Public Health by Plebiscite

Recently there has been a push by some local residents (and others) to revisit the idea of fluoride in the water.  A few blog readers have sent me emails to get my "opinion" on fluoride.  The fluoride issue is an interesting one - it is one of the few "public health measures" that is ever put to public vote.

No matter what your stance is on the fluoride issue, I think it behooves everyone to consider the concept of public health by plebiscite.  This does not only apply to fluoridation.

For the most part, you and I (and the general community as a whole) are not experts in chemistry, biology or medicine.  Every single day we make decisions based on ideas/facts/evidence that we have encountered/learned/accepted - some of them could be decisions that are counter to what we believe/know to be "good" for us and others we make simply because we believe/know them to be the right thing to do. 

We suspect and accept the idea that food that is prepared for us is relatively safe - whether it be organic foods to canned goods.  You may purchase items from health food stores and you trust that what is in the bottle/package is exactly listed on the label.  It is almost impossible for any of us to confirm all of this information for ourselves - considering that the time that it takes to test a single product might take longer than it normally takes to spoil, the product that you would be consuming would be from a different package that could contain different elements than the one tested. 

To stop consuming a product that we enjoy (or believe/feel is giving us benefit) would take a fair amount of convincing.  A sensible suggestion that "maybe you should not be eating chocolate glazed donuts" may reduce the amount of donuts that you'll eat but it isn't likely going to have you avoid them at all costs.  However, if someone were to tell you that chocolate glazed donuts contained as much fat as a 2 kg. steak (I'm just making this up, by the way), you may avoid them.  As the "dangers" begin to outweigh the benefits, you may reduce your consumption accordingly.  If you believed/accepted, however, that the donut contained "toxic" compounds, you would likely stop eating them altogether and may, too, encourage others to follow your lead.

If it were your goal to get someone to stop eating chocolate glazed donuts (to do the negative), you would probably talk about all of the "bad" things about them.  You would probably actively suggest that the donuts contain all that fat, are packed with "toxic" compounds/"chemicals" and any other number of possible reasons why someone shouldn't eat chocolate glazed donuts.  Using words like "toxic" and "chemicals" illicit a feeling of concern and fear in most people.  To get someone to stop eating them (or to reduce their intake) you only have to get them to accept one of the "facts" that you're presenting. 

To get someone to regularly ingest something (to do the positive) would require a lot more work.  Saying things like "chocolate glazed donuts are good for you" or "lower your cholesterol" or "contain dietary fibre to help boost your immune system", etc. would have little effect if someone had the opinion that "I don't care, I don't like the taste of chocolate" or "I'm not fond of the texture of donuts", etc.  People could simply respond with "my cholesterol is already low" or "I get my dietary fibre from another source".  Using words like "toxins" and "chemicals" is not likely going to get someone to start eating a particular product.

The point I'm trying to make (forgive me if I failed to do so) is that to get somebody to be "against" something simply requires them to "buy" into any of a number of "negatives".  If they perceive the negatives to outweigh any benefits, they will be "against" whatever it is.  (Mind you, we know that certain things are bad for us but we still partake in them.)

How this relates to public health by plebiscite is this:

If we're presented with the question to accept or reject an idea, fear mongering always works in favour of the "negative" proposition (and by negative, I mean, the decision to do nothing rather than to do something).  If a small number of people actively use fear mongering, they can win simply because to vote "against" something a person needs only to accept one of the "ideas" that suggests a greater negative (or removes any supposed positive).

Therefore a minority of people can affect a plebiscite simply by employing "fear".  They can also achieve their desired results by presenting false information or blatantly lying. 

How this applies to fluoride:

No matter what the science says about fluoride, there are going to be people against it.  Even if it is a small minority of people who are against it, you can assume that the relative proportion of people who can make an informed decision about fluoride is also small.  The "for" side would be limited to providing the "benefits" as reasons for continuing the addition of fluoride.  There is almost nothing that they could say that could utilize "fear" to get people to "accept" the "positive". 

Since plebiscite allows for each and every registered person to 'vote' on the proposition, you can be sure that there will be a good number of people who are voting (as in every election) without knowing the facts.  To vote against fluoride, they would simply have to buy any of the arguments (valid or not) against the addition of fluoride.  To vote for it, they would have to be adamant and sure that the need existed.  If the "negative" side ventured into falsities and lies, it is almost impossible to overcome such with straight facts.  Humans simply would rather allow harm by doing nothing than to potentially cause harm by doing something even if the relative statistics for potential harm are on completely opposite ends of the spectrum.

Consider the annual influenza shot - though the risk of being harmed by the shot is far far less than the potential of harm from getting the actual flu (never mind the benefits that it offers to other people and populations), many people would rather not be "responsible" for the harm should they give a shot to their child/loved one.  By simply not doing the "positive" (actually giving/getting the shot) they believe that they are not responsible.  (I realize that I've just had some blog readers close their minds to further argument/suggestion because they've been sold on fear mongering from the anti-vax side.  In that case, my point has been made.)

Dilemmas like this have been studied extensively (see the "Trolley Dilemma" - it is a fascinating thought experiment) - it is the doctrine of double effect.  Morally, if the result of doing something that has a potential for harm has a greater potential for reducing harm, one should do it.  However, when the actions of a person may cause direct harm (though providing a greater benefit) most people would refrain from doing so.

What is my opinion on fluoride?

My opinion hardly matters - it is what the science shows, based on the available evidence, that matters.  Do I think that I need fluoride in my drinking water?  Maybe not - but the benefit for fluoride may not be for me as I'm possibly beyond the point where fluoride is essential in my life.  Simply because I may no longer need it does not justify me to take away the benefit from others who may/do - especially considering the potential harm to me (if any) is very small.

Should fluoride be put to a public vote?

No.  Decisions like these in public life should be made by those who are most familiar with the situation and those who we have elected/chose to do the research and learn about the issues at hand.  Fluoride (like many public issues) is only a complicated issue because people choose to make it that way.  Special interest groups, people with a distrust in government (conspiracy theorists too) and even people who dislike personalities in government will push for an agenda - and sometimes at all costs. 

Fear mongering in fluoride and other areas

Just as I've talked about "all natural" in older blog entries, I think I've even written about the words "toxic" and "chemicals".  Any time that someone uses the phrase "all natural" to push the idea that it is safe (or safer), remember that chlorine, E. coli, anthrax, lead and mercury are also "natural".  On the other hand, when someone says "it's a chemical" or "it's toxic" remember this: water is a chemical, water is toxic (fluoride is not a chemical, by the way).

My concern with the fluoride argument then is that it has gotten to a point where some are employing fear mongering.  (In so far as there may be reasons to not add (or remove, as it may be) fluoride to water, the use of fear as a method should make you think twice about any arguments against it.)