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Entering the Fray

Local fight over community water fluoridation offers lessons for leading on contentious public health issues. The climate for making progress on public health challenges has been difficult at times in recent years, both in Kansas and across the country.

 

Voters in Wichita, for instance, soundly defeated a proposal to add fluoride to their water in 2012. Other high-profile proposals widely supported by public health advocates in the Statehouse have also languished.

Meanwhile, national conflicts over mandating vaccinations in order for children to attend school have ratcheted up as several states passed laws curtailing religious and personal exemptions to vaccinations in response to a growing number of parents opting out of them.

Amid the clashes, the outcome of the Salina fluoridation debate in 2014 looms large as an example that health advocates in Kansas can look to at a time when distrust of authority and government runs high, and when balancing
the common good with deeply held ideals of individual liberty and autonomy can be tough.

The result, it is worth noting, didn’t come solely through disseminating scientific information to the public. Instead, the driving force was the existence of passionate local supporters who were willing to get out in front of the issue with a clear purpose, get organized, be visible, understand their own limitations and productively deal with conflict.

The story begins with a petition drive for a ballot question on whether to continue fluoridating Salina’s water supply. The proposal was greeted with a fair amount of apathy, even among the city’s dentists.

“Some of them were like, ‘This is silly. Salina is going to (keep fluoride). They’re smart people. Don’t worry about it. You don’t need to do anything,’” says Allison Lesko, a Salina dentist in her 30s.

She didn’t listen. Instead, she and others decided to act. Lesko was a driving force behind the Keep Fluoride campaign, which sought to unite the Salina medical community and leverage the support of state and national health organizations to persuade residents to keep community water fluoridation.

Fluoridation became an issue because Lou Tryon, a retired schoolteacher in her 70s, and other members of a group she named Salina Cares pushed the Salina City Commission and city administration to remove fluoride from the water more than a year earlier.

 

“Some of them were like, ‘This is silly. Salina is going to
(keep fluoride). They’re smart people. Don’t worry about it.
You don’t need to do 
anything,’” says Allison Lesko,
a Salina dentist in her 30s.

 

Based on her belief that the compound causes health problems, Tryon had been concerned about fluoride since 2001, when she held community meetings on fluoridation. When Wichita voters rejected adding fluoride to their water, it inspired her to take her effort a step further.

“We decided we wanted the fluoride out of the water, and there wasn’t anybody else out saying they were opposed to it, so we took it upon ourselves,” says Tryon, whose group consisted of her husband, Reg, and about a dozen other Salina residents.

Pursuing the issue as a matter of freedom of choice, of allowing people to decide what to put in their bodies, the group launched a petition drive that successfully forced a vote. That set the stage for what has become a familiar battle in Kansas and elsewhere: Public health supporters spar with small but fervent networks of grassroots activists over the scientifically validated but hardly universally understood benefits of fluoridation.

The public then has to sort through competing and potentially confusing claims to try to determine what the facts actually are, often pitting the professional expertise of medical professionals against the personal credibility and emotional claims of friends and neighbors.

But unlike in Wichita, fluoride supporters in Salina scored a convincing victory at the polls in 2014. By a vote of 6,596 to 3,160 – more than a 2-1 ratio – voters refused to repeal the ordinance that allows the municipality to fluoridate its water.

That means the city of about 50,000 people – which since 1968 has been fluoridating its water to the level prescribed by the Centers for Disease Control for tooth-decay prevention
– will remain among the majority of cities in Kansas (64 percent) and the United States  (75 percent) that fluoridate their water.

 

Getting Out In Front

Here’s how the story unfolded.

In response to fluoridation becoming an issue in Salina, the city’s public works department posted an information page on its website that states, in part: “Fluoride is a naturally occurring mineral in our water. When fluoride is adjusted to an optimal level, it has been proven to reduce the incidence of dental decay.

“In the United States, 44 of the 50 largest cities adjust the level of fluoride in their drinking water. They are all regulated and monitored by several different entities to ensure public safety.”

But even in situations where common practice and scientific information seem clearly documented, they do not always hold sway. The benefits of governmental action might not be good for everyone in every situation, opening the door to exceptions that muddy the big picture. And a clash of values – distrust of authority and the desire to preserve personal choice and autonomy versus doing what might be good for the greatest number of people in a community – is never far from the surface, even if it’s often couched in the presentation of information rather than ideals.

Lesko and other oral-health supporters weren’t content to assume that voters would find factual information about fluoride on their own – or that it would sufficiently motivate them to vote against repealing the fluoridation ordinance.

After participating in a November 2013 fluoridation public forum that Salina Cares had pushed for, Lesko says she was convinced that the anti-fluoride group would at some point conduct a petition drive to try to put the issue to a public vote. In preparation for that day, Lesko got in touch with organizations such as Oral Health Kansas, the Kansas Dental Association, the American Medical Association and the Kansas Bureau of Oral Health.

“I figured it was inevitable that it was going to be a vote, so we made what we called the fluoride SWAT team,” Lesko says.

Groups supportive of community water fluoridation agreed in advance to provide campaign contributions as well as advocacy to respond to claims being made by Salina Cares about the health effects of fluoride.

 

One of those people was Tanya Dorf Brunner, executive director of Oral Health Kansas, an advocacy organization that has been involved in several fluoridation battles over its 10 years of existence.

 

“The idea of the SWAT team was to find a team of individuals from these organizations, because we don’t know everything,” Lesko says, referring to the campaign’s core group of dentists. “We didn’t know how to answer all the claims being made by the anti-fluoride people. We didn’t have time to reinvent the wheel, so we contacted people who have already done that.”

One of those people was Tanya Dorf Brunner, executive director of Oral Health Kansas, an advocacy organization that has been involved in several fluoridation battles over its 10 years of existence.

“It really started bubbling in Salina about a year (earlier),” Dorf Brunner says, referring to the Salina City Commission’s rejection of the Salina Cares’ request to repeal the fluoridation ordinance. “We very quietly talked to people behind the scenes about, ‘What do you need?’ We’ve kind of always been at the table with them.

“One of the reasons we get involved is that we know that to make progress in oral health or fluoridation issues, you really need unusual suspects. It can’t be dentists and hygienists beating the same drum.”

 

Organizing for a Tough Debate

By Election Day, more than 150 health professionals and 20 to 30 lay volunteers – most of whom contacted Keep Fluoride through its Facebook page – were on board.

Fluoridation is an issue Lesko is passionate about because she sees a night-and-day difference between the oral health of children she treats from Salina and those who come from towns without fluoridation.

She identified early on the need to unite Salina’s medical community, and many of Keep Fluoride’s campaign materials contained quotes from local doctors or dentists. A late-October postcard the group sent to likely voters pointed out that Salina’s water had been fluoridated for 46 years, that removing fluoride could increase Salina’s dental costs by $580,000 a year and that nearly 70 years of research proves water fluoridation is safe and effective for people of all ages.

A second, larger postcard sent just before the election listed the endorsements of more than 30 Salina dentists, more than 20 doctors and several other medical professionals. It also included a quote from William Cathcart-Rake, a Salina oncologist and dean of the KU School of Medicine’s Salina campus: “I urge voters to be wary of unproven claims regarding the effects of fluoride, especially with regards to an association with cancer. This claim is simply not true.”

Being Visible

The effort required a considerable amount of work. Lesko estimates that she put in at least 35 hours a week in the three months leading up to the election.

“It truly felt like a second full-time job for me, on top of being a dentist and a mom,” says Lesko, who is president of the Salina Dental Society. “The other members of our campaign put in numerous hours, too, anywhere from 10 to 25 hours per week depending on what was needed.”

Oral-health advocates in Salina also tried to recognize their limitations and turned to professional help for dealing with matters outside their expertise. Because they were inexperienced in running an election campaign, Keep Fluoride hired Stephanie Sharp, a former member of the Kansas House of Representatives who runs a Lenexa-based political communications firm called Sharp Connections LLC.

“We have a campaign strategist we hired to do this, because as dentists we have no clue,” Lesko says. “I’ve never done anything political, so we hired an expert. It’s much like running a campaign for office, except that fluoride has no face. It’s very odd to be running a campaign for a nonperson.”

Keep Fluoride sought to have a high degree of visibility in the community. Its strategy included 1,400 yard signs – nearly three times the number of its competitors’ – and a “blitz week” on the final full week leading up to the election, Lesko says. That’s when the final postcard went out with the medical-community endorsements. Local dentists took advantage of a holiday that normally is their nemesis by giving away 5,000 toothbrushes with a pro-fluoride message
on Halloween.

Keep Fluoride sent out 20,000 postcards to likely voters, using an app developed by Sharp that allows her clients to access loads of real-time voter data on their personal digital devices even as they are going door-to-door to shake hands and pass out fliers. The group also ran full-page newspaper ads on the three days leading up to Election Day, and Lesko and two other members of her group scored guest spots on local radio talk shows over that time.

The group’s efforts resulted in an immense spending gap in the race. Keep Fluoride raised $50,000 – including $25,000 from Oral Health Kansas and $15,000 from the United Methodist Health Ministry Fund – and ended up spending about $40,000, Lesko says. Salina Cares spent about $3,000, Tryon says, mostly on yard signs and radio commercials.

To put that into perspective, the fee of about $4,000 paid to Sharp to run the Keep Fluoride campaign was more than Salina Cares’ total spending. Tryon, who in the weeks leading up to the election spent hours holding up homemade anti-fluoride signs at busy Salina intersections, noted spending as a factor when asked what led to the lopsided loss.

“There’s no way a grassroots group of 15 people could keep up with that,” Tryon says. “Even if we could spend a couple of thousand, that would be our limit.”

 

Dealing with Conflict

Yet even a professionalized campaign doesn’t insulate supporters from conflict when there’s a contentious public dialogue. Being able to stomach conflict in promoting public health is one lesson that carried over from one of the last times that Salina found itself at the epicenter of a far-reaching public health issue.

In 2002, the city at the crossroads of Interstates 70 and 135 passed the state’s first ordinance to restrict smoking in public places. It was a landmark action and a hotly debated one.

Trent Davis, a Salina neurologist who was chairman of the anti-smoking coalition, says there can be immense pressure on community members to stay out of such a fray for fear of angering others.

“I was surprised how hard it was to get my medical colleagues involved,” says Davis, who is currently serving as a Salina city commissioner. “They were afraid they might lose patients or they might lose referrals. A lot of people don’t want to risk their livelihood because of a ‘little’ issue.”

In a local controversy, conflict often feels very personal, sometimes pitting individuals against people who on any other day might be colleagues, customers, friends or neighbors. Davis says that it’s important to choose to advance what you truly believe in and understand going in that exercising leadership may carry some consequences.

“You can’t really be afraid of losing anything,” Davis says. “If I believe enough in an issue and I lose some friends or lose some influence or lose a few patients, if that issue means that much to me, then that’s the cost of doing business. So many times, we want to hold on to everything and we don’t want to risk anything, but we want to win it all. That’s just not the way it works.”

Lesko needed to look no farther than Wichita – where she has dentist friends who took a stand for fluoridation in the campaign there and paid a price for it – to understand that there were risks involved in spearheading Keep Fluoride in Salina.

“It was kind of an ugly battle in Wichita,” Lesko says. “The anti-fluoride people were kind of going after the personal lives of the dentists and discrediting dentists individually, and I’m really grateful that they didn’t do that here.”

Any fears she might have had about consequences haven’t materialized.

“No one left our practice,” Lesko says. “We know there are anti-fluoride patients here, but they’re still our patients. But I did have patients who saw us in our ads and did come to us because they knew that I was behind keeping fluoride, which was really cool. I did not expect that at all. Some of those patients were some of our biggest helpers and turned out to be some of our volunteers, which was really neat. I didn’t expect that flip side.”

When it was approved back in 2002, Salina’s clean indoor air ordinance applied only to restaurants and only at certain times of the day. It was later replaced with stronger ordinances and caused a ripple effect throughout the state.

Will there be any ripples elsewhere in the state stemming from Salina’s vote on community water fluoridation? So far, the answer appears to be no. The anti-smoking ordinance was a relatively new idea in Kansas when Salina passed it, but water fluoridation is something that has been on the books for decades.

Yet Salina is unlikely to be the last battlefront over fluoridating community water supplies in Kansas. An organization called Fluoride Free Kansas seeks to “stop new referendums/initiatives by the fluoride mafia,” according to its website.That’s not news to Lesko and the health organizations that supported Keep Fluoride, which is why she was glad to see such a decisive victory in Salina.

“I know state-level-wise that we believe there are things we are going to need to get involved in,” Lesko says. “There will be other cities that will be attacked. They’ve gone after Wichita, and they had a state bill (in 2014). We feel like there is a big push that they are trying to make, and we are organizing on our end as well.”

If public-health supporters learned one lesson from Salina, she says, it’s the need for doctors, dentists and others who care about the health of a community to step forward and engage others when they can make a difference.

“When you’re looking at a local community fluoride issue, it’s best done by the local community,” says Lesko, who was named Oral Health Kansas’

Outstanding Community Leader of the Year two days after the Salina vote took place. “You can’t sit back and not do anything. You have to do something.”

JournalWinterCover

 

This article was originally published in the Winter 2016 issue of The Journal, a publication of the Kansas Leadership Center. To learn more about KLC, visit http://kansasleadershipcenter.org. For a subscription to the printed edition of The Journal, visit klcjr.nl/amzsubscribe

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