This Conversation was facilitated by Ms. Emily Firman, MPH, MSW (ARCORA Foundation) and Jen Wroblewski, MPH (NWABR) on January 16, 2018.
The question of community water fluoridation (CWF) has been long debated in Spokane, WA. Citizens have voted three times on the matter and all times chosen not to introduce fluoride to the drinking water. The most recent vote in 2000 failed by 1%.
Given this history, I expected our Conversation last night to include some significant voices of opposition. It turns out that our audience was either neutral or in favor of CWF. Our attendees were mainly college or medical school students, public health officials and professors. This demographic has traditionally supported CWF. What WAS surprising was that many who attended did not know the historical opposition to CWF and did not understand why the benefits of CWF were even in question. Prior to the Conversation both NWABR and our partners received letters or queries from known opponents to CWF from California and Colorado. I had hoped some would attend the Conversation.
Attendees accepted that CWF has great benefit in strengthening tooth enamel and therefore reducing dental decay. They trust the judgment of most health authorities, who have either conducted their own observational population research or reviewed the research of others, who state that CWF is a safe and effective way to prevent and treat tooth decay.
Based on available data and personal stories, attendees perceived that it is more economical to offer CWF than to pay for the subsequent oral health costs of increased decay. Some studies cite that every dollar spent on CWF saves $38 on future health costs. The Spokesman Review cited in 2001 that installing CWF would cost about $1million with an additional $300,000 per year (Hansen, 2/12/2001). One attendee shared that she has 11 crowns, several implants and other dental work. She wondered, “maybe if I lived in an area with community water fluoridation this [amount of dental work] wouldn’t be the case.” She went on to say, “If I spent the money on my dental work, about $30,000, on fluoridation instead imagine the good I could have done!”
GREATEST GOOD VS. AUTONOMY
It’s a classic clash of two ethical principles in public health: maximizing good vs. autonomy (individual choice, determination). The clash fascinates me because it’s a natural dilemma at which groups of people arrive whether or not they have training in bioethics. “I don’t see why, if just a small percent of people are against it, the rest of the population shouldn’t have a voice when they want fluoridation.” While the attendees tonight strongly valued maximizing good, they also understood the argument for personal choice.
A medical student suggested that autonomy goes both ways. “People should have a choice on whether to consume water with fluoride, but so should people have the right to smile with comfort and have a pain free mouth.” Poignant.
COMPROMISE POSITION…the THIRD WAY
Someone suggested that the ethics of autonomy and maximizing community good didn’t have to be in conflict. She thought that perhaps the community water supply could remain nonfluoridated and people could have free access to fluoride drops or tablets.
Numerous comments unfolded about the success of this approach. A mother who moved to Spokane in 2000 just as the “no” vote emerged, said “I wanted fluoride for my kids in their water. I thought, ‘What sort of backwater place have we moved to?’” She went on to tell the story about administering fluoride drops to her kids. She thought that if some drops were good, more were better. Her son is now grown and has cosmetic fluorosis—but no cavities! When her kids were little the fluoride drops were a prescription and she had to provide a copay. She acknowledges that the copay system may prevent some people from accessing fluoride drops.
A physician in the group noted that patient compliance is not as good as he’d like and worries that leaving the administration of fluoride up to parents might not be broadly successful. This is even more true when you consider than only 50% of kids in Spokane see a dentist regularly. In addition, fluoride drops are not currently given to adults who would benefit from cavity reduction through remineralization of early cavities.
BENEFITS OF RESPECTFUL CONVERSATION
I was struck tonight by the impact of the information, stories and shared conversation among folks, even though they largely agreed with one another. Evaluation comments indicate that people plan to take action on this issue. Attendees want to build relationships with those who oppose CWF, talk to their city councilpeople, share what they learned with friends and colleagues and invest their time and energy in this issue. They are eager to influence nuanced thinking about water fluoridation.
By together setting discussion ground rules, by presenting opposition perspectives and by encouraging any and all opinions, tonight’s Conversation had a strong impact. The secret? Strong science. Compassionate listening. Personal stories. Moving toward nuanced rather than binary thought. Seeing one another as people first and opponents second. This Conversation was one of the best yet.