A book review published in the Bulletin of the History of Medicine, Volume 84, Number 2, Summer 2010, pp. 314-315
The proposition seems straightforward: should fluoride be put in public water supplies in order to prevent tooth decay? Fluoridation was tested in the 1940s, endorsed by the U.S. Public Health Service in 1950, and implemented in the United States and many other countries in the following decades. But from the beginning, there was vociferous opposition.
The fluoridation debate was in full swing in the 1950s and continues today in much the same form, with the same sorts of claims and counter-claims. Scientifically, the debate has always been one-sided, with an overwhelming majority of dentists and doctors supporting fluoridation but with a significant minority of critics.
The remarkable persistence of the debate has attracted the attention of social analysts. Attempting to take a middle ground is a perilous enterprise, because the partisans on either side are likely to either adopt a contributor as an ally or attack him or her as an enemy.
Scientists R. Allan Freeze and Jay H. Lehr have boldly entered the fluoridation arena with The Fluoride Wars. Their ambitious aim is to provide a balanced social history of the U.S. controversy. They tackle the major issues in the debate, including arguments over benefits of fluoridation and alleged adverse health impacts such as allergies, cancer, and skeletal fluorosis. They give special attention to dental fluorosis, the staining of teeth due to excess fluoride, typically said by proponents to be of only cosmetic significance but seen by opponents as a sign of fluoride toxicity.
A major contribution of the book is its covering of key developments in recent decades, including the antifluoride position of scientists from the U.S. Environmental Protection Agency, the debate among proponents about whether there is too much fluoride in people's diets, the switch by a few proponents to become opponents, the discrediting of some antifluoride claims, and the support for fluoridation by U.S. courts.
Freeze and Lehr also address the social dynamics of the debate, looking at referenda and statewide implementation measures and commenting on explanations of forces driving the proponents and the opponents. All in all, this is the most comprehensive treatment of the debate available in the literature. It draws on key sources, scientific, sociological, and historical.
Several episodes are given detailed treatment, for example, the first trials in which fluoride was added to town water supplies in the 1940s. The historical detail is not a sustained narrative but more like an occasional highlight, with some irrelevant digressions, such as a lengthy account of the Jonestown massacre, included because it had a deep effect on a key legislative promoter of fluoridation in California.
Freeze and Lehr are sufficiently even-handed that their treatment will please neither side in the debate. The book, though, is not a purely dispassionate account because, as well as discussing the scientific and political issues, the authors want to pass judgment and, in doing so, they often shift from nonpartisan social description to summary judgment that can seem to sweep aside disagreement. In particular, they sum up the debate as if it were a matter only of science and of benefits versus costs. The book is more an assessment of arguments than a social history.
The Fluoride Wars is almost entirely about fluoridation in the United States. The authors mention the situation in other countries but do not pursue the implications of fluoridation outcomes elsewhere. They conclude that popular opposition to fluoridation in the United States is due to risk aversion in referenda, but this does not explain the near absence of fluoridation in Europe, where governments make the decisions.
Freeze and Lehr sometimes make sweeping references to proponents or opponents, attributing the views of a few to an entire movement. Their language is frequently flamboyant and occasionally dismissive, for example in referring to scientist opponents as "zealously committed" (p. 362) - and less commonly labeling proponent scientists in a similar way.
The Fluoride Wars concludes with an appeal for the two warring sides to sit down and talk. Although this suggestion almost certainly will be ignored, Freeze and Lehr have set an admirable example of measured analysis and stimulating writing.
Brian Martin
University of Wollongong, Australia
Thanks to Peter Gibson, Michael Matteson and Selvie Sinage for useful feedback on drafts.