When evidence alone is not enough: the politics and policy of water fluoridation

Author:Matthew Flinders, Gary Lowery and Barry Gibson

This post was originally published by the Evidence & Policy blog on 3 March 2021.

We have re-issued the article that has already been published by the Evidence & Policy blog. We would like to express gratitude to the kind offer of the editorial board of the Evidence & Policy blog.



Matthew Flinders, Gary Lowery and Barry Gibson


The COVID-19 pandemic has sparked a major debate about the role of experts in policymaking and the capacity of politicians to ‘follow the science’. The trend we have seen, where expert advisers have increasingly become the public face of the pandemic, raises questions about the evolving role of experts in other public policy challenges – including challenges where the scientific base is arguably far clearer about effective policy responses. If politicians are willing to ‘follow the science’ with such diligence in relation to COVID-19, why does the same principle not apply to other public health challenges?


Why, for example, when paediatric oral health remains a dire challenge for the UK, don’t politicians ‘follow the science’ in relation to the apparent benefits of fluoridating public drinking water? This is a question that a two-year project at the University of Sheffield has sought to answer through our recent Evidence & Policy article, ‘When evidence alone is not enough: the problem, policy and politics of water fluoridation in England’ . On balance, the available data confirms that fluoridation is a low-cost, high-benefit, low-risk response, which explains its promotion by global health bodies.


The Sheffield study reveals two fundamentally different and seemingly irreconcilable ‘world views’ vis-à-vis fluoridation. The first is scientific in nature and technocratic in terms of presentation, and generally promotes fluoridation; the second is highly normative in nature and ethically-charged in terms of presentation. The former focuses on data, evidence and scientific expertise, while opponents of fluoridation tend to focus on ethical complaints, emotive triggers and outliers within the research base.


When these contrasting positions come into contact, usually when a ‘window of opportunity’ opens when brave or foolish politicians dare to put fluoridation on the agenda, they result in a visceral and heated debate. But what this research really brings to the fore is the role of emotions and feelings and the limits of purely fact-based arguments. Put slightly differently, when it comes to fluoridation and a range of other public health issues, ‘feelings trump facts’. This study also reveals a possibly dangerous lop-sidedness to the evidential levels required of each side: proponents of fluoridation are expected by the media, the public and policymakers to demonstrate complete safety, which is – as is the case with any intervention – impossible. Opponents, however, need only sow the seeds of doubt because fear is a powerful emotion.


This raises broader questions concerning the social amplification of risk and the dysfunctions of democracy.


The jump from the perennial debate concerning fluoridation to the contemporary COVID-19 crisis is clearly massive in terms of scale and complexity. What’s interesting in terms of the relationship between policy, politics and expertise is that the scale of the crisis (i.e. the problem stream) runs so deep across society that those ethically-charged and highly normative world views that,, in ‘normal’ times, would have rallied against the expansion of the state and the restriction of civil liberties, have to some extent been silenced. They’ve not rallied completely, of course, as is reflected in the COVID deniers and anti-vac campaigns, but because these conspiracy theories are not actually rooted in facts, ‘they cannot be approached with facts…they have to be approached through emotion’, as recently argued by Dannagal Young. The paradox is that the scientific/technocratic ‘world view’ tends to reject the adoption of approaches that are rooted in emotion for fear of self-contaminating their notion of objectivity. Yet what this Sheffield study suggests is that, at least when it comes to fluoridation, ‘evidence alone is not enough’.


But if the ‘evidence alone is not enough’, then what needs to be added to the policymaking formulae in order to engender a more balanced debate in a politicised context?


Two proposals might help provoke discussion.


First and foremost, those in favour of fluoridation might seek to frame the data within a connecting narrative. That is, a story that highlights the real world pain and suffering that accrues from childhood tooth decay, and how it flows into (and reflects) broader structural inequalities in society and affects the subsequent life chances of those kids.


The second proposal relates to capacity, leadership and the need to think more strategically about the decision-making processes through which decisions about fluoridation are made. The devolution of responsibility for fluoridation to local authorities can obviously be couched in terms of the devolution of power and revitalising democracy, but it might also be interpreted as an attempt to ‘pass the buck’ for a notoriously tricky topic. Stronger support from Whitehall in terms of promoting fluoridation and protecting those local authorities that consider the issue is needed.


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This post was originally published by Transforming Society on 3 March2021


You can read the original research in Evidence & Policy:


Lowery, G. Flinders, M. and Gibson, B.J. (2021). When evidence alone is not enough: the problem, policy and politics of water fluoridation in England. Evidence & Policy, DOI: 10.1332/174426420X16079614941921.

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Professor Flinders is Founding Director of the Crick Centre and Professor of Politics at the University of Sheffield. He is also Vice-Chair of the Political Studies Association of the United Kingdom and Chair of the Universities Policy Engagement Network [www.upen.ac.uk]. His research focuses on modes of depoliticization, governance and public policy, legislative studies, and political disengagement.


Gary Lowery is University Teacher in Politics and International Relations at the University of Sheffield. His research focuses on the politics of ideas and knowledge, the politics of change in the context of crises, and public policy.


Barry Gibson is Professor of Medical Sociology at the University of Sheffield. His research explores the relationship between communication in dental settings, accounts of illness and social structure.


Image credit: Image by Bob van Aubel

If you enjoyed this blog post, you may also be interested to read:


The silver bullet reversed: the impact of evidence on policymaker attention


Networks, advocacy and evidence in public health policymaking: insights from case studies of European Union smoke-free and English health inequalities policy debates


The strategic uses of evidence in UK e-cigarettes policy debates


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