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The Politics of Water Fluoridation from a Problem Definition Perspective

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The Politics of Water Fluoridation from a Problem Definition Perspective 1 THE POLITICS OF WATER FLUORIDATION FROM A PROBLEM DEFINITION PERSPECTIVE A dissertation presented by Robyn Olson to The Department of Political Science In partial fulfillment of the requirements for the degree of Doctor of Philosophy in the field of Public and International Affairs Northeastern University Boston, MA November, 2008 2 Abstract The Politics of Water Fluoridation from a Problem Definition Perspective Community water fluoridation has been controversial since it was first proposed more than 60 years ago. Proponents of fluoridation state that it is a safe and cost- effective method of solving a public health problem while opponents question its safety and effectiveness and whether it is a legitimate function of government. Most decisions regarding water fluoridation reside at the local level. In MA, the current law allows the local board of health to order water fluoridation. The law stipulates that within 90 days of public notice opponents can submit a petition with the signatures of 10% of the registered voters in the community, in which case a referendum would be held. Very often a referendum is held and more than half of the time and with little predictability the order is overturned. Several explanations have been offered including demographic determinism, the structure of the city government and alienation however none of these are fully explanatory. This paper examines fluoridation decisions from a problem definition perspective which purports that the way problems are defined and framed in public discourse has an impact on decision outcomes. To examine the extent that problem definition principles contribute to fluoridation decisions comparative case studies were utilized. Two communities in MA were chosen. In Worcester, MA voters said NO to a fluoridation referendum in 2001 while in New Bedford, MA voters voted YES in a 2006 referendum. The case studies included an examination of the demographics, structure of government, issue initiators and opponents as well as a comprehensive analysis of media coverage to determine how the issue was defined and framed by spokespersons and the 3 media. Lastly, the cases were reviewed to determine the impact that problem definition and issue framing may have had on the expansion of the conflict. This review identified common elements of framing and problem definition between the cases. Proponents in both cases defined the issue from an instrumental perspective while opponent arguments were more expressive in nature. Descriptions of the problem included many elements often used commonly by issue advocates and opponents to gain support for their views. This analysis suggests that in Worcester opponents were able to steal support from proponents who had public opinion in their favor at the start of the campaign by redefining the argument and tying their arguments to deeply held American values. In New Bedford, the opponents were not able to mobilize and were not able to change the game as they had in Worcester. This may have been due to problem definition but also the differences may have been influenced by the length and nature of the campaign and voter turnout. Future research may include a more comprehensive understanding of public opinion surrounding this issue and the development and testing of messaging campaigns that incorporate not only facts but values. 4 Acknowledgements Thank you to the Political Science Department at Northeastern University where I have spent more than 15 years! Several professors should be acknowledged for inspiring me including Governor Michael Dukakis and Bruce Wallin both of whom made me believe in the importance of the public sector and public service. Thank you to David Rochefort and Christopher Bosso who agreed to be on my dissertation committee and for all of their guidance throughout my tenure at Northeastern. As my advisor, Chris Bosso was more helpful than he will ever know. With special thanks to my professional colleagues who assisted me along the way in this endeavor. Some provided me with material for this project while others were there to listen, give advice, direction and support. They are friends and co-workers from the Forsyth School for Dental Hygienists, The Group Insurance Commission, Delta Dental of MA and its associated companies, The MA Coalition on Oral Health and the Oral Health Advocacy Task Force. Thank you to Catherine Hayes who served on my dissertation committee but also has been a professional mentor for more than 15 years. Last but not least, thank you to all of my friends and family who understood and accepted my busy life and made me believe that I really could do anything I set my mind to! Without your love and support I could have never accomplished this. 5 TABLE OF CONTENTS Abstract 2 Acknowledgements 4 Table of Contents 5 Chapter 1: Why is fluoridation a problem? 6 Chapter 2: Explaining Outcomes 32 Chapter 3: Theories of Problem Definition and Methods 57 Chapter 4: Worcester 97 Chapter 5: New Bedford 203 Chapter 6: Comparing Worcester and New Bedford 273 Chapter 7: A Policy Advocate’s Final Thought 307 References 344 6 Chapter 1 Why is Fluoridation a Problem? Introduction Why do campaigns to institute fluoridation of public water supplies fail? Why do they succeed? This study examines the politics of fluoridation. In one sense, it looks at how a health profession sought to address what it perceived to be a major public health problem and why one of its major efforts generated considerable opposition. In another sense, the goal of this study is to examine the explanations offered for what may determine whether a particular community will decide to fluoridate its water supply and examine the extent to which the problem definition literature may contribute to these explanations. Much of the research done on fluoridation decisions has focused on institutional and demographic determinants of the outcomes. The problem definition literature encompasses the impact of public perception of problems on chosen government solutions and the way in which advocates for specific issues can help or hinder their cause based on the ways in which they frame their arguments. Last, I will analyze fluoridation campaigns in two communities in Massachusetts, Worcester and New Bedford, as well as data from a survey of state legislators to determine the extent to which these explanations can be applied to these cases. The results of the analysis may help advocates in their efforts surrounding community water fluoridation. 7 The problem – tooth decay According to the Centers for Disease Control, tooth decay affects more than 1/5 of the children in the U.S. age 2-4 and more than 50% of those ages 5-9 have at least one cavity or filling, and that number increases to more than more than 75% of 17 year olds. Low- income children are the hardest hit, with more than one third of this population having untreated tooth decay. Poor children suffer twice as much caries as their affluent peers and again it is much more likely to be untreated. In the adult population, over ¼ of those 60 or older have lost all of their teeth mostly due to tooth decay, and tooth decay affects more than 95% of all adults. 1 Tooth decay is a progressive disease so generally as one ages the effects of the disease will grow from one requiring simple restorative treatment (fillings) to much more extensive and expensive treatment such as crowns or extractions and dentures. In 2004, Americans made about 500 million visits to dentists, and an estimated $78 billion was spent on dental services. About 70% of employed Americans have private dental insurance through their employer, the remainder is covered through government programs such as Medicaid or in the case of most over age 65 (the majority of Medicare plans do not cover dental care) and others not covered through employers to pay for care out of their own pocket. This is if they are able to afford the cost of care. There is a great disparity in the oral health of Americans, with those having private dental insurance experiencing oral health superior to those who do not. Although Medicaid programs make insurance available and provide financial access to care, they have significant problems meeting the dental needs of members. One reason for this is the 8 lack of access to appropriate numbers of providers to treat their members. This lack of access may lead to members putting off much needed preventive care and being seen for emergency care in a hospital emergency room. Not only can poor oral health lead to unnecessary expense, but also it is important to overall health. Infections in the mouth can exacerbate and contribute to other medical conditions. In addition, pain and infection in the mouth can also have an affect on a person’s overall well-being and productivity at school and in work. For these reasons, the dental public health profession has spent much of the past 60 years in concerted efforts to lessen the incidence of acute tooth decay. These efforts included school based programs involving simple oral health education programs, sealant programs in local schools, the addition of dental clinics in community health centers, improving dental Medicaid programs and of course, community water fluoridation. The dental profession (dentists and hygienists and their professional associations) has contributed to these public health efforts as well as helping to reduce the disease burden by providing preventive and restorative care to individual patients in their offices. In addition, consumer product companies have been involved in helping to reduce the incidence of decay by adding fluoride to toothpastes, developing mouthwashes and other products such as toothbrushes and dental floss and marketing these products heavily in the marketplace. Many of these items have become over time a “must have” for many American households.
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