Did you know that scientific studies have found most people lie once every 10 minutes? In my new podcast, Truthless, I'm talking to people about the lies they tell from faking illnesses in high pressure moments to making up stories on national TV. From Spotify and the Ringer Podcast Network, I'm Brian Phillips. Listen to Truthless on Spotify or wherever you get your podcasts.
Today, America's broken public health discourse and a better way to talk about scientific controversies and conspiracies. Robert F. Kennedy Jr., who for better or worse will be a fixture in our lives for a while, it seems, said last month that if he's confirmed as the Secretary of Health and Human Services, the new Trump administration will recommend removing fluoride from public water supplies.
Upon hearing this, many public health experts were aghast. They called this approach anti-science, misinformation, even a conspiracy. I saw several people I consider smart and generally good faith make some commentary along the lines of R.I.P. America's teeth. Or, well, this ought to stimulate employment in the field of dentistry. I'll admit, my initial reaction was similarly scornful.
My instinct was to wave this off. R.K. Jr. is, among other things, America's most famous vaccine skeptic. You know, maybe a few months ago, that's what I would have done. Mock, ignore, move on. But I really want to resist that instinct in today's episode and in episodes going forward.
This is for a few reasons. First, we don't have a complete explanation for why Trump won, but I do put some stock in the partial explanation that liberal media has developed a reputation for being dismissive of unofficial narratives, critical of stories they deem out of bounds, and censorious of people who disagree with the ones they call experts.
This is an instinct I really want to push back against on this show. I think we live in a world where if people in authority pretend that complicated topics are actually easy, even obvious, they don't just risk misrepresenting the truth. They might in the long run be sawing off the leg of their own legitimacy.
So I want to take this fluoride thing seriously, and I want to take the larger concept of America's public health discourse seriously. So what is fluoride? What was the world like before fluoridated water? And what's really the truth about fluoride's reasonable risks today? Fluoride is a mineral.
a naturally occurring mineral. In our mouths, it binds with calcium ions and other molecules to strengthen our enamel, which covers the crown of our teeth. For the majority of human history, nobody knew any of this. For most of human history, we have lived with our teeth, our dumb, little, pathetic teeth rotting inside of our mouths and falling out of our faces by the time we reach middle age.
I want to read you a passage from an extraordinary essay on this subject that Charles C. Mann wrote in the Atlantic in 2020. Quote, our grandparents jaws used to hurt all the time.
Tooth decay plagued everyone, rich and poor, famous and obscure. George Washington had lost all but one of his teeth by age 57 when he was first sworn in as president. His quest to fill his mouth led him to where sets of dentures made from his own pulled teeth, from animal teeth, donkey and horse up top, cow on the bottom, and from other people's teeth, possibly including those of his slaves.
People on both sides of the Atlantic participated in a lively black market in Cadaver's teeth. Fortunately for denture customers, Europe had a ready supply. Scavengers followed wartime armies. After the shooting stopped at the Battle of Waterloo, many of the dead were toothless within hours.
And I'm sorry, I'm just pausing here. Holy Jesus, the past was terrible. It's probably good mental hygiene to read history exclusively to remember how terrible everything used today. So just want to make that quick detour. Okay, back to Charles Mann, quote.
The widespread introduction of sugar worsened society's dental difficulties. In the first decade to the 20th century, American dentists regularly made full sets of dentures for teenagers so that they would look presentable at graduation. American soldiers were required to have a minimum number of opposing teeth, six on the top, six on the bottom.
Thousands of would-be GIs were barred from service in the First and Second World Wars for failing to meet this standard." End quote. What changed this horror show of our ancient disgusting mouths was science, or at least an openness to science.
In the early 20th century, dentists in the western states like Colorado recognized that water with high levels of naturally occurring fluoride caused gross stains on the teeth of young children, but these grossly stained teeth also seemed unusually resistant to cavities.
In the 1940s, several cities in the US ran experiments to test the hypothesis that fluoride was protective against tooth decay. Two New York cities in the Hudson River joined this experiment. One city, Newburg, received fluoridated water. Another city, Kingston, was the control group, and no fluoride was added to their water.
Ten years later, data was collected on the rate of tooth decay in each city, and it was determined that on a per capita basis, children in Kingston had twice as much tooth decay as Newberg. Fluoride had cut their cavities in half.
For the last 80 years or so, fluoride has been routinely added to community drinking water systems at a targeted concentration of 0.7 milligrams per liter, about half the levels tested in Newburg and Kingston in the 1940s. Rates of tooth decay have plummeted. Rates of cavities have plummeted, and this is true even despite a surge in sugar consumption.
The CDC declared water fluoridation one of the 20th century's greatest public health achievements. But there's been a vibe shift in the debate over fluoride in the last few decades. It's happening on the naturalist left. It's happening on the right. And if we're seeing reality clearly, it's also happening in the center. In his Atlantic essay, Charles Mann points out that American teeth have clearly enjoyed a century of major improvement.
But exactly how much of that is due to the fluoride in our water versus fluoride in our toothpaste. It's hard even for experts to say. In fact, non-fluoridated nations such as Belgium and Denmark have better dental health than we do according to the OECD. Meanwhile, the evidence is quite clear that elevated levels of fluoride do have real risks.
In one meta-analysis, researchers from Harvard and the China Medical University looked at 27 studies, mostly based in China, and found strong indications that fluoride adversely affects cognitive development in children. Other international studies have suggested that elevated fluoride levels in pregnant women reduced the IQ of their children. A nightmare, of course, for expectant mothers who God knows already have too much to worry about.
Notably, however, there are no high quality studies that I've seen reported anywhere, suggesting a pattern of dangerously elevated fluoride in America's community drinking water. Quite the opposite, some cities like Buffalo have paused fluoridation only to see cavities surge and then added the fluoride right back. So what should a responsible 21st century public health communicator do with all this information, you might ask?
Today's guest has an answer. You just report it all. You tell people all the truth, even when it's complex. You trust people with nuance. You tell the full story or as much of it as you can. You talk to them as if they will do their own research, because in most cases, they will. Today's guest is Emily Auster.
She is a professor of economics at Brown University. She writes about pregnancy, parenting, and public health. And I think in today's environment, where health truths compete with health conspiracies, she is a model of public health communication. Today we talk about RFK's views on fluoride and vaccines, but more generally we talk about her approach to explaining science to the public. Because this is a new age of information.
where trust seems to be shifting from institutions like the FDA and CDC to individuals like RFK and Emily Oster. I'm Derek Thompson. This is Plain English.
Emily Oster, welcome to the podcast. Thanks for having me. You're a professor of economics. You're also widely known as a public health communicator, whether it's your books about pregnancy and parenting or your commentary about the pandemic and other public health issues. How do you think economics can make people smarter about public health?
The kind of economics that I'm most interested in is the kind where we analyze data and we try to understand what data is telling us. And the other really important piece of economics is decision making, weighing costs and benefits. And in my mind,
Those are both really key in how we talk about, communicate about public health and how we evaluate the public health advice we give, that there's a piece where we really want to understand what the data says about something. And then we want to communicate that out to people. And at the same time, we want to think about the cost and benefits of any of the advice that we're giving. So for me, economics is really core to all of this discussion.
These costs and benefits, the trade-offs, I think, that economics seems to bring to the fore is really important, right? Economics says, you know, you raise taxes, that's good now, you have more revenue, but there's a trade-off, it's not just more revenue, those taxes also discourage activity, trade-off here, trade-off here. And public health
is a set of interventions and interventions are rarely all good or all bad. So for example, during the pandemic, you were very influential and in some corners controversial for calling for the reopening of schools. Do you think this was a good example of people in the public health space failing to think deeply about trade-offs, costs, and benefits at play when it came to the policy of school lockdowns?
Yes, and no. So I think initially there was a lot of disagreement and misunderstanding around the data, so around how risky was it to open schools. And this is a place where I tried to positively contribute to the body of evidence, and where I think initially maybe reasonable people differed. I think ultimately it became pretty clear that schools were not a source of substantial spread.
As time went on and that became more clear, I think we did get into a place where the cost and benefit argument started to fracture a bit between how an economist would think about it and how public health was thinking about it. For my mind, there was a potential cost.
If everybody gets together, there could be some cases spread in schools, certainly some were, but there was an enormous benefit to opening schools, which is that it was the right thing for kids. And I think in the public health language, and this was an argument I heard a lot at the time, it was like much more what economists would call lexicographic, caring only about one thing, which was the amount of COVID and kind of never wanting to think about the
the risks on the other side, only thinking about the risk that was in front of you. And I just don't think that's a good way to make decisions.
And quickly, if I'm wrong, one of the contributions that you made to this debate is that you gathered a lot of data that people could use so that whether or not people are going to think lexicographically, if that's an advert that maybe I just made up for, if they were going to, or if they were going to think more, okay, this is about a classical economic weighing of costs and benefits. Well, the thing you have to do before you even get to that debate is have all the data on the table, right?
Yes, I believe that the thing that we needed in front of, to have in front of us was the data, so we could have a reasonable discussion about
about this question, but I will say that if you have the view that the only thing you're in 100% of your goal is not ever spreading COVID in this particular case, then actually you don't really need data because it wouldn't matter how costly it was for kids to be out of school because it's infinitely costly if even one person gets
COVID. My view on this was actually the benefits to opening school are quite real. And so therefore we do need to understand the size of the costs. And that's why it's so important to get data on how much COVID is spreading in schools, because we need to weigh the cost of benefits. If you're not interested in weighing the cost of benefits, maybe it's less interesting to have evidence.
And there's another theme that emerges, I think, from your work on pregnancy and parenting in particular. And that is, I think, this idea that information data is power. Yes, values will ultimately play a role in shaping the decisions that we make. But you and your work, you seem to say, you don't just say, I've done the research, here's a conclusion, made simple, we're moving on.
You seem to be more interested in saying, here's a study that says this, and here's a study that says that. And that approach assumes a lot of intellectual curiosity on the part of the audience. Why do you take that approach?
I think people are very intellectually curious. I mean, I spend a lot of time talking to parents and my sense in particular in the parenting and pregnancy space is that people are thinking about this all the time, that they are thinking about how to make the best choices for their kids and that they don't just want to be told what to do. They want to understand the choices they're making. In my mind, there are two reasons why we should
really be careful to convey to people the actual information to make these choices. One is that not everyone will make the same choice with the same information. And that's where values and preferences I think stack on top of, not separate from, but on top of knowing what the data says.
And the second thing is that people are going to be more confident and more engaged with their decisions if they know why they make them. If you tell someone, here's what you should do. And just trust me, do it because I'm an expert. Maybe they'll do it. But when someone comes to them and they say, well, why would you do that? I did this different thing. Then they're like, I don't really know why I did it actually in the first place. Whereas if they've thought about it,
Carefully, they have an easier time engaging with that. And actually, the place I often talk about this is in these parenting decisions that you're constantly getting judged for. If you choose to sleep train your kid. And you do that just because your pediatrician is like, sleep train your kid.
Then the first time someone comes in, they're like, did you know that ruins your kid and they're going to hate you forever? You're like, oh my God, I didn't even think about that. I just did this thing this person told me. Whereas if you've thought about, here's what the evidence says, here's the right choice for my family. Then when someone comes at you with that, it's like, thanks very much. We welcome comments, but I've made my choice.
I think it's really interesting to juxtapose two different models of public health communication, which really are two different models of being a public intellectual. One model is to tell people what to do and tell people what not to do and don't really explain why.
And another model is to say, I'm going to try to give you as much evidence and as many citations as I possibly can so that when I give you the final recommendation, you will at least hear that recommendation in the context of understanding that I'm trying to give you nuance. And the reason that I juxtapose those two approaches is that I think you're a model of nuance. And I think that public health agencies in the US, maybe around the world,
have instead been a model of telling people what to do and what not to do and not regularly explaining why or why some people might find contributing evidence. And the reason that that model has started to really concern me is that it's a great model for a world where no one does their research.
We're the CDC and the FDA are God, and it's a top-down world. But we live in a bottom-up world where people are constantly Googling and we're going to chat to BT, you're listening to podcasts or talking to their friends. And in this bottom-up world, I think public health indicators,
need to respect that everybody is going to do their own research. That's the first thing they do when they have a public health anxiety. They want to exercise by tapping away at their phones. So what I want to do now is to model the officer approach for two public health items that are very much in the news. First, fluoride and second, measles vaccines in particular. This is an RFK special for this particular episode.
So Robert F. Kennedy Jr. said this month the new Trump administration is going to recommend removing fluoride from public water supplies.
And this is stimulated a really energetic conversation around fluoride. I am sure that we now have more people reading fluoride papers about the levels in rural India than any period in human history. And as I said in my open, I don't think fluoride is simple. How would you encourage public health figures to discuss the benefits and risks of fluoride in public drinking water?
So I think the first thing is we should be explaining to people the benefits. So much of this discussion about fluoride has just been like, it's good for you and it's fine. So let's start with the benefits. I would like them to explain why we do fluoride, why we put fluoride in the water. It is because of tooth decay and there is evidence from say Israel where they took the water, the fluoride out of the water and there was more tooth decay in kids. We know there's a lot of evidence to suggest that fluoride protects teeth.
And I think we could get to a point that's actually not that complicated that evidence. It's not that nuanced. I think you get to the point where people would understand, okay, there's a benefit. It's to teeth. And then I want them to talk about the risks. And rather than saying all amounts of fluoride are totally fine and fluoride just isn't something to worry about.
I think we need to explain to people that it is true that at high levels, levels that we do see in water supplies, largely not in the US, but places with a lot of high, naturally occurring fluoride, we do see some evidence of impacts on development, on neurodevelopment for pregnant women who are consuming this very high fluoridated water.
but that we don't see those effects when we look at studies that have fluoride levels that are what we have in municipal water supplies. If you kind of put that together, there's a sense in which taking fluoride out of the water in the US would not have any significant benefits because it is not at the level where it's dangerous and it would have these costs.
But I also think that it tells people it's not crazy to ask what's the water, what's the floor and the water supply. And the CDC could say, look, you can look on this website. There's a website that will tell you what's the floor level in your water. And we agree on what is the level that is too high. You can see where you are.
So there's a sense it's the benefits, it's explaining the context, and then it's giving people something that they can do to reassure themselves about their particular situation.
And the dose, of course, is the thing that matters. There is a number, there's a parts per million number that marks the difference between the yellow and red zone, right? This is more or less okay, and this is dangerous. And if people know that number, then they can compare that to the number reported by the Romanists for water supply. I think that what you said is actually as notable as what you didn't say. You didn't say
what I heard so often after the RFK announcement. Oh, well, everyone say goodbye to your teeth, right? Florida levels in the US are safe. End of story. This is nonsense. RFK is a nut move on with your life. And the reason that I think
That kind of mockery is it's tempting, but it's dangerous is that people are going to look into themselves, right? It's the DIY research era. Like people are going to hear the media say RFK is conspiratorial nut. And then they're going to say, wait, what about that 2019 study from Canada that raises concerns about explosion pregnancy? I heard Israel
Israel decided to end water fluoridation in 2014. Wait, why aren't they telling us? I'm finding all of these holes in the RFK as in that fluoride story. I mean, maybe I wonder how you think about like combating this or how you even think, what name you would even give to this phenomenon I'm describing, which is essentially like this temptation of oversimplification to ironically feed conspiratorial thinking
because it increases the target zone for how easy it is for people to find holes in your story, right? Do you think about this as a public communicator?
totally. I mean, I think that when that we have to accept that people are going to come across claims that disagree with you. And I think that's in some sense the core like when you say people are doing their own research and they go look for something like this, it's going to be the internet places that they're going even people that they that they trust are going to come at them with things which
or counter to what you suggested or at least problematize. And if you haven't given them a place, if the communication hasn't given them a place to put those, a way to understand those in some context of what we said, then it's just like, well, you're obviously wrong. Like you told me not to think about this, but this paper is in like a reputable journal, you know, and this, you know, this
number this country is like a real country that we've heard of that's doing something different. So you've told me only a tin hat loony would do this, but also that's obviously wrong. And there and I'm not really listening to you anymore.
And I want to be clear, I don't think that everyone doing their own research at home is a brown PhD in economics or public health. I'm not saying that all research that is done at home is pulling up good studies. But I do think that very often what I'll see in the emergence of a conspiracy theory is that there's this tiny little foothold
that the conspiracy theorists can grab onto, that's real, that says the media hasn't quite given enough attention to this, and that ends up like cracking open a space through which doubt flows. You're making a face that's made me disagree with that determination. No, I don't disagree with that, but I think there's another piece of it for me, which is that there are a lot of people in the world, and there are some people who no matter what public health
officials say, no matter how much they explain, no matter how much nuance you provide, they're just not going to trust you. And they just they've decided that like the CDC is not to be trusted. And there's really nothing that public health communication can do to kind of fix that particular kind of lost trust. What I worry about, I think there's a much larger set of people who are
would like to do the right thing but are not interested in just being mansplained by the about what they should do and who are sort of
curious, open, interested in facts. And that's the people that you lose. I think that group is big. And so I worry if we sort of come at some of these conspiracies in this very, sort of forget about it, that's nuts kind of way, that that much larger group is going to be lost.
There's also potentially a boy who cries wolf problem where if public health authorities pretend that many complicated ideas are actually simple, when they're finally greeted with a truly simple thing to explain, the public doesn't trust their representation of simplicity, which is an interesting on-ramp for me to ask you about another RFK claim, which is we're sticking with the arcade greatest hits here, vaccines.
RFK is perhaps America's most famous vaccine skeptic. His vaccine skepticism is shape shifty. It takes many forms, but one form it takes that he's questioned the measles vaccine, suggested that it and other infant vaccines might contribute to the large increase that we've seen in diagnosed autism. What is the auster public health communications approach to the measles vaccine?
There's an enormous amount. I think, again, we go with benefits and risks. If we start with, there is an enormous amount of evidence that the measles vaccine, which has been around for many decades, prevents people from dying. Measles is really
really contagious. So it can live on surfaces for a very long time. That's not true of something like COVID. So if a kid with measles comes to the doctor's office and touches stuff and then your kid touches that even like five or 10 hours later, they can get measles. This is just like a really contagious disease. That's why all these people got it in Disneyland a number of years ago. And it kills people. It kills people every single year. And the vaccine
is incredibly effective. So one dose of the MMR vaccine is 95% effective. Two doses, 99% effective. It's a sterilizing vaccine. Your kid has the vaccine. They're not going to get measles or not going to spread measles. So this is a place where the like benefits are really crystal clear. And where the discussion of risks has been so widely debunked. So there
is decades of evidence of the measles vaccine safety and this particular claim about vaccines and autism, which you will sometimes hear people say, well, we don't really know. We need to do more research. There are studies with hundreds of thousands of people that compare kids who are vaccinated, kids who are out who see, and they see nothing.
on the link between vaccines and autism. And if you look then at like, why would you think that? What makes you think the vaccines cause autism in the first place? You get to a paper, one paper in the Lancet from a number of years ago.
It turned out the results in that paper were made up. So the person had basically engaged in a bunch of unethical data manipulation behavior because he was motivated to try to get money from some lawsuits. The guy had his medical license revoked. The paper was retracted. There's a huge amount of evidence that there's nothing that would have made you think this in the first place. If you did think it, there's a lot of evidence that it's not true.
the measles vaccine is a really good thing.
I agree. I also looking at the data see that the number of infants not vaccinated for measles seems to be growing. So while overwhelmingly, more than 90%, I believe still over 95% of infants in America are inoculated for measles, the share that are not vaccinated is rising and that increases quite stark and quite recent. How do you think about combating
a misunderstanding. I don't know if I want to call it a conspiracy theory, a misunderstanding, a fear, a fear that is ungrounded in empirical literature is the best way to combat that fear
to, on the positive side, overwhelm them with the evidence that the vaccines are good. Here's the data. Here's the data. Or do you think about appealing to people, maybe emotionally first, to say, I know that you're scared for the health of your child. And there's a lot of uncertainties when it comes to infants and a lot of uncertainties when it comes to infant development and autism itself.
But that provides a little opening, that emotional connection provides a little opening for the conversation. Do you have a theory for how to talk to folks that are resistant to the case that you just made?
Not really. You know, I have a little bit of research actually around pertussis where when there are local pertussis outbreaks, people tend to vaccinate their kids more in the following years, suggesting that there's something about the sort of recency of kind of, oh, actually my kid could get this. And I think that is a big issue with the measles vaccine in particular, that people think their kids aren't going to get measles because most people don't have measles. That's because of the measles vaccine. But anyway,
So I mean, I do think meeting people where they are, acknowledging people's fears, giving them an opportunity to ask questions. I mean, these are all kind of standard pediatrician approaches to this. But as a public health messaging, I think it's really hard when people are afraid for their kids. And I think the other piece of it that's tricky is
you know, we do a lot of vaccines. And when we start talking about vaccine skepticism, skepticism about some vaccines sort of filters over to other vaccines. So one of the, I think part of what has happened with the measles vaccine is actually that people got nervous about the COVID vaccine. And then they kind of were like, oh, maybe all vaccines are problematic. And we've had trouble separating those, that trouble separating those.
Yeah. And there's something that I've seen at least among some people in my larger sort of work, not workspace, but just sort of communication space is that it's not even skepticism about the COVID vaccine at first. It's it's skepticism at the mandates.
The policy that's layered on top of the vaccines, which then becomes a skepticism to vaccines, which then translates to measles. People are complex and the way that they link various policies and health outcomes can sometimes be a little bit dizzying.
And I don't want to say, I think this is really hard. I have sort of a particular view about how we should be more nuanced and so on, but I'm the first to acknowledge. It's hard to convince people of things. It's hard to get people to understand a lot of these questions.
And on the topic of persuasion, I do have a final question that's maybe a little bit orthogonal to the discussion of information and data we've been having. And it's about this quality of authenticity. The truth is, I'm not even sure I know what authenticity is, but I do think that there's something about
Today's information ecosystem that rewards people who have the ability to speak naturally about their ideas in a way that seems authentic rather than stuffy and institutional. You're an economist, but you're also a straight-to-camera public intellectual. You're an online personality.
sort of layered on top of the substance of everything that they were talking about. I guess I'm interested in your approach, your theory of style, right, which is fundamentally what authenticity is about. Do you think about the style of approach as a public health communicator? Do you think about authenticity? I think about trust. I think about trust much more than I think about authenticity. I think that the
thing that people are looking for is someone who they feel like, yeah, is authentic, but they feel like they understand them, and here's what their issues are, and that they trust that person to tell them the truth, and they trust that person to come back to them and correct themselves if they think if something new comes up. And that trust is really hard.
to develop. And I think it's easier in some ways to develop as a person than as an institution. And so a lot of, you know, that's part of what I think that's part of why some people, not everyone, but some people listen to me is that I think I have developed that trust over time. And yeah, some of that is by kind of
being a person who people think of as like their friend because my face is in their Instagram feed all the time. But some, but some of it is because of a sort of willingness to come back and say, you know, I, well, I told you, I'm telling you this now, when I learned or I'm very sure I'll tell you something, you know, I'll tell you what we learned later.
I love that. I really am obsessed with this question of how do we build a model of elites that works for this sort of bottom-up era that I described. And I do think it's something like this. I think the power of institutions is declining and the power of individuals is growing. And this old model of talk to people like you're the pope, that doesn't work anymore. Talk to people like your, their friend,
talk to people as if you respect their intellectual curiosity, talk to them as if they do their own research because they probably do. That does seem like the model going forward. And yeah, I'd be remiss to not tell you before we leave. I'm an enormous fan of your work. I did not tell my wife that I was having on the podcast, but I'll know that she listened to this episode because I will hear squeals of happiness from downstairs when she makes her coffee. Emily Austro, thank you so, so much for joining me.
Thank you so much for having me.
