The writer George Orwell used a metaphor involving two people shouting at each other from upper-story windows to describe a type of argument; they were arguing from different premises (where the two meanings of premise are conflated). This might explain why casual observers of the debate over water fluoridation think it is just a two-sided one where both parties share a common premise. That couldn’t be further from the truth.
Since the Health and Care Act has come into force, a new generation of healthcare workers has come into contact with community water fluoridation (CWF). Indeed, the new way of achieving water fluoridation involves a wider selection of people in greater numbers than in the past. As well as the public health team, there are now communication teams, civil servants, IT professionals and many others. Various people now involved in the implementation of new CWF schemes know little about the intricacies of the intervention, and many of the old-timers would be at sea with the new arrangements.
These new hands are looking at issues the old hands have taken for granted. Gone (or greatly diminished) is the cadre of professionals working in the NHS or public health who understood the important details of water fluoridation. The institutional memory of CWF has been dissipated. So, delivering new schemes involves bringing up to speed a new cohort of people from many backgrounds and states of knowledge. It’s not surprising, then, that some of the issues surrounding CWF need revisiting.
One old issue that has been dusted off is this: aren’t we and people opposing it (antifluoridationists) just using our own versions of propaganda in a propaganda war? Is it just a matter of upping the propaganda heat to win the argument? Aren’t we profluoridationists just the other side of the coin? And if we are merely using propaganda, our new colleagues feel uncomfortable about that.
Fortunately, the answer is no. Ours is an honest espousal of a cause; the antifluoridation case is not, which makes it qualify as propaganda. What distinguishes us from the opposition goes to the heart of the issue - the seeking of truth. It seems to me that there are two contrasting approaches:
- Evidence first, then position (E1P2): This is often referred to as the scientific or empirical approach.
- Position first, then evidence (P1E2): This is often associated with a more biased or subjective approach.
The E1P2 approach to seeking the truth is the only way to an honest espousal of a cause.
The antifluoridationists’ preferred approach to water fluoridation is the second. They are fundamentally against it to start with, the P1E2 approach. The result is propaganda (communication that is primarily used to influence or persuade an audience to further an agenda, which may not be objective and may be selectively presenting facts to encourage a particular synthesis or perception, or using loaded language to produce an emotional rather than a rational response to the information that is being presented). If the goal is to persuade or advocate for a specific position, this approach can be quicker, more straightforward and clearer. And starting with a clear position can provide a focused direction for seeking supporting evidence.
How does this dichotomy (evidence first versus position first) play out in real life? Take the measles, mumps and rubella (MMR) vaccination in children (which had been introduced because the evidence showed its safety and efficacy). A UK senior doctor took against the intervention. He used selective evidence to back up his stance. Subsequently, vaccination rates declined, killer epidemics broke out and he was struck off. The same can be seen with fluoridation (where the evidence first, position second approach is long-established):
- Portland, Oregon (2013): Portland is one of the largest U.S. cities without fluoridated water. Despite strong recommendations from health experts and a campaign to introduce fluoridation, a public vote rejected the measure due to fears and misinformation spread by antifluoridation activists.
- Calgary Alberta, Canada (2011): A city of 1.3m people lost its fluoridation because one physician, allied to the US fluoridation opposition organisation, misstated the safety of fluoridation, convincing 10 of 15 city councillors to remove the public health measure. It took four years of determined effort by fluoridation advocates for the council to reverse its decision. The pandemic supply chain and other issues have meant that fluoridation still has not been returned to Calgary.
These examples highlight how antifluoridation campaigns, driven by a ‘position first, evidence second’ approach, can lead to decisions that negatively impact public health.
It is a flawed approach, with the following disadvantages:
- Confirmation bias
- Distortion
- Reduced credibility and resistance to change
With confirmation bias there's a significant risk of only seeking or valuing evidence that supports one’s pre-existing position, while ignoring or dismissing contradictory evidence. This approach can lead to the distortion of facts and misrepresentation of the truth to fit the predetermined position. A stance formed this way can be less credible, especially if the evidence used is selectively chosen or misinterpreted. Positions formed before examining evidence can be harder to change, even in the light of new, contradictory evidence.
So that is why CWF advocates do (and should) use the E1P2 method, despite its problems. It can be both time-consuming (collecting and analysing evidence can be a lengthy process), and complex (interpreting evidence correctly often requires specialised knowledge and skills). But the advantages far outweigh the disadvantages.
The advantages of the E1P2 approach include:
- Objectivity
- Reliability
- Adaptability
- Credibility
This method minimises biases as the position is derived from the evidence rather than preconceived beliefs. Positions based on evidence are typically more reliable and robust because they are supported by verifiable data. This approach allows for changing one's position if new evidence emerges, promoting continual learning and improvement. Positions based on evidence tend to be more credible and persuasive, particularly in scientific and academic contexts.
Why does the approach to the issue matter to something like water fluoridation? It boils down to truth and objectivity, decision-making and ethics. The evidence-first approach is crucial in contexts where objectivity and truth are paramount, such as in scientific research, legal investigations, and academic studies. For sound decision-making, especially in complex and uncertain situations, relying on evidence first helps ensure that decisions are based on the best available information. In public discourse, policymaking, and journalism, starting with evidence helps uphold ethical standards of honesty and integrity.
So that’s what distinguishes us from the opposition. Our approach strives to be a genuine, honest espousal of the cause, but their approach ends up down the propaganda route.
What are we to make of all this? First, advocates of CWF must stick to the E1P2 formula. Second, we should alert the targets of antifluoridation propaganda, helping to minimise the effects of their techniques, whilst exposing the P1E2 faults. Genuine debate on CWF is welcome. Underhanded techniques and propaganda (from either side) are not.