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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

Getty
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Inside the minds of the Isis murderers

As pressure on the terror group who claimed responsiblity for the Manchester attack intensifies, the threat to Britain will only become more acute.

The police and security services had consistently warned that a significant terrorist attack in Britain was inevitable. Yet no warning could have prepared us for the horror of the suicide attack on the Manchester Arena on Monday night. Twenty-two people were killed and at least 60 were wounded as they were leaving a concert by Ariana Grande in what was the most deadly attack in Britain since the London bombings of 7 July 2005, in which 56 people died.

Like the London bombers, the Manchester suicide attacker, Salman Ramadan Abedi, was British. He was 22, lived in Manchester and studied business management at Salford University before dropping out. He worshipped at Didsbury Mosque. The son of Libyans, Abedi is said to have returned recently from a visit to the North African country, where Islamic State has a foothold.

Ariana Grande is a former children’s TV star who made her name on channels such as Nickelodeon. Her fan base is overwhelmingly young and female, and many of those killed or wounded were children, including Saffie Rose Roussos, an eight-year-old girl from Leyland, Lancashire.

Islamic State inevitably claimed responsibility for the massacre, dismissing the victims as “crusaders”, “polytheists” and “worshippers of the cross”. This is not the first time Islamist terrorists have targeted children.

A Chechen jihadist group calling itself ­Riyad-us Saliheen (meaning “Gardens of the Righteous”) took more than 1,100 hostages, including 777 children, in a school siege in Beslan, Russia, in September 2004. In the event, more than 330 were massacred, including 186 children. Gunmen from the Pakistani Taliban also stormed a school in 2014, killing 148.

For terrorist actors, these are neither whimsical nor irrational acts. Contemporary jihadist movements have curated a broad and expansive intellectual ecosystem that rationalises and directs their actions. What they want is to create an asymmetry of fear by employing indiscriminate barbarism to intimidate and subdue their opponents into submission.

We have grown accustomed to a wave of terrorist attacks being carried out in the name of the self-styled Islamic State ever since the group’s official spokesman Abu Muhammad al-Adnani began prioritising them in 2014. (He was killed in an American air strike on Aleppo province in Syria in August last year.)

The US-led coalition against Islamic State has weakened the terror group in its former strongholds of Mosul in Iraq and Raqqa in Syria. In response, IS has been forced to concentrate more on what it calls “external operations” – by which it means inspiring its sympathisers and operatives to carry out attacks on Western countries. Indeed, al-Adnani encouraged the group’s supporters not to migrate towards IS-held territory but rather to focus their efforts on attacks in their home countries.

“The tiniest action you do in the heart of their [Western] land is dearer to us than the biggest action by us,” he said in an audio statement released last year. “There are no innocents in the heart of the lands of the crusaders.”

Islamic State refers to its strategy as “just terror”. Its framing places culpability for attacks on Western states on these nations themselves by claiming that IS actions are a response to aggression or assault. That much has been outlined in the group’s literature. “When will the crusaders end their hostilities towards Islam and the Muslims? . . . When will they recognise that the solution to their pathetic turmoil is right before their blinded eyes?” the militants ask in the IS magazine Dabiq. “Until then, the just terror will continue to strike them to the core of their deadened hearts.”

IS offered a rationale of this sort as justification for its bombing of a Russian commercial aircraft – Metrojet Flight 9268, travelling from Sharm el-Sheikh in Egypt to St Petersburg. That attack in October 2015 killed 224. Similar reasoning was offered for the attacks in Paris the following month in which 137 people were killed, in a series of co-ordinated, commando-style gun and bomb outrages across the city.

“Revenge was exacted upon those who felt safe,” IS declared in Dabiq. “Let the world know that we are living today in a new era. Whoever was heedless must now be alert. Whoever was sleeping must now awaken . . . The [caliphate] will take revenge for any aggression against its religion and people, sooner rather than later. Let the ­arrogant know that the skies and the lands are Allah’s.”

***

Through my academic research at King’s College London, I have ­interviewed scores of Westerners who became foreign fighters in Syria and Iraq to quiz them about their motives. Last year, one man from High Wycombe who had joined IS told me that it wanted to attack British targets in response to the vote in the House of Commons to extend British air strikes against IS targets to include sites in Syria (the British had only been targeting the group in Iraq until that point). “Do they [the British government] expect us to sit back and do nothing? ­Idiots,” he said.

In this respect, IS frames its attacks as acts of “revenge” and predicates its response on the Islamic principle of qisas, which is comparable to lex talionis or the doctrine of “an eye for an eye”. Qisas was always intended to be a tool of private redress for an individual or his/her family to seek justice in matters relating to bodily harm. Typically, it relates to cases of murder and manslaughter, or acts involving physical mutilation (say, leading to loss of limbs). The principle creates a framework for retributive justice.

The contemporary Salafi-jihadi movement has adopted a particularly innovative approach to the concept of qisas in two ways. First, groups such as IS have taken the idea and construed it in a way that justifies indiscriminate terrorism, such as the attack in Manchester. They argue that qisas has a political dimension and that it can be applied to international affairs in a way that holds civilians responsible for the perceived crimes of their governments.

Second, qisas is normally applied only in cases where the aggressor is known. IS, by contrast, holds every citizen-stranger of an enemy state responsible for the actions of his or her government. Thus, when it released its statement claiming responsibility for the Manchester attack, it said that it had struck against a “gathering of the crusaders . . . in response to their transgressions against the lands of the Muslims”.

It is this militaristic construction of qisas that allows IS to rationalise the bombing of a venue where large numbers of young girls had gathered to watch a pop concert, dismissing them as “crusaders”.

This is not new. In 1997, Osama Bin Laden told CBS News that “all Americans are our enemies, not just the ones who fight us directly, but also the ones who pay their ­taxes”. His rationale was that all Americans, by virtue of citizenship alone, are vicariously liable for the actions of their government.

Just a few years later, Bin Laden used the same idea to justify the 11 September 2001 attacks and also invoked it in reference to the Israeli-Palestinian conflict. “The blood pouring out of Palestine must be equally revenged,” he wrote. “You must know that the Palestinians do not cry alone; their women are not widowed alone; their sons are not orphaned alone.”

IS used the concept most dramatically in January 2015, when it burned alive a Royal Jordanian Air Force pilot, Muath al-Kasasbeh, whose plane had crashed in its territory. A video of the killing was circulated on the internet and social media. The group claimed his bombing raids had killed civilians and that it wanted to punish him with “equal retaliation”, in keeping with qisas.

What is well known about al-Kasasbeh’s murder is that he was burned alive inside a cage – but that is not the whole story. To understand how IS tethered this to the principle of qisas, it is the end of the gruesome video that is invested with most significance. After al-Kasasbeh has died, a truck emerges and dumps rubble over the cage. It was claimed this was debris from a site he had bombed, thus completing the “equal retaliation” of returning like for like. The idea was that IS had retaliated using the two principal forms in which a missile attack kills – by fire or debris.

***

The Manchester attack came on the fourth anniversary of the brutal murder of Fusilier Lee Rigby in Woolwich, south London. Rigby was killed by Michael Adebolajo and Michael Adebowale in the middle of the afternoon on a street outside a military barracks. That attack was in keeping with a pattern we have become increasingly accustomed to in Europe: an unsophisticated plot that employs ordinary, everyday items – a car, say, or a knife.

The consequences of such attacks have been seen across Europe, most notably in Nice on 14 July 2016, when 86 people were killed during Bastille Day celebrations after a jihadist drove a truck into crowds on the promenade. Similar attacks followed in Berlin, Westminster and Stockholm.

The security services find that these murderous attacks are extremely hard to disrupt because they typically involve lone actors who can mobilise quickly and with discretion. The Manchester attack was different. Explosives were used, which means the plot was inherently more sophisticated, requiring careful planning and preparation.

We know that two of the 7/7 bombers had previously trained in Pakistan’s lawless tribal regions, where they honed their skills. In other plots, such as the connected attacks in London and Glasgow Airport of 2007, the explosive devices failed mainly because the bomb-makers had found it difficult to travel abroad and develop their skills in safe environments. Whatever Abedi’s connections, the long war in Syria and Iraq has once again created a permissive environment for terrorist training and attack planning.

The devastating impact of this has already been felt across Europe. Since the Syrian uprising began in 2011, more than 800 Britons are believed to have travelled there to fight. From Europe as a whole, the figure is over 5,000, of which a significant number are believed to have joined IS. Of the British contingent, the security services estimate that about half have returned or become disengaged from the conflict. Of those who remained, a hundred are believed to be active, the rest having been killed.

It is improbable that Abedi acted alone in Manchester or that this plot had no international component. Indeed, he was already known to the authorities (and had returned recently from Libya). As pressure on IS intensifies across Syria and Iraq, the threat to Britain will only become more acute as the group’s sympathisers prepare for what they consider to be a fightback.

This speaks to the scale of the threat facing Britain, and Europe more generally. Our police and security services have been stretched and continuously tested in recent years. Just recently, in March, the Metropolitan Police assistant commissioner Mark Rowley told Radio 4’s Today programme that 13 plots had been thwarted since Lee Rigby’s murder in 2013. Put another way, the police have disrupted terrorist plots every four months for the past four years.

Naturally, Islamic State is not the only threat. On 13 May, one of Osama Bin Laden’s sons, Hamza, released a video, titled “Advice for martyrdom-seekers in the West”, on behalf of al-Qaeda. Hamza, 27, who was his father’s favoured successor to lead the group, called on its supporters to concentrate on attacks in the West rather than migrating to conflict zones in the Middle East and beyond. Scenes of previous ­terrorist attacks in Britain played throughout the video.

The central leadership of al-Qaeda is increasingly looking for opportunities to reassert itself after being eclipsed by Islamic State and losing control of its affiliates in Syria. It needs attacks and a cause in the West with which to revive itself. Hamza therefore cited the January 2015 Charlie Hebdo attack in Paris as a critical example, calling for the assassination of anyone deemed to have “insulted” Islam.

The Charlie Hebdo attack was especially important for al-Qaeda because it enabled the group to transcend the fratricidal conflicts that frequently define relations between the various jihadist groups. In Syria, for instance, al-Qaeda’s affiliates (when it had better control over them) and Islamic State have been in open war with each other.

Yet, the Charlie Hebdo attack brought warm praise from the group’s Islamist rivals because none of them wanted to appear ­unsupportive of an atrocity that had, as the terrorists proclaimed, “avenged” the Prophet Muhammad’s honour.

The British man from High Wycombe who joined IS told me the group had welcomed the attack for precisely those reasons. It was something that, in his view, had confirmed the “nobility” of the attackers, even if they had not been members of IS.

Is it too late for the West to save itself, I asked him. What if the West simply accepted all of Islamic State’s demands: would that provide respite?

The answer was as emphatic as it was stark: “We primarily fight wars due to ppl [sic] being disbelievers. Their drones against us are a secondary issue.”

He went on: “Their kufr [disbelief] against Allah is sufficient of a reason for us to invade and kill them. Only if they stop their kufr will they no longer be a target.”

In other words, we are all guilty, and we are all legitimate targets.

Shiraz Maher is a contributing writer for the New Statesman and a senior research fellow at King’s College London’s International Centre for the Study of Radicalisation.

This article first appeared in the 25 May 2017 issue of the New Statesman, Why Islamic State targets Britain

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