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HomeMy WebLinkAboutRoger Oakes November 18, 2015 To: Port Angeles City Council Re: Community Water Fluoridation From: Roger Oakes, MD Thinking about government's role in public health is the crux of the issue with water fluoridation. Opponents of fluoridation are concerned about individual liberties, as well as efficacy and safety of adding fluoride to our water. The science regarding safety and benefit is actually quite clear. While concern about individual liberties is understandable, it is important to understand that solid evidence leads to public health measures that ultimately trump individual rights to choose. Public health measures are often controversial yet today many that were once considered misguided are now understood to promote the heath and safety of our citizens. Think about vaccination mandates, helmet laws, auto seatbelts, micronutrients added to foods like folic acid to prevent birth defects, iodization of salt to prevent goiters, laws against alcohol-impaired driving and public smoking restrictions. These measures came about through public health actions that our society thought important enough to trump individual rights to choose. The decision before you, as a City Council, centers on the role of government in promoting public health when the evidence is quite clear about the benefit and safety of a measure such as community water fluoridation. The Center for Disease Control has deemed water fluoridation as one of the ten great public health achievements of the 20'b century. (MMWR, 42-99. 48(12): 241-243). They state, "Fluoridation of drinking water began in 1945 and in 1999 reaches an estimated 144 million persons in the U.S. Fluoridation safely and inexpensively benefits both children and adults by effectively preventing tooth decay, regardless of socioeconomic status or access to care. Fluoridation has played an important role in the reductions of tooth decay (40%- 70% in children) and of tooth loss in adults(40%- 60%)." Thank you for the thoughtful approach you have taken on this important issue. n S c.e +'S. G �✓. S r/} liter e'`''" CJ � C `dl ► l/ ����,.. C7'�-e�.v� :�'" ��—G °/ I ' �"`�1 1 `mot" r' ''i' The NEW ENGLAND JOURNAL of MEDICINE M AY 16, 2413 Government's Role in Protecting Health and Safety Thomas R. Frieden, M.D., M.P.H. spread by tobacco companies, which have been convicted of de- - — liberately deceiving the public about the health effects of tobac- co. Antitobacco advertising helps counteract the industry's efforts sometimes characterized as in- applications of this principle in- to undermine science and its mas- appropriately__intrusive. Such crit clude calorie labeling in restau- sive marketing expenditures. Op- icism has a long history, but to- rants, which appears to encour- position to such government ef- day we accept many public health age some companies to offer and forts may have financial as well as measures t at were once consid- some people to choose more philosophical or legal bases. ered misguided, intrusive, or con- healthful food options.'The ini- A second key role of govern- tro_ versiA Public health initiatives tial costs to restaurants to per- ment is to protect individuals include efforts to promote free and form nutritional analyses and re- rof m preventable harm caused open information to facilitate in- print menus and menu boards are by otr her individuals or Qronns. formed decision making, protect the focus of most objections, but An individual's right to engage individuals from being harmed by these costs may be counterbal- in particular conduct may affect other individuals and groups, and anced by lower health care costs others ("your right to swing facilitate societal action rn �nrn- and increased productivity. Some your fist ends at my nose"). mote and protect health(see table), people value the transparency Government has a responsibility Free and open information that such laws require, regard- to protect individuals from un- empowers people to make in- less of the health effects. healthy environments, whether formed choices and reduces the Another example of the pow- the sources of health risks are likelihood that misinformation er of information is the graphic natural (e.g., mosquito infesta- or hidden information will en- warnings on tobacco packages tion) or created by people or or- danger health. Laws may require and antitobacco advertising to en- ganizations. Few Americans now disclosure of factual information courage smoking cessation.2 Pack question government's role in (e.g.,product content), provide for warnings convey clear information preventing sales of contaminated government transparency (free- about the health effects of to- food,water, and medications;re- dom of information), or prevent bacco use, creating a visual and ducing alcohol-impaired driving; dissemination of inaccurate or visceral counter to the aggressive or protecting workers and com- misleading information. Newer and often misleading information munities from industrial toxins. N ENGLJ MED 368;2o NEJM.ORG MAY 16,2013 1857 The New England Journal of Medicine Downloaded from nejm.org by ROGER OAKES on November 6,2015.For personal use only.No other uses without permission. Copyright 0 2013 Massachusetts Medical Society.All rights reserved. PER SPEC FIVE GOVERNMENTS ROLE IN PROTECTING HEALTH AND SAFETY 3 . ests.Limiting promotion of tobacco health than the actions of indi-_ t and alcohol helps individuals by iduals. Immu_n_ization mandates, (fluorid reducing consumption and benefits ation of water,,iodization Promoting Free and open Information business by increasing workforce of salt, ana micronutrient forti- Long-standing productivity and reducing health fication of flour are_ all classic yp Truth-in-advertising laws care costs.Although increased use examples of this te of action; Nutrition-facts panel of their products benefits tobacco many were controversial initially Pharmaceutical package inserts and alcohol companies' employees but are widely accepted today Newer and shareholders,other companies because they save money and re- Public reporting of health care provider and society bear increased medi- duce illness, disability, and death. ` performance Calorie labeling at chain restaurants cal, economic, and social costs, More recent and controversial as well as the illness and deaths examples o oeietal action include Graphic tobacco-pack warnings Antitobacco advertising caused by use of these products. zoning laws that require or pro- Sex education for teens Opinions vary about whether de In entives to create bicycling a given behavior's risk to others is and walking paths or that reduce Protecting Individuals from Harm Caused by Other People or by Groups sufficient to warrant governmen- the neighborhood density of liquor Long-standing tal action. But where there are stores. These actions serve entire Nonadulteration of food clear ways to prevent substantial communities, and individuals can- Laws against alcohol-impaired driving harms, government may have a re- not feasibly implement them on Infectious-disease reporting sponsibility to act. Smokefree laws their own—characteristics that Worker safety illustrate the growing acceptance also apply to efforts to reduce Protection against naturally occurring health of actions that protect people from sodium in processed and restau- threats(e.g.,West Nile virus) others' behavior. Such laws are rant foods. Objections to such ac- Tobacco excise tax often controversial when intro- tions usually focus on their costs, Alcohol excise tax duced, with opponents predicting effectiveness, or importance, but Newer reduced hospitality-industry prof- the appropriate role of government Laws requiring smokefree workplaces and its and decrying infringement of and the relative costs and bene- other public places personal freedoms, but they gain fits are also debated. Controversy Alcohol ignition interlock devices for people acceptance as people see their can be reduced by providing data convicted of drunk driving - Restrictions on sales and marketing of tobacco health benefits — and no eeo- documenting the health burden and alcohol(especially to children) nomic harm to businesses.Smoke- and building consensus about the Elimination of artificial trans fat free laws cost little to implement, problem and the action's efficacy. Taking Societal Action to Protect improve health, reduce health care Government action need not con- and Promote Health costs, increase productivity, save sist solely of mandates: micronu- Long-standing lives, and do not reduce overall trient fortification of food has Vaccination mandates business revenues or tax reeeipts.3 often been accomplished through Water fluoridation A large majority of the U.S. pub- voluntary industry actions coor- Micronutrient fortification of manufactured lic now favors such laws.4 dinated through public–private foods Newer examples of actions that partnerships. Iodization of salt prevent harm by others are the The most controversial public Clean water,air,food elimination of artificial trans fats health actions seek to regulate Elimination of lead in paint and gasoline from the food supply,which pro- the behavior of adults in such a Newer tects people against a contributor way as to improve their own Zoning laws to promote physical activity to cardiovascular disease, and ig- health. Public health agencies (e.g.,walking and bicycle paths) ninon interlock devices in vehicles, operate on the belief that gov- School policies(e.g.,food,physical activity, safe transportation) which can protect the public from ernment has a valid interest in a Reduction of sodium in packaged and restau- co drunk drivers. healthier populace, but many ar- rant foods A third key role of govern- gue that people have the right to m to protect and promote knowingly make decisions that For some issues, government health throng population-wide may result in harm to their health- may be the only entity capable of action. Governmental action is Taxing, decreasing access to, or promoting the greater good by rec- often a more effective and effi- limiting portion sizes of sugar- onciling social and economic inter- cient means of protecting public sweetened beverages is one ex- 1858 N ENGLJ MED 368;20 NE)M.ORG MAY 16,2013 The New England Journal of Medicine Downloaded from nejm.org by ROGER OAKES on November 6,2015.For personal use only.No other uses without permission. Copyright©2013 Massachusetts Medical Society.All rights reserved. PERSPECTIVE G9 ERNMENT'S ROLE IN PROTECTING HEALTH AND SAFETY ample of recent controversial pro- ernment, ind stry, and the econ- judicial philosophies may limit posals of this type. Seatbelt and omy and to ' dividuals who might possibilities for public health �j motorcycle-helmet laws exemplify not benefit ersonally.There may action in the United States. the balancing act etween health also be p ilosophical objections, Government has a responsi- benefits and individual rights: such as perceived loss of personal bility to implement effective these laws have financial costs for autonomy or tffie` e ief that these public health measures that in- enforcement and the purchase of ac ns wily undermine self reli crease the information available helmets and perceived societal ance or 1n lal choice. Some to the public and decision mak- costs in loss of personal freedom, opponents ear a slippery slope r ers, protect people from harm, 15u--f tTiey prevent traffic injuries toward"sabotaging our rights on/ promote health, and create envi- U U and deaths and reduce societal all fronts.115 ronments that support healthy costs, including health care costs The potential benefits of pub- behaviors. The health, financial, and lost productivity. Such mea- lic health action include econom- and productivity gains from pub- sures may be best enacted at the ic, health care, and productivity lic health actions benefit indi- local or state level, where gov- gains, as well as the intrinsic viduals and society as a whole. ernment's proper role can be de- benefit of longer, healthier lives. Disclosure forms provided by the author-- bated; deliberations will be fair- The dissemination of accurate are available with the full text of this article est if there are no major vested information on costs and bene- at NEJM.org. financial interests, as is generally fits may be the best way to re- Dr.Frieden is the director ofthe Centers for the case with helmet laws. duce opposition and implement Disease Control and Prevention,Atlanta. Beyond the societal costs in effective public health actions. This article was published on April 17,2013, health care and lost productivi- When government fails to pro- at NEJM.org. ty, actions to protect health are tect and improve people's hhealtIi, 1. Dumanovsky T,Huang CY,Bassett MT, supported by the recognition that society suffers. Opponents O Silve rLD.Consumer awareness offast-food calorie information in New York City after although many people express pn lic—health action often fail to implementation of a menu labeling regu- remorse over past behavior, we acknowledge the degree to which lation.Am J Public Health 2010;100:2520- tend to assign limited weight to individual actions are influenced 2. Hammond D-Health warning messages future events or conditions — a by marketing, promotion, and on tobacco products:a review.Tob Control pattern behavioral economists other external factors. They also 2011;20:327-37. call "hyperbolic discounting" may underestimate the health 3. Chang C, Leighton J, Mostashari F, Mc- Cord C, Frieden TR. The New York City Action by democratically elected costs of inaction and overesti- Smoke-Free Air Act:second-hand smoke as leaders may therefore be needed mate the financial or other costs a worker health and safety issue.Am J Ind to protect_public health over the of action. For-profit corporations Med 2004;46:188-95. 4. Callinan JE,Clarke A,Doherty K,Kelleher long term. have a fiduciary responsibility to C. Legislative smoking bans for reducing / Opponents of specific public increase return on investment; secondhand smoke exposure,smoking prev- health actions may believe that the some (e.g., tobacco companies) alence and tobacco consumption.Cochrane health burden is low, the inter- have incentives to oppose actions Database Syst Rev 2010;4:CD005992, 5. Harsayani D.Nanny state:how food fas- vention is too costly or is likely that may harm their business, cists,teetotaling do-gooders,priggish mor- to be ineffective, and that there- even if these actions would pro- alists and other boneheaded bureaucrats are turning America into a nation of children. fore the expected benefits don't mote overall economic develop- New York:Broadway Books,2007. warrant the costs. The costs cited ment and benefit other business- may include financial costs to gov- es. And in some cases, current Copyright©2013 Massachusetts Medical Society. r