In Spokane's latest fight over fluoride, advocates are making their case to leaders, not voters

Aug. 16--After decades of failure at the ballot box, proponents of adding fluoride to the city of Spokane's water supply are taking a different approach.

They are pleading with city leaders to circumvent voters and take immediate action, counting on a renewed prioritization of public health during the COVID-19 pandemic.

Dental health experts and fluoridation proponents argue that the coronavirus has demonstrated the importance of science-based public health measures and highlighted the inequities caused by their absence.

"People understand more about public health right now, so maybe this is a good time to go in and push on the City Council to say, 'Hey, you can do something about this,'" said Dr. James Sledge, a retired Spokane dentist who previously served on the state Board of Health. "We don't have to hash through another (voter initiative) campaign."

While fluoridation has historically been divisive in Spokane, the same cannot be said of the scientific and public health communities, which overwhelmingly endorse the practice of supplementing drinking water with fluoride. The Centers for Disease Control and Prevention, the American Dental Association and countless others all trumpet water fluoridation as an effective and efficient means to reduce tooth decay.

Still, it's not a dentist or oral health researcher that local advocates have to convince -- it's the seven members of the Spokane City Council and the citizens of Spokane. And they believe they have struck a chord.

"The public health data has continued to grow," said City Council President Breean Beggs. "We're the biggest city in Washington that's not doing it, and the people who are pushing this are essentially the dental and health care insurance folks who have said, 'We'll put our money where our mouth is.'"

Who they are

The proponents for fluoridation in Spokane are as well-organized as ever.

A coalition of nonprofits, health care providers, philanthropic leaders and higher education institutions formed Smile Spokane in 2015 with financial backing from the Arcora Foundation, the nonprofit arm of insurer Delta Dental. The coalition advocates for improved community oral health, particularly through water fluoridation and includes the Native Project, Eastern Washington University and the Empire Health Foundation.

Desautel Hege -- the Spokane advertising firm responsible for the "Spread Kindness, not COVID" banners now on storefronts and advertisements throughout Spokane County -- is also part of the group.

Former Spokane City Council President Ben Stuckart was brought on as a political consultant to Smile Spokane earlier this year.

The same level of organization may not exist among those who oppose fluoridation locally, but they have historically found ways to make their voices heard -- such as billboards -- and are once again reaching out to elected leaders.

The Fluoride Action Network, which fights against fluoridated water programs in cities across the country, flagged Spokane's renewed fluoridation effort to its followers in a Thursday Facebook post . It charged that fluoride's proponents have withheld evidence regarding fluoride's toxicity.

"With the help of the Council President Breena Beggs" -- misspelling his first name -- "whose personal dentist is leading the charge, the council appears to be poised to work on behalf of the dental, chemical, and insurance lobbies and completely ignore the public will and approve the use of fluoridation chemicals," the group wrote.

A Facebook page, "Safe Water Spokane," as of Friday had a couple dozen likes and followers, but is urging city residents to contact local leaders and express opposition to fluoridation.

Jeff Irish, a Spokane resident, is spearheading the Safe Water Spokane effort, which he described as "grassroots." His main goal is to ensure that fluoridation opponents have the opportunity to present their argument to city leaders.

"I'm an advocate that, whether I agree with a person or not, that they should have a voice (and) be able to get their piece presented so that people can make an informed decision," Irish said.

Why 2020?

The quest for fluoridation has a long history in Spokane and has thrice been shot down by voters, most recently in 2000.

Although the COVID-19 pandemic is now central to their cause, fluoridation proponents had already considered 2020 for action prior to the arrival of the novel coronavirus. But doing so would have come with a cost. Sledge demands that fluoridation be treated apolitically as a public health issue, but he acknowledges that putting the question to the voters innately makes it political.

A political campaign requires funding and boots on the ground, both of which would be hampered by restrictions implemented during the pandemic and subsequent economic fallout. A City Council vote, on the other hand, requires neither.

Adding urgency is the fear among advocates that if fluoridation were to again lose at the ballot box, it would be another two decades until they could try again.

Advocates conducted public polling to help weigh their odds of success, although Sledge did not provide the specific numbers. Although the city has thrice turned down proposals to fluoridate the water, Sledge notes that the vote got closer each time, with the 2000 effort falling short by only 2 percentage points. He believes if the issue were to head to the ballot this year, voters would approve.

But the fight could be costly, both literally and metaphorically.

So the advocates fell back on an alternative plan: bypass the voters and lobby the Spokane City Council, which could pass an emergency ordinance to increase fluoride levels from naturally occurring levels to the 0.7 milligrams per liter recommended by the CDC. (Proponents state that Spokane's water naturally has 0.2 milligrams of fluoride per liter, but city spokesman Brian Coddington says a 2019 report showed the level at less than 0.1 milligrams per liter.)

Last month, fluoridation proponents presented the City Council with their request during a council study session. The council did not invite fluoridation opponents to speak at the meeting, but proponents outlined how the children in Spokane lag behind the nation when it comes to oral health, with higher rates of cavities. The proponents say the same inequities on display during the coronavirus pandemic are evident in the dental health of Americans, particularly in young children.

According to the CDC, children between ages 5 and 19 in low-income households are more than twice as likely to have a cavity. In Spokane, four of every 10 kindergarten children has had a cavity and one-fifth of third-graders have rampant tooth decay. A survey of Washington State state children conducted by the Department of Health in 2015 and 2016 found that 71% of Hispanic children experienced tooth decay, compared to 45% of white children.

That the disparities in the health of poor and wealthier Americans have become increasingly glaring gives advocates hope that they'll earn community support.

"It seemed to all of us that this was an opportunity to go back again and point out that it isn't simply a matter of cavities and that sort of thing, but this is also a socioeconomic issue, an equity issue," Sledge said. "It's laid bare the idea that people of color and lower socioeconomic folks suffer disproportionately."

Councilwoman Betsy Wilkerson, a supporter of fluoridation, said it hasn't traditionally been an issue discussed in the Black community, but she views it through a health and equity lens.

"We've had so many other things that we've addressed, fluoride had never risen to the topic of discussion in the communities of color. Now here it is, and we're sitting up and paying attention," Wilkerson said, though she noted fluoridation can also be divisive within communities of color.

The pandemic has only exacerbated existing disparities in dental care, argued Torney Smith, the retired former administrator for the Spokane Regional Health District. As dentist's offices and schools closed, people lost access to treatment.

Equity factors hit home for Councilwoman Kate Burke, who represents the city's economically disadvantaged northeast district.

"My constituents have less access to dental facilities and services that will take insurances that they have," Burke said.

Opponents balk at the use of COVID-19 as justification for an emergency ordinance, noting the infrastructure would take months to put in place. For the City Council to adopt fluoridation without voters weighing in, Irish said, is a "strong-arm approach."

Controversial from the start

Spokane is hardly the first city to wrestle with whether to fluoridate its water supply, though it remains the largest in Washington state to resist it. The residents of Seattle, Tacoma and numerous other smaller cities such as Cheney all drink fluoridated water.

Fluoridation exploration in America began in the 1930s, when scientists eager to fortify the fast-rotting teeth of children identified a link between dental health and consumption of water with naturally high levels of fluoride.

Fluoride was first added to drinking water in the United States in the 1940s and, since the beginning, there has been vocal opposition to the practice.

Conspiracies have always been at least tangential to the opposition movement. In the 1940s and '50s, as the United States entered the Cold War, skeptics warned the water fluoridation could be a communist conspiracy to degrade the minds of Americans with chemicals.

Despite the widespread acceptance and endorsement from a slate of medical associations and public health organizations, the resistance to fluoridation remains persistent. Yet Beggs said his email inbox has been surprisingly light with anti-fluoridation sentiment as the council takes up the issue, and what resistance trickles in tends to be from people out of state.

"We're in this time of focus on public health, and in the polling on public health, the confidence in it has been going up, despite a very vocal minority that seems to disregard science," Beggs said.

Wilkerson said she's received a flood of emails about the topic, but much of the opposition she's received also appears to be from outside Spokane.

"We're getting this swarm of advocates from the outside who are bringing pressure to bear on the people who live here, and that just doesn't play well with me," Wilkerson said. "They go around taking up this fluoride battle wherever it pops up."

The Centers for Disease Control and Prevention counts fluoridation as among the greatest achievements in public health during the 20th century. Now widely adopted, water treated with fluoride flows out of the taps for about 75% of the country's population.

It's also cost-efficient. Rather than dealing with tooth decay after it sets in, a small investment upfront saves a community in the long term. A city of more than 200,000 people, like Spokane, can exceed savings of $27 for every $1 it invests in fluoridation, according to the CDC.

"I'm a kid that grew up with non-fluoridated water, and it cost me a lot of money, so I'm very interested in the topic, I support it," said Councilwoman Karen Stratton.

It can reduce tooth decay in children and adults by 25%, according to the CDC and the multiple scientific studies it cites, and with little health risk.

"Expert panels consisting of scientists from the United States and other countries, with expertise in various health and scientific disciplines, have considered the available evidence in peer-reviewed literature and have not found convincing scientific evidence linking community water fluoridation with any potential adverse health effect or systemic disorder such as an increased risk for cancer, Down syndrome, heart disease, osteoporosis and bone fracture, immune disorders, low intelligence, renal disorders, Alzheimer disease, or allergic reactions," the CDC states.

Excess exposure to fluoride can lead to dental fluorosis, which causes spotting on the surface of teeth, in children. According to a 2019 report by the World Health, children who consume more than 6 milligrams of fluoride per day could result in skeletal fluorosis, which causes weakened bones. (The same report endorsed water fluoridation.)

Although not monolithic in their reasoning, opponents of fluoridation generally rest on one or more of a few arguments: that the government should not force an individual to ingest an additive, that there is inadequate scientific research proving the benefits (or risks) of fluoridation and that there are better ways to prevent tooth decay that don't require a blanket approach like water fluoridation.

Opponents question the ethics of manipulating the drinking water of thousands of people without their individual consent, often equating it to forced medication.

Topical fluoridation -- in other words, applying fluoridated toothpaste or fluoride treatments directly to the teeth -- could be an effective alternative to adding the mineral to a water supply, many opponents will note.

That approach puts the onus on individuals -- particularly children -- to properly brush their teeth. And in many homes, that simply doesn't happen, Smith said. And the use of fluoridated toothpaste is great, but Smith asks, why not both?

"It'd be like saying 'We have seat belts in cars, why do we need airbags?'" Smith said.

To vote or not to vote?

The City Council could vote on the proposal as early as this month, after it is vetted by the council's public infrastructure committee and discussed in a virtual community forum, according to Beggs.

Council members will have to answer two central questions: is fluoridation an effective and safe public health measure, and is it the city council's role to implement it?

Councilman Michael Cathcart said he has too many unanswered questions to take a vote.

"If you're going to make me take a vote on something where there are very valid open questions, I just think it's irresponsible to take that vote," Cathcart said.

Cathcart pointed to a study published in the JAMA Pediatrics last year, which linked fluoride consumption by more than 500 pregnant Canadian women with a slightly lower IQ in their children. (The study was divisive, and many quickly criticized its methodology.)

To accommodate skeptics, several council members have endorsed a proposal for the city to offer a supply of drinking water that is not fluoridated, which residents could freely access.

But Cathcart said that such a supply could be difficult for disabled or low-income residents to access, so such a system should be made deliverable. Irish, too, questioned the practicality of offering an alternative water supply.

Cathcart also questions how the city's fluoridation would impact its agreements to deliver water to residents outside the city's borders, in places such as Airway Heights.

Delta Dental has committed $3 million toward the infrastructure necessary to fluoridate the water, and the advocates say they can scrape together the remaining $1 million from philanthropic sources. The annual cost of operation, the city estimates, would be $600,000.

Cathcart questions that startup budget and the annual costs, which he said could force the city to raise utility rates.

Coddington, the city spokesman, said the Mayor Nadine Woodward is also evaluating the costs.

"She is studying the costs and benefits of fluoridation, including the initial cost to ratepayers to equip the system for adding it to the water supply and ongoing cost to operate and maintain it along with how much of consumer consumption is for drinking water," Coddington said.

But Beggs believes the financial commitment for infrastructure should be taken advantage of now, before the offer is withdrawn. If the state Legislature were to impose fluoridation requirements in large cities like Spokane, companies like Delta Dental would lose any incentive to fund the infrastructure necessary to implement it, Beggs said.

"It's a good moment to take advantage of that opportunity," he said

Ultimately, the City Council will ultimately have to decide whether it's comfortable taking on an issue that has traditionally been left to the voters to decide.

Beggs points to a 2010 decision in which the state Supreme Court turned down an effort by residents in Port Angeles to reverse the implementation of Port Angeles's water fluoridation program.

"I would much rather see these groups, if they want to do this, collect signatures and put it on a ballot," Cathcart said of fluoridation advocates.

But putting it on the ballot would attract out-of-town money, and out-of-town people, to influence the campaign, Beggs said. He was struck by Sledge's argument, during the City Council study session, that fluoridation is not a political issue. He compared it to public health measures during the COVID-19 pandemic.

"We shouldn't have a vote on wear masks or don't wear masks. You can't afford to that," Beggs said.

The role of council is tricky, Burke acknowledged. But, ultimately, voters can remove a council member they disagree with.

"We don't do a vote to the people on all of the things we work on. People elect elected officials to do the work that not every single person would have the time to do," Burke said.

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