Published in Sociological Quarterly, Vol. 30, No. 1, 1989, pp. 59-76
pdf of published article
Published in Sociological Quarterly, Vol. 30, No. 1, 1989, pp. 59-76
Brian Martin's publications on fluoridation
Brian Martin's publications
Brian Martin's website
Previous studies have explained opposition to fluoridation in terms of misinformation, alienation, or confusion. These studies have several shortcomings stemming from an uncritical attitude toward scientific knowledge. Recent perspectives in the sociology of scientific knowledge provide the basis for developing a wider understanding of the fluoridation issue, including analysis of scientific disagreements, the promotion of fluoridation, and experiences in other countries. Contrary to the usual view, public opposition to fluoridation does not necessarily signify a failure of education or democracy.
A satisfactory sociological explanation of the fluoridation controversy remains elusive. Despite decades of research on the topic, the persistence and passion of the fluoridation debates are yet incompletely understood by social scientists (Frazier 1980, p. 214).
An understanding of the fluoridation issue has important implications. If, according to the experts, fluoridation is unquestionably a beneficial and nonhazardous measure, then the wisdom of allowing the public to vote on and reject it must be questioned. Crain, Katz, and Rosenthal (1969, p. 228) conclude that "broad popular participation ... spells defeat to fluoridation." Sapolsky (1968, p. 432) concludes that "The experience with fluoridation seems to confirm the inappropriateness of direct citizen involvement in policy-making." This is a far-reaching conclusion concerning policy making in a democracy, and hence it seems worthwhile to reexamine the studies of the fluoridation controversy to see if any alternative hypothesis can be sustained.
The point of reexamining the sociology of the fluoridation controversy is to evaluate the sociological assumptions in this body of work, in particular the assumption that the value of fluoridation has been scientifically proved. Almost all the studies made have assumed that the scientific aspects of the controversy are unproblematical; in other words, they have excluded science from sociological examination. A recently developed strand in the sociology of science has deconstructed this positivist conception of scientific knowledge and shown how scientific knowledge is socially negotiated and inevitably linked to the values and interests of relevant actors, both scientists and nonscientists. The question here is: Does this relativist perspective provide insights into the fluoridation controversy not available using the traditional positivist picture?
This article begins with a sketch of the traditional and relativist perspectives on scientific knowledge. Then, turning to the fluoridation issue, the major varieties of social scientific studies of fluoridation are examined and some of the shortcomings of these studies are outlined. The relativist perspective is shown to allow an expansion of the analysis of the controversy to cover scientific opposition, promotion of fluoridation, and overseas responses diverging from those in the United States. This perspective, although not endorsing ignorance or prejudice, provides more support for direct public involvement in social decision making than the models heretofore used in studying fluoridation.
The traditional view is that scientific knowledge is a special kind of knowledge, characterized by an objectivity that is established through the scientific method as applied by members of a scientific community based on such norms as disinterestedness, universality, communism, and organized skepticism (Barber 1952; Merton 1949; Storer 1966). The claims to the special character of scientific knowledge have been sustained by the disjunction between facts and values and between the contexts of discovery and verification (Popper 1959).
This traditional view has elements of positivism, although it might better be called scientism. In the social sciences, positivist approaches have been extensively criticized (Gouldner 1970; Habermas 1974; Mills 1959). But this sociological critique was restricted for the most part to the social sciences themselves. The traditional sociology of knowledge (Mannheim 1936) exempted the physical sciences and mathematics from its project of providing social explanations for the origins and developments of knowledge.
In recent years there has been a major challenge to this picture by the development of a sociology of scientific knowledge that no longer takes scientific knowledge as uniquely exempt from social inquiry (Barnes 1974, 1977; Bloor 1976; Collins 1983; Knorr-Cetina and Mulkay 1983; Mendelsohn, Weingart, and Whitley 1977; Mulkay 1979). The view of scientific knowledge as socially constructed begins where Kuhn (1970) left off. Kuhn argued that scientific knowledge does not always grow in a monotonic process of accumulation, but is characterized by periodic revolutions in which the concepts for understanding nature, the methods of study, and the criteria for assessing adequacy and value change discontinuously. The shift from one scientific paradigm to another, according to Kuhn, is not made entirely on the basis of explicit rules of correct formal scientific practice, but can include various social factors, even though Kuhn has never developed a full analysis of what these might be.
The idea that social factors might be involved in the process of deciding what correct scientific knowledge is during the shift from one paradigm to another has been greatly expanded into an understanding of the way in which all scientific knowledge - including "normal science" - is subject to social negotiation (Ravetz 1971; Barnes 1982). That is, the outcome of experiments, for example, is not something whose meaning is immediately apprehended, but rather something for interpretation, discussion between scientists, and reinterpretation in the light of other experiments (Collins 1975). In short, scientific knowledge is not uniquely related to nature, but rather is always embedded in a social discourse and a humanly created social practice (Latour and Woolgar 1979).
One of the many implications of this sort of analysis of science is that the traditional rigid distinctions between facts and theories and between scientific knowledge and values can no longer be sustained (Feyerabend 1975; Hesse 1974). Because social processes are involved at all stages of the creation, evaluation, and establishing of scientific knowledge, social values may also be involved. The idea that in a controversy there are "the facts" that may be separated out, neatly and unproblematically, from values and interests can no longer be sustained (Barnes 1982). The mixing of "facts" and "values" is much more conspicuous in scientific controversies, which is why controversies provide a valuable social laboratory for examining science.
Instead of treating scientific knowledge as a revealed truth about nature, the relativist perspective examines the ways in which scientific knowledge can be used as a resource in social struggles. For example, advocates in a controversy may use claims to be the sole repositories of scientific truth as a way to advance their side of the debate. To call opponents "irrational" is, in this perspective, not a claim that can be validated in terms of some higher rationality - because assessments of rationality are always socially negotiated - but rather serves as a ploy in a social struggle in which "rationality" is seen as desirable and "irrationality" as stigma.
It should be mentioned that the sociology of scientific knowledge is an approach to the study of science, not necessarily a personal belief system. For example, one might well use relativist conceptual tools, treating scientific knowledge as socially negotiated and as a resource in social struggles, while still preferring to believe personally in the ultimate separability of facts and values.
Fluoridation consists of the addition of the element fluorine to public water supplies with the aim of reducing dental caries (tooth decay). Fluorine, a highly reactive element, is normally incorporated in a compound such as sodium fluoride, and in solution becomes the fluoride ion. The desired concentration in public water supplies is approximately one part per million (more or less) depending on the temperature and hence the amount of water people are likely to drink.
Many studies have shown that when children drink fluoridated water, their average rate of tooth decay seems to be greatly reduced (McClure 1970; Murray and Rugg-Gunn 1982; Newbrun 1975; Striffler, Young, and Burt 1983). A typical figure claimed is 50% reduction. This apparently enormous benefit for children's teeth is the major argument in favor of fluoridation. There are no generally acknowledged benefits for adults from drinking fluoridated water.
Water fluoridation is only one way to obtain the benefits of fluoride. Other approaches are fluoride tablets, including fluoride in table salt, and receiving topical (surface) applications of fluoride from dentists. Water fluoridation has been favored because it is cheaper and requires no individual initiative.
Fluoridation was introduced on a trial basis in a few communities in the United States in the 1940s and then on a much larger scale in the 1950s, when it suddenly met widespread public resistance (McNeil 1957). Since then the fluoridation of public water supplies has been one of the most widely debated public health measures in English-speaking countries. Many referenda have been held on the fluoridation of town water supplies, and over a period of decades the majority of referenda have rejected fluoridation (Crain et al. 1969).
Three main grounds for opposition to fluoridation have been expressed. First, opponents claim the benefits are exaggerated or not established. Second, there are claims of health risks to some members of the population, ranging from allergic reactions to cancer. It is accepted that high levels of fluoride can cause dental fluorosis or so-called mottling of teeth; proponents do not consider this to be a problem at one-part-per-million concentrations, whereas opponents argue it is a problem especially because some people drink more water and obtain much more than the standard 1 milligram of fluoride per day. Third, fluoridation is thought to be an infringement on individual rights because it is compulsory medication of all members of a community, as opposed to chlorination, which is treatment of the water.
In the United States, these and other arguments have been heatedly debated in numerous confrontations. The result of various types of decision-making processes is that about half the population drink water that has been fluoridated by addition of fluorides, a process called "controlled fluoridation" by proponents and "artificial fluoridation" by opponents. (Only 1-2% of water supplies worldwide contain one part per million or more of fluoride naturally; most waters contain less than 0.2ppm of "natural" fluoride.)
Since the 1950s, most major dental and medical associations have strongly supported fluoridation, and likewise most dentists and doctors. In the face of the near-unanimous expert support for fluoridation, the popular opposition drew the attention of social scientists. There have been hundreds of accounts of fluoridation struggles, including dozens of serious social scientific analyses of the issue. Much of the work has been on the sociology of opposition to fluoridation: how to explain popular resistance to a measure that experts attested was highly beneficial and without any known risks.
The numerous studies of fluoridation have included so many different theories that it would be tedious to catalog them all, and in any case there are a number of useful reviews and summaries (Conant 1966; Frazier 1980; Gamson 1961b, 1965; Gamson and Lindberg 1961; Motz 1971). Only a brief overview is given here in order to provide a basis for the discussion in the following sections.
There have been several focuses in the studies of fluoridation (Motz 1971), including demographic studies, social psychological studies, and studies of social change. In practice characteristics of different approaches are found together in particular studies.
The demographic approach looks for relationships between variables such as age, race, education, number of children, or income, and attitudes or voting behavior on fluoridation. For example, Mausner and Mausner (1955), in one of the earliest prominent studies, found a smaller fraction of opponents had completed high school. This finding is associated with the idea that any educated, well-informed, and progressive person will support fluoridation.
Another demographic correlation studied was between age and opposition to fluoridation. People over age 60 were found to be more likely to oppose fluoridation. This could be due to lower levels of education, to conservatism, or to lack of any personal benefit from the process: people with young children were more likely to favor fluoridation (Metz 1966). Antifluoridationist views have also been linked to conservatism through opinion surveys or studies of correlations between votes on different issues (Plaut 1959).
The demographic approach has had many difficulties. Of the many correlations discovered by investigators, few have stood the test of further examination. For example, Gamson (1961a) and Gamson and Irons (1961) found a more complex relationship between education and attitudes to fluoridation than did the Mausners: both those with high levels of education and those with very low education favored fluoridation, whereas those with medium levels of education were more opposed. Likewise, the correlations between political views and fluoridation views have not stood up (Frankel and Allukian 1973). Another problem with many demographic studies is that correlations at the collective level derived from secondary sources ("unit demographic data") do not necessarily imply causation at the individual level.
More fundamentally, studies of correlations between education, age, or other variables and attitudes to fluoridation do not provide by themselves an explanation for opposition. Further, correlation studies do not explain the way in which people's views on fluoridation change during debates, for example, prior to referenda. Often, opinion polls conducted before any public debate on fluoridation have shown large majorities favoring the measure. But after public debate, referenda results frequently show impressive majorities against fluoridation (Sapolsky 1968).
Another major approach to the fluoridation issue has been through social psychology, typified by the alienation hypothesis (Gamson 1961c; Green 1961; Linn 1969; Simmel 1961). According to this picture, the most widely used in analyzing the fluoridation controversy, a certain segment of the population is poorly integrated into society and feels powerless to affect the course of events. They grab at opportunities to attack those who they perceive as powerful groups. Fluoridation is thought to provide such an opportunity: antifluoridationism, according to this hypothesis, is essentially a revolt of the powerless who have latched onto fluoridation as a symbol of the impositions which they oppose.
Support for this hypothesis was obtained by examinations of antifluoridation literature (Davis 1959), by interviews with antifluoridation leaders (Green 1961), and by attitude surveys (Gamson 1961c; Simmel 1961). But there are several problems with this hypothesis (Crain et al. 1969, pp. 6-9, 31-51, 215-222; Sapolsky 1968). Attitudes portrayed by antifluoridation leaders in their literature are unlikely to be typical of all those who vote against fluoridation. The surveys of alienation have been limited in size and may not show typical responses. Even the operationalization of the concept alienation in survey questions leaves much to be desired. Finally, the concept of alienation, like the demographic hypothesis, does not explain why opinion surveys prior to referenda campaigns can show massive support for fluoridation whereas votes typically show major shifts against it.
A different approach to the issue focuses on community power structures rather than on the characteristics of individual opponents of fluoridation (Coleman 1957; Crain et al. 1969; Petterson 1969; Pinard 1963; Pomper 1961). In their major study, Crain et al. (1969) obtained information from over 700 cities on how the fluoridation issue had been dealt with. The most important findings were that stable blue-collar cities are most amenable to fluoridation, that "the most educated communities have most trouble with fluoridation" (Crain et al., 1969, p. 215), and that the implementation of fluoridation depends on the form of government. This last point is important: When local political power structures allowed little citizen input into decision making, as in partisan council-manager and partisan mayor-council forms of government, the decision was most likely to favor fluoridation. When citizen participation in local decision making was facilitated by nonpartisan forms, this was more likely to lead to a referendum. Because most referenda oppose fluoridation, the more participative polities have had fewer adoptions of fluoridation.
Crain et al.'s study provides several messages. It is in conflict with the alienation hypothesis because middle-class communities with greater opportunities to participate in local politics are more likely to reject fluoridation. It alerts researchers to the danger of focusing exclusively on referenda because it is governmental structure that has a greater influence on fluoridation outcome. Finally, it suggests that citizen participation in policy making is not favorable to the "rational" outcome of fluoridation. (Crain et al. 1969, p. 228).
There is one major shortcoming of the community power structure approach: it provides no indication of why individuals and communities support or oppose fluoridation. By restricting attention to the procedures for adopting fluoridation, it avoids any consideration of the issue itself.
The confusion hypothesis (Crain et al., pp. 58-70; Sapolsky 1968, 1969) is an attempt to explain why a population initially favorable to fluoridation can swing to being strongly opposed in the course of a referendum debate. Sapolsky argued that in a public campaign, potential voters are confronted with conflicting claims, each presented by those who are apparently experts. The voters, most of whom are not able to distinguish the differences in authority between the American Dental Association and the American Academy of Nutrition (for example), simply register that there is a divergence of opinion about the safety benefits of fluoridation. In this confused state about the merits of the procedure, they choose the "safe" course: a vote against fluoridation and any possible health risks.
The confusion hypothesis seems to explain the dynamics of the development of antifluoridation concerns, but it leaves much unexplained. Why, for example, have antifluoridationists been able to mount campaigns in so many cities over so many years? Why have campaigns to stop fluoridation continued to succeed whereas similar efforts against pasteurization faded away?
After the massive amount of sociological research on fluoridation in the 1950s and 1960s, there has been a marked decline in the 1970s and 1980s. No new attractive hypotheses have been taken up in large research programs. One response has been to look to the different insights provided by the variety of research already done. Hastreiter (1983), for example, advocates building an integrated perspective using the alienation, community power structure, and confusion hypotheses. But instead of proceeding in this direction, it is worth looking at some of the assumptions underlying the work so far in the light of the sociology of scientific knowledge.
Sociological research on fluoridation has been built on a number of assumptions. Some of these have been made explicit, such as the assumptions that attitudes of citizens or characteristics of community power structures can help explain the dynamics of fluoridation controversies. But other assumptions have mostly been implicit and seldom questioned. These assumptions are the ones most worth examining.
The social science literature has largely assumed that fluoridation is correct. This has far-reaching ramifications.
To begin, it is assumed that the fluoridation controversy can be studied without a detailed examination of the scientific issues. This can be seen as a reflection of a positivist view of science, that there are scientific facts that are incontrovertible and that scientific authorities are the people who can tell us those facts. Most of the fluoridation studies do not even bother to cite scientific literature on fluoridation and are content to state without qualification that fluoridation is proven to be effective and safe. For example: fluoridation "began as a technically conceived and rationally considered public health measure" (Green 1961, p. 13); fluoridation is a "proven preventive measure to combat the most widespread health problem of today" (Grossman 1966, p. 1595); "Seldom has there been a measure to protect the public's health which has been so effective, so certain, and so simple" (Paul 1961, p. 1); and fluoridation offers "what appears to be a well-tested, relatively inexpensive, and effective avenue to improved dental health" (Sapolsky 1969, p. 240). Yet social science studies such as these, which actually spell out their assumption that fluoridation is scientifically established, are more the exception than the rule: most studies simply assume this without stating it.
Social scientists studying the fluoridation issue have ignored or downplayed an important part of the debate: the existence of scientists, including a number of eminent scientists, who have questioned aspects of fluoridation or opposed it outright. These scientists provide an invaluable resource for the opponents of fluoridation; hence to study the public opposition without analyzing the scientific opposition is to neglect an important factor.
An example is the study by Sutton (1960), who analyzed the classic North American longitudinal studies of the effect of fluoridation on tooth decay and found that each one of them showed significant methodological shortcomings. This detailed and careful study throws doubt on the frequently quoted claims of massive reductions in tooth decay from fluoridation. Yet Sutton's book is not, according to the Social Sciences Citation Index, cited by a single social science analysis of the fluoridation issue.
Another example is the book by Exner, Waldbott, and Rorty (1957), which contains many detailed scientific criticisms of fluoridation. Although dismissed by profluoridationists as biased and extremist, the point is that Exner and Waldbott, physicians with excellent credentials, systematically presented scientific and other arguments against fluoridation. These arguments are far more than methodological quibbles with evidence supporting fluoridation. With only a few exceptions (e.g., Sapolsky 1968; Mazur 1973), the existence of this opposition was not recognized or acknowledged at the time in the social science literature on fluoridation. The more recent, and also detailed and documented, studies by Waldbott (1965) and by Waldbott, Burgstahler, and McKinney (1978) are not cited at all in more recent social science studies of the issue.
Those few social science studies that take a nonpartisan stance on fluoridation have been ignored by social scientists. Wollan (1968), who examined some of the deficiencies in the U.S. Public Health Service's aggressive promotion of fluoridation, is never cited in other social science studies or bibliographies on fluoridation. An even more surprising omission is Mazur (1973, 1981), who gives a comparison of rhetorical devices in the technical disputes over both low-level ionizing radiation and fluoridation. Mazur's 1973 paper is a very highly cited one in the literature on scientific controversies (see Nelkin 1979), but not by other social science studies of fluoridation.
By neglecting the scientific opposition to fluoridation, sociologists have missed out on the existence of a significant scientific dispute and the awareness by many members of the public that such a dispute existed. The opponents of fluoridation not unnaturally have scoured the dental and scientific literature for material and quotes that might support their cause, and disseminated this material widely, for example, in National Fluoridation News (see Waldbott 1965). As long as significant scientific criticism of fluoridation exists, it can be used by opponents to pursue their case. This criticism persists today. Recently the prestigious scientific journal Nature published a paper (Diesendorf 1986a) questioning the argument that fluoridation has caused major reductions in tooth decay, thus echoing the critique of Sutton (1960). Significant claims about the health hazards of fluoridation also continue to be published (Bundock, Burk, Graham, and Morin 1985; Colquhoun 1985; Diesendorf and Sutton 1986; Rose and Marier 1977; Waldbott et al. 1978; Yiamouyiannis 1983).
In a situation of some scientific uncertainty, the importance of differences in values is highlighted. Two characteristic lines of thought might go as follows. A supporter of fluoridation might argue, "The evidence for the benefits of fluoridation is quite substantial, while the evidence for harm is limited and dubious. I think the likely benefits outweigh the possible dangers, hence I support fluoridation because it is the cheapest and easiest way to make sure every child reaps the benefits." An opponent of fluoridation might argue, "Though the evidence for the benefits of fluoridation is substantial there is some doubt about it. Since fluoridation is not necessary for good teeth, we should forego the benefits if there is some slight chance of harm. Some scientists claim that a small percentage of the population could be harmed by fluoride. Therefore I oppose fluoridation of water supplies and favor the voluntary use of fluoride tablets by those who want to take them."
Both these lines of argument take into account the scientific evidence concerning fluoridation, but they differ in their assessments of the social benefits and costs. This difference is not between rationality and irrationality but rather a legitimate difference in values, for example, the positive value placed in good teeth, the negative value placed on possible health risks, and the social benefits or costs in compulsory or voluntary intake of fluorides.
From the point of view of the sociology of scientific knowledge, opposition to fluoridation is not necessarily irrational (Barnes 1972, p. 281). Rather, claims to rationality and to scientific authority are better seen as part of a strategy to promote fluoridation than as incontrovertible statements of fact. Second, social values are likely to be bound up in decisions about fluoridation, and these are not issues on which pronouncements by scientific experts should be considered the final word. An examination of some of the studies of the fluoridation controversy illustrates how the assumption that fluoridation is unquestionable scientifically leads to a potential misunderstanding of public perceptions. Arcus-Ting, Tessler, and Wright (1977) surveyed signers of an antifluoridation petition in Massachusetts. They then compared the answers of those who really opposed fluoridation and those signers who said they actually favored it. Their conclusion is that opponents are misinformed compared to supporters.
One of twelve statements with which Arcus-Ting et al. asked respondents to either agree or disagree was "The long-term effects of fluoride have not been thoroughly tested." Their correct response was disagree. Another statement was "Fluoridating the public water supply could reduce children's cavities by 50-60%." Their correct response was agree. Yet in both these cases there are some reputable scientists who disagree with the "correct response." Now, it is quite possible that each one of Arcus-Ting et al.'s "correct responses" will, by the evaluation of future researchers, actually be judged to be correct. But at least for the present there is some degree of scientific disagreement, a disagreement repeatedly emphasized by antifluoridation campaigners. In this situation is it really possible to conclude that those who gave the "incorrect response" are misinformed?
Yet this is the conclusion of Arcus-Ting et al. They state, "In twelve tests of the hypothesis, those supporting fluoridation are uniformly better informed about costs, benefits, and safety" (1977, p. 285). They conclude that opponents of fluoridation are misinformed and indeed that in part "people become 'confused' and 'misinformed' because they oppose fluoridation, at least as frequently as the reverse" (1977, p. 288). But there is another interpretation of Arcus-Ting et al.'s results: that supporters of fluoridation are better informed according to their criteria because those criteria are established according to the received wisdom of the profluoridation position.
Also illuminating is the way in which various authors respond to beliefs of dental students which are critical of fluoridation (deShazer 1967; Garverick, Kight, and Bissell 1979; Isman 1984; Myers and Ballhorn 1968; Petterson 1979). These authors do not accept that there might be legitimate differences of opinion on some of the issues, both scientific opinion and social values. For example, Isman reports, "One somewhat surprising finding is that 15% of the respondents believed that fluoride as supplied through water fluoridation is allergenic for some people" (1984, p. 925). He assumes that this must be wrong; he comments: "This suggests that the nondentally related effects of fluoridation may not be receiving enough emphasis in dental education" (1984, p. 925). The existence of several independent reports in the medical literature of allergic reactions to fluoride (for references see Waldbott et al. 1978) - whatever assessment one makes of this work - is not mentioned by Isman. The suggestion by all these authors is that improved educational methods will convince all dental students of the value of water fluoridation.
From the point of view of the sociology of scientific knowledge, claims about nature (truth) can be interpreted as tactics in a social struggle inside or outside the scientific community. By ignoring the scientific opposition to fluoridation, sociologists have missed out on an important factor in explaining the public opposition, namely, the way that opponents have used scientific claims about risks and lack of benefits of fluoridation as a key resource in mobilizing support. This use of scientific claims has been vitally important even though the scientific opponents argue from a position of considerable weakness in terms of the weight of scientific opinion.
As well as missing out on an important factor in explaining the opposition, the assumption that fluoridation is scientifically correct has led to a one-sided focus on opponents and neglect of the promotion of fluoridation. Many of the studies have set out assuming that there must be something wrong with opponents - poor education, political conservatism, ignorance of the issue, alienation or confusion. The studies of the social psychology of opponents have usually looked for psychological shortcomings of opponents. Proponents seem to have been assumed to be psychologically healthy or normal. As pointed out by Motz (1971, pp. 359-360), the literature has an implicit profluoridation bias that has meant that some possible research projects have never been undertaken, such as surveys of communities which have never been embroiled in fluoridation controversies. Motz also notes that the significance of fluoridation in people's lives takes on an exaggerated importance in the eyes of researchers, who may see it as epitomizing some sort of deviant attitude on health or other issues. Motz (1971, p. 360) points out that a sizable fraction of people do not even know what fluoridation is in the first place.
In contrast, there are no studies of the social psychology of leading proponents, aside from comments in McNeil's (1957) impressive account of the history of fluoridation. In one of the few studies of proponents, Raulet (1961) provides the important message that a role conflict may exist between, on the one hand, the desire of dentists and doctors promoting fluoridation to rely on their expert status and avoid debate with the opposition and, on the other hand, the need to wage a political campaign, which may jeopardize the image of the neutral expert.
The study of the promotion of fluoridation has been left largely to the antifluoridationists because social scientists have assumed that this promotion is unproblematical. The promotion of fluoridation is too big an issue to treat here (see Martin 1988); any such treatment should consider the important recent study by Varney (1986).
The assumption that fluoridation is correct is most apparent in that portion of the literature which deals with "recommendations for the conduct of successful campaigns" (Motz 1971, pp. 357-359). A number of studies assume that the aim of social science is to help promote fluoridation (e.g., Kegeles 1961; Gamson 1964). Suggestions in this area range from promoting long-term education to avoiding debates with opponents. As the sociological understanding of the fluoridation issue has languished in the 1970s and 1980s, the literature on campaigning has remained healthy (e.g., Barrett and Rovin 1980; Easley 1985; Isman 1981). Whether much of this writing can properly be called social science is debatable, but certainly there has been a continued effort, often by social scientists whether in the dental area or not, to use insights from social scientific studies of fluoridation to improve the campaigns of proponents. (The actual value of this literature for fluoridation proponents is another question, as noted by Grossman .)
Another consequence of the assumption that fluoridation is correct is the exclusion of a substantive analysis of ethical issues in fluoridation campaigns. While a number of writers have noted that concern about individual rights is a key factor in the opposition to fluoridation, they have not examined why it is that proponents have seized on the fluoridation of public water supplies as the way to spread the benefits of fluoride. The options of fluoride tablets, topical fluoride treatments by dentists, fluoridation of school water supplies or school milk, and fluoride added to table salt each reduce or eliminate the compulsion associated with water fluoridation. There are some reasons why these alternatives have not been preferred, such as the difficulties of getting people to take fluoride tablets. But given the manifest difficulty of promoting water fluoridation, and the straightforward way in which fluoride tablets sidestep the individual rights issue, it would seen to have been an obvious sociological issue to examine why water fluoridation has been seen by proponents as the essential way forward (Hastreiter, Lambo, and Anderson 1985).
Another important assumption underlying fluoridation studies is that experience in the English-speaking countries, and especially in the United States, is adequate for providing a full understanding of the social dynamics of the issue. Most of the studies have been done by researchers in the United States with a focus on experience in the United States. Occasionally a study from another English-speaking country is cited in support of findings. These include Australia (Head 1978), Britain, Canada (O'Meara 1960), and New Zealand (Mitchell 1960).
The English-speaking countries are the ones in which major public controversies have arisen over fluoridation. The citation of U.S. studies is understandable given that most studies have been conducted there and relatively very few in other countries. But experiences from other countries are worth examining because they may throw a different light on the issue.
In particular, experiences in Europe are a direct counter to all the major explanations, namely, those based on demographics, alienation, community power structures, and confusion. In most countries in Europe decisions are not based on referenda: decisions are made administratively by governmental bodies, often at a national level. While a number of European countries have introduced fluoridation to a limited degree, most of these programs have been terminated. There is no large-scale water fluoridation in Europe today (Auermann and Lingelbach 1964; Farkas 1982; Forrest 1967; Myers, Plueckhahn, and Rees 1980, pp. 70-87; Scobie 1975). (The countries with the highest percent of population drinking water with added fluoride include Australia [about 67%], Ireland [66%], United States [53%], New Zealand [50%], and Canada [37%].)
Because the main decisions against fluoridation in Europe have been made administratively, this immediately challenges the demographic, alienation, and confusion hypotheses that trace opposition to the general public rather than to administrators: there have been few opportunities in many of the European countries for direct public participation. The community power structure hypothesis is also challenged because it predicts that fluoridation is more likely to be implemented when the public is not directly involved in the decision making.
An example of the reasons for not fluoridating is that given by the Danish Minister for the Environment: "Inter alia a number of questions concerning human health and environment in connection with fluoridation have not been and hardly can be clarified" (Nielsen and Goldschmidt 1977, p. 6). In many of these countries, administrators and governments have decided, after hearing advice from various experts including proponents of fluoridation, not to proceed with fluoridation on a large scale.
In the preceding discussion, I have suggested that sociologists have accepted both the traditional picture of scientific knowledge and the authority of professional endorsement of fluoridation in forming their assumption that fluoridation is scientifically beyond question. There are some alternative, or complementary, perspectives on this. One is that sociologists themselves have weighed up the costs (potential risks) and benefits (improved dental health) and, in the face of uncertainty, chosen to support fluoridation. Although possible, there is no evidence of such a weighing up of the evidence in any social science paper cited here. Neither does this picture explain the neglect of scientific opposition, the neglect of the promotion of fluoridation, and the neglect of overseas experience.
Another perspective is that support for fluoridation by social scientists is a feature of "ratpack sociology," in which the assumptions of key investigators are slavishly followed by others. This perspective is complementary to the one offered here. The conspicuous lack of citation of those who stray from the dominant approach (such as Wollan  and Mazur 1973]) fits into this picture. Positivist underpinnings nevertheless are suggested by the lack of attention to scientist opponents of fluoridation; in the 1950s and 1960s, the heyday of fluoridation sociology, no recognized body of relativist sociology of scientific knowledge was available to guide attention in this direction.
Another perspective is that the social position of sociologists is similar to that of the prominent promoters of fluoridation - middle-class, white, male professionals - and diverges from some of the antifluoridation groups. This idea is worth pursuing further, but note that most of the scientist opponents fall into this same category.
It is worth looking again at Sapolsky's (1968, 1969) explanation of opposition to fluoridation in terms of confusion: "Unable to decide between what appear to be two contending scientific positions, the voters opt to avoid the greatest potential health risks by defeating the fluoridation proposals" (Sapolsky 1968, p. 431). According to Sapolsky, there only "appear to be" two contending scientific positions, whereas in reality there is only one rational, scientific position, which supports fluoridation. It is this picture of science providing a final authoritative conclusion that has been challenged by the sociological picture of science as a process of social construction.
Another way to interpret the shift toward opposing fluoridation that often occurs in fluoridation campaigns is that some citizens, hearing both sides of the issue, choose to oppose fluoridation as a value decision. For example, they might prefer to oppose water fluoridation to avoid risks compulsorily imposed while allowing individuals to take fluoride tablets if they wish to obtain the benefits. Sapolsky's formulation of the problem denies that there are values involved in supporting fluoridation, although it seems hard to see how technical and scientific procedures could produce an ironclad support for water fluoridation over fluoride tablets. It would seem that there are issues here involving costs (economics), compulsion (ethics), and distribution of benefits (equity). To assert that fluoridation is rational (Isman 1984, p. 927; Kegeles 1962, p. 672) is either to deny the existence of values in fluoridation decisions, or to incorporate a value position under the guise of rationality.
Davis (1959) argues that the public should not be allowed to decide on scientific issues until they understand the scientific method and outlook. He comments, "While the intellectual may well know a scientist is rational, empirical, and objective, what would ordinary people think?" (Davis 1959, p. 482). The irony here is that the sociology of science has shown numerous ways in which scientists deviate from the picture of "rational, empirical, and objective" behavior - see Mitroff (1974) - and that Davis's view of what science is like is closer to the "story book" picture routinely used to legitimate science (Brush 1974).
To admit that there is genuine scientific disagreement in the fluoridation issue is not to admit that the views of all scientists are equal. It is certainly the case that the major dental and medical authorities uniformly favor fluoridation. That is not the issue. The point is that voters are not necessarily irrational, alienated, or confused simply because they oppose fluoridation. No doubt many of them are irrational, alienated, and confused, but not all opponents can be categorized in this fashion. If scientific knowledge is not an edifice set forever in concrete but rather a dynamic enterprise in which social negotiation and conflict are routine, and if there are values embedded in all aspects of science including scientific knowledge, then opposition to fluoridation in at least some cases can be interpreted as a reasoned stance. This does not mean that we must agree with the reasoning involved and the values underlying it, but it does mean that it is inappropriate to explain away all opposition through categories such as irrationality, alienation, or confusion.
Marmor, Bernard, and Ottenberg (1960, p. 330) recognize that whereas much of the opposition to health programs such as fluoridation may be irrationally motivated, there can also be opposition based on rational considerations. They "recognize also that today's scientific proposal can end up as tomorrow's fad. Many of can still remember, for instance, the scientific zeal with which tonsils, teeth and other supposed 'foci of infection' were removed in wholesale proportions. How does such 'rational' zeal differ from the 'irrational' opposition to such measures?" (Marmor et al. 1960, p. 344).
Sapolsky (1968) is among those who conclude from a study of fluoridation controversies that direct citizen involvement in the determination of public policy is inappropriate. Roemer (1983, p. 12) contends that "it is a distortion of the democratic process to submit such a complex scientific question to lay judgment." Crain et al. (1969, pp. 158, 228) find that fluoridation, which they consider to be a progressive innovation, will be defeated if there is citizen participation, but more moderately consider that this may be a necessary price to pay for having a government which can do other "good things." Similarly, McNeil (1985, p. 153) considers that the fluoridation controversy is a price "that Americans pay for having the kind of open political system they do."
The perspective advanced here does not support this sort of conclusion. If values are involved in the fluoridation issue, then rejection of fluoridation may be deplored but cannot be rejected as unscientific as these writers do. It is only by adopting an uncritical scientism that antidemocratic conclusions have been drawn from the study of fluoridation controversies. Contrary to Sapolsky, Sklair (1973) argues that there should be more rather than less public participation in decision making about issues involving science, seeing the obstacles to useful public involvement being due to the nature of education and the media rather than to people's inability to understand the essence of scientific issues.
The irony is that the preferred model of Sapolsky and others, for decision making to be done by legislatures and administrative agencies, has led, in Europe, to widespread rejection of fluoridation. These sorts of national differences in science policy making have been analyzed sociologically in controversies, for example, over environmental lead (Robbins and Johnston 1976), aldrin and dieldrin (Gillespie, Eva, and Johnston 1979), and estrogen replacement therapy (McCrea and Markle 1984).
There is much to be learned by further studies of the fluoridation issue. But rather than assuming in advance that both the scientific arguments and promotion of fluoridation are unproblematical, a more fruitful approach would deal with the sides to the debate more symmetrically (Bloor 1976). In this way a richer understanding of both the opposition to and promotion of fluoridation can be obtained, in both unfluoridated and highly fluoridated countries. This does not require the sociologist to forswear any personal preference for or against fluoridation. Indeed, a more sophisticated understanding of the role of scientific knowledge in the fluoridation controversy potentially can help both proponents and opponents. In one case, proponents lost a court case because they thought all they had to do was attack the opponents' arguments (Christoffel 1985).
The point here is that the scientific debate on fluoridation, such as it is, cannot be left to the scientists. Sociologists need to examine the processes of scientific opinion formation as well as processes of public opinion formation.
Valuable comments were received from Mark Diesendorf, Stephen Hill, Tom Jagtenberg, Evelleen Richards, Terry Stokes, and several anonymous referees. This work was supported by a University of Wollongong Research Grant.
1. Partisan and nonpartisan here refer to types of political systems, not to partisanship in regard to fluoridation.
2. One referee of this article argued that the sociology of scientific knowledge perspective must deal with the fact that fluoridation works. Against this, a key principle in the strong program of the sociology of scientific knowledge (Bloor 1976) is symmetry: the analysis should be independent of the truth or falsity of the knowledge claims being examined sociologically. The strong program has much to offer precisely because it is not interested in the truth or falsity of knowledge claims, and because among other things the social analysis does not have to be rewritten every time scientific consensus is revised: The current scientific orthodoxy is not privileged sociologically. Therefore, even if every opponent as well as every proponent agreed that fluoridation is effective, a sociology of scientific knowledge analysis would still be relevant. It so happens, though, that the claim that fluoridation "works" to reduce tooth decay has been challenged by the statistical critiques of Sutton (1960) and more recently by Colquhoun (1987), Colquhoun and Mann (1986), and Diesendorf (1986a, b).
3. There is ample documentation of extreme right wing and other fringe groups that oppose fluoridation (American Dental Association 1965; Barrett and Rovin 1980) and would be considered by many to be alienated from the political or medical mainstream, although the existence of their alleged alienation needs to be demonstrated rather than just asserted.
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