A little bit of poison can be good for you.
It's a pretty fundamental tenet of medicine and of life.
Just the right amount of aspirin, even wine or beer, can extend your life; too much and you're on your way to detox.
The old axiom of excess and moderation is also the basis of a recent city decision to, for the first time, begin putting fluoride -- a compound containing the element fluorine -- into the water systems of thousands of Colorado Springs residents.
Though potentially fatal when large amounts are ingested, the compound is thought to reduce the chances of tooth decay, or cavities, if taken in extremely small doses, according to health authorities.
Now nearly ubiquitous -- showing up in everything from toothpaste to soft drinks to rat poison -- fluoride has been controversial ever since cities and towns began putting it in water supplies in the 1940s.
Conspiracy theorists have long been skeptical of mass medication efforts, seeing fluoride (which has been used as a calming drug on livestock) as a form of mass mind control.
Perhaps building on general paranoia that the Axis powers would poison water supplies during World War II, anti-fluoride sentiment peaked in the post-war era. The issue was seized upon by followers of Sen. Joseph McCarthy, who labeled water fluoridation a communist plot to dumb down Americans so they'd acquiesce to socialism.
Today, conspiracy theorists continue to latch on to the fluoride issue. But more down-to-earth critics say such mass-drugging schemes are simply bad medicine because, among other things, there's no way to control dosage. Some people drink a lot of water; some very little.
Increasingly, critics say, people digest large amounts of fluoride from other sources such as soft drinks, juice, vegetables exposed to fertilizers, and, last but not least, toothpaste.
"The one thing that fluoridation proponents refuse to address is individual dosage," said Dr. Thomas Levy, a Colorado Springs cardiologist who is a leading opponent of fluoridation. "You have some children who drink enormous amounts of water; you have some who hate water. A child that has five cups of (fluoridated) water per day can be getting five times the recommended amount of fluoride. This is significant."
Such concern has not been relegated simply to anti-fluoride activists. In the late '70s, makers of infant formula voluntarily removed fluoride from water they used to make baby bottle products after studies suggested the souped-up water was causing fluorosis, a permanent yellowing and browning of teeth.
On the other side, however, the full weight of the American health establishment has come down in favor of fluoride. The Centers for Disease Control in Atlanta go so far as to call water fluoridation one of the ten greatest public health achievements in medical history -- up there with the polio vaccine, water chlorination and the pasteurization of milk.
Likewise, organizations such the American Dental Association have endorsed small doses of fluoride as a safe means to control tooth decay.
"This is really a no-brainer," said Dr. Reginald Finger, the chief epidemiologist for the El Paso County Health Department, which strongly supports Colorado Springs' fluoridation program. "The CDC is normally very cautious in its recommendations. They'll say 'consider' using this vaccine, or 'consider' this treatment; so for them to say that this is one of the biggest health achievements is really something."
Finger concedes that numerous studies have shown that cities with fluoridated water have experienced higher rates of some negative side effects, such as hip fractures.
But he said most of these studies are unreliable because they are what he calls "ecologic" studies that compare statistics but don't take other variables into account. Studies that do take variables into account -- i.e. trying to track down other potential causes of fractures -- have found no significant difference between cities with fluoridated water and those without.
Finger also conducted an informal study (not reviewed by peers) of hip fracture rates in Colorado Springs. In short, he said, zip codes with high fluoride rates showed no more hip fractures than zip codes with low fluoride rates. "In fact it was the other way around; there were slightly more fractures in the low-fluoride areas," said Finger.
Finger concedes his study is far from definitive. But he said it does show there's little evidence suggesting that hip fracture is something Colorado Springs residents should worry about.
Finger and other proponents are also quick to note that Colorado Springs is hardly alone in its fluoridation plans. More than 150 million Americans now gulp down fluoride every day; roughly 10,000 U.S. cities and towns take their water from fluoride-spiked reservoirs.
Beyond that, proponents note, courts have long affirmed the right of city, state and county government to use their police powers to prescribe medication as long as it's in the interest of public safety.
Maybe so. But opponents of fluoridation have also gained steam in recent years. Some 56 cities have dropped their fluoridation programs in part because of heath concerns while in several other cities and towns, voters have launched voter initiatives to pull fluoride out of the drinking water
Colorado brown teeth
No matter what you think of fluoride or government-sponsored medication schemes, the conflict raises interesting questions, particularly in Colorado Springs, where the electorate already tends to be skeptical of government intrusion into private affairs.
But there's an extra tinge of irony to the way the controversy is playing out here in Colorado Springs, a relative latecomer to a national trend of water fluoridation that began in earnest more than 50 years ago.
For years, much of the city has already suffered from high levels of naturally occurring fluoride in its drinking water. And it's for that reason that Colorado Springs helped give birth to the national drive to fluoridate drinking water almost 100 years ago.
It all began with an inquisitive young dentist who set up practice in Colorado Springs and observed an unusual phenomenon particular to those living near Pikes Peak -- a gritty discoloration of teeth that came to be known as "Colorado Brown Teeth" or "Colorado Brown Stain."
Dr. Frederick Sumner McKay's horse-drawn stage left just before dawn. "It was the first day of January 1901, when in the early morning, the horse-drawn stage left the small hamlet, Evergreen, in the Colorado Rockies," he would write in his memoirs years later.
"Another train ride from Denver brought me to Colorado Springs, my destination, in the late afternoon," he wrote. "My broken and crooked pathway had now become a straight line with no deviations, what was to lead to my life's work."
That life's work became evident soon after the then 27-year-old Massachusetts native set up his dentistry practice. As McKay scraped, poked and cleaned the mouths that opened to his tools, the doctor realized that many of his new patients had what he would later describe as "mottled enamel," a yellow-brown streaking that permanently disfigured the grins of thousands of area residents.
"There for the first time, [McKay] noted that many of his patients had teeth where the enamel appearance ranged from a few white marks to a disfiguring brown color," dentists Norman Harris and Linda Schierton wrote in a 1989 paper on the history of fluoridation.
The effect would later come to be known as "Colorado Brown Teeth," in part because of the attention McKay brought to the condition, which is not unique to Colorado. Within the state, however, the effect was particularly evident in Colorado Springs, which drew its water from the watersheds around Pikes Peak.
Many of McKay's peers in Colorado Springs were resigned to the symptom, describing it as "normal" for the area. But the young Easterner was intrigued because he had never read anything about the phenomenon in his dental texts.
So McKay began to collect data on his patients, writing letters to dentists as far away as Canada and Europe. It turned out that some dentists had experienced the phenomenon in pockets throughout the Rocky Mountains, from Mexico to Canada. Still, no one knew the cause.
When G.V. Black came to deliver a talk in Denver in 1914, McKay enlisted the help of the eminent dentist. (Black was already known as "the father of American dentistry" in dental circles.) Two years later, the pair published "An Investigation of Mottled Teeth," describing the condition but offering no solutions, in the journal Dental Cosmos.
But it wasn't until 1931, after McKay enlisted the help of chemists for the American Aluminum Company (Alcoa) at an Alum mine in Bauxite, Arkansas, that they found an interesting similarity shared by water samples from every region that had chronic tooth staining.
They all had high levels of fluoride.
The discovery led McKay to rename the condition "fluorosis," a condition that still affects many children growing up in Colorado Springs and many other cities around the world where children are exposed to high levels of naturally occurring fluoride.
McKay and others also made another important observation about the patients afflicted with Colorado Brown Stain: they had fewer cavities than most. And so, a second wave of studies began, which ultimately confirmed that small amounts of fluoride can prevent tooth decay and cavities.
By the late '30s, the U.S. Public Health Service and other dental researchers would claim to have honed down exactly how much fluoride was good, and how much was harmful.
In general, the scientists found that if cities added one part of fluoride per million units of water (or one milligram per liter), then people would experience fewer cavities, without harmful side effects.
If even two parts per million (two milligrams per liter) were added, the general thinking goes, then a significant portion of the population would begin to experience the streaking, browning and yellowing. At 3 parts per million, severe cases of Colorado Brown Stain would be more common.
What a Hassle!
Though Colorado Springs plays a central role in the fluoridation of water supplies around the world, the move to intentionally fluoridate water supplies in Colorado Springs began much more recently.
Last November, local dentist Bob Koff organized the local dental community to convince the City Council (which serves as the board of directors for Colorado Springs Utilities) to put fluoride in two reservoirs that serve the city's expanding northern and eastern communities.
Fluoride levels coming out of faucets in the northern and eastern portions of the city are well below the one-part-per-million level recommended by health agencies to promote stronger teeth.
Citing anecdotal evidence that the rate of tooth decay has been increasing in those areas, a group of dentists and pediatricians asked the City Council for help. "It's really a problem," said Dr. Bruce MacHaffie, a pediatrician with an office on Palmer Park Boulevard.
The problem, says MacHaffie, is that fluoridation rates vary too widely around the city so it's very hard to know how much, if any, fluoride to prescribe to patients with tooth decay.
Water fluoridation is a good idea because it will allow physicians and dentists to know that anyone living over a wide geographic area is getting a basic, uniform dose of the decay-fighting compound.
"Right now, before prescribing supplemental fluoride, we have to find out where [a patient] lives, then look at a fluoride map that is like a big checkerboard," said MacHaffie. "Sometimes, people live right on the border [of two areas with different fluoride rates] and you're not sure how accurate the maps are."
After sending out a brief and somewhat vague notification about the plan inside utility bills, the City Council held a hearing last month in which proponents and opponents testified for and against the proposal.
Reaction to the announcement was swift and furioius.
"I live in the 80909 zip code where fluoride is not available," said one caller, who described herself as a patient of Dr. Koff. "So, my son has to take a pill for it everyday. What a hassle!"
The calls were recorded by utilities staffers, who paraphrased the comments in a report to Council. "Cavities are caused by eating junk food," went another citizen comment. "Fluoride will not help if people are [drinking] pop."
"We are in favor of returning fluoride to Colorado Springs' water system to the recommended levels for cavity prevention," said a supporter, apparently unaware that fluoride levels in that part of the city were never high.
"I don't want fluoride in my water," another told city staff. "When you begin poisoning my water, I'm going to install filters in my home to remove it. And I'm going to send you the bill."
According to Kristin Bricker, who directs community relations for the utility agency's fluoride plan, reaction was split pretty evenly between critics and supporters, though opposition began to dominate after Council's initial approval in December.
That was borne out at a public hearing in late March, when the only citizens not aligned with a health agency who spoke at the hearing were opponents of the plan. In general, opponents reiterated their claims that any additional fluoride intake was unwise, and suggested in essence that the city was drugging the populace without its consent.
In the end, Council approved the plan, citing no credible evidence that fluoridation at the suggested rates pose a health problem. The process is estimated to cost $634,000 for equipment and roughly $95,000 a year to run (though the expenses will result in no rate increase, according to utilities spokespersons).
The fluoride will be added to water stored at two underground reservoirs -- the Pine Valley and McCullough water-treatment facilities -- built into the earth on the grounds of the United States Air Force Academy.
While Bricker's quick to admit she's no expert on fluoride's health effects, she rejects the argument that the plan constitutes medication without the patient's informed consent.
In raising fluoride levels on the north and east portions of town to one part per million, she said, the city is simply bringing those areas closer to a desirable city average. "So I don't see this so much as mass medication," said Bricker, noting that many other areas already have fluoride rates that exceed one part per million. "We're just balancing out the levels somewhat."
Which leads to another irony lurking just beneath the surface of the great Colorado Springs fluoride controversy: Levels of fluoride in most of Colorado Springs are already well above the one-part-per-million ratio targeted in the city's fluoride treatment plan.
The same watersheds that caused "Colorado Brown Stain" -- most notably Bear Creek, which has the highest levels of fluoride of all area watersheds -- have been pumping high levels of fluoride down the pipes into downtown kitchens and bathrooms for years.
That's because most of the water serving downtown and southern Colorado Springs, for example, comes from sources right around Pikes Peak, where fluoride levels have been historically high. To correct the problem, utility engineers have been mixing high-fluoride local water with "cleaner" West Slope water in order to bring down fluoride levels.
The department has already made considerable progress. Up until a few years ago, some parts of town saw averages in excess of three parts per million -- one reason perhaps why many who grew up in Colorado Springs suffer from dental fluorosis.
Still, even with the blended water, most of downtown and southern Colorado Springs still get roughly twice the fluoride recommended by the American Dental Association and other groups. That's one reason workers at the water treatment plant on Mesa Boulevard -- a facility that filters the water for downtown and southern parts of the city -- have devoted considerable time in recent years to bringing down fluoride levels.
In recent years, water provided by the City of Colorado Springs has averaged below two parts per million -- the level at which the Environmental Protection Agency requires cities to notify customers that fluoride levels are a concern.
To get those lowered rates, however, the city has stopped using water from Bear Creek, where fluoride rates are very high. "We're dumping it," said Charles Conser, a senior engineer with the utility department's water resources division. "That's the term we use when we're not using an allocated water right."
The water from Bear Creek is simply too potent with fluoride to add to the city water supply, utility staffers said. In the meantime, city engineers are also experimenting with a new process called "advanced coagulation" in which utility workers at the Mesa Plant add alum into the water. The alum bonds with fluoride and settles to the bottom, where the compounds are removed.
"It's kind of ironic," said Conser. "We're raising levels of fluoride in one part of the system but at the same time, we're facing levels that are too high in another part."
That fact has led some to suggest that the water supplier simply mix its flouride-free water from the west slope with its fluoride enriched reservoirs. It turns out not to be so simple. A recently completed computer-modeling study showed that during times of low rainfall, the more fluoridated watersheds would provide enough extra water to adequately fluoridate the "cleaner" reservoirs serving the north part of the city, Conser said.
Meanwhile, the city of Manitou is still struggling with fluoride levels that now averaging 2.5 parts per million, though the city has posted an average exceeding 3 parts per million routinely in the past.
Just this month, residents of Manitou Springs (which gets its water exclusively from the Pikes Peak watershed) received warnings with their water bills claiming that fluoride levels in the drinking water there could cause yellow streaking and browning of teeth if given to children.
In a large open office space off of Edison Avenue, just east of Academy Boulevard, Dr. Thomas Levy sits beside a long, folding conference table. Spread out before him in neat stacks are dozens of articles from scientific journals and various health and environment magazines.
And there are two props: a can of vintage insecticide laced with sodium fluoride and a tube of Crest toothpaste. "Your average tube of fluoride toothpaste has concentrations of roughly 1,500 parts per million; that's enough to kill a small child if he ate a whole tube," Levy said.
Levy isn't predicting mass death if city reservoirs are spiked with minute amounts of fluoride. But he is saying that for a population already overdosing on fluoride, the fluoridation plan is bad medicine.
Among other things, Levy cited articles that claim fluoride, which accumulates in bone and other body tissues, can cause an accelerating rate of degenerative disease with age, increase the chances of hip fracture in the elderly, reduce vitamin C levels in the body, even cause lowered IQs in children (at least according to one study of fluoridated and unfluoridated villages in China).
Such claims often lead fluoride proponents to roll their eyes at the critics, who have been portrayed by some as conspiracy-minded hypochondriacs.
Levy concedes that in regard to some of these more serious conditions, the fluoride issue has become a huge "he-said, she-said," with both sides waving studies that support their point of view.
But Levy accurately noted that there's general agreement that even small amounts of fluoride can cause fluorosis, the same condition that caused Dr. Frederick McKay to spawn the water fluoridation revolution.
And though no one knows exactly why, there's widespread evidence that dental fluorosis is on the rise throughout the United States -- in communities with fluoridated water and in those without.
In a 1995 article in the Journal of the American Dental Association, researchers attribute most of that increase to excessive use of fluoride toothpaste, or fluoride tables, not to fluoride in drinking water.
But the ADA, the country's pre- eminent source of dental research, did make some recommendations that pose a potential problem with water fluoridation programs.
Along with advising children not to swallow their Colgate, and use only a pearl-sized glob of toothpaste, the ADA made a series of recommendations for fluoride consumption for children.
In places with the same amount of fluoride already found in north Colorado Springs -- the area targeted for increased fluoride -- the ADA recommends that children under six months of age should get no supplemental fluoride.
Likewise, kids aged six months to three years, should only get an additional .25 milligrams per day of supplemental fluoride, according to the ADA council on scientific affairs.
Because Colorado Springs plans to raise the amounts to roughly one part per million, a three-year-old who drinks one liter of water per day under the proposed fluoridation plan would be getting two to three times the dosage recommended by the ADA in 1995.
To Levy, this is what makes this city's fluoridation plan disturbing. Parents mixing formula for babies under six months of age may be condemning them to a lifetime of either permanently stained teeth, or expensive crown work, if they use fluoridated water.
"One thing [the city] said they are concerned about is the economic effect on poor people who can't afford to buy fluoride tablets," said Levy. "But now you're forcing the poor in the population to go buy bottled water for their infants. Now how is that economic favorably and reasonable to a large portion of population?"
Proponents of fluoride downplay the ADA's recommendation as an attempt to be overly cautious about a potential cosmetic condition. They point to the ADA's own study that says it's overuse of toothpaste, not water fluoridation, that's the issue. They also cite studies that show only small increases in fluorosis when 1 part of fluoride is added to one million parts of water.
Levy counters that if the ADA is being overly cautious, then that's exactly what Colorado Springs should be when it comes to fluoride. In the case of hip fractures, Levy notes that even a one-percent increase in hip fracture could theoretically mean that hundreds or even thousands of Springs residents could be affected.
"The proponents say there's no proof that fluoride is harmful," he said. "But with all the studies that have been done that do find problems, isn't it better to err on the side of caution?"