factors:

The wisdom of the exercise of governmental power is no longer assumed in this post- Watergate era. The theme of freedom of choice is exploited to the utmost. Concern over environmental issues (air and water pollution, nuclear wastes, car- cinogens) has increased. People are skeptical about public health practices (e.g., swine flu immunization program). Alternative approaches to health care, health habits, and nutrition are in vogue with many people - a trend which is accompanied by an “antiscience” attitude and distrust of established scientific methods. A growing reluctance prevails toward placement of additive agents into food, water, and the general environment.

Just when the opponents of fluoridation were mounting their strongest and most concerted attacks, the ADA and USPHS posture was weakest, both in personnel and budgetary support. Other commitments t o promoting fluoridation were also dropped. In 1975 the ADA terminated its excellent Fluoridation Reporter, and the USPHS stopped regular publication of the Fluoridation News in 1974, although they continued to send out periodic news releases. No renewal of either of these reliable sources of information on fluoridation is currently contemplated. In contrast, almost every issue of the NHF‘s monthly bulletin carries some misinforma- tion on this topic.

Belatedly, some of these deficiencies were recognized by the ADA, which established a National Advisory Committee on Fluoridation in 1978 and then appointed a Director of Fluoridation Activities with a scientific background to function as an in-house expert at ADA headquarters. Similarly, not until 1979 did the D H E W allocate $10 million for grants to initiate fluoridation projects and for increasing the staff directly concerned with fluoridation at the Dental Disease Prevention Activity of CDC. In the President’s 1980/81 budget a $3.0 million increase in funds for community water fluoridation has been requested. These changes augur well for fluoridation in the eighties.

FA1 LIJ R ES: S PECl FIC COM M UNIT1 ES Oregon has one of the lowest percentages of population (16 percent) served by

fluoridated water; only Hawaii, Nevada, and Utah have less protection. Oregonians pride themselves on being conservationists and protectors of the environment (e.g., there is a state law requiring deposits on all beer and soft drink containers). In 1979a statewide initiative attempting to ban water fluoridation was defeated by 57 to 43 percent, a narrower margin than in neighboring Washington that same year (65 versus 35 percent). ‘ ‘ I Water fluoridation was narrowly approved by a 50.8 to 49.2 percent vote in a referendum in Portland in November 1978, but because of legal dilatory tactics by opponents it has not been implemented, and another referendum is scheduled in May 1980.*

*Editor’s note. And fluoridation lost.


With this background in mind, I would like to review communal water fluoridation in Eugene, a city with a population of 94,000 in Lane County, 105 miles south of Portland. Eugene is the home of the University of Oregon, a center of lumber industry, plywood and wood products manufacture, and fruit and vegetable canneries. In 1958 a fluoridation referendum was defeated. Six years later, in 1964, fluoridation was approved, briefly instituted but subsequently defeated. In November 1976 at a general election, fluoridation was again approved, but in a special election in June 1977 it was rejected by an almost 2 t o I margin (64 versus 36 percent). An article about this latter referendum, written by a reporter with a clear antifluoridation bias,44 gives some insight into the local situation. The chairperson of the local Committee for Better Dental Health, the Lane County Medical Health Officer, a member of the statewide Committee of Oregonians for Fluoridation, and the President of the Oregon Dental Society were all interviewed by the reporter. Their responses to questions concerning the Burk-Yiamouyiannis claims, National Cancer Institute studies, Rappaport’s paper claiming a fluoride-Down’s syndrome link, and the Bartlett-Cameron study in Texas - at least as reported ~ reveal a lack of familiarity with the fluoride literature. Leaders in fluoridation campaigns need to be aware of the opponents’ literature in order t o effectively refute their spurious arguments. A continuing educational program for such community leaders should be instituted to train them and thus avoid such embarrassing situations. Of course it is impossible to know all of the extensive fluoride literature, but some arguments are repeatedly raised by opponents and can be demolished effectively, 24

Utah, with a total population of just over one million inhabitants, ranks last of all the states in the U.S. in percentage (2.4) of population served by optimally fluoridated water. In November 1976, a statewide initiative, prohibiting fluoridation by the State Board of Health and requiring approval by a vote of a majority of the users of a water supply in order t o fluoridate, passed narrowly (51.6 percent of the vote). In an analysis of this referendum, Dwore’’ found that the major political figures sidestepped the fluoridation issue. The Church of Jesus Christ of the Latter Day Saints, encompassing about 70 percent of Utah residents, declared in 1972 that fluoridation was not a moral issue and therefore took no stand. However, many individual church members were antifluoridationists. Much of the campaign information and literature was provided by the NHF. The news media accorded much free coverage t o the campaign - probably more advantageous to the antifluoridationists because they gained publicity and could sow the seeds of doubt. Their strategy was based on citations of quasi-scientific studies and the stimulation of grassroots support. The profluoridation campaign was based upon scientific evidence and conducted largely through the media. The opponents’ concerns about freedom of choice were dealt with sparingly, and community organizations were not utilized to deal with citizen anxiety at the local level. Professional and voluntary organizations throughout the state were not mobilized in a coordinated effort. ‘I Given Utah’s early opposition to and slow acceptance of smallpox vaccinations, poliomyelitis vaccinations, and water chlorination, the defeat of statewide fluoridation was not surprising.

Since the AADR is convening in Los Angeles, one of the few large American cities not yet optimally fluoridated, it is appropriate that we consider L.A. among our failures. The City of Los Angeles, population 2,858,000, served by the Depart- ment of Water and Power, obtains its water from several different sources. About 60

Vol. 40, No. 3-Summer, 1980 243

percent comes from the Owens Valley-Mono Basin aqueduct system and has a natural fluoride content of 0.6 ppm. This serves the San Fernando and West Los Angeles areas. Residents in the east side and south central area (Watts) obtain their water mostly from the Colorado River (0.3 ppm F) and from wells (0.2 to 0.3 ppm F). A mixture of Owens Valley and Colorado River water supplies Eagle Rock, Hollywood, Silverlake, downtown and adjacent areas and has about 0.4 ppm fluoride. The recommended concentration of fluoride for Los Angeles and vicinity is 0.8 ppm, so that at present it is suboptimally fluoridated. A few neighboring communities (Beverly Hills and Long Beach) have optimally adjusted fluoridated water.

Since 1967 the Los Angeles City Council has regularly considered introducing fluoride into the water supply. In 1966 the Council narrowly rejected such a plan. In 1973 all 15 councillors were personally canvassed about their position on fluoridation by the Fluoridation Committee; 10 favored the measure and five opposed it. A resolution on fluoridation was introduced. Following extensive testimony and approval by the Public Health, Welfare, and Environment Committee, the regulation finally passed the City Council, 10 to five, in September 1974. Imme- diately the councillors were subjected to extensive antifluoride mail, calls, and even threats.” Within two months some of the councillors, bowing to the political pressure of the antifluoridation lobby, voted to place the ordinance on the ballot for the municipal general election of May 1975.

The battle lines were drawn, proponents obtained endorsements from Mayor Bradley, some well-known sports personalities (Sugar Ray Robinson, Arthur Ashe, Henry Hine), local health authorities and the Los Angeles Times. Opponents gained the support of the Herald- Examiner and Station KNX. The antifluoridationists waged an effective scare campaign, exploiting some misleading and inaccurate statistics relating cancer death rates t o fluoridation. These spurious associations have since been fully answered, ”but a t the time they clearly influenced some voters. Also, during a critical stage in the campaign, Governor Brown’s newly appointed director of the state health department, Dr. Jerome Lackner, stated in a letter to the Los Angeles Times that the department had a “neutral” policy on water fluoridation - in other words, favoring the status quo and the antifluoridation lobby. The fluoridation ordinance went down to defeat with only 44 percent of the electorate in favor versus 56 percent opposed.

Analyzing the returns and the campaign strategy reveals some of the tactical errors. At the beginning, when the Council approved the ordinance, the Fluoridation Committee should not have rested on their laurels and allowed the lobbying of the opponents t o force an election. The Council vote ought to have been sustained by a massive letter-writing and phone campaign demonstrating popular support of the ordinance. The financial support of the campaign (about $32,000) was inadequate for such a large city. Much of the money was provided only in the last few weeks and was therefore not used to maximum effect. Proven campaign methods such as community outdoor graphic signs were not adequately used, nor were the local resources (e.g., dental students and faculty at UCLA and USC). Proponents participated in public debates with the antifluoridationists, unnecessarily providing them with a forum and media exposure. The most serious tactical error was to ignore the minority vote - the widest margin against fluoridation (two to one) occurred in a district with one-third black and one-third Spanish-speaking population. Such mistakes must not be repeated.


FLUORIDATION OF SCHOOL WATER SUPPLIES Communal water supplies are not available to large segments of the world’s

population which depend on wells, cisterns, or other individual sources of water. Approximately 20 percent of the U.S. population lives in areas lacking a central water system. In such areas, fluoridating a school’s water is a suitable way to provide systemic fluoride to children. l 4 It is not an alternative to communal water fluoridation where a communal water supply exists. An obvious limitation of school-water fluoridation is that children are five or six years old when they start school, a t which time the crowns of their incisors, first bicuspids and first permanent molars are already fully formed. Maximum dental benefits accrue when fluoridated water is consumed from birth. Another disadvantage of school-water fluoridation is that children receive only intermittent exposure to fluoride. ‘5There are usually about 180 class days during a school year, and only six to seven hours are spent in school on these days. T o compensate for this part-time exposure, the fluoride concentration for school fluoridation must be higher than that recommended for community fluoridation - 4.5 times the optimum level for the community. Considerable protection from caries is obtained, particularly for later-erupting teeth, and the extraction rate of permanent teeth is lowered by about 65 percent.

According to the Fluoridation Census of 1975, 4x school fluoridation programs had been instituted in 13 states in the U.S. These programs serve 383 schools with a total enrollment of 124,475 students (Table V). Some schools cover only kindergarten to 3rd grade o r 6th grade, most serve kindergarten to 8th grade, and a few

TABLE V

PROGRAMS FOR FLUORIDATION OF SCHOOL WATER SUPPLIES IN U S A . , * BY STATE

Number of State Schools Enrollment

Florida 1 450 Indiana 27 10,115 Kentucky I23 36,632 Maine 8 2,238 Montana I 170 Nebraska I 1,288 New Mexico 6 1,473 North Carolina 105 43,574 Pennsylvania 4 3,600 Tennessee 17 4,976 Vermont 54 12,98 I Wisconsin 24 5,229 Wyoming 12 I ,749

United States 383 124,475

*Fluoridation census 1975, U.S. Department of Health, Education and Welfare

Vol. 40, No. 3-Summer, 1980 245

extend to the 12th grade. Currently it is estimated that 400 schools have water fluoridation programs, most of which were instituted during the seventies. Regret- tably, they account for a very small number of children in the overall scheme of things .

S U M M A R Y Communal water fluoridation continues t o be the cornerstone of a n ideal caries

prevention program. Its efficacy in reducing caries prevalence by about 50 to 60 percent was demonstrated throughout the seventies from Perth to Toronto. During the past decade, opponents of fluoridation have relentlessly attacked the safety of the procedure, but careful scientific analyses have not sustained their criticisms. The health and other scientific communities continue to endorse and recommend the practice of water fluoridation for improving dental health. During the seventies a n additional 17 million Americans have benefitted from drinking fluoridated water, but this progress is too slow, particularly when compared with that of the fifties and sixties. Fluoridation campaigns in Seattle, Greater Boston, and California’s Marin County and East Bay Municipal Utility district provide examples of successful tactics. An analysis of unsuccessful campaigns in Eugene, Los Angeles, and the State of Utah reveals mistakes which should not be repeated in future elections. For the eighties new approaches will be needed, particularly to reach the many smaller remaining communities. It is essential that the ADA and the USPHS maintain a stable office with sufficient staff and expertise on fluoridation. Training programs are needed to help prepare local community leaders and to assist them in obtaining fluoridation for their communities. Additional studies have documented the efficacy of school fluoridation programs for areas lacking a public water supply. Many school fluoridation programs were introduced during the seventies; nevertheless, they serve a very small number of children.

ACKNOWLEDGMENTS

Thanks to Harold Hodge, Professor of Pharmacology and Oral Biology a t the University of California, S a n Francisco, for his critical review of the manuscript and to Ms. Evangeline Leash for her careful editing.

References 1 . Abukurah. A.R. , et al. Acute aodium fluoride poisoning. Am. Med. A. J . , 222816-7, Nov. 1972 2. Alluhian, Myron. Fluoridation - a continual struggle in Massachusetts. Harvard Dent. Alum. Bul.,

2X:I-4. Dec. 1968. 3. Allukian. Mbron, Steinhurat, J . , and Dunning, J .M. Community organization and a regional

approach to fluoridation of greater Boston. (Pape r delivered at) the 104th Annual Meeting, American Public Health Association, Dental Health Section, Miami Beach, Florida, Oct. 18. 1976. I 2 p. duplicated.

4. Anderson, R., Beard, J .H. , and Sorley, D. Fluoride intoxication in a dyalisis unit ~ Maryland. Morbidity-Mortali ty Weekly Rep. 29: 134-6, Mar. 28, 1980.

5 . Bacher-Dirks, 0. The benefits of water fluoridation. Caries Res., 8(Suppl.):2-15, 1974. 6. Backer-Dirks, O., K u n i e l , W., and Carlos, J.P. Caries-preventive water fluoridation. Caries Res.,

I?(Suppl. 1):7-14. 1978. 7. Boriskin, J . M . The winning of a large fluoridation campaign. Cal. Dent. A. J., 7:53-63, June 1979. 8. Carter. J immy. Telegram t o Dr. F.T. Bowyer, President, American Dental Association, Oct. 20,

1978.

246 J o u r n a l of Public Health Dentistry

9. 10. I I .

12.

13.

14.

15.

16. 17.

18.

19. 20.

21.

22.

23.

24.

25.

26.

27. 28.

29.

30.

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Fluoridation: the cancer scare. Consumer Rep. 43:392-6, J u l y 1978. Crecelius, C.I. Letter to members of the National Health Federation. Nov. I , 1974. Domoto, P.K., Faine. R.C., and Rovin, S. Seattle fluoridation campaign 1973 ~ prescription for a victory. Am. Dent. A. J., 91:583-8, Sept. 1975. Dwore, R.B. A case study of the 1976 referendum in Utah on fluoridation. Pub. Health Rep.,93:73-8, Jan.-Feb. 1978. Ericksson, Y. Report on the safety on the drinking water fluoridation. Caries Res., X(Suppl.):16-27, 1974. Environmental Protection Agency. Water Supply Division. School water supply fluoridatton by Bellack, Ervin, Publ. No. 759-904! 1126, Washington, Government Printing Office, 1972. 18 p. Evans, C.A., and Pickles, T. Statewide antifluoridation initiatives: a new challenge to public health workers. Am. J . Pub. Health, 68:59-62, Jan. 1978. Faine, R.C. An agenda for the eighties. J. Pub. Health Dent., 40:258-67, Summer, 1980. Faine, R.C., Evans, C.A., and Danforth, H. Political action; a new era in fluoridation campaigns. Health Educ., 9:5-7, Nov.-Dec. 1978. Feldstein, P.J. Health associations and the demand for legislation: the political economy of health. Cambridge, Mass., Ballinger, 1977. xii + 255 p. Fletcher, D.C. Revised statement on fluoridation. Am. Med. A. J., 231:l 167, Mar. 1975. Frankel, J.M., and Allukian, Myron. Sixteen referenda on fluoridation in Massachusetts, an analysis. J . Pub. Health Dent., 33:96-103, Spring 1973. Grants for preventive health services; grants for fluoridation. Federal Register, 44( 188):55378-9, Sept. 26, 1979. Heifetz, S.B., Horowitz, H.S.. and Driscoll, W.S. Utili~ation of fluorides in areas lacking central water supplies. Canad. Dent. A. J., 40:136-46, Feb. 1974.

. Effect of school water fluoridation on dental caries: results in Seagrove, N.C., after eight years. Am. Dent. A. J., 97:193-6, Aug. 1978. Hodge, H.C. Evaluation of some objections to water fluoridation. p. 147-70. (In Newbrun, Ernest. ed. Fluorides and dental caries. 2nd ed. Springfield, 111.. Thomas, 1975. xxi + 181.) Horowitz, H.S. School fluoridation for the prevention of dental caries. Internat. Dent. J., 23:346-53, June 1973. Horowitz, H.S., et al. School fluoridation studies in Elk Lake, Pennsylvania, and Pike County. Kentucky - results after eight years. J . Pub. Health, 58:2240-9, Dec. 1968. Hunter, W.B. L.A. fluoride and politics. Dental Dimensions, 9:12, 25, Jan. 1975. Hushower, T.N. Fluoridation surveillance: how good is it? (Paper delivered at) the 23rd National Dental Health Conference, American Dental Association, Chicago. Ill . , Apr. 1972. 8 p. duplicated. International Association for Dental Research. Policy statement of the IADR fluoridation of water supplies. J . Dent. Res., 58(Spec. Iss. D):2160, Nov. 1979. Leukhart, Cora S. An update on water fluoridation: triumphs and challenges. Pediat. Dent.. 1:32-7, 1979. Murray, J.J. Fluorides in caries prevention. Bristol, Wright. 1976. 195 p. National Health Federation. This is the National Health Federation, NHF Bul. 2I:Flyleaf. 1975. National Nutrition Consortium. Statement on water fluoridation, Dec. 2 I , 1976. Newbrun, Ernest. Objective and blind measurements demonstrating the effcctiveness of water fluoridation. p. 9-1 I . (In Newbrun, Ernest, ed. Fluorides and dental caries. 2nd ed. Springfield, I l l . , Thomas, 1975. xxi + 181.)

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The FCC, F, and Fairness (Editor’s note: A memo from Bob Isman, Director of Dental Health Services in Portland, Oregon, relates his problems with “The Fairness Doctrine” of the FCC. - DFS)

Fluoridation proponents in Portland, Oregon, recently learned the hard way about a decision of the Federal Communications Commission that potentially affects the ability of opponents to gain free advertising time on radio and television.

The so-called “Cullman doctrine” is an interpretation of the “fairness doctrine” by the FCC that requires television and radio stations to “aff_ord reasonable oppor- tunities for the presentation of contrasting views by spokesmen for other responsible groups.” Stations a re allowed considerable discretion as to the techniques or formats to be employed and in the selection of spokesmen for each point of view.

What is particularly noteworthy about the Cullman doctrine is that it states that a station cannot re.ject a presentation and thus leave the public uninformed ~~ on the ground that the station cannot obtain paid sponsorship for that presentation.

In Portland, fluoridation proponents recenty spent approximately $25,000 on the production and airing of two 30-second television spots promoting the defeat of a ballot measure aimed at repealing fluoridation. One television station, totally on its own and invoking the Cullman doctrine. produced a 30-second spot for free and pro\,ided approximately $4,500 worth of free air time to run i t for an antifluoridation group. That group was then able to go to other TV stations that had run the profluoridation spots and demand free air time for their spots. In total, the antifluoridation group 1-eceived for free about 25 percent of the value of the time that had to be purchased by proponents.

While the Cullman doctrine does not speak specifically to commercial advertising versus programming, the FCC has interpreted i t as also applying to paid political spots on controversial ballot measures. Also. while there is no requirement as t o the amount or value of time that must be made available for opposing views, it must be “reasonable” enough so that the public is adequately informed on both sides of the issue.

Fluoridation proponents .who are contemplating a radio and;or television advertising campaign around a ballot measure would d o well t o study the Cullman doctrine and its implications for making free media time available to opponents.

Documents

Achievements of the Seventies: Community and School Fluoridation