Anti-fluoridation crankery? How quaintly 1960s! I only wish it weren’t on ScienceBlogs

No, no, no, no, no!

I hate it when a fellow ScienceBlogger goes astray!

Fortunately, it’s been a long time indeed since I felt obligated to administer a dose of Insolence, Respectful or otherwise, to a fellow ScienceBlogger. It’s been even longer (as in, I think, never) that I’ve ever seen one whose resource I use regularly screw up so amazingly. I’m talking about Coby of A Few Things Ill-Considered, whose How To Talk To A Climate Skeptic (also found here) is a resource I turn to again and again and again when faced with denialist arguments about anthropogenic global warming. Indeed, I’ve been having periodic exchanges with a certain AGW denialist with whom I’ve tussled before, and How To Talk To A Climate Skeptic coupled with Skeptical Science have helped me enormously.

That’s why I take no pleasure in what I’m about to do, but two days ago Coby laid down a heapin’ helpin’ of anti-fluoridation fear mongering, chock full of dubious arguments (at best) that don’t belong on ScienceBlogs. Because Coby has been so good for so long in other areas, I’m willing to give him somewhat of a pass, but not so much that I will ignore or decline to rebut what he’s posted. Actually, it’s what his father, Dr. James S. Beck, who wrote the post and who has co-authored a book with well-known anti-fluoridation crank Paul Connett, the driving force behind the Fluoride Action Network entitled The Case Against Fluoride: How Hazardous Waste Ended Up in Our Drinking Water and the Bad Science and Powerful Politics That Keep It There, posted on Coby’s blog at Coby’s invitation, namely a post entitled The Case Against Fluoride.

Now, I understand that it’s Coby’s father and all, but he made quite the mistake in letting his father hijack his blog for a day. The hit to his reputation will be depressingly epic. Or maybe not. The right-wingers who don’t believe in anthropogenic global warming and would be most likely to be all over Coby for a misfire like this tend to be by and large, if not receptive, at least not overtly dismissive of the anti-government arguments used against water fluoridation; they may not take him on (much) for this. On the other hand, a lot of people who defend the science of AGW recognize dubious arguments when they see them.

Before I begin in earnest, let me just say that I really don’t have a dog in this hunt. I really don’t. (If you don’t believe me, search this blog for the term “fluoride” or “fluoridation.” You won’t find much at all, and most of it will be in comments.) Unlike the case with the the anti-vaccine movement and other pseudoscience and anti-science movements that I regularly write about here, I don’t have a strong feeling one way or the other about water fluoridation. I tend to go where the evidence leads me, and I realize that lately fluoridation has been questioned, given the widespread use of fluoride in toothpaste, which could potentially produce the same benefits, and increasing concerns about fluorosis. I get it. The issues surrounding the benefits and risks of water fluoridation are not straightforward. They never have been, actually. However, what I don’t get are the overheated simplistic arguments that come out of the anti-fluoridation movement. In fact, I had thought that the anti-fluoridation cranks disappeared decades ago; being anti-fluoridation is so…Cold War. It’s teh Communism, I tell ya! Just like Obama! Hmmmm. Come to think of it, maybe President Obama is the reason the fluoride cranks are coming out of the woodwork again. Certainly they came out of the woodwork in the comments of Coby’s post, and I expect the same thing to happen here. Perhaps we could have a contest: Which cranks are most persistent, tobacco/smoking denialists, AGW denialists, anti-vaccine loons, or anti-fluoridation activists?

Besides, Mandrake, have you ever seen Obama drink a glass of water?

And you do know, don’t you, the true purpose of introducing foreign substances into our precious bodily fluids:

But I digress. I ask your forgiveness because I love this particular movie and will use any excuse to quote it or use video from it. Just be glad I didn’t find an excuse to use the classic “Mein Fuhrer, I can walk!” scene or making some crack about how we “must not allow a mine shaft gap.”

Before I get into the post itself, let’s take a look at the main author of the book whose coauthor has sullied ScienceBlogs. Who is Dr. Paul Connett? I had, believe it or not, never heard of him before. Thankfully, the almighty Google is my friend, and it didn’t take much to find out a fair amount about him. First, take a look at his website, the Fluoride Action Network, for a minute. Coby’s father specifically mentioned this website as a source of more information; so I consider it fair game. Take a long look at the website. Peruse it. Feel anything familiar? I did. My pseudoscience Spider senses started tingling with a weaker version of the feeling I get when I read anti-science and pseudoscience blogs like Age of Autism–and with good reason too. One reason is right there on the front page in the form of 3,209 Medical, Scientific, and Environmental Professionals Sign Statement Calling for End to Fluoridation Worldwide

Oh no.

If there’s one very strong indicator of a crank, it’s the production of lists of scientists signing “statements” like the one above. For example, there’s the famous list of over 600 scientists against anthropogenic global climate change being circulated by James Inhofe (R-OK), which has been thoroughly debunked, the Perth Group signatories who reject HIV as the cause of AIDS, and the Discovery Institute’s list of scientists who dissent from Darwin or its list of physicians who reject “Darwinism.” If there’s one one major red flag indicating crankitude, it’s compiling lists like this. True, it’s not always a sign of crankitude, but when you examine the list and find out that most of the scientists actually don’t have any expertise in the field in question it’s a pretty good indication.

In the case of Connett’s list, we have:

  • 522 Nurses (RN, MSN, BSN, ARNP, APRN, LNC, RGON)
  • 458 DC’s (Doctor of Chiropractic, includes M Chiro)
  • 411 PhD’s – includes DSc (Doctor of Science); EdD (Doctor of Education); DrPH (Doctor of Public Health)
  • 356 MD’s (includes MBBS)
  • 291 Dentists (DDS, DMD, BDS)
  • 138 ND’s (Doctor of Naturopathic Medicine)
  • 77 Lawyers (JD, LLB, Avvocato)

Wait a minute. 458 chiropractors and 138 naturopaths? That means that at least 18.6% of the list is made up of CAM practitioners. Seriously. let me just put it this way. If you’re going to trumpet that you have all these “medical” and “scientific” professionals allegedly on your side, it sure doesn’t help your credibility to have so many quacks in the list mixed in with the real medical professionals. Make no mistake, naturopathy is a hodge-podge of quackery that includes homeopathy, reiki, traditional Chinese medicine and various detoxification woo, while many chiropractic practices are also highly dubious. In any case, naturopaths and chiropractors are hardly reliable health care professionals who can be counted on to evaluate science and epidemiology. Both CAM specialties tend to be anti-vaccine and anti-pharmaceutical to the core and can be reliably expected to be against fluoridation just on the basis of its not being “natural” or because it’s adding a chemical to water, regardless of what the evidence shows. Neither are lawyers. Come to think of it, neither are most nurses and doctors, either, and, I bet, most of the PhDs who signed.

In other words, it’s the classic appeal to authority. Dubious authority.

But what about Dr. Beck’s arguments, which are summaries of the arguments from the book he co-authored with Dr. Connett? His first argument is this:

Is fluoridation effective in reducing the incidence of dental caries (cavities)?

Fluoridation of public water supplies has been in effect somewhere in the world for seven decades now. Over that time the prevalence of dental caries has fallen in industrialized countries. This has been taken by many to indicate efficacy. But research has consistently shown that the decrease has occurred in countries without fluoridation to the same or greater degree as in those with fluoridation. Furthermore it is observed that in jurisdictions where fluoridation has been discontinued the incidence of caries has not risen. And studies comparing caries experience of cities fluoridated with cities not fluoridated have shown no difference, except where the nonfluoridated cities do better.

The answer to this first question is clearly no.

Well, that’s not what this systematic review says:

Fluoridation of drinking water remains the most effective and socially equitable means of achieving community-wide exposure to the caries prevention effects of fluoride. It is recommended (see also www.nhmrc.gov.au/news/media/rel07/_files/fluoride_flyer.pdf) that water be fluoridated in the target range of 0.6-1.1 mg/l, depending on the climate, to balance reduction of dental caries and occurrence of dental fluorosis, in particular with reference to care in hospital for those following stroke.

It was based on 77 studies. Multiple studies over several decades attest to the efficacy of water fluoridation in decreasing dental caries. Now, it may be possible that fluoridation of water is arguably no longer necessary in some communities because of the widespread use of fluoride toothpaste and other sources of fluoride, but to argue that fluoridation is not effective requires some very nice cherry picking of studies, as it’s not difficult to find a large number of studies supporting the efficacy of fluoridation There’s also the issue of better dental care. Dr. Beck seems to ignore the fact that better dental care is also associated with decreases in dental caries; it’s quite likely that better access to dentists and better self-dental care could have contributed to the decline in dental caries. Dr. Beck’s argument is as simplistic as he accuses fluoridation boosters’ arguments of being. Once again, an argument can be made that fluoridation may not be necessary anymore in some communities, but to argue that fluoridation is ineffective is just not supportable.

The next argument is that fluoridation is dangerous. It is true that one well known potential complication of fluoride therapy is fluorosis; no one argues that. The vast majority of fluorosis is so mild that it isn’t even noticeable. One can argue if the benefit in terms of reductions in dental caries is worth the risk of mild fluorosis at the concentrations usually used, but it seems like a reasonable trade-off to me in most cases.

More worrisome are the other risks Dr. Beck cites:

Aside from dental fluorosis, evidence uncovered over the last two decades has shown an association of fluoride in drinking water with lower IQ in children. There are over twenty published studies showing this association. In laboratory studies of animals and of aborted human fetuses an association with abnormalities of cells of the brain has been found. Also it has been shown that fluoridation is associated with high levels of lead, a known neurotoxin, in the blood of children.

It irritates the crap out of me that Dr. Beck doesn’t include citations in his post. I couldn’t look up the articles easily and see for myself. No doubt he wants people to buy his book, but, quite frankly, I’m not going to buy his book. If he wants to convince in the blogosphere, he really should include links to all the studies. Still, it wasn’t too hard to find the study claiming lower IQ, which appears to be this one. A quick perusal demonstrates–surprise! surprise!–that there’s much less to this study than meets the eye. First, the “high” fluoride group was exposed to pretty darned high levels (8.3 ± 1.9 mg/L, which is more than eight times the typical level in fluoridated water). Second, the error bars were large and highly overlapping. Third, the study has not been replicated. Let’s just put it this way: Convinced, I am not. A perusal of a few other studies didn’t look any better. Who knows? There might be a case to be made here; if there is, though, Dr. Beck didn’t really make it.

I’m also not at all impressed with this argument either:

The possible incidence of bone fracture with fluoridation has been studied with mixed results. One of the strongest studies is presented in a paper by Li et al. published in 2001 which shows a rising prevalence of hip fracture correlated with a rising intake of fluoride starting with concentrations comparable with those used in fluoridation in North America. And this is just one example that suggests that hip fracture is caused by fluoridated water.

The study to which Dr. Beck is referring is this one, Li et al, from 2001. I’ll show you what I mean. This is one of two “money graphs” from the paper showing the relationship between overall fracture risk and fluoride in water:

i-b88847ec4ca0656a66ff609279116c69-fig2.jpg

Notice that the low point of the graph is right around 1 ppm, which is right around where fluoride concentrations are in areas where water is fluoridated. Hmmmm. If you believe this graph represents causation rather than just correlation, you’d want to fluoridate your water to be right around 1 ppm in order to decrease the prevalence of fractures, wouldn’t you? After all, 1 ppm is the low point on the graph.

In all fairness, there is another graph that looks at hip fracture prevalence adjusted for age and BMI. It’s that graph that Dr. Beck appears to be zeroing in on, and it looks like this:

i-a1b30a3331a69b7036575d952d042213-nfig003.jpg

Note that in this graph only the very highest fluoride level is statistically significantly different than the 1 ppm level. In any case, this second graph is what we in the biz call a “subgroup analysis.” My guess is that the authors were either puzzled by or didn’t like the first graph because it didn’t show the expected association. So, as researchers are far too frequently wont to do, they probably started looking for subgroups in which they could find a statistically significant result that they did like. This is, unfortunately, how a lot of medical research “finds” statistically significant results, particularly in retrospective studies. Sometimes it’s dishonest when investigators do it; more often it’s more desperation for a way to salvage a negative study with some positive results. (This latter motivation is particularly true in negative clinical trials of a new treatment.) Unfortunately, subgroup analysis is highly dubious if the subgroups were not specified and incorporated into the design of the study from the very beginning. When they’re done post hoc, they are virtually always regarded with suspicion and their results as, at best, hypothesis-generating rather than hypothesis-confirming. Unfortunately, in the vast majority of studies, it’s very difficult to tell whether the subgroup analysis done was incorporated into the original design of the trial.

Then there’s the issue of the number of actual fractures that can be analyzed, which is very small. Indeed, the authors themselves estimate that a study of at least 400,000 people would be required to answer the question of whether there is a relationship between hip fractures and fluoridation levels in water. It would also require a different trial design, namely a cohort study. Finally, also note that this is an ecological study, and ecological studies are well known in epidemiology for producing false positives. I’ve even blogged about this, as has Epiwonk. The bottom line is that ecological studies frequently find effects that aren’t there or find larger effects than more rigorous studies later find to be supported.

Let’s just put it this way. Li et al is just not particularly convincing, and there are no others that I could find that show such a relationship. A quick perusal of other studies that I tried to find to back up Dr. Beck’s other claims–at least those that I could find without doing too many PubMed searches; by this point it was late last night and I was rapidly tiring of looking up Dr. Beck’s references–reveal nothing any more impressive than either of these studies. It’s possible that I’m wrong. It would have taken a lot more time to go through all these claims than I had last night. Maybe if I have the time and inclination tonight I’ll look up a few more.

In the meantime, I remain completely underwhelmed.

Finally, Dr. Beck argues that, because it is ineffective and risky, fluoridation is therefore unethical and, even if it did work, it would still be unethical:

Given the evidence that fluoridation is ineffective and that it is unsafe, the question of ethicality is easily answered in the negative. But even if it were effective, it would not be acceptable for the following reasons.

It is unethical to administer a substance or procedure to a person without the consent of that person, consent informed by a qualified professional who must answer questions from that person and who must inform the recipient of the reasons for the administration and of possible side effects. Such consent has never been sought from, much less given by, those whose tap water is fluoridated.

Well, yes, water fluoridation would be unethical if it were indeed ineffective and dangerous, but it is not. It would also cost a hell of a lot of money for no benefit. As for the argument that, even if fluoridation were effective, it would still violate informed consent, well, that’s actually a political and ethical argument about acceptable and desirable public health measures, not a scientific argument. It’s perfectly fine to make that argument, if that’s what you believe, but it never ceases to irritate me how, like “health freedom” supporters of alternative medicine, anti-fluoridation activists seem to feel compelled to make their resistance to policy sound like a scientific argument.

Of course, one wonders why Dr. Beck and his co-authors don’t appear to be similarly worked up by the fact that most municipal water systems use chlorine in the water supplies as a disinfectant. It’s in there, and most of us who live in urban areas drink it, and the chlorine left over is on the order of 0.5 ppm, which is on the order of the fluoride concentration. Why is it OK to chlorinate water to kill bacteria but not OK to fluoridate water to try to reduce the incidence of dental caries? Using the same arguments, why isn’t Dr. Beck arguing that putting chlorine in drinking water similarly violates the principle of informed consent?

Then there’s Connett himself. It doesn’t take much to see that he’s descending into crankery, if he’s not already there. For example, he’s shown up being interviewed by the odious promoter of quackery, Dr. Joe Mercola, who asserts that the real cause of dental caries is high fructose corn syrup. That’s not enough, though. Connett has also shown up on the web video interview show of the even more odious seller of quackery, Mike Adams. It gets even better, though. Connett has also been on the show of über-conspiracy theorist crank Alex Jones.

That’s not the worst of it, though. He’s been showing up around Autism One. Yes, that’s right. Paul Connett appears to be associating with anti-vaccine cranks. Indeed, apparently he’s worked with the even bigger crank Russell Blaylock.

Yes, yes, I know that just being interviewed by a crank does not necessarily mean Connett is a crank. After all, anyone can be taken in by a crank, and it’s probably impractical to vet every interviewer who asks to interview you, particularly when you have a book (and, more importantly, a message) to sell. However, there comes a point when the cranks interviewing you are so cranky that you really should be able to figure it out; Google is available to all. With Dr. Connett, there is a disturbing pattern; he’s covered nearly all the crank bases, even Whale.to, where he is praised, and Gary Null. Cranks appear drawn to his ideas, and he doesn’t send them away.

The bottom line is that I’m exceedingly disappointed in Coby for posting this tripe on ScienceBlogs, just as disappointed as I’m sure he’d be in me were I ever to do a post with Ian Plimer, Lord Monckton, Steve Milloy, or another AGW denialist expressing “skepticism” about the scientific consensus regarding global climate change. He’d give me a right nasty blog smackdown I bet, and I’d richly deserve it. I realize that we all have our blind spots, and, of course, this is Coby’s father who’s teamed up with someone who appears to be an utter crank to write a book. I can even understand how Coby might want to help his dad sell some books. But, damn, for someone who’s in the past done such a spectacular job deconstructing pseudoscientific and denialist arguments regarding global warming, Coby sure has gone down the rabbit hole of bad arguments regarding fluoridation. Worse, this is even in the case of a situation where, when trying to weigh the risks of fluorosis versus the benefit against dental caries, there actually is probably a case to be made that a one-size-fits-all approach to water fluoridation may not even be necessary anymore. However, such a case, if it is made, will be nuanced and complex, based on a realistic assessment of the benefits, risks, and costs. Dr. Beck’s argument was anything but that. After all, he did entitle his post The Case Against Fluoride, and there clearly was a reason for that, namely to argue more like a lawyer advocating for a client rather than a scientist soberly assessing the evidence.