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Wisdom teeth

Can't find an NHS dentist? Don't despair, it may soon be easier than you think. Private dentists, it

patient: How much to have this tooth pulled?

dentist: £180.

patient: £180 for just a few minutes' work?

dentist: I can extract it very slowly if you like.

Jokes about going to the dentist used to be about the pain of tooth extraction, but in 21st-century Britain they're more likely to be about the pain to our wallets. An estimated one in five people in Britain is deterred from going to the dentist because of the cost; eight million of us have refused a course of treatment because it was too expensive. The seemingly inexorable decline of affordable National Health Service dentistry, and the growth of private practice (the most expensive in Europe), have certainly hurt our pockets.

But could it be that, after years of decline, the tide is turning? You wouldn't think so, judging by newspaper headlines reacting to newly published figures showing that more than one million patients in England have lost access to free dentistry since the introduction of the government's new NHS dental contract in April 2006.

The figures, according to Susie Sanderson, chair of the British Dental Association's executive board, were "further evidence of the persisting problems with the 2006 NHS dental reforms". But look a little closer. There were 655 more dentists doing NHS work in 2007-2008 than there were in the previous year, an increase of 3.2 per cent. NHS dental treatments also rose last year by nearly one million, to 36 million. And while Sanderson and her organisation attack the government for introducing a "crude, target-driven system", there is growing evidence that the BDA's members don't share this disdain.

The government's chief dental officer, Dr Barry Cockcroft, cites the example of Cornwall Primary Care Trust, which, when asking for tenders for four new NHS practices, received more than 80 applicants. "When primary care trusts ask for tenders for new services, dentists are falling over themselves to bid for them," he says.

It seems that some dentists are deciding that the NHS contracts, which provide dentists with a guaranteed salary of roughly £80,000 a year for three years and a 5 per cent reduction in their workload, are not such a bad deal after all. The economic slowdown could also be helping the return of dentists to the fold. Dr Mark Harris was among 2,000 to resign from the NHS prior to the introduction of the new contracts. Now he has applied to Devon Primary Care Trust to provide NHS care for adults at his Totnes practice. "I think when there isn't much money about, the best arrangement is a mixture of NHS and private work," he admits.

The dramatic decline of NHS dentistry can be traced to the decision of John Major's government to cut the fees payable to NHS dentists in the early 1990s - something to remember during the current wave of nostalgia for the former Conservative prime minister. The decision led to an exodus of dentists from the NHS into private practice. In 1990, before the cuts, only 5 per cent of dentists' earnings came from the private sector; today it accounts for more than half. And as private practice has grown, so the overriding commitment of the dental profession and its governing body to the NHS has weakened.

Throughout the 1990s, one could not question the fervency of the BDA's support for the NHS, but today the emphasis appears to have changed. In her speech to the BDA's May conference in Manchester, Sanderson enthused over the merits of private dentistry. "For many [here], private dentistry has given you the opportunity to work the way you want to, without any sense of compromise," she said. "It has given you freedom." She went on to express scepticism as to whether the NHS could ever meet the "expectations of patients and users".

It is hard not to detect a certain air of defeatism - Sanderson claimed last year that the future of NHS dentistry was "increasingly fragile" - and the BDA's disenchantment with NHS reforms has been seized upon by those opposed to the very idea of NHS care. In its own words, Nurses for Reform, a pro-privatisation pressure group, wants "to see NHS dentistry totally collapse".

"We want customers to be angry at how little they are getting for their taxation, and we want them to defect to a burgeoning private dental sector," writes the group's director, Dr Helen Evans, whose anti-NHS polemic Who Cares for the NHS? was published by the Institute of Economic Affairs earlier this year. "Already, in many [politicians'] minds, the NHS is dead," Evans claimed, having previously described the service as a "Stalinist embarrassment".

Open wide (your wallet)

The favoured gambit of the private dentistry lobby is to make NHS dentistry seem like a lost cause and the complete privatisation of dental care inevitable. If this all sounds familiar, then cast your mind back to the early 1990s when the same "the system's so broke it can't be mended" arguments were made by free-market think tanks lobbying for British Rail's denationalisation.

But nothing is inevitable until it happens - and there is nothing inevitable about the demise of NHS dentistry. The return of dentists to the NHS fold is a fact that fits neither Nurses for Reform nor the BDA's doom-laden prognosis. The increased number of places for training NHS dentists also gives grounds for optimism, as does the government's decision to increase funding for NHS dentistry by 11 per cent next year. And all three main parties remain formally committed to increasing provision.

In the final analysis, the future of NHS dentistry will be guaranteed only if voters raise their voices to urge that more resources be spent on improving access to the service. And the importance of expanding NHS dentistry cannot be overestimated if we care about both our teeth and our wallets: the decline in NHS provision over the past two decades has led to a major deterioration in the nation's oral health. In some parts of the country, tooth decay rose by 50 per cent between 1993 and 2003; mouth cancer has risen by around 25 per cent, with more than 4,700 new cases being diagnosed in the UK each year. The replacement of NHS dentistry with a wholly private system, as free-market pressure groups desire, would prove as catastrophic as the privatisation of the railways has been.

If we want to know what a Britain without any NHS dentistry would be like, we need only look to the United States, where more than 100 million people are without dental insurance and 27 per cent of children and 29 per cent of adults have cavities that go untreated. Last year, a child in Mississippi and another in Maryland died from infections caused by decayed teeth.

When the NHS was formed, exactly 60 years ago this summer, it promised to provide "all medical, dental and nursing care". Free NHS dental care may only have lasted until 1951 - the first year that NHS charges were introduced - but for more than 40 years the NHS provided Britons with access to good-quality and affordable dental treatment. The question that needs to be asked of the free-market ideologues who are already gleefully writing its epitaph is a simple one: if Britain could afford - and operate - a comprehensive NHS dental system in the austerity years of the 1940s and the recession-hit 1970s, why on earth can't we do the same today?

We'll know for sure that we've stopped the rot when dentist jokes are once again about extracting teeth, and not extracting money.

The roots of modern

dentistry

    The ancient Sumerians believed that tooth decay was caused by the "tooth worm". As did Homer and Guy de Chauliac, 14th-century inventor of the "dental pelican", which pulled teeth out sideways

    In Elizabethan times, teeth were cleaned with powdered pumice stone, brick and coral, removing the enamel in the process. Placing turnip parings behind the ear was said to cure bad breath. A bad tooth could be replaced with one from the mouth of a pauper, a dog, a sheep, a baboon . . . or a dead soldier

    Before the 18th century, dentistry was the preserve of barbers, blacksmiths - and others even less capable. Unsurprisingly, extraction could be fatal, as practitioners dislocated teeth from their sockets and pulled out the roots

    As well as hippopotamus bones, one of the first materials used for false teeth was celluloid - which proved extremely flammable

    In Britain in 1968, 79 per cent of the elderly had no natural teeth, partly explained by the trend, in the early years of the NHS, of replacing all your teeth with a nice new set of dentures

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Why the elites always rule

Since an Italian sociologist coined the word “elite” in 1902, it has become a term of abuse. But history is the story of one elite replacing another – as the votes for Trump and Brexit have shown.

Donald Trump’s successful presidential campaign was based on the rejection of the “establishment”. Theresa May condemned the rootless “international elites” in her leader’s speech at last October’s Conservative party conference. On the European continent, increasingly popular right-wing parties such as Marine Le Pen’s Front National and the German Alternative für Deutschland, as well as Poland’s ruling Law and Justice party, delight in denouncing the “Eurocratic” elites. But where does the term “elite” come from, and what does it mean?

It was Vilfredo Pareto who, in 1902, gave the term the meaning that it has today. We mostly think of Pareto as the economist who came up with ideas such as “Pareto efficiency” and the “Pareto principle”. The latter – sometimes known as the “power law”, or the “80/20 rule” – stipulates that 80 per cent of the land always ends up belonging to 20 per cent of the population. Pareto deduced this by studying land distribution in Italy at the turn of the 20th century. He also found that 20 per cent of the pea pods in his garden produced 80 per cent of the peas. Pareto, however, was not only an economist. In later life, he turned his hand to sociology, and it was in this field that he developed his theory of the “circulation of elites”.

The term élite, used in its current socio­logical sense, first appeared in his 1902 book Les systèmes socialistes (“socialist systems”). Its aim was to analyse Marxism as a new form of “secular” religion. And it was the French word élite that he used: naturally, one might say, for a book written in French. Pareto, who was bilingual, wrote in French and Italian. He was born in Paris in 1848 to a French mother and an Italian father; his father was a Genoese marquis who had accompanied the political activist Giuseppe Mazzini into exile. In honour of the revolution that was taking place in Germany at the time, Pareto was at first named Fritz Wilfried. This was latinised into Vilfredo Federico on the family’s return to Italy in 1858.

When Pareto wrote his masterpiece – the 3,000-page Trattato di sociologia ­generale (“treatise on general sociology”) – in 1916, he retained the French word élite even though the work was in Italian. Previously, he had used “aristocracy”, but that didn’t seem to fit the democratic regime that had come into existence after Italian unification. Nor did he want to use his rival Gaetano Mosca’s term “ruling class”; the two had bitter arguments about who first came up with the idea of a ruling minority.

Pareto wanted to capture the idea that a minority will always rule without recourse to outdated notions of heredity or Marxist concepts of class. So he settled on élite, an old French word that has its origins in the Latin eligere, meaning “to select” (the best).

In the Trattato, he offered his definition of an elite. His idea was to rank everyone on a scale of one to ten and that those with the highest marks in their field would be considered the elite. Pareto was willing to judge lawyers, politicians, swindlers, courtesans or chess players. This ranking was to be morally neutral: beyond “good and evil”, to use the language of the time. So one could identify the best thief, whether that was considered a worthy profession or not.

Napoleon was his prime example: whether he was a good or a bad man was irrelevant, as were the policies he might have pursued. Napoleon had undeniable political qualities that, according to Pareto, marked him out as one of the elite. Napoleon is important
because Pareto made a distinction within the elite – everyone with the highest indices within their branch of activity was a member of an elite – separating out the governing from the non-governing elite. The former was what interested him most.

This is not to suggest that the non-governing elite and the non-elite were of no interest to him, but they had a specific and limited role to play, which was the replenishment of the governing elite. For Pareto, this group was the key to understanding society as a whole – for whatever values this elite incarnated would be reflected in society. But he believed that there was an inevitable “physiological” law that stipulated the continuous decline of the elite, thereby making way for a new elite. As he put it in one of his most memorable phrases, “History is the graveyard of elites.”

***

Pareto’s thesis was that elites always rule. There is always the domination of the minority over the majority. And history is just the story of one elite replacing another. This is what he called the “circulation of elites”. When the current elite starts to decline, it is challenged and makes way for another. Pareto thought that this came about in two ways: either through assimilation, the new elite merging with elements of the old, or through revolution, the new elite wiping out the old. He used the metaphor of a river to make his point. Most of the time, the river flows continuously, smoothly incorporating its tributaries, but sometimes, after a storm, it floods and breaks its banks.

Drawing on his Italian predecessor Machiavelli, Pareto identified two types of elite rulers. The first, whom he called the “foxes”, are those who dominate mainly through combinazioni (“combination”): deceit, cunning, manipulation and co-optation. Their rule is characterised by decentralisation, plurality and scepticism, and they are uneasy with the use of force. “Lions”, on the other hand, are more conservative. They emphasise unity, homogeneity, established ways, the established faith, and rule through small, centralised and hierarchical bureaucracies, and they are far more at ease with the use of force than the devious foxes. History is the slow swing of the pendulum from one type of elite to the other, from foxes to lions and back again.

The relevance of Pareto’s theories to the world today is clear. After a period of foxes in power, the lions are back with renewed vigour. Donald Trump, as his behaviour during the US presidential campaign confirmed, is perfectly at ease with the use of intimidation and violence. He claimed that he wants to have a wall built between the United States and Mexico. His mooted economic policies are largely based on protectionism and tariffs. Regardless of his dubious personal ethics – a classic separation between the elite and the people – he stands for the traditional (white) American way of life and religion.

This is in stark contrast to the Obama administration and the Cameron government, both of which, compared to what has come since the votes for Trump and Brexit, were relatively open and liberal. Pareto’s schema goes beyond the left/right divide; the whole point of his Systèmes socialistes was to demonstrate that Marxism, as a secular religion, signalled a return to faith, and thus the return of the lions in politics.

In today’s context, the foxes are the forces of globalisation and liberalism – in the positive sense of developing an open, inter­connected and tolerant world; and in the negative sense of neoliberalism and the dehumanising extension of an economic calculus to all aspects of human life. The lions represent the reaction, centring themselves in the community, to which they may be more attentive, but bringing increased xenophobia, intolerance and conservatism. For Pareto, the lions and foxes are two different types of rule, both with strengths and weaknesses. Yet the elite is always composed of the two elements. The question is: which one dominates at any given time?

What we know of Theresa May’s government suggests that she runs a tight ship. She has a close – and closed – group of confidants, and she keeps a firm grip on the people under her. She is willing to dispense with parliament in her negotiation of Brexit, deeming it within the royal prerogative. Nobody yet knows her plan.

The European Union is a quintessentially foxlike project, based on negotiation, compromise and combination. Its rejection is a victory of the lions over the foxes. The lions are gaining prominence across the Western world, not just in Trumpland and Brexit Britain. Far-right movements have risen by rejecting the EU. It should come as no surprise that many of these movements (including Trump in the US) admire Vladimir Putin, at least for his strongman style.

Asia hasn’t been spared this movement, either. After years of tentative openness in China, at least with the economy, Xi Jinping has declared himself the “core” leader, in the mould of the previous strongmen Mao Zedong and Deng Xiaoping. Japan’s prime minister, Shinzo Abe, has also hardened his stance, and he was the first world leader to meet with President-Elect Donald Trump. Narendra Modi in India and Rodrigo Duterte in the Philippines are in the same mould, the latter coming to power on the back of promising to kill criminals and drug dealers. After the failed coup against him in July, Recep Tayyip Erdogan has also been cracking down on Turkey.

***


In Les systèmes socialistes, Pareto elaborated on how a new elite replaces the old. A, the old elite, would be challenged by B, the new, in alliance with C, the people. B would win the support of C by making promises that, once in power, it wouldn’t keep. If that sounds like the behaviour of most politicians, that is because it probably is. But what Pareto was pointing out was how, in its struggle for power, the new elite politicised groups that were not political before.

What we know of Trump supporters and Brexiteers is that many feel disenfranchised: the turnout in the EU referendum could not have been greater than in the 2015 general election otherwise, and significant numbers of those who voted for Trump had never voted before. There is no reason to think that they, too, won’t be betrayed by the new leaders they helped to bring to power.

In the last years of his life, Pareto offered a commentary on Italy in the 1920s. He denounced the state’s inability to enforce its decisions and the way that Italians spent their time flaunting their ability to break the law and get away with it. He coined the phrase “demagogic plutocracy” to characterise the period, in which the rich ruled behind a façade of democratic politics. He thought this particularly insidious for two reasons: those in power were more interested in siphoning off wealth for their personal ends than encouraging the production of new wealth, and consequently undermined national prosperity (remember Pareto’s training as an economist); and, as the demagogic elites govern through deceit and cunning, they are able to mask their rule for longer periods.

Much has been made of Trump’s “populism”, but the term “demagogic plutocrat” seems particularly apt for him, too: he is a wealthy man who will advance the interests of his small clique to the detriment of the well-being of the nation, all behind the smokescreen of democratic politics.

There are other ways in which Pareto can help us understand our predicament. After all, he coined the 80/20 rule, of which we hear an intensified echo in the idea of “the One Per Cent”. Trump is a fully paid-up member of the One Per Cent, a group that he claims to be defending the 99 Per Cent from (or, perhaps, he is an unpaid-up member, given that what unites the One Per Cent is its reluctance to pay taxes). When we perceive the natural inequality of the distribution of resources as expressed through Pareto’s “power law”, we are intellectually empowered to try to do something about it.

Those writings on 1920s Italy landed Pareto in trouble, as his theory of the circulation of elites predicted that a “demagogic plutocracy”, dominated by foxes, would necessarily make way for a “military plutocracy”, this time led by lions willing to restore the power of the state. In this, he was often considered a defender of Mussolini, and Il Duce certainly tried to make the best of that possibility by making Pareto a senator. Yet there is a difference between prediction and endorsement, and Pareto, who died in 1923, had already been living as a recluse in Céligny in Switzerland for some time – earning him the nickname “the hermit of Céligny” – with only his cats for company, far removed from day-to-day Italian politics. He remained a liberal to his death, content to stay above the fray.

Like all good liberals, Pareto admired Britain above all. As an economist, he had vehemently defended its system of free trade in the face of outraged opposition in Italy. He also advocated British pluralism and tolerance. Liberalism is important here: in proposing to set up new trade barriers and restrict freedom of movement, exacerbated by their more or less blatant xenophobia, Trump and Brexit challenge the values at the heart of the liberal world.

***


What was crucial for Pareto was that new elites would rise and challenge the old. It was through the “circulation of elites” that history moved. Yet the fear today is that history has come to a standstill, that elites have ­become fossilised. Electors are fed up with choosing between the same old candidates, who seem to be proposing the same old thing. No wonder people are willing to try something new.

This fear of the immobility of elites has been expressed before. In 1956, the American sociologist C Wright Mills published The Power Elite. The book has not been out of print since. It is thanks to him that the term was anglicised and took on the pejorative sense it has today. For Mills, Cold War America had come to be dominated by a unified political, commercial and military elite. With the 20th century came the growth of nationwide US corporations, replacing the older, more self-sufficient farmers of the 19th century.

This made it increasingly difficult to ­distinguish between the interests of large US companies and those of the nation as a whole. “What’s good for General Motors,” as the phrase went, “is good for America.” As a result, political and commercial interests were becoming ever more intertwined. One had only to add the Cold War to the mix to see how the military would join such a nexus.

Mills theorised what President Dwight D Eisenhower denounced in his January 1961 farewell speech as the “military-industrial complex” (Eisenhower had wanted to add the word “congressional”, but that was thought to be too risky and was struck out of the speech). For Mills, the circulation of elites – a new elite rising to challenge the old – had come to an end. If there was any circulation at all, it was the ease with which this new power elite moved from one part of the elite to the other: the “revolving door”.

The Cold War is over but there is a similar sense of immobility at present concerning the political elite. Must one be the child or wife of a past US president to run for that office? After Hillary Clinton, will Chelsea run, too? Must one have gone to Eton, or at least Oxford or Cambridge, to reach the cabinet? In France is it Sciences Po and Éna?

The vote for Brexit, Trump and the rise of the far right are, beyond doubt, reactions to this sentiment. And they bear out Pareto’s theses: the new elites have aligned themselves with the people to challenge the old elites. The lions are challenging the foxes. Needless to say, the lions, too, are prototypically elites. Trump is a plutocrat. Boris Johnson, the co-leader of the Leave campaign, is as “establishment” as they come (he is an Old Etonian and an Oxford graduate). Nigel Farage is a public-school-educated, multimillionaire ex-stockbroker. Marine Le Pen is the daughter of Jean-Marie Le Pen. Putin is ex-KGB.

Pareto placed his hopes for the continuing circulation of elites in technological, economic and social developments. He believed that these transformations would give rise to new elites that would challenge the old political ruling class.

We are now living through one of the biggest ever technological revolutions, brought about by the internet. Some have argued that social media tipped the vote in favour of Brexit. Arron Banks’s Leave.EU website relentlessly targeted disgruntled blue-collar workers through social media, using simple, sometimes grotesque anti-immigration messages (as a recent profile of Banks in the New Statesman made clear) that mimicked the strategies of the US hard right.

Trump’s most vocal supporters include the conspiracy theorist Alex Jones, who has found the internet a valuable tool for propagating his ideas. In Poland, Jarosław Kaczynski, the leader of the Law and Justice party, claims that the Russian plane crash in 2010 that killed his twin brother (then the country’s president) was a political assassination, and has accused the Polish prime minister of the time, Donald Tusk, now the president of the European Council, of being “at least morally” responsible. (The official explanation is that the poorly trained pilots crashed the plane in heavy fog.)

It need not be like this. Silicon Valley is a world unto itself, but when some of its members – a new technological elite – start to play a more active role in politics, that might become a catalyst for change. In the UK, it has been the legal, financial and technological sectors that so far have led the pushback against a “hard” Brexit. And we should not forget how the social movements that grew out of Occupy have already been changing the nature of politics in many southern European countries.

The pendulum is swinging back to the lions. In some respects, this might be welcome, because globalisation has left too many behind and they need to be helped. However, Pareto’s lesson was one of moderation. Both lions and foxes have their strengths and weaknesses, and political elites are a combination of the two, with one element dominating temporarily. Pareto, as he did in Italy in the 1920s, would have predicted a return of the lions. But as a liberal, he would have cautioned against xenophobia, protectionism and violence.

If the lions can serve as correctives to the excesses of globalisation, their return is salutary. Yet the circulation of elites is a process more often of amalgamation than replacement. The challenge to liberal politics is to articulate a balance between the values of an open, welcoming society and of one that takes care of its most vulnerable members. Now, as ever, the task is to find the balance between the lions and the foxes. l

Hugo Drochon is the author of “Nietzsche’s Great Politics” (Princeton University Press)

This article first appeared in the 12 January 2017 issue of the New Statesman, Putin's revenge