The joint meeting of the Assembly Committee on Health and Human Services and the Senate Committee on Human Resources and Facilities was called to order at 3:40 p.m., on Thursday, March 11, 1999. Chairman Vivian Freeman presided in Room 4100 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All Exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

ASSEMBLY COMMITTEE MEMBERS PRESENT:

Mrs. Vivian Freeman, Chairman

Mrs. Ellen Koivisto, Vice Chairman

Ms. Sharron Angle

Ms. Barbara Buckley

Ms. Dawn Gibbons

Ms. Sheila Leslie

Mr. Mark Manendo

Ms. Kathy McClain

Mr. Kelly Thomas

Ms. Kathy Von Tobel

Mr. Wendell Williams

Senator Raymond D. Rawson

Senator Maurice Washington

Senator Mark Amodei

Senator Bernice Matthews

Senator Valerie Wiener

COMMITTEE MEMBERS ABSENT:

Ms. Merle Berman

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Mrs. Freeman advised the meeting would be limited to 2 hours of testimony.

She invited Assemblywoman Chris Giunchigliani to make opening remarks.

Assemblywoman Chris Giunchigliani, Assembly District 9, identified herself and introduced A.B. 284 as a bill that promoted public health and prevention. All water was fluoridated, and the bill attempted to allow the Board of Health to work with the two urban areas to regulate the proper amount of fluoride to maximize its usefulness. She provided EXHIBIT C, a suggested amendment from the committee to clarify an issue of wells, which stated:

Sec. 2.1. The state board of health shall adopt regulations requiring the fluoridation of each public water system that serves a population of 100,000 or more.

Sec. 3

The provisions of NRS 455A.025 to 445A.050, inclusive, apply only to

those public water systems that serve a population of less than 100,000.

She stated it had been 53 years since fluoride had been regulated in the United States. More than 136 million Americans were served by water supplies where fluoride concentration had been regulated by government to ensure the optimal level for dental health was provided. Another 10 million were served by supplies where the natural fluoride content was sufficient for improved dental health. Fluoride had many supporters among which were the:

• Nevada Association of Homeopathic Physicians
• American Dental Association
• American Medical Association
• World Health Association
• American Cancer Society
• Center for Disease Control and Prevention
• United States Public Health Service

Nevada State Groups:

• Maternal Child and Family Board
• State Board of Health
• Nevada Dental Association
• Community Health Centers
• Great Basin Primary Care Association
• Nevada Nurses Association
• Dental Hygienists Association
• Indian Health Services
• Concerned Citizens for Fluoridation
• Junior League of Las Vegas

The opposing organizations were:

• Independent American Party
• Nevada Eagle Forum
• John Birch Society
• Nevada Concerned Citizens

Ms. Giunchigliani introduced a similar bill in the last 69^th Session. She related some of the arguments she had heard and commented on them:

• "This should only be about children."

The issue was not just about children, but it was about children as well. Adults got cavities too. There was a new concern with tooth and gum disease increasing in the senior population due to many of them using reverse osmosis in their homes, so they were not even receiving the small amount of natural fluoridation.

• "Let the locals put it to a vote."

Legislators were elected to make public policy decisions and not evade duty by putting everything to a vote of the people. Health was a public policy and legislators should act on it. The decision to immunize had not been put to a vote.

Ms. Giunchigliani had not pushed for a vote last session because she felt legislators had to have a comfort level and an opportunity to hear from their constituents. In speaking to legislators since then, the small amount of opposition had not appeared to come from the constituency, rather, from a vocal minority. Much of the public supported fluoridation; they assumed the government already regulated the proper amounts. Especially if those individuals had recently moved from a state that fluoridated; 42 states fluoridated. The issue had been in the public for more than 3 years and the opposition continued to be minimal while support had grown.

• "Let the dentists dispense the pills and liquid."

If dentists did not give fluoride, money could be saved and directed to more severe needs rather than spending it on prevention.

She had students in her classroom in severe pain, they could not concentrate because they hurt too much. Toothaches began with cavities; they could be reduced or eliminated with fluoride. The cost was minimal for the local entities to start the fluoride program. In the 69^th Session a project was funded to provide dental care for 1,750 children statewide at a cost of $660,000. That amount could have covered a majority of the cost from the water districts for implementing fluoridation which would have covered 1.5 million people.

The fluoridation issue was emotional for those who thought it was a poison, a communist plot, or a concern about mottling; which occurred when there was too much natural fluoridation and could be stopped or prevented if regulated.

While being sensitive to the emotional issue, Ms. Giunchigliani urged the committee to consider the legislation based on facts not fiction.

Senator Raymond D. Rawson representing Senate District 6, Clark County, identified himself and as co-sponsor of A.B. 284 made the following remarks:

He addressed the issue of legislative responsibility and cited the executive budget document which spoke of the vision, the philosophy, and the mission of the state to:

"Provide the highest quality of life for Nevada citizens and visitors by ensuring the public safety, protecting the state's natural resources, promoting a strong economy, fostering an environment that is open to diversity, accepting of individual differences, and encouraging to individual development, and providing for those who cannot care for themselves."

Senator Rawson said Nevada was a wonderful state, there were many good things about it, but it was not a perfect state. The problems were due primarily to the state's growth and state government's inability to respond. In a 1998 study that grew out of concern for the state's health issues, Nevada ranked 47^th among states nationwide on the 17 weighted issues. In that broad range of health issues, the State of Nevada had not been doing enough for its residents.

Generally, Nevada had a good water supply, but there were areas where there were significant problems. In some parts of the state there was too much selenium which was dangerous and caused mental retardation. In the northern end of the state there was too much arsenic in the water. In others areas, lead or mercury could be found in the water. And still other areas where there was too much fluoride. Individual wells around volcanic areas reveal the presence of excessive fluoride and in some areas of the state, too little fluoride. It was appropriate to examine the situation and find an optimal or safe level of all those elements in the water supply.

Nevada was home to 550,000 children; 75,000 had no access to dental care and reflected 80 percent of the dental disease in the state, and 18,000 of those children really suffered with pain and infection. No one had raised an alarm about those children because no one took care of them. They did not go to dentists because they had no insurance and no means of paying for dental treatment. A report from the Milbank Foundation stated "Tooth decay increasingly is concentrated in low-income children whose personal and family health behaviors, diet, salience for dental care, and socio-economic restraints overwhelm the public health and preventative modalities that have helped their more affluent peers."

Senator Rawson acknowledged there was a serious problem in the state and it was within the responsibility and obligation of the legislature to safeguard and protect the public health.

Dr. Mary Guinan, State Health Officer identified herself and stated the public water supplies that contained fluoride levels of approximately 1 part per million reduced tooth decay in the population served. Naturally occurring fluoride in Nevada's public drinking water varied considerably. Healthy People 2000, a U.S. Public Health Service initiative, had a goal for the year 2000 that 75 percent of the U.S. population be served with water supplies with optimal fluoride levels to prevent tooth decay. In 1992, over 62 percent of the U.S. population was served by water supplies with optimal levels of fluoride. As of 1999, approximately 2 percent of Nevadans were served by water supplies with optimal fluoride levels. Both physicians and dentists recommended daily oral fluoride supplements for Nevada children; that was unlikely for children in low income families with limited access to health care. Even in families with health care access, preventive fluoride supplements were inconsistently provided to children. The safety and efficacy of adjusting fluoride levels had been repeatedly shown over more than 50 years.

Claims had been made that fluoridated drinking water caused cancer, birth defects, heart, kidney or bone disease, and infant deaths. Numerous scientifically sound studies had shown no increased rates of those diseases or conditions. Excess fluoride could cause fluorosis, a cosmetic condition of the teeth and had been associated with fluoride supplements in some areas. Fluorosis in Nevada was for the most part linked to fluoride supplementation.

Oral fluoride supplements would be eliminated by adjustment of Nevada water supplies to optimal levels of fluoride.

Assemblywoman Chris Giunchigliani thanked Dr. Guinan who had testified neither for nor against, rather, provided insight into the health impact of the fluoride issue on the State of Nevada.

Chairman Freeman opened the testimony to those opposed to A.B. 284.

Jeff Green identified himself as the Director of Citizens for Safe Drinking Water. Highlights of his testimony were:

• His group formed in 1996 in response to the legislature's decision to fluoridate.

• The decision followed a California city's rejection of fluoridation by 213,000 votes in 1975.

• Fluoridation was a water issue not a dental issue.
  
• The proponents of the bill would not state the total amount of fluoride should any individual in the community be exposed. The reason was because the amount established in the 1940s was 1 milligram a day—not 1 part per million. One milligram a day was chosen because 2 milligrams a day was enough to create unacceptable dental fluorosis. At 1 milligram per day, at least 10 percent of all children would experience dental fluorosis.

• A second question that would not be answered by the proponents was: How much total fluoride exposure was anyone in the community receiving from all sources as opposed to water.

• It was convenient to talk about 1 part per million because that was how 1 milligram per day was going to be achieved in the 1940s when there had been no exposure from fluoride in other areas. There was no fluoride in toothpaste, white grape juice, Coca Cola, or other food sources we now had that contained fluoride. The exposure level was different now.

• A third question that would not be answered by the proponents was exactly what the product was that would be introduced in the water. The proponents would say it was "natural."

• The product was fluorine that came from a "scrubber" system as a waste by-product in the manufacture of phosphate fertilizer. Fluorine had to be separated via a "scrubber" system because if it went into the air it would kill plants, animals, and people. Therefore it was put into the "scrubber" system and captured and that captured fluorine was what would be put into the water.

• It was not a pharmaceutical product. It was not food grade or industrial grade quality. It was a hazardous waste. It could not be given away, but once paid for it could be distributed in the places it could not have been before.

Mr. Green introduced individuals who would next appear on a video:

• Dr. William Hersey, representing the union responsible for providing ethical protection for scientists, toxicologists, biologists, attorneys, and statisticians at Environmental Protection Agency (EPA) in Washington, D.C., (although, Mr. Green said, EPA management continued to support fluoridation).

• The second scientist (no name given) lost her job after publishing an item that showed during certain gestation periods laboratory animals became permanently hyperactive.

• The third individual (no name given) was responsible for the only military station in the U.S. that was not fluoridated.

NOTE: VIDEOTAPE WAS SHOWN BUT NOT PROVIDED AS A PHYSICAL EXHIBIT THEREFORE COULD NOT BE INCLUDED WITH SUPPORTING MATERIALS ATTACHED TO THESE MINUTES.

Mr. Green informed that 98 percent of Europe was fluoridation free because those countries already examined, investigated, experimented, and found no reason that fluoride should be put into the water. Finally, he said it was not the first time someone had tried to place something in the water: iodine, an essential nutrient, was placed in the water in the 1920s to reduce goiter and later removed. It was now found in salt. If the proponents of fluoride had scientifically credible evidence that showed it was safe and effective, and the product was consistent and of food quality, it could have been put in salt 50 years ago and we would all have unfettered freedom of choice.

Mr. Green introduced Dr. David Kennedy, past president of the International Academy of Oral Medicine and Toxicology, a group formed to examine toxic elements and procedures in dentistry.

Dr. Kennedy introduced himself and said he had a degree in biochemistry and physiology and had learned a great deal about fluoride. He then presented a slide program titled "Fluoride and Scientific Fraud." Among the points he made were:

• The fundamental basis for fluoridation was a "house of cards."

• There was not a single broad-based blinded study of animals or humans that showed water with fluoride reduced tooth decay.

• Six vast epidemiological studies showed no difference in tooth decay.

• Fluoridation caused cancer, increased hip fracture, definitely caused dental fluorosis, no decrease in dental care cost, and was not Federal Drug Administration-approved.

• Congress ordered the National Cancer Institute to study fluoride as a carcinogen. A press release following Congressional hearings stated "We can no longer assure the American public that fluoride is not a carcinogen."

• In animal studies there had been a significant increase in bone cancer.

• The Center for Disease Control said a study of fluoride found increased osteosarcoma in rats.

• Fluoride was more toxic than lead and about the same as arsenic.

• Four studies published in the Journal of the American Medical Association since 1990 showed increased hip fracture following exposure to water fluoride.

• Hip fracture was caused because fluoride accumulated in and poisoned hip bones.

• Hip fracture dwarfed the cost of tooth decay.

NOTE: DR. KENNEDY DID NOT PROVIDE SLIDES AS A PHYSICAL

EXHIBIT THEREFORE THEY COULD NOT BE INCLUDED IN THE SUPPORTING MATERIALS ATTACHED TO THESE MINUTES.

The balance of Dr. Kennedy's lengthy testimony reiterated and re-emphasized points already made.

Dr. Michael Gerber identified himself as a medical doctor and homeopathic physician, and Secretary-Treasurer of the Association of Homeopathic Physicians. He thanked Chairman Freeman for her even-handed hearing of the important issue.

He said that in addition to what he already knew about the fluoride issue hearing the vast amount of information and statistics just presented had made him extremely upset. There was absolutely no need for fluoride in human or mammalian nutrition. No part of body chemistry needed fluoride. It was an enzyme poison. He cited excerpts from a letter (not provided as an exhibit) from Fuller Royal, M.D., H.M.D., chairman of the Board of Homeopathic Medical Examiners, that reiterated the theme that fluoride was not natural to the environment and repetitious consumption of water by individuals resulted in physical and mental symptoms known as "provings" in homeopathy. Those could be misdiagnosed by physicians unaware of the phenomenon causing complications in iatro-genic or doctor-caused illness. Fluoridation violated the state requirements for the responsible administration of a chemical substance to human subjects. Dr. Royal's letter concluded by urging the committee to defeat A.B. 284.

Dr. Gerber asked the committee to consider the health implications for everyone and especially for children.

Laurie Yarborough identified herself as an opponent of fluoride and acknowledged the information heard so far was overwhelming. The research and statistics she had uncovered while examining the fluoride issue over the past 3 years had already been presented. She supported those findings. This was a very passionate issue, similar to the Boston Tea Party in 1773 when people were fighting for individual rights and liberties. That was the foundation of the passion. Add to that, the amount of research given intelligent people to interpret and A.B. 284 was a "real kick in the teeth" because it took away the voice and the choice of Nevadans to decide whether or not they wanted to take fluoride into their bodies.

Ms. Yarborough referenced statistics in dental journals relating to the amount of fluoride found in juices. One, the Journal of Clinical Pediatric Dentistry, stated the reason grape juice was so high in fluoride was because "it was a common practice to use fluoride containing insecticide in growing grapes, it is believed that contamination of these juices is occurring." In another example, Ms. Yarborough said ingesting one Coca Cola provided the maximum amount of fluoride one should have daily, in which case no other liquid such as tap water could be taken without over-burdening the body with fluoride. Nor, she said, should one have pasta boiled in tap water because when boiled the fluoride became concentrated. It did not filter out with a normal home filtering system. See EXHIBIT D for photographs and statistical data.

In conclusion, Ms. Yarborough read a quote by Dr. Carl Sagan, recipient of the highest award presented by the National Academy of Science: "Finding the occasional straw of truth awash in a great ocean of confusion and bamboozle requires vigilance, dedication and courage. But if we don't practice these tough habits of thought we cannot hope to solve the truly serious problems that face us and we risk becoming a nation of suckers, a world of suckers, up for grabs by the next charlatan who saunters along." She said she did not believe the people who testified in favor of A.B. 284 were trying to hurt anyone in any way. She did believe misinformation or lack of information proliferated and from the voluminous data and testimony provided she hoped the committee would be able to decipher the truth.

Kasey Thomassian identified herself as a Reno mother of three young children opposed to water fluoridation. She provided EXHIBIT E containing pertinent statistics on fluoride dosage approved by the American Dental Association and other dental societies, as well as journal excerpts on fluoridation and hip fracture.

If Nevada's water was fluoridated, 1 litre of formula for a 3-month old baby would contain 1 milligram of fluoride, which was the adult dosage. The baby would be receiving an adult dose every day. Another reason for her opposition, she said, was when she was pregnant her doctor prescribed fluoride to strengthen her unborn child's teeth. She developed a rash condition on her face called perioral dermatitis which no medicine would help. A dermatologist said it was caused by fluoride. The problem was alleviated when her child was born; however, whenever she ingests anything containing fluoride the rash returns for months. Having her teeth cleaned causes ulcers in her mouth. The only thing she could do was strictly avoid all fluoride, but if fluoride was put into Nevada water she would be unable to do so. She urged the committee to keep fluoride out of Nevada water.

Chairman Freeman called Hans Fridscheisen to speak. He rose from his seat in the gallery and yodeled. He was a very good yodeler. He said Europe had almost entirely done away with fluoride. He yodeled again and deferred to the next speaker.

Doug Collins identified himself as a chemical engineer who had been in the waste water and environmental industry for more than 20 years. He had worked with waste water all over the world. Whenever anything was done with the water it had an economic impact on everyone who paid their bill. One-half of 1 percent of treated water was consumed internally. The remaining 99.5 percent was used for fighting fires, washing roads, and watering lawns. As a result of watering lawns fluoride would be put onto the surface and when it rained or snowed it would migrate and find its way into the ground water. He found it unbelievable that would be done especially up in Lake Tahoe where eventually the fluoride would make its way into the lake. It did not make sense, he said, to spend so much money to treat one half of 1 percent that would be consumed.

Mr. Collins hypothesized, if fluoride was put into the water, how much would be at the beginning of the line and what sort of monitoring would be done to ensure the resident at the end of the line would receive the residual amount of 1 part per million. What kind of concentration would be required to achieve the right effect. It did not make sense from an economic standpoint, he concluded, to add fluoride to Nevada water. Moreover, fluoride should be viewed as a medication, and if introduced in the water it would be the same as municipally medicating the entire state.

Ben Moss identified himself as a Reno resident for more than 50 years. He said sodium fluoride was a major industrial chemical. The idea of putting it into water came from a biochemist, Gerald Cox, in 1939. It was a popular idea because of the low cost of disposing a great amount of the chemical into the water. It took 6 years to develop a metering device and in 1945 fluoride was finally put into the water. By 1974 so many people had been killed by sodium fluoride spills caused by the metering devices failing that Public Law 93.523 was signed into effect by President Gerald Ford. It stated no national primary drinking water regulation could require the addition of any substance for preventive health care purposes unrelated to contamination of drinking water.

Congress and the President of the United States, in effect, "declared fluoridation to be a fraud, a hoax, a flim-flam and a rip-off." (Mr. Moss received a round of applause from his fellow opponents.)

Assemblywoman Chris Giunchigliani announced the proponents of A.B. 284 would be the next speakers.

Louise Helton identified herself as the mother of two children, a member of Junior League of Las Vegas, founder of Classroom on Wheels, and chairman of the Concerned Citizens for Fluoride Coalition. Her testimony (EXHIBIT F) stated in part:

• Her daughter had her first cavity at age 3; it was then she learned their community's water was not fluoridated.

• A natural public safety net capable of making teeth resistant to tooth decay and a basic need supplied by most communities since the 1950s was not available in Nevada by the 1980s.

• By the 1990s thousands who had enjoyed cavity free years had to start counting cavities as adults after moving to Nevada.

• Through her work with Classrooms on Wheels, she had seen many youngsters with orange ridges on their teeth and puffy gums that meant their teeth were actually rotting out of their heads.

• The Head Start program provided meals for children and had to have a special menu for children who had no teeth. It was a challenge to feed those children at a time in their lives when nutrition was vital to developing young bodies into strong adults.

• There were very few pedadontists in Las Vegas and patients with the ability to pay for treatment had a long wait for appointments. Those unable to pay were never seen.

• Without fluoride 70 to 80 percent of Nevada children suffered from dental caries. The only option was to prevent cavities from forming. That could only be done with fluoride.

• Regulated fluoride in Nevada drinking water could reduce dental cavities by half.

• Signatures of 4,500 Nevadans supported fluoridation. (EXHIBIT G)

• Concerned Citizens for Fluoride was a group of parents, health professionals and community service organizations who had asked for the committee's support to provide the first line of defense against tooth decay for the people of Nevada.

Next to speak was Dr. LeAnn Truesdale who stated she appeared on behalf of the Junior League of Las Vegas as their legislative representative. She was also a first year student at the Boyd School of Law, a practicing dentist in Las Vegas, and president of Southern Nevada Dental Society. She held a degree in neurobiology, a graduate degree in biochemistry, and a doctoral degree in dentistry. Dr. Truesdale provided substantial supporting documentation for her testimony, marked as EXHIBIT H. Highlights of her testimony were:

• Experience with the indigent care clinics where she was a volunteer had been horrifying. People who had not seen the population the clinics served were unaware of the degree of oral infection in those young mouths. It had been a routine finding.
• A.B. 284's opponents had said it was a water issue not a dental issue, however, Dr. Truesdale could read scientific literature and was able to identify a control that was correct and whether it was a blind study, and what those results meant. She acknowledged there was some distrust in general about reports from the American Dental Society or other governmental bodies. She believed that while many of the reports and statements were heartfelt, they were also often misleading.

• Consider the future not only of children but also the subject of eldercare, brought up repeatedly in earlier testimony, and the concern the opponents have of hip fractures and bone density.

• There had been numerous studies that had shown no correlation positive or negative with bone density. She asked for clarification from the opponent who stated the fluoride incorporated into the bone making it more dense but yet increased hip fractures, and the bone density studies being lower, it seemed incongruent. The studies she had read were neutral and showed no correlation.

• The best thing that could be done for the children of Nevada was not to pull out their rotten teeth, which was so often done. Better to give them something that guaranteed their teeth would not decay to the extent currently seen.

Chairman Freeman thanked Dr. Truesdale and asked to speak to her further.

Anita Patton identified herself as a Reno resident. She had a systemic immune dysfunction, also known as chronic fatigue syndrome, which made it difficult for her body to fight infection. Last year she had an infection caused as a result of a cavity. Her dentist wanted to put a crown on the tooth. After the temporary was in place she had such pain the dentist wanted to do a root canal.

However a bone scan revealed the infection had gone into the bone and she was too ill to have the root canal. A lengthy process of medical treatment ensued, her tooth was still badly infected and she faced the decision of having the tooth (a major molar) pulled. Her dentist advised her she needed a constant source of fluoride, which would have prevented her condition, and would prevent it in the future.

Dr. Stephen Corbin, D.D.S., identified himself as vice president for Professional Development and Institutional Advancement at Oral Health America, a group based in Chicago. Dr. Corbin lived in Rockville, Maryland. He was here because he had a connection in Nevada: for the last 3 years Oral America had worked with a community health center in southern Nevada to address some of the oral health problems in Nevada school children. His organization also worked in other states. They were the only independent nonprofit organization in the United States working directly on behalf of the oral health of Americans.

Prior to his work with Oral Health, he was a Public Health Service dental officer for 23 years and served as chief dental officer in the U.S. Public Health Service and chief of staff to the Surgeon General of the United States. He provided substantial documentation, marked as EXHIBIT I. Salient points of his testimony were:

• The evidence concerning the health benefits of fluoridation and fluorides was robust.

• The evidence of the safety of fluoride and fluoridation was also robust.

• The evidence on all counts about fluoridation was extensive. Some of it was good, some bad, some relevant, and some irrelevant.

• When trying to make a decision about whether something was scientifically advisable, it was critical to try to distinguish between the relevant and the irrelevant. The powerful predictive data, and that which was only circumstantial. It was a hard task for scientists and certainly a hard task for nonscientists.
  
• Earlier testimony said it was a water issue, not a dental issue. He believed it was a child health issue, not just a dental issue. Only 1 in 5 Medicaid-eligible children in the U.S. had access to dental care. In Nevada that represented 14 percent.

• Unmet dental health needs and wants were the highest unmet health care wants in the U.S., surpassing medical, surgical, and podiatric for all age groups, both genders, in all socio-economic stata.

• The issue was clearly a health issue for children and for adults. Fluoridated water was not just a child health program but a population health program.

• The countless dozens of studies about cancer done in the last 50 years, the majority by leading scientific organizations and reputable epidemiologists and biostatisticians, had shown absolutely no relationship between exposure to fluoridated drinking water and cancer of any kind.

• Over 20 years there had been studies that showed fluoride in drinking water benefited bone health and reduced fractures. And, there were studies done that showed fluoride was a liability, though not a strong liability, for bone health and fracture. Those were very weak, rudimentary study designs. As a result, other studies had come along and had not been mentioned by those who testified previously about the problem of fluoride and bone health.

• There was now fairly definitive evidence that fluoride in drinking water at optimal levels provided a slightly increased risk of fracture of the wrist radial bone, but it also provided protection to hip fracture. Hip fracture was a widespread public health problem in the country. It generally affected older people, they became hospitalized, they got secondary conditions, infections, and many expired as a result of a hip fracture. Very few people ever became incapacitated from a wrist fracture.

• Fluoride in higher doses was being used to treat people with advanced osteoporosis of the vertebrae, in combination with slow-release calcium citrate. It was very important when unleashing the bone-building effects of fluoride in high does that there was adequate calcium.

• Fluoride was being used preventively in community water supplies and clinically in individuals with the most advanced retribral fracture problems from osteoporosis and it was being used effectively.

• The Federal Government had not backed off in its support of community water fluoridation as the keystone of community oral health programs. There was a year 2010 objective for the nation that 75 percent of the people on public water supplies in the U.S. would have fluoride in their drinking water.

• Nevada now had 2 percent, but could rise to the top of the list quickly if the two counties being considered were fluoridated.

• There was funding at the Centers for Disease Control to help communities start fluoridation and to help communities already fluoridating to improve their systems. Those funds were available in 1999.

• Since Nevada was high on the list of priority for improving fluoridation, there would be a good opportunity to request funding support to assist in the non-health aspects of the endeavor.

• Every surgeon general for the last 30 years had supported fluoridation, including Dr. C. Everett Koop who still traveled and wrote letters in support of fluoridation. Dr. Satcher, the current surgeon general, had also issued a statement in support of fluoridation.

Chairman Freeman thanked Dr. Corbin and commented that Dr. Koop had recently been in Reno and although she missed his appearance had always had a great deal of respect for him. Because Oral Health America was a national group, Mrs. Freeman asked Dr. Corbin if he would provide to the committee the statistics for the State of Nevada in regard to the measurement of fluoride in the water. He said he would.

Next to speak was Sue Larson, a Reno resident, wife and mother of two young children. Her youngest daughter was born 4 months premature and deprived of vitamins and minerals needed for strong bones and teeth. She was now a 9 year old with cerebral palsy and a mouthful of braces. Mrs. Larson brushed fluoride on her teeth twice a day. She strongly supported the passage of A.B. 284. Her written testimony was provided (EXHIBIT J).

Dr. Stephen Vaughn, D.D.S., identified himself as a practicing dentist in Sparks, and currently dental director for the Saint Mary's Take Caravan, on the board of directors for the Health Access Washoe County Clinic, and one of the directors of the Northern Nevada Dental Health Program. The program was originally started as a pediatric dental care program which provided dental care to school children free of charge. All the programs provided free or state-subsidized dental care for children. Dr. Corbin provided, as EXHIBIT K, a folder of photographs showing the mouths of young children he had treated in various stages of decay. Key points of his testimony were:

• 50 years of fluoridation and the benefits provided speak for itself.

• In the positions he had held over the years he had ample opportunity to see the ravages brought about by dental disease. The photographs provided (EXHIBIT K) were a representative example of 1 day in the Saint Mary's Take Caravan.

• He saw children in great pain from dental decay on a daily basis. Those children were unable to concentrate in school. Some children had such incapacitating pain they could not make it to school. Others were fighting such chronic serious infections their bodies were unable to do the things necessary for growth and development.

• San Francisco, where he went to dental school, had been fluoridating its water since the 1950s. It had been difficult there to find a population of youngsters who would provide the dental students with the education experience necessary to learn the broad based pediatric dentistry needed in private practice. It was Vietnamese refugees coming into the area at that time who provided the opportunity. During the Vietnam War they had been exposed to a western diet of sugars and sodas and had mouths full of decay.

• Medicaid paid many millions of dollars for dental care annually. Currently Medicaid struggled to find enough providers for dental care for the kids who needed it. There was a staggering caseload. If Medicaid were to increase its reimbursement to dentists, which might have to be done to get more providers, or if dentists began signing up as providers en masse, the amount of money the state would spend on Medicaid alone would be astronomical compared to what was currently paid.

• The importance of fluoride in the drinking water could not be emphasized enough. The control of dental practitioners was limited at best. Most of the kids that came through the Take Caravan did not own a toothbrush, had never been to a dentist, and were never given instruction on how to brush their teeth.

In conclusion, Dr. Vaughn urged the committee to spend a day on the van with him to see the problem first hand, and to pass A.B. 284 for fluoridated water.

Assemblywoman Chris Giunchigliani asked to go to the Las Vegas video site where people had been waiting to testify.

Dr. Bernard Feldman identified himself as chairman of the Nevada State Board of Health, a member of the Governor's Advisory Board on Maternal and Child Health, and acting chair of the Department of Pediatrics at the School of Medicine. He had practiced pediatrics in Nevada since 1974. He fully believed in fluoride supplementation and fluoridation of the water. He prescribed fluoride for his patients, for his children, grandchildren, and for his wife to prevent her osteoporosis. Dr. Feldman's supporting documentation was provided as EXHIBIT L.

Dr. Feldman said he was glad Dr. Corbin had testified and refuted some of the poorly supported statements made by the opposition. They were not studies and had not been studies, and had not indicated at all any danger from fluoridation in the water. Increased bone density from fluoride in women was a preventative of osteoporosis and not cause of fracture. Data compiled at University Medical Center (UMC) where he taught showed that dental disease was among the top 7 diagnoses for children that came into the emergency room at UMC. They came to the emergency room because that was where they could get care if they were uninsured. The children were in pain and infected. The average cost of care for the dental problem for child under 6 years of age was $123. Over 6 years of age the cost was approximately $140.

Infants developed carious teeth even before brushing was begun. Small children did not brush effectively. Kids swallowed most of the toothpaste and needed a parent to monitor how much fluoridated paste they were ingesting. If the drinking water was fluoridated they could use fluoride-free paste which was cheaper and safer and would save the parents time and frustration.

Only the most privileged families in Nevada would visit a dentist frequently enough to get sealant and topical fluoride treatment for their children. Only the most compulsive families would use fluoride supplements with regularity. The poorest of the state's children could not afford either and would do neither. For the small price of 50 cents per capita per year the reduction of dental decay in Nevada's children would be significant, leading to reduced health care costs in the future and for years to come, better school attendance, and better quality of life in adulthood. Nevada already ranked 47^th or 48^th in most health care indicators. For those who said fluoride would "dumb down" our children and fluoride would cause cancer, they were quite wrong.

Senator Rawson asked to say something about Dr. Feldman. Thirty years ago Nevada had the worst statistics in the ability to save a premature infant. Dr. Feldman had been running the neonatal program in San Diego when he started coming to Las Vegas. Within a few years of his coming to Las Vegas, Nevada moved to the top five in being able to save premature infants. At one point the state reached number one. Senator Rawson said people should know that about Dr. Feldman, he had a tremendous effect on the state.

The next speaker from Las Vegas was Christine Garvey who identified herself as a student from the Community College of Dental Hygiene in Las Vegas. She and her husband both were native Nevadans and the history of the state's lack of fluoride was evident in the amount of dental work they had. Dental problems had become more evident in their children's teeth as well. A recent exam indicated restorative work would cost $402 over what their insurance would pay. There had been a vast difference in the teeth of their daughters who had been born in Reno, where their doctor had prescribed fluoride and vitamin supplements, and her son, born in Las Vegas, where fluoride had not been prescribed. At a recent presentation at her son's school, she asked who in the room of 35 children had seen a dentist; 20 raised their hands. When she asked who had not had a cavity only 6 raised their hands. 70 percent of those children had some kind of dental work done.

With the older population, who often took medication that dried out their mouths and reduced saliva production, fluoridation in the water could help prevent root caries and decay.

In conclusion, Mrs. Garvey urged support of A.B. 284 and asked that fluoride not be allowed to fall by the wayside for another 2 years.

Also from Las Vegas, Deborah Campbell identified herself as the senior vice president of operations at United Way of Southern Nevada, a member of Nevada Kids Count Committee, and a mother of a 4-year-old born and being raised in Clark County. United Way studied community needs and problems and recommended solutions, and through association and funding with community health centers and the Clark County Health District the organization was aware of the tremendous number of young and school-aged children who had experienced severe tooth decay. She described the various programs they had funded for an amount of several hundred thousand dollars:

• Community Health Centers of Southern Nevada, a children's dental sealant program, Clark County's first and only sealant program for low-income children. About 2,500 children were provided access to exams and sealant.

• The Pediatric Dental Services Program, provided emergency and urgent dental services to low-income uninsured children in distress due to pain, infection or another dental condition which if left untreated resulted in more costly future dental care, the loss of permanent teeth, or the risk of serious medical complications. Last year 51 children were served.

• Clark County Health District's Youth Dental Program targeted children through age 18 who had no means of getting any dental care. The agency served a minimum of 400 clients annually.

United Way had appeared not as a lobbying organization but as one that was raising money in the community from people who were directly affected by the dental tragedy on a daily basis. Prevention was both the right thing to do and the financially beneficial thing to do and United Way supported A.B. 284.

The final speaker from Las Vegas was Ted Twesme, president of the Nevada State Board of Dental Examiners, and a practicing dentist for 20 years in Las Vegas. The State Board of Dental Examiners strongly urged support of A.B. 284. For every dollar invested in fluoridation it returned $80 in reduced cost of dental care. That did not take into account the human cost of dental pain and suffering. The Medicaid budget for dental care was $13 million annually. Fluoride could reduce caries by 63 percent. That would have a tremendous impact on that budget. One hundred thirteen scientific studies had been done in 23 different countries all over the world over the last 53 years; all were in strong support of fluoride. Only 2.1 percent of public water in Nevada was fluoridated which ranked Nevada 50^th of all states, the lowest.

Dr. Twesme recounted incidents of being called to UMC at 2 a.m. to treat a child whose eyes were swollen shut from a dental infection. The child would be hospitalized for 7 to 10 days to have intravenous antibiotics to control that infection. It was frightful for the child and the family. Fluoride would go a long way to reduce the frequency of that kind of situation.

Chris Fourche identified herself as a dental hygienist and a member of Nevada Dental Hygienists Association. She presented slides, provided to her by Dr. Bill Waggoner, a pediatric dentist in Las Vegas, of children Dr. Waggoner had seen in his practice.

Ms. Fourche recounted an incident of a 12-year old boy who had come in for a cleaning and check-up as a result of a toothache. Every one of his permanent 6-year molars had a major cavity. The teeth were so badly decayed even a root canal and a crown would not fix them. The only way to get the child out of pain was to extract every one of his permanent molars. The boy's mother was told by another dentist the boy would probably be in dentures by age 16. That had made Ms. Fourche a "passionate believer" of optimally fluoridating the water supply in Nevada.

Numerous public health issues had already been instituted, such as:

• Chloride to water to prevent cholera and dysentery
• Iodine to salt to prevent goiter
• Vitamins A and D to milk to prevent rickets
• Folic acid to wheat products for pregnant mothers to prevent spina bifida in babies.

In conclusion, Ms. Fourche said dental decay was an epidemic in Nevada communities and should be treated accordingly. The legislators had the power to protect current and future Nevadans by passage of A.B. 284.

Again from Las Vegas, came rebuttal testimony:

Kris Jensen identified herself as representing Nevada Concerned Citizens. She stated fluoridation of an entire water supply was not cost effective, because:

• 75 percent of the water was used outdoors for lawns, washing cars, and so on.

• 18 percent of indoor water was non-consumption use such as laundry, bathing, and dishwashing.

• Less than 7 percent of the water supply was used for drinking and cooking.

• Only 13.76 percent of Nevada children would benefit from the 7 percent of water used for drinking and cooking.

• Internal ingestion had minimum effect. Fluoride in water benefited the smooth surfaces of the teeth yet 95 percent of cavities occurred in the pits and fissures.

• It would be better to provide sealant that was highly effective. It was more cost-effective and more directed to those who needed the help.

• In the 69^th Session the dental community testified that children from birth to 1 year should never have fluoride.

• Fluoridation in water would force low-income mothers to buy bottled water or put their children at undue risk.

• The issue of controlled intake needed to be addressed.

• Tooth decay would be more correctly attributed to an over-abundance of soda pop, sugar, and poor nutrition.

She said topical fluoride applications such as toothpaste, rinses, gels, and tablets were available and allowed for a degree of personal responsibility and choice in dental care.

Ms. Jensen added further, according to the proposed legislation water suppliers would potentially be guilty of a misdemeanor if the level of fluoride was not properly maintained and would not be compensated for the ongoing cost of the fluoridation operation. It became an unfunded mandate from the state upon the local water systems then passed on in a hidden tax or fee to the citizens. A.B. 284 precluded the need for voter approval currently in state law in communities over 100,000. That meant the rights of the citizens in larger communities were selectively being removed. She cited the language in A.B. 284 on page 3, Sec. 3 lines 12 and 13. For those reasons, Ms. Jensen urged the bill be defeated.

Chairman Freeman stated Assemblywoman Chris Giunchigliani had amendments coming forward that would address some of the concerns raised by Ms. Jensen.

Next from Las Vegas was Sally Ellis, Health Coordinator for Head Start, who stated they had been giving fluoride tablets to 3 and 4-year olds for 20 years. The children's parents had always been happy with the results and dentists had been impressed by the improvement in the children's teeth after 2 years of fluoridation.

Ms. Ellis asked a mother (whose name was not given) with children in the Head Start program to speak. The mother said her daughter had been raised in states with fluoridated water and had good teeth. Her son was raised primarily in Nevada and was going into surgery the next morning to have removed 15 of his 20 teeth which had rotted. The mother urged passage of A.B. 284.

Cathy Jackson, a concerned parent from Las Vegas, remarked a 1989 study by researchers in Missouri who had examined the tooth decay records of rural sixth grade children and had found no significant difference in tooth decay rates between those living in fluoridated and non-fluoridated areas. In some primitive societies in Mexico and Israel where drinking water contained negligible amounts of fluoride, 80 to 90 percent of the population had no tooth decay. In those societies, consumption of refined carbohydrates was extremely low. Mrs. Jackson felt therefore proper diet not fluoridation was necessary for good dental health and probably had been the cause of most of the extreme dental decay histories heard in testimony. Judges in two court cases in Pennsylvania and Illinois had found compelling evidence and serious risk from fluoridation. Because of compelling testimony on both sides of the issue, Mrs. Jackson urged careful consideration of A.B. 284.

Patricia van Betten, R.N., represented the Nevada Nurses Association in support of A.B. 284. Her testimony, a written copy of which had been provided and marked EXHIBIT M, stated in part:

• For more than a century nurses had been advocates for community actions that impacted public health.

• Such concerns had led to government involvement in things now taken for granted, such as sewer systems, safe drinking water, and childhood immunizations.

• Actions such as those had been controversial, particularly from those who protested what they saw as government interference. Yet history had proven everyone benefited from those decisions.

• Fluoridation of drinking water was such an issue.

• The most common chronic childhood disease, tooth decay, was also the most preventable. Untreated dental cavities resulted in disfigured smiles, poor speech, and poor nutrition, among other things.

Ms. van Betten urged passage of A.B. 284 as an affordable and cost-effective intervention.

Dr. James Canard identified himself as a practicing dentist in Las Vegas. He believed fluoridation was a step forward. Since utilization of fluoride during his 17 years of practice he had seen a reduction in tooth decay. Fluoridation worked but had to go hand in hand with dietary controls. The teeth of geriatric patients were helped by fluoride. He urged passage of A.B. 284.

The testimony returned to Carson City where the next to speak was Stanleigh Harold Lusak, a concerned citizen from Fallon. Mr. Lusak provided printed material (EXHIBIT N) which urged he be elected as president of the United States, and excerpts from the Health and Freedom News, September/October 1997 edition, which stated, among other things, that "Fluoride is cancer-causing in rats, mice and humans." Mr. Lusak stated in part:

• Several generations of American Indians had been raised with fluoridated water and had the worst teeth of any group.

• Goals 2000 sounded like a conspiracy.

• History revealed Hitler and Stalin gave fluoride to their prisoners because it made them docile. It was the same reason the U.S. Government gave Indians fluoridated water.

• Fluoridated water would not correct a dietary problem.

Dr. LeeAnn Truesdale asked to clarify a misconception about fluoride and how it affected teeth. There were two types of application:

1. A systemic application to which water fluoridation pertained primarily and was the ingested supplementation; and
2. A topical application, as water was ingested passed by the teeth and stuck to the surface a little. That was addressed by dentifrice and gel.

Fluoridation addressed the formation of the tooth structure; it started in utero, which was why many prenatal vitamins contained fluoride. In the formation of the enamel, the strength of the enamel was directly related to how much fluoride was incorporated into the structure, which was related to how much fluoride was ingested. Teeth formed with the benefit of fluoride were stronger and had fewer incidences of pit and fissure decay.

Mike Workman, Utilities Superintendent at Incline Village, stated Incline Village was opposed to A.B. 284. He was charged with providing safe, clean water to consumers. People were becoming very concerned about what was in the water. He suggested the people who would be drinking the water have an opportunity to vote on whether fluoride was added to the water. Failure to do that would give people one more reason to distrust the government.

Dr. Kennedy, who had spoken earlier, spoke again in rebuttal of a point made by Dr. Truesdale. Virtually all scientists were in agreement there was no systemic effect from ingested fluoride, according to "Featherstone," a major conference in 1992. Regarding hip fractures, he said he had referenced, during his earlier testimony, the four major studies published by the American Medical Association; there were actually nine studies that indicated ingested fluoride increased hip fracture. He said, if his testimony was impeached it should be done on scientific evidence, not on the heartstrings of damaged children.

Dr. Kennedy said he established the Children's Dental Health Center in San Diego in 1974. It was free for indigent and needy children. He cared about children. He had seen the kind to decay put into evidence at the hearing and believed it was poverty that caused decay. All the blinded, broad-based studies

showed no statistically significant difference in tooth decay when fluoride was present in the water. Four major things happen when fluoride was added to the water: Bone density was increased, the I.Q. was decreased, the children in remedial education were increased, and the blood level of lead was increased. In closing, Dr. Kennedy said scientists from all walks of life from 17 countries had discussed the toxicological impact of ingested fluoride, and he urged defeat for A.B. 284.

Dr. Christopher Husser, A Reno physician and dentist, said he was trained in downtown Detroit where academic requirements were filled by treating poor and indigent people. Detroit, Michigan, had been a fluoridated community for probably 40 years before he went to dental school there. They treated rampant dental decay in a fluoridated state. In Nevada citizens prided themselves on having freedom of choice. Those who wanted fluoride could take tablets and brush with a fluoride toothpaste.

Dr. Stephen Corbin returned to address the question who would benefit from fluoride in drinking water and clearly the evidence was that both children and adults, particularly older adults, benefited. Fluoride prevented 50 percent of pit and fissure decay and up to 90 percent of smooth surface decay. He cautioned not be distracted by the issue of cost. Work being done by Dr. John Brown at the University of Texas, in San Antonio, indicated raising the fluoride level in drinking water by 1 ppm reduced the annual expenditure of dental care for Medicaid children by $35 per child per year; a substantial savings. With 29,000 Medicaid eligible in Nevada, 4,000 others on the Children's Health Insurance Program (CHIP), a lot of teeth and a lot of money could be saved. There was no permanent restoration. A tooth once restored continued to be restored and the costs continued throughout a lifetime, for that reason, too, protection that continued throughout the lifetime was needed.

Jeff Green spoke again to remind that no one had spoken about how much fluoride anyone would receive or the product that would be put into the water.

Chairman Freeman said the committee was there to listen and questions would be asked at a later date. She said she had made every effort to deal with testimony in a fair-handed manner.

Laurie Yarborough said the bottom line was how much fluoride was the optimal safety amount. To determine that amount she suggested committee members use the Physicians Desk Reference or any of the "bibles" of medicine and drugs to research on their own the correct level. There were negative effects of fluoride. People were currently getting more than they needed in food products. Better labeling of products was needed. Ms. Yarborough asked to be included in any question session held at a later date, and offered additional material to inform and help legislators make the right decision for the people of Nevada.

David Horton identified himself as an attorney representing the Homeopathic Medical Association in opposition to A.B. 284. Mr. Horton provided material (EXHIBIT O) in support of his testimony. His written statement, pages 1 and 2 of EXHIBIT O reiterated the testimony from the opponents heard earlier in the meeting.

Senator Rawson stated the issue of fluoridation had been well heard over a period of time. He would be scheduling it for a senate work session to ensure a full representation on the vote.

Chairman Freeman said the bill would also be scheduled for an assembly work session in approximately 3 weeks. She added that correspondence had been received from Sierra Pacific, the water supplier for Washoe County (EXHIBIT P) and from Southern Nevada Water Authority, the supplier for Clark County (EXHIBIT Q) and was available for committee members to read.

Additional written testimony and/or material was submitted to the committee as follows:

EXHIBIT R – Assemblyman Bill Petrak, Assembly District 18

EXHIBIT S – Barbara Hunt, Director, Washoe County Health Department

EXHIBIT T – Janine Hansen, Nevada Families Eagle Forum

EXHIBIT U – Robert Hall, Private citizen

EXHIBIT V – Mylan Hawkins, Executive Director, Diabetic Educational Center

EXHIBIT W – Hamilton Barhydt, Ph.D., Retired scientist

EXHIBIT X – Bob Sonderfan, Researcher/Author, Citizens In Action

EXHIBIT Y – Michael A. Sowers, Private citizen

EXHIBIT Z – Ernest Colton, Private Citizen

EXHIBIT AA – Juanita Cox, Citizen Lobbyist, People to Protect America and People Organized for the Next Generation.

With no further business before the committee, meeting was adjourned at 6:40 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

DATE: