DAlthough we are practicing physicians and medical researchers, we have spent as much time in our careers thinking about fluoride as most Americans – very little. This changed with the appointment of Robert F. Kennedy Jr. to oversee the federal government’s medical, public health, and research infrastructure. Kennedy expressed concerns about fluoridation of the public water supply, question the practice while highlighting research studies on fluoride toxicity.
The dormant topic of water fluoridation has quickly become a hot-button public health issue, outpacing a long list of far more pressing health threats. How did we get here?
We fear that our rapidly expanding scientific evidence base, coupled with an increase public access to and familiarity This makes it easier to rely on “science” to distract from important, but often uncomfortable, discussions about the values and trade-offs that are truly at the heart of any political issue.
Take this example of fluoride. Fluoride has been added to public water supplies in the United States since the mid-20th century, when research clearly showed that fluoride in water could significantly reduce tooth decaywhen fluoride occurs naturally in water sources or added in treatment facilities. Fluoridating a public water supply provides a cavity prevention benefit to all who drink it, regardless of their dental hygiene habits or access to dental care. Yet, as with any substance – from water to food and medicine –excessive amounts of fluoride can cause problems. This can range from whitish discoloration of the teeth (a purely cosmetic problem) to negative effects on the brain resulting from prolonged exposure to excessive levels of fluoride.
Proponents and critics of fluoridation rely on their own favorite scientific studies to support their claims. Proponents of fluoridation point to research on fluoride’s clear dental benefits and its safety at low levels. And the U.S. Centers for Disease Control and Prevention, which Kennedy is appointed to oversee, considered fluoridation “one of the 10 major public health interventions of the 20th century.” However, critics focus on research suggesting toxic effects of fluoride at high levels, fearing that it can be harmful even at low levels. Kennedy plans to “advise all water systems in the United States to eliminate fluoride.” Both sides cite various studies to justify their contradictory positions.
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When those who cite scientific research come to completely opposite conclusions, we must ask ourselves: is this debate really about science, or is science being used – consciously or not – to distract from a uncomfortable conversation? At its core, the fluoride debate pits great public benefit against low potential risk and personal autonomy. It’s much easier to cite and overinterpret research on toxicity than to say, “I don’t think we should have fluoride in the water supply because of the low risks, even if it means removing the dental benefits.” known to the community. .” It’s also easier to focus on the number of cavities prevented rather than saying, “I think the population-wide dental benefits outweigh both the small potential risk of toxicity and the loss individual choice about what goes into our drinking water. »
Fluoride in our water can be a health problem. But it is also a political question.
Science, when properly applied, can and should inform the most difficult decisions we as individuals and societies must make, whether it is a specific medication for a patient to take or of a public policy to be implemented. This can tell us what benefits we might gain from choosing a path and what it would cost – financially or otherwise – to achieve those benefits.
But science cannot tell us if compromises are worth making; it’s a question of values. A randomized controlled trial tells us what the benefits and side effects of a medication are, but only the patient can tell us if they are willing to tolerate those side effects to benefit from it. Similarly, researchers can estimate the impact a new tax credit might have on the bank accounts of American families, but they can’t tell us whether tradeoffs in the form of budget cuts are worth making. .
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When these value-based decisions are particularly difficult or uncomfortable to consider, science can also serve to distract the public—intentionally or not—when it is presented without considering the trade-offs involved.
Think about COVID-19. Early in the pandemic, it was easier to focus on community infection rates and other epidemiological assessments than to address head-on the tradeoffs between health benefits for some and long-term education. night to children caused by the closure of schools – harms which were not easy to measure but which were reasonable to foresee. The debate around mask and vaccine mandates draws inspiration from scientist studies on their role in the transmission of COVID-19, but often glossed over a careful assessment of the trade-offs between public health and personal autonomy that were the real heart of the problem.
Science, and its quality, is often a topic of debate, when the debate should instead focus on what we value when we choose one path or another. Rather than determining exactly what trade-offs to make, science is increasingly misused to justify the values a person holds – a mental sleight of hand to avoid a frank assessment of one’s own beliefs and the value of costs and benefits. Avoiding discussing these tradeoffs and the values behind them only makes it more difficult to move forward and create policy that works for a majority of Americans.
Science tells us, for example, that alcohol is bad for us: This leads to liver disease, heart attacks, strokes, cancers, accidents, crimes, deaths and loss of economic productivity, among other problems. Holding on to this science would make an easy argument for a total alcohol ban. Yet the reason people haven’t taken to the streets to demand one is that after centuries of battling the problem, society has decided that the scientifically measured harms of alcohol don’t completely outweigh the benefits more familiar.
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Science is used appropriately – even imperfectly – to help us reasonable compromises when it comes to alcohol in our society, for example by restricting the freedom to consume alcohol before driving or preventing its sale to teenagers who are less likely to drink responsibly. No one who thinks alcohol should be legal thinks it should be legal because the science is inconclusive about its harms; rather, with benefits for many, there are simply trade-offs to be made.
All of this means that when we hear politicians, other leaders, or anyone say that they “listen to the science,” we have to wonder what part of the debate they might not I listen or maybe I don’t want to talk about it. Truly listening to science requires accepting that science, while useful, is no substitute for honest human judgment which will reasonably differ between individuals and over time in a diverse and dynamic society. This means that we must be prepared to change our minds if new data suggests to us that the trade-offs between potential harms are not worth making for the potential benefits.
There are some issues where there is already broad agreement on what compromises are worth making. For example, surveys tell us that the vast majority of Americans support requiring vaccinations against potentially devastating childhood diseases in order to attend school. But for most people, fluoride represents a new debate, and here, a good faith debate involves considering the real benefits of fluoride for dental health, rigorously evaluating any risk of toxicity due to excess fluoride and to recognize the greater availability of other sources of fluoride in toothpastes, mouthwashes, supplements and varnishes than in the last century. Reasonable minds might come to different conclusions, which is why communities in the United States and abroad both choose to add and to withdraw fluoride from their public water supplies.
Moving forward, transparent, evidence-based discussions about the trade-offs at play in public health decisions – without being obscured by distracting, misinterpreted, or non-existent research that does not actually illuminate these trade-offs – could help us help make better collective decisions for our health, and could help restore declining trust in public health.