Why can’t we rely on science alone to make public health decisions?
DAlthough we are both practicing physicians and medical researchers, we have spent as much time over our careers thinking about fluoride as most Americans—very little. That changed with the nomination of Robert F. Kennedy, Jr. to oversee the federal government’s medical, public health, and research infrastructure. Kennedy expressed concerns about fluoridation of public water supplies, calling the practice into question while pointing to research studies on fluoride toxicity.
Water fluoridation has quickly become a hot-button public health issue, jumping on a long list of most pressing health threats. How did we get here?
We are worried that we have Expand quickly The scientific evidence base is increasing Public access if affinity However, it has made it easy to rely on “science” to distract from important, but often uncomfortable, debates about the values and trade-offs that are truly at the heart of every political issue.
Let’s take this example of fluoride. Fluoride has been added to public water supplies in the United States since the mid-20th centuryy last century, when research showed that fluoride in water could lead to a significant increase Reduce tooth decayWhen fluoride is found naturally in water sources or added in treatment facilities. Fluoridation of public water supplies provides everyone who drinks it with the benefit of preventing cavities, regardless of their dental hygiene habits or access to dental care. But as with any substance — from water to foods and medicines —Excessive amounts of fluoride It can cause problems. This can range from white discolouration of teeth (a purely aesthetic problem) to negative effects on the brain from prolonged exposure to excessive fluoride levels.
Both advocates and critics of fluoridation rely on their favorite scientific studies to support their claims. Proponents of fluoridation point to research on fluoride’s clear dental benefits and its safety at low levels. The US Centers for Disease Control and Prevention, which Kennedy was nominated to oversee, is currently in place It is considered Fluoridation is “one of the 10 greatest public health interventions out of the 20.”y Century.” However, critics focus on research indicating toxic effects of fluoride at high levels, and worry that it may be harmful even at low levels. Kennedy Plans “To advise all water systems in the United States to remove fluoride.” Both sides cite various research studies for their contradictory positions.
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When those who cite scientific research reach diametrically opposite conclusions, we have to ask: Is this debate really about science, or is science being used — consciously or unconsciously — to distract from an uncomfortable conversation? At its core, the fluoride debate pits broad public good against small potential risks and personal autonomy. It’s much easier to cite and over-interpret toxicity research than to say, “I don’t think we should use fluoride in our water supplies because of the small risks, even if it means cutting off the known dental benefits to society.” It is also more comfortable to focus on the number of cavities prevented than to say, “I believe the population-level benefits of dentistry outweigh the small potential risks of poisoning and loss of individual choice in what goes into our drinking water.”
Fluoride in our water may be a health problem. But it’s also political.
Science, when applied correctly, can and should guide us to the most challenging decisions we, as individuals and societies, need to make – whether they are about a specific medicine a patient should take or a public policy that should be implemented. It can tell us what benefits we might gain from choosing one path and what the financial or non-financial cost of obtaining those benefits will be.
But science cannot do that Tell us whether the trade-offs are worth making; This is a matter of values. A randomized controlled trial tells us what the benefits and side effects of a drug are, but only the patient can tell us whether they are willing to put up with those side effects to get the benefit. Likewise, researchers can estimate how much the new tax break will impact American households’ bank accounts, but they cannot tell us whether the trade-offs in the form of budget cuts are worth making.
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When these values-based decisions are particularly difficult or uncomfortable, science can also serve to mislead the public – intentionally or unintentionally – when it is presented in isolation from the trade-offs at hand.
Consider COVID-19. During the early stages of the pandemic, it was easier to focus on community infection rates and other epidemiological assessments than to address the trade-offs between health benefits for some and long-term educational benefits. damage For children caused by school closures – harms that are not easy to measure but are reasonable to anticipate. The controversy over mask and vaccine mandates is drawn from scientific studies focused on their role in COVID-19 transmission, but they often neglected to carefully evaluate the trade-offs between public health and personal autonomy that were the real crux of the issue.
Science and its quality are often what is up for debate, when debate should instead focus on what we value when choosing one path or another. Rather than clarifying precisely what the trade-offs are, science is increasingly being misused to justify the values someone holds – a mental trick to avoid explicitly assessing what one’s beliefs are, what the costs are worth, and what the benefits are. Avoiding discussing those trade-offs and the values behind them only makes it more difficult to move forward and create a policy that works for the majority of Americans.
Science tells us, for example, that alcohol Bad for us: It leads to liver disease, heart attacks, strokes, cancer, accidents, crime, death, and loss of economic productivity, among many other problems. Clinging to this science would make an easy case for supporting comprehensive alcohol bans. However, the reason people have not taken to the streets to demand it is because after centuries of struggling with the issue, society has decided that the scientifically measured harms of alcohol do not completely outweigh the familiar benefits.
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Science is used adequately – even if imperfectly – to help us make things Reasonable trade-offs When it comes to alcohol in our society, such as restricting the freedom to consume alcohol before driving or preventing its sale to teenagers who are less likely to use it responsibly. No one who thinks alcohol should be legal believes it should be because science is not conclusive about its harms; Instead, with the benefits to so many, there are simply trade-offs to be made.
All of this means that when we hear politicians, other leaders, or anyone say they are “listening to science,” we have to wonder what part of the discussion they might be listening to. no You listen to it – or you may not want to talk about it. Really listening to science means accepting that science, although useful, is no substitute for honest human judgment which will plausibly vary between individuals and across time in a diverse and dynamic society. This means that we must be prepared to change our minds if new data suggest to us that trading off potential harms is not worth making for potential benefits.
There are some issues where there is already broad agreement on which trade-offs are worth making. For example, surveys tell us that a large majority of Americans support requiring vaccination against potentially devastating childhood diseases for school attendance. But for most people, fluoride represents a new debate, and a good-faith debate includes considering the true benefits of fluoride for dental health, evaluating any risks of poisoning from excess fluoride, and recognizing the availability of other sources of fluoride in the teeth. There are more toothpastes, mouthwashes, nutritional supplements and varnishes than in the last century. Reasonable minds could reach different conclusions, which is why societies in the United States and abroad choose both options He adds And to Removes Fluoride from public water supplies.
Moving forward, transparent, evidence-based discussions about the trade-offs that public health decisions play—not obscured by scattered, misinterpreted, or non-existent research that does not actually inform these trade-offs—may help us make better collective decisions for our health. It can help rebuild flagging confidence in public health.