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October Monthly

The US dollar was driven higher in September by two main factors. The first was the anticipation of the Federal Reserve continuing to move toward tapering before the end of the year.  Investors have discounted one hike and part of a second one next year. 

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The US dollar was driven higher in September by two main factors. The first was the anticipation of the Federal Reserve continuing to move toward tapering before the end of the year.  Investors have discounted one hike and part of a second one next year.  To be sure, the US is not leading the move away from maximum monetary stimulus.  Norway hiked rates last month, and the Reserve Bank of New Zealand will likely do so this month.    

Not coincidentally, the Norwegian krone was the best-performing major currencies against the dollar last month until the very end when the Canadian dollar edged past it.  The Bank of Canada and the Reserve Bank of Australia have already begun the tapering process. The Bank of England appears to be signaling a hike in early 2022, though it has been playing up the risks of a move before Christmas.    However, those moves are different from the Federal Reserve, the European Central Bank, or the Bank of Japan.  

The second driver was the shift in risk appetites.  The pullback in stocks and bonds seemed to help the dollar against the Scandinavian and dollar-bloc currencies, as well as the emerging market complex.  Of course, risk tolerance is often a function of other developments. The idea that peak monetary and fiscal policy is broadly at hand (with notable exceptions) may have encouraged profit-taking after substantial run-ups in recent weeks and solid year-to-date performances. 

By many measures, stocks looked vulnerable.  The S&P 500, for example, was up seven months in a row before last month's setback.  Europe's Dow Jones Stoxx 600, which is less tech-sensitive, also advanced for the seven months through August to reach record highs.  Japan's Topix reached its best level since 1990.  There were also concerns about the Chinese property market, where the demise of Evergrande weighed heavily on the sector.  Many investors were concerned about the contagion through the banking and shadow banking exposures. Still, these seem exaggerated, and references to a "Lehman moment" or the Great Financial Crisis are out of place.  

One of the implications of peak monetary and fiscal support is that growth has peaked.  This has been a thread that has been woven into our commentary over the past several months.  US growth appears to have peaked in Q2, and Europe, maybe Q3. Due to the extended state of emergency and the prospects for a substantial fiscal package (one of the exceptions to the general pattern), Japan's recovery could begin in earnest in Q4 but may really be an H1 2022 story.  

The preliminary September PMIs showed that activity in the US and Europe had moderated.  The US composite PMI fell for the fourth consecutive month in September (initial reading) and at 54.5 is the lowest since September 2020. Many economists have revised down US growth forecasts for Q3.  Negotiations are ongoing, and it appears that the infrastructure initiative will be considerably smaller than President Biden sought.  The preliminary September eurozone composite PMI stands at 56.1, a five-month low, after peaking at 60.2 in July.  

Many businesses report ongoing supply chain disruptions that lead to later deliveries and more expensive goods.  Auto production and sales have been particularly hard hit and are also drags on consumption and growth.  Rising prices may also deter some sales.  The cost of transporting goods from Asia to Europe and the US has skyrocketed. The shortage of containers outside of Asia has raised the cost of storage around the rail yards and ports. An under-appreciated drag to growth is coming from the rise in energy prices. It may seem counter-intuitive, but the dramatic rise in the cost of energy is not inflationary as much as a tax, and a regressive one at that.  One of the apparent regularities that we have noted before is that the last three business downturns in the US, before the pandemic, were proceeded by a doubling of the price of oil.  

The April 2020 drop of oil prices below zero was a fluke and was not truly representative.  Instead, since the eve of the US election last November, the price of crude has doubled.  From as recently as Ides of March, the price of natural gas has more than doubled, as well.  The jump in oil and gas prices has been over-determined: factors include the storms in the Gulf of Mexico, droughts that reduce the supply of hydroelectricity,  the lack of wind in other parts of the world, like the UK, Russia possibly playing politics to force the controversial Nord Stream 2 pipeline into operation, China rebuilding its inventories, slow rebound in US shale producers, pessimism regarding the US and Iran returning to compliance with the nuclear agreement, and of course, the unpredictable and uneven rebound in demand.  

September was an important month for central bank meetings.  Forecasts and forward guidance were updated. The Federal Reserve gave its strongest hint to date that tapering will likely start in November and be completed around the middle of next year.  More Fed officials see a hike next year, but half do not. The ECB recalibrated its bond purchases. The fight is shifting to the size and flexibility of the Asset Purchases Program that predated the emergency facility and will continue after the PEPP winds down next March.  The Bank of England maintained its hawkish rhetoric and fanned speculation of an early hike.  

Norway became the first high-income country to raise rates. The Reserve Bank of New Zealand expected to follow suit on October 5.  The Reserve Bank of Australia will make its announcement several hours earlier.  In September, it decided to proceed with tapering plans (to A$4 bln a week from A$5 bln) and extending the purchases at least three months, through mid-February 2022, even though the economy appears to be contracting.  The composite PMI has been below the 50 boom/bust level each month in Q3. The median forecast in Bloomberg's survey anticipates a loss of almost 2% of output quarter-over-quarter.  The Australian dollar was the weakest of the major currencies last quarter.  The 3.6% decline brings the year-to-date loss to a little more than 6.0%.  

Toward the end of October, two G7 central banks meet: the Bank of Canada, October 27, and the ECB the following day.  The Bank of Canada will offer updated forecasts and may taper further.  It is buying C$2 bln a week of federal bonds and may bring to C$1 bln, which some officials have suggested maybe neutral.  The market appears to be pricing in the first hike in Canada around the middle of next year and two moves by the end of Q3 22.   Despite the 2.2% depreciation of the Canadian dollar in Q3, it is the only major currency to gain against the greenback this year (~0.35%).   

The European Central Bank is unlikely to break new ground at its October meeting.  Its current forecasts go out through 2023, but recently, there have been claims about what the models may show later.  Apparently, several ECB members think that the staff projections updated in mid-September are too low (1.7% in 2022 and 1.5% in 2023).  The ECB staff will update and extend the forecasts to 2024 in December. The next big debate at the ECB is not about the Pandemic Emergency Purchase Program.  That will wind down next March. Instead, the challenge is over the pace and flexibility of the pre-pandemic facility, the Asset Purchase Program (currently ~20 bln euros a month).  The is no urgent need to resolve the issue until next year.  

Bismark once quipped that in a democracy, one should not see the way laws or sausage are made.  It is especially true of US fiscal policy.  Brinkmanship tactics require going to the brink, and that is where it went.  It managed to extend spending authorization less than 12 hours before the government would be shut down.  The stopgap measure ends in early December.  Meanwhile, the debt ceiling restraint looms large.  It is not clear how it is resolved, yet investors are largely looking through it outside of the T-bills that expire around the middle of October.   It seems to reflect a faith that the US would not do something as foolhardy as missing a debt payment.  The optics are poor, disruptive, and doubly so during a pandemic, but the material economic impact is marginal. 

Most of the world's currencies depreciated against the dollar in September. As a result, the Bannockburn World Currency Index (BWCI), a GDP-weighted basket of the dozen largest economies, fell for the second consecutive month.  Only two currencies in the index appreciated against the dollar in September, the Russian ruble (~2% weighting) rose by 0.7%, and the Chinese yuan (21.7% weighting) rose 0.25%.  The worst performer in the index was the Brazilian real, which despite aggressive rate hikes by the central bank (three 75 bp, followed by two 100 bp moves, and the promise of another at least 100 bp), the currency fell a little more than 5.4%.  At the end of August, it was up about 0.75% for the year.  

Brazil had been a market favorite earlier this year, and positioning seemed to work against it.  The political climate discourages foreign investment.  The drought, which has hit the hydroelectric grid, adds to the rise in energy and food costs, fueling inflation.   It was also partly emblematic of the sentiment toward emerging markets more broadly.  Their currencies were mainly out of favor in September, and the JP Morgan Emerging Market Currency Index fell almost 3%.

The major currencies in the BWCI fell against the dollar in September.  A dramatic Canadian dollar bounce on the last trading day of the month pared its losses to about 0.5% for the month, the best performer.   The Australian dollar recouped nearly a third of its monthly losses at the end of the month to finish down off around 1.25% lower.  Sterling and the euro each lost about 2%.  Since the eve of the FOMC meeting (September 21), the Canadian dollar has been the only major currency to have risen (~1.1%).  


Dollar:   The Federal Reserve has confirmed what the market has been anticipating since early this year.  It is prepared to taper before the end of the year and likely will announce it at the next FOMC meeting that concludes on November 3.  The market has fully discounted a hike next year, for which the Fed itself is split.  In fact, it has about a 30% chance of a second hike, something that only three of the 18 Fed officials anticipate according to the last Summary of Economic Projections (dot plot). The more hawkish stance appears to have been the key factor driving the dollar higher in late September.  However, more immediately, fiscal policy is the focus, though investors appear to be looking through it, as many find it inconceivable that the US would default on its debt.  At the last minute, spending authorization was granted, but only until early December when the fight will be taken up again to prevent a government shutdown.   Treasury Secretary Yellen warned that her room to maneuver around the debt ceiling, which limits the ability to service obligations related to past spending, maybe exhausted around the middle of October.  

Euro:  The euro was turned back after briefly trading above $1.19 on the back of the disappointing August US jobs report.  The divergence of the likely trajectory of monetary policy is seen as a critical weight on the euro.  The ECB could be a year or more behind the Fed in raising rates.  The US 2-year premium over Germany is approaching 100 bp, a level it has not been over since the pandemic struck.  At the end of 2019, the spread was closer to 220 bp.  It may take several weeks before the next German government is formed. Still, the tail risks have ebbed, and broad continuity is likely even with a modest tilt toward greater environmental action.  There is some talk that an off-balance sheet green investment bank would allow for the "black zero" of fiscal policy to be retained.  The euro fell to new lows for the year low at the end of September, near $1.1565.  A break of the $1.1500 area, the midpoint of the rally from March 2020's low (~$1.0635) to the high set ironically as the demonstration turned violent in Washington DC on January 6 (~$1.2350), could spur a test on $1.13.  

(Septembr indicative closing prices, previous in parentheses)

 

Spot: $1.1580 ($1.1810)

Median Bloomberg One-month Forecast $1.1660 ($1.1810) 

One-month forward  $1.1585 ($1.1820)    One-month implied vol  5.1%  (5.4%)    

 

 

Japanese Yen:  The LDP chose Suga's successor as party leader, and therefore, Japan's new prime minister pending a formal vote in the Diet.  Within the narrow confines of the Liberal Democratic Party, there will be a great degree of continuity.  As the LDP often does, a new fiscal stimulus package is expected in Q4 that could be as large as JPY30 trillion (~$270 bln)o ostensibly to close the output gap.  Separately, the large factions within the LDP, including the one associated with former Prime Minister Abe, have long advocated a more robust defense policy, and China's aggressiveness in the region has been seized upon as the opportunity to press their case.  The dollar-yen exchange rate appears to be driven more by the US Treasury market than domestic developments in Japan.  The jump in US yields, especially after the FOMC meeting ensured the first monthly rise since March.  As September wound down, the dollar briefly traded above JPY112 for the first time since late February 2020.  The 2020 high was around JPY112.25, and the 2019 high was close by (~JPY112.40).  

 

Spot: JPY111.30 (JPY110.00)      

Median Bloomberg One-month Forecast JPY111.00 (JPY110.00)     

One-month forward JPY111.25 (JPY109.95)    One-month implied vol  5.6% (5.3%)

 

British Pound: The hawkishness of the Bank of England surprised market participants and initially lent sterling support.  With inflation well above the 2% target (headline and core above 3.0%), the BOE intimated that it needed it could hike rates while it is buying bonds (QE).  Since the BOE is expected to complete its bond-buying this year, the market had to price in the risk of a hike in Q4.   The implied yield of the December 2022 short-sterling (three-month) interest rate contract rose to new highs for the year around 25 bp.  That suggests the market has nearly priced in a 15 bp hike, or the unwinding its last cut in 2020. This seems a stretch. The furlough wage subsidy program finished at the end of September, and the impact will take time to sort out.  Growth appears to be faltering, and the composite PMI has fallen for four consecutive months through September to its lowest level since February.  The energy shock that is being widely experienced is hitting the UK particularly hard by the less flexible labor market on this side of Brexit. The army has been enlisted to deliver petrol.  The UK Chancellor of the Exchequer will present next year's budget (October 27).  It is expected to project a halving of the 2021 deficit (9.5% of GDP). The risk is that the monetary and fiscal tightening is delivered and weakens the economy. On the other hand, the market could correct its overshoot to anticipates less BOE tightening.  Neither scenario appears sterling-friendly. 

 

Spot: $1.3475 ($1.3755)   

Median Bloomberg One-month Forecast $1.3630 ($1.3790) 

One-month forward $1.3480 ($1.3760)   One-month implied vol 7.1% (6.2%)

  

 

Canadian Dollar: Prime Minister Trudeau's election gambit did not pay off.  For the second consecutive election, the Liberals lost the popular vote but secured a plurality of seats in Parliament.  Trudeau again leads a minority government but has tacked to the left on the environment and fiscal issues.  The Bank of Canada continues to project the output gap will close around the middle of next year.  Not coincidentally, the market anticipates the first hike then as well.  The trajectory of the policy mix (less accommodative monetary policy and more stimulative fiscal policy) tends to support the currency.  September was the third consecutive monthly gain for the US dollar.  The exchange rate is sensitive (correlation) to the general risk appetite (S&P 500 proxy) and oil prices. The S&P 500 snapped a seven-month rally, while oil (WTI) rallied more than 10%.  That the Canadian dollar spent most of the month on defense suggests that the influence of equities and the risk appetite outweighed the positive impulses for rising commodity prices, especially oil.  

 

Spot: CAD1.2680 (CAD 1.2610) 

Median Bloomberg One-month Forecast CAD1.2580 (CAD1.2560)

One-month forward CAD1.2685 (CAD1.2615)    One-month implied vol 6.9% (7.3%) 

 

 

Australian Dollar:  The recovery from the year's low set on August 20, just ahead of $0.7100, ran out of steam in early September, close to $0.7480.  It spent most of the month trending lower and returned to the $0.7170 area before jumping at month-end.  Despite a likely economic contraction as the extended lockdown cripples activity, the RBA reduced its bond purchases (A$4 bln vs. A$5 bln a week) through at least mid-February 2022, which was extended from mid-November. Two prices main prove problematic for Australia.  The first is the surge in house prices (~20% year-to-date), despite the extended lockdowns in Sydney and Melbourne. The IMF is urging macroprudential checks, like lending curbs, via tighter debt-income and loan-to-value ratios.  The second is the price of iron ore, which accounts for around a fifth of the country's exports.  The price found some support late in September after falling about 40% in Q3 before bottoming on September 22.  Long-term contracts may give Australia buffer, but this is a severe terms-of-trade shock.  Australia put the free-trade talks with Europe at risk by its strategic decision to terminate the French conventional submarine contract for a nuclear deal with the UK and US.  Although the French ambassador to the US returned, the one to Australia has not.  The Reserve Bank of New Zealand meets on October 5 and is expected to be the second high-income country after Norway to hike rates.  There has been some speculation of a 50 bp move, but this never seemed credible.  The divergence of the trajectory of monetary policy between Australia and New Zealand drove the Australian dollar down nearly 5% against the New Zealand dollar from mid-June through mid-September.  Position adjustments into the month- and quarter-end helped the Aussie recover (~1.7%) in the second half of September to finish a new high for the month.  

 

Spot:  $0.7230 ($0.7315)       

Median Bloomberg One-Month Forecast $0.7290 ($0.7360)     

One-month forward  $0.7235 ($0.7320)     One-month implied vol 9.0  (8.5%)   

 

 

Mexican Peso:  The peso fell by about 2.3% since the FOMC meeting before recovering from a three-month low at the end of September.  Its year-to-date loss to bring its year-to-date loss to about 2.8%.  Its weakness was in line with the JP Morgan Emerging Market Currency Index, which by about 2.6%, making it the biggest monthly loss since March 2020.  The dollar's broad strength on the back of rising rates seemed to be the main culprit.  Earlier in September, it had appeared that the central bank would pause in its tightening cycle after hiking in July and August. However, price pressures continue to accelerate, and the peso's weakness, falling to new three-month lows, seemed to have forced Banxico's hand. The market appears to be pricing in about 100 bp of tightening by the end of Q1 22. Meanwhile, Mexico's trade balance has deteriorated sharply. The three-month average through August (~-$2.4 bln) is the largest since 2008.  The impact has been blunted by the record worker remittances that are even larger.

 

Spot: MXN20.64 (MXN20.07)  

Median Bloomberg One-Month Forecast  MXN20.41 (MXN20.06)  

One-month forward  MXN20.74 (MXN20.16)     One-month implied vol 11.0% (9.9%)

  

 

Chinese Yuan: What seems like a second cultural revolution in China, where President Xi is reasserting the Communist Party and state over various aspects of society, has spooked.  The demise of one of the largest property developers, Evergrande, is a separate issue, but Beijing appears opportunistically to take advantage of the debt crisis to restructure the sector, which broadly measured, accounts for almost a third of  GDP. Chinese stocks have so far escaped little scathed by the developments, and the Shanghai Composite eked out a slight gain (0.03%).  Hong Kong listings bore the burden, and the Hang Seng was among the weakest markets in the world, falling nearly 5.6% in September, bringing the year-to-date loss to 9.75%.  Rising energy prices and a slowing economy can still prompt the PBOC to support the economy.  Mainland markets are closed October 1-7, during which the yuan is likely to remain broadly stable.  The prisoner swap with Canada shortly after the Canadian elections may help set the stage for a Xi-Biden meeting.

 

Spot: CNY6.4450 (CNY6.4605)

Median Bloomberg One-month Forecast  CNY6.4470 (CNY6.46155) 

One-month forward CNY6.4725 (CNY6.4750)    One-month implied vol  3.4% (3.5%)



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‘I couldn’t stand the pain’: the Turkish holiday resort that’s become an emergency dental centre for Britons who can’t get treated at home

The crisis in NHS dentistry is driving increasing numbers abroad for treatment. Here are some of their stories.

This clinic in the Turkish resort of Antalya is the official 'dental sponsor' of the Miss England competition. Diana Ibanez-Tirado, Author provided

It’s a hot summer day in the Turkish city of Antalya, a Mediterranean resort with golden beaches, deep blue sea and vibrant nightlife. The pool area of the all-inclusive resort is crammed with British people on sun loungers – but they aren’t here for a holiday. This hotel is linked to a dental clinic that organises treatment packages, and most of these guests are here to see a dentist.

From Norwich, two women talk about gums and injections. A man from Wales holds a tissue close to his mouth and spits blood – he has just had two molars extracted.

The dental clinic organises everything for these dental “tourists” throughout their treatment, which typically lasts from three to 15 days. The stories I hear of what has caused them to travel to Turkey are strikingly similar: all have struggled to secure dental treatment at home on the NHS.

“The hotel is nice and some days I go to the beach,” says Susan*, a hairdresser in her mid-30s from Norwich. “But really, we aren’t tourists like in a proper holiday. We come here because we have no choice. I couldn’t stand the pain.”

Seaside beach resort with mountains in the distance
The Turkish Mediterranean resort of Antalya. Akimov Konstantin/Shutterstock

This is Susan’s second visit to Antalya. She explains that her ordeal started two years earlier:

I went to an NHS dentist who told me I had gum disease … She did some cleaning to my teeth and gums but it got worse. When I ate, my teeth were moving … the gums were bleeding and it was very painful. I called to say I was in pain but the clinic was not accepting NHS patients any more.

The only option the dentist offered Susan was to register as a private patient:

I asked how much. They said £50 for x-rays and then if the gum disease got worse, £300 or so for extraction. Four of them were moving – imagine: £1,200 for losing your teeth! Without teeth I’d lose my clients, but I didn’t have the money. I’m a single mum. I called my mum and cried.

Susan’s mother told her about a friend of hers who had been to Turkey for treatment, then together they found a suitable clinic:

The prices are so much cheaper! Tooth extraction, x-rays, consultations – it all comes included. The flight and hotel for seven days cost the same as losing four teeth in Norwich … I had my lower teeth removed here six months ago, now I’ve got implants … £2,800 for everything – hotel, transfer, treatments. I only paid the flights separately.

In the UK, roughly half the adult population suffers from periodontitis – inflammation of the gums caused by plaque bacteria that can lead to irreversible loss of gums, teeth, and bone. Regular reviews by a dentist or hygienist are required to manage this condition. But nine out of ten dental practices cannot offer NHS appointments to new adult patients, while eight in ten are not accepting new child patients.

Some UK dentists argue that Britons who travel abroad for treatment do so mainly for cosmetic procedures. They warn that dental tourism is dangerous, and that if their treatment goes wrong, dentists in the UK will be unable to help because they don’t want to be responsible for further damage. Susan shrugs this off:

Dentists in England say: ‘If you go to Turkey, we won’t touch you [afterwards].’ But I don’t worry because there are no appointments at home anyway. They couldn’t help in the first place, and this is why we are in Turkey.

‘How can we pay all this money?’

As a social anthropologist, I travelled to Turkey a number of times in 2023 to investigate the crisis of NHS dentistry, and the journeys abroad that UK patients are increasingly making as a result. I have relatives in Istanbul and have been researching migration and trading patterns in Turkey’s largest city since 2016.

In August 2023, I visited the resort in Antalya, nearly 400 miles south of Istanbul. As well as Susan, I met a group from a village in Wales who said there was no provision of NHS dentistry back home. They had organised a two-week trip to Turkey: the 12-strong group included a middle-aged couple with two sons in their early 20s, and two couples who were pensioners. By going together, Anya tells me, they could support each other through their different treatments:

I’ve had many cavities since I was little … Before, you could see a dentist regularly – you didn’t even think about it. If you had pain or wanted a regular visit, you phoned and you went … That was in the 1990s, when I went to the dentist maybe every year.

Anya says that once she had children, her family and work commitments meant she had no time to go to the dentist. Then, years later, she started having serious toothache:

Every time I chewed something, it hurt. I ate soups and soft food, and I also lost weight … Even drinking was painful – tea: pain, cold water: pain. I was taking paracetamol all the time! I went to the dentist to fix all this, but there were no appointments.

Anya was told she would have to wait months, or find a dentist elsewhere:

A private clinic gave me a list of things I needed done. Oh my God, almost £6,000. My husband went too – same story. How can we pay all this money? So we decided to come to Turkey. Some people we know had been here, and others in the village wanted to come too. We’ve brought our sons too – they also need to be checked and fixed. Our whole family could be fixed for less than £6,000.

By the time they travelled, Anya’s dental problems had turned into a dental emergency. She says she could not live with the pain anymore, and was relying on paracetamol.

In 2023, about 6 million adults in the UK experienced protracted pain (lasting more than two weeks) caused by toothache. Unintentional paracetamol overdose due to dental pain is a significant cause of admissions to acute medical units. If left untreated, tooth infections can spread to other parts of the body and cause life-threatening complications – and on rare occasions, death.

In February 2024, police were called to manage hundreds of people queuing outside a newly opened dental clinic in Bristol, all hoping to be registered or seen by an NHS dentist. One in ten Britons have admitted to performing “DIY dentistry”, of which 20% did so because they could not find a timely appointment. This includes people pulling out their teeth with pliers and using superglue to repair their teeth.

In the 1990s, dentistry was almost entirely provided through NHS services, with only around 500 solely private dentists registered. Today, NHS dentist numbers in England are at their lowest level in a decade, with 23,577 dentists registered to perform NHS work in 2022-23, down 695 on the previous year. Furthermore, the precise division of NHS and private work that each dentist provides is not measured.

The COVID pandemic created longer waiting lists for NHS treatment in an already stretched public service. In Bridlington, Yorkshire, people are now reportedly having to wait eight-to-nine years to get an NHS dental appointment with the only remaining NHS dentist in the town.

In his book Patients of the State (2012), Argentine sociologist Javier Auyero describes the “indignities of waiting”. It is the poor who are mostly forced to wait, he writes. Queues for state benefits and public services constitute a tangible form of power over the marginalised. There is an ethnic dimension to this story, too. Data suggests that in the UK, patients less likely to be effective in booking an NHS dental appointment are non-white ethnic groups and Gypsy or Irish travellers, and that it is particularly challenging for refugees and asylum-seekers to access dental care.


This article is part of Conversation Insights
The Insights team generates long-form journalism derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.


In 2022, I experienced my own dental emergency. An infected tooth was causing me debilitating pain, and needed root canal treatment. I was advised this would cost £71 on the NHS, plus £307 for a follow-up crown – but that I would have to wait months for an appointment. The pain became excruciating – I could not sleep, let alone wait for months. In the same clinic, privately, I was quoted £1,300 for the treatment (more than half my monthly income at the time), or £295 for a tooth extraction.

I did not want to lose my tooth because of lack of money. So I bought a flight to Istanbul immediately for the price of the extraction in the UK, and my tooth was treated with root canal therapy by a private dentist there for £80. Including the costs of travelling, the total was a third of what I was quoted to be treated privately in the UK. Two years on, my treated tooth hasn’t given me any more problems.

A better quality of life

Not everyone is in Antalya for emergency procedures. The pensioners from Wales had contacted numerous clinics they found on the internet, comparing prices, treatments and hotel packages at least a year in advance, in a carefully planned trip to get dental implants – artificial replacements for tooth roots that help support dentures, crowns and bridges.

Street view of a dental clinic in Antalya, Turkey
Dental clinic in Antalya, Turkey. Diana Ibanez-Tirado, CC BY-NC-ND

In Turkey, all the dentists I speak to (most of whom cater mainly for foreigners, including UK nationals) consider implants not a cosmetic or luxurious treatment, but a development in dentistry that gives patients who are able to have the procedure a much better quality of life. This procedure is not available on the NHS for most of the UK population, and the patients I meet in Turkey could not afford implants in private clinics back home.

Paul is in Antalya to replace his dentures, which have become uncomfortable and irritating to his gums, with implants. He says he couldn’t find an appointment to see an NHS dentist. His wife Sonia went through a similar procedure the year before and is very satisfied with the results, telling me: “Why have dentures that you need to put in a glass overnight, in the old style? If you can have implants, I say, you’re better off having them.”

Most of the dental tourists I meet in Antalya are white British: this city, known as the Turkish Riviera, has developed an entire economy catering to English-speaking tourists. In 2023, more than 1.3 million people visited the city from the UK, up almost 15% on the previous year.


Read more: NHS dentistry is in crisis – are overseas dentists the answer?


In contrast, the Britons I meet in Istanbul are predominantly from a non-white ethnic background. Omar, a pensioner of Pakistani origin in his early 70s, has come here after waiting “half a year” for an NHS appointment to fix the dental bridge that is causing him pain. Omar’s son had been previously for a hair transplant, and was offered a free dental checkup by the same clinic, so he suggested it to his father. Having worked as a driver for a manufacturing company for two decades in Birmingham, Omar says he feels disappointed to have contributed to the British economy for so long, only to be “let down” by the NHS:

At home, I must wait and wait and wait to get a bridge – and then I had many problems with it. I couldn’t eat because the bridge was uncomfortable and I was in pain, but there were no appointments on the NHS. I asked a private dentist and they recommended implants, but they are far too expensive [in the UK]. I started losing weight, which is not a bad thing at the beginning, but then I was worrying because I couldn’t chew and eat well and was losing more weight … Here in Istanbul, I got dental implants – US$500 each, problem solved! In England, each implant is maybe £2,000 or £3,000.

In the waiting area of another clinic in Istanbul, I meet Mariam, a British woman of Iraqi background in her late 40s, who is making her second visit to the dentist here. Initially, she needed root canal therapy after experiencing severe pain for weeks. Having been quoted £1,200 in a private clinic in outer London, Mariam decided to fly to Istanbul instead, where she was quoted £150 by a dentist she knew through her large family. Even considering the cost of the flight, Mariam says the decision was obvious:

Dentists in England are so expensive and NHS appointments so difficult to find. It’s awful there, isn’t it? Dentists there blamed me for my rotten teeth. They say it’s my fault: I don’t clean or I ate sugar, or this or that. I grew up in a village in Iraq and didn’t go to the dentist – we were very poor. Then we left because of war, so we didn’t go to a dentist … When I arrived in London more than 20 years ago, I didn’t speak English, so I still didn’t go to the dentist … I think when you move from one place to another, you don’t go to the dentist unless you are in real, real pain.

In Istanbul, Mariam has opted not only for the urgent root canal treatment but also a longer and more complex treatment suggested by her consultant, who she says is a renowned doctor from Syria. This will include several extractions and implants of back and front teeth, and when I ask what she thinks of achieving a “Hollywood smile”, Mariam says:

Who doesn’t want a nice smile? I didn’t come here to be a model. I came because I was in pain, but I know this doctor is the best for implants, and my front teeth were rotten anyway.

Dentists in the UK warn about the risks of “overtreatment” abroad, but Mariam appears confident that this is her opportunity to solve all her oral health problems. Two of her sisters have already been through a similar treatment, so they all trust this doctor.

Alt text
An Istanbul clinic founded by Afghan dentists has a message for its UK customers. Diana Ibanez-Tirado, CC BY-NC-ND

The UK’s ‘dental deserts’

To get a fuller understanding of the NHS dental crisis, I’ve also conducted 20 interviews in the UK with people who have travelled or were considering travelling abroad for dental treatment.

Joan, a 50-year-old woman from Exeter, tells me she considered going to Turkey and could have afforded it, but that her back and knee problems meant she could not brave the trip. She has lost all her lower front teeth due to gum disease and, when I meet her, has been waiting 13 months for an NHS dental appointment. Joan tells me she is living in “shame”, unable to smile.

In the UK, areas with extremely limited provision of NHS dental services – known as as “dental deserts” – include densely populated urban areas such as Portsmouth and Greater Manchester, as well as many rural and coastal areas.

In Felixstowe, the last dentist taking NHS patients went private in 2023, despite the efforts of the activist group Toothless in Suffolk to secure better access to NHS dentists in the area. It’s a similar story in Ripon, Yorkshire, and in Dumfries & Galloway, Scotland, where nearly 25,000 patients have been de-registered from NHS dentists since 2021.

Data shows that 2 million adults must travel at least 40 miles within the UK to access dental care. Branding travel for dental care as “tourism” carries the risk of disguising the elements of duress under which patients move to restore their oral health – nationally and internationally. It also hides the immobility of those who cannot undertake such journeys.

The 90-year-old woman in Dumfries & Galloway who now faces travelling for hours by bus to see an NHS dentist can hardly be considered “tourism” – nor the Ukrainian war refugees who travelled back from West Sussex and Norwich to Ukraine, rather than face the long wait to see an NHS dentist.

Many people I have spoken to cannot afford the cost of transport to attend dental appointments two hours away – or they have care responsibilities that make it impossible. Instead, they are forced to wait in pain, in the hope of one day securing an appointment closer to home.

Billboard advertising a dental clinic in Turkey
Dental clinics have mushroomed in recent years in Turkey, thanks to the influx of foreign patients seeking a wide range of treatments. Diana Ibanez-Tirado, CC BY-NC-ND

‘Your crisis is our business’

The indignities of waiting in the UK are having a big impact on the lives of some local and foreign dentists in Turkey. Some neighbourhoods are rapidly changing as dental and other health clinics, usually in luxurious multi-storey glass buildings, mushroom. In the office of one large Istanbul medical complex with sections for hair transplants and dentistry (plus one linked to a hospital for more extensive cosmetic surgery), its Turkish owner and main investor tells me:

Your crisis is our business, but this is a bazaar. There are good clinics and bad clinics, and unfortunately sometimes foreign patients do not know which one to choose. But for us, the business is very good.

This clinic only caters to foreign patients. The owner, an architect by profession who also developed medical clinics in Brazil, describes how COVID had a major impact on his business:

When in Europe you had COVID lockdowns, Turkey allowed foreigners to come. Many people came for ‘medical tourism’ – we had many patients for cosmetic surgery and hair transplants. And that was when the dental business started, because our patients couldn’t see a dentist in Germany or England. Then more and more patients started to come for dental treatments, especially from the UK and Ireland. For them, it’s very, very cheap here.

The reasons include the value of the Turkish lira relative to the British pound, the low cost of labour, the increasing competition among Turkish clinics, and the sheer motivation of dentists here. While most dentists catering to foreign patients are from Turkey, others have arrived seeking refuge from war and violence in Syria, Iraq, Afghanistan, Iran and beyond. They work diligently to rebuild their lives, careers and lost wealth.

Regardless of their origin, all dentists in Turkey must be registered and certified. Hamed, a Syrian dentist and co-owner of a new clinic in Istanbul catering to European and North American patients, tells me:

I know that you say ‘Syrian’ and people think ‘migrant’, ‘refugee’, and maybe think ‘how can this dentist be good?’ – but Syria, before the war, had very good doctors and dentists. Many of us came to Turkey and now I have a Turkish passport. I had to pass the exams to practise dentistry here – I study hard. The exams are in Turkish and they are difficult, so you cannot say that Syrian doctors are stupid.

Hamed talks excitedly about the latest technology that is coming to his profession: “There are always new materials and techniques, and we cannot stop learning.” He is about to travel to Paris to an international conference:

I can say my techniques are very advanced … I bet I put more implants and do more bone grafting and surgeries every week than any dentist you know in England. A good dentist is about practice and hand skills and experience. I work hard, very hard, because more and more patients are arriving to my clinic, because in England they don’t find dentists.

Dental equipment in a Turkish treatment room
Dentists in Turkey boast of using the latest technology. Diana Ibanez-Tirado, CC BY-NC-ND

While there is no official data about the number of people travelling from the UK to Turkey for dental treatment, investors and dentists I speak to consider that numbers are rocketing. From all over the world, Turkey received 1.2 million visitors for “medical tourism” in 2022, an increase of 308% on the previous year. Of these, about 250,000 patients went for dentistry. One of the most renowned dental clinics in Istanbul had only 15 British patients in 2019, but that number increased to 2,200 in 2023 and is expected to reach 5,500 in 2024.

Like all forms of medical care, dental treatments carry risks. Most clinics in Turkey offer a ten-year guarantee for treatments and a printed clinical history of procedures carried out, so patients can show this to their local dentists and continue their regular annual care in the UK. Dental treatments, checkups and maintaining a good oral health is a life-time process, not a one-off event.

Many UK patients, however, are caught between a rock and a hard place – criticised for going abroad, yet unable to get affordable dental care in the UK before and after their return. The British Dental Association has called for more action to inform these patients about the risks of getting treated overseas – and has warned UK dentists about the legal implications of treating these patients on their return. But this does not address the difficulties faced by British patients who are being forced to go abroad in search of affordable, often urgent dental care.

A global emergency

The World Health Organization states that the explosion of oral disease around the world is a result of the “negligent attitude” that governments, policymakers and insurance companies have towards including oral healthcare under the umbrella of universal healthcare. It as if the health of our teeth and mouth is optional; somehow less important than treatment to the rest of our body. Yet complications from untreated tooth decay can lead to hospitalisation.

The main causes of oral health diseases are untreated tooth decay, severe gum disease, toothlessness, and cancers of the lip and oral cavity. Cases grew during the pandemic, when little or no attention was paid to oral health. Meanwhile, the global cosmetic dentistry market is predicted to continue growing at an annual rate of 13% for the rest of this decade, confirming the strong relationship between socioeconomic status and access to oral healthcare.

In the UK since 2018, there have been more than 218,000 admissions to hospital for rotting teeth, of which more than 100,000 were children. Some 40% of children in the UK have not seen a dentist in the past 12 months. The role of dentists in prevention of tooth decay and its complications, and in the early detection of mouth cancer, is vital. While there is a 90% survival rate for mouth cancer if spotted early, the lack of access to dental appointments is causing cases to go undetected.

The reasons for the crisis in NHS dentistry are complex, but include: the real-term cuts in funding to NHS dentistry; the challenges of recruitment and retention of dentists in rural and coastal areas; pay inequalities facing dental nurses, most of them women, who are being badly hit by the cost of living crisis; and, in England, the 2006 Dental Contract that does not remunerate dentists in a way that encourages them to continue seeing NHS patients.

The UK is suffering a mass exodus of the public dentistry workforce, with workers leaving the profession entirely or shifting to the private sector, where payments and life-work balance are better, bureaucracy is reduced, and prospects for career development look much better. A survey of general dental practitioners found that around half have reduced their NHS work since the pandemic – with 43% saying they were likely to go fully private, and 42% considering a career change or taking early retirement.

Reversing the UK’s dental crisis requires more commitment to substantial reform and funding than the “recovery plan” announced by Victoria Atkins, the secretary of state for health and social care, on February 7.

The stories I have gathered show that people travelling abroad for dental treatment don’t see themselves as “tourists” or vanity-driven consumers of the “Hollywood smile”. Rather, they have been forced by the crisis in NHS dentistry to seek out a service 1,500 miles away in Turkey that should be a basic, affordable right for all, on their own doorstep.

*Names in this article have been changed to protect the anonymity of the interviewees.


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Diana Ibanez Tirado receives funding from the School of Global Studies, University of Sussex.

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The Coming Of The Police State In America

The Coming Of The Police State In America

Authored by Jeffrey Tucker via The Epoch Times,

The National Guard and the State Police are now…

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The Coming Of The Police State In America

Authored by Jeffrey Tucker via The Epoch Times,

The National Guard and the State Police are now patrolling the New York City subway system in an attempt to do something about the explosion of crime. As part of this, there are bag checks and new surveillance of all passengers. No legislation, no debate, just an edict from the mayor.

Many citizens who rely on this system for transportation might welcome this. It’s a city of strict gun control, and no one knows for sure if they have the right to defend themselves. Merchants have been harassed and even arrested for trying to stop looting and pillaging in their own shops.

The message has been sent: Only the police can do this job. Whether they do it or not is another matter.

Things on the subway system have gotten crazy. If you know it well, you can manage to travel safely, but visitors to the city who take the wrong train at the wrong time are taking grave risks.

In actual fact, it’s guaranteed that this will only end in confiscating knives and other things that people carry in order to protect themselves while leaving the actual criminals even more free to prey on citizens.

The law-abiding will suffer and the criminals will grow more numerous. It will not end well.

When you step back from the details, what we have is the dawning of a genuine police state in the United States. It only starts in New York City. Where is the Guard going to be deployed next? Anywhere is possible.

If the crime is bad enough, citizens will welcome it. It must have been this way in most times and places that when the police state arrives, the people cheer.

We will all have our own stories of how this came to be. Some might begin with the passage of the Patriot Act and the establishment of the Department of Homeland Security in 2001. Some will focus on gun control and the taking away of citizens’ rights to defend themselves.

My own version of events is closer in time. It began four years ago this month with lockdowns. That’s what shattered the capacity of civil society to function in the United States. Everything that has happened since follows like one domino tumbling after another.

It goes like this:

1) lockdown,

2) loss of moral compass and spreading of loneliness and nihilism,

3) rioting resulting from citizen frustration, 4) police absent because of ideological hectoring,

5) a rise in uncontrolled immigration/refugees,

6) an epidemic of ill health from substance abuse and otherwise,

7) businesses flee the city

8) cities fall into decay, and that results in

9) more surveillance and police state.

The 10th stage is the sacking of liberty and civilization itself.

It doesn’t fall out this way at every point in history, but this seems like a solid outline of what happened in this case. Four years is a very short period of time to see all of this unfold. But it is a fact that New York City was more-or-less civilized only four years ago. No one could have predicted that it would come to this so quickly.

But once the lockdowns happened, all bets were off. Here we had a policy that most directly trampled on all freedoms that we had taken for granted. Schools, businesses, and churches were slammed shut, with various levels of enforcement. The entire workforce was divided between essential and nonessential, and there was widespread confusion about who precisely was in charge of designating and enforcing this.

It felt like martial law at the time, as if all normal civilian law had been displaced by something else. That something had to do with public health, but there was clearly more going on, because suddenly our social media posts were censored and we were being asked to do things that made no sense, such as mask up for a virus that evaded mask protection and walk in only one direction in grocery aisles.

Vast amounts of the white-collar workforce stayed home—and their kids, too—until it became too much to bear. The city became a ghost town. Most U.S. cities were the same.

As the months of disaster rolled on, the captives were let out of their houses for the summer in order to protest racism but no other reason. As a way of excusing this, the same public health authorities said that racism was a virus as bad as COVID-19, so therefore it was permitted.

The protests had turned to riots in many cities, and the police were being defunded and discouraged to do anything about the problem. Citizens watched in horror as downtowns burned and drug-crazed freaks took over whole sections of cities. It was like every standard of decency had been zapped out of an entire swath of the population.

Meanwhile, large checks were arriving in people’s bank accounts, defying every normal economic expectation. How could people not be working and get their bank accounts more flush with cash than ever? There was a new law that didn’t even require that people pay rent. How weird was that? Even student loans didn’t need to be paid.

By the fall, recess from lockdown was over and everyone was told to go home again. But this time they had a job to do: They were supposed to vote. Not at the polling places, because going there would only spread germs, or so the media said. When the voting results finally came in, it was the absentee ballots that swung the election in favor of the opposition party that actually wanted more lockdowns and eventually pushed vaccine mandates on the whole population.

The new party in control took note of the large population movements out of cities and states that they controlled. This would have a large effect on voting patterns in the future. But they had a plan. They would open the borders to millions of people in the guise of caring for refugees. These new warm bodies would become voters in time and certainly count on the census when it came time to reapportion political power.

Meanwhile, the native population had begun to swim in ill health from substance abuse, widespread depression, and demoralization, plus vaccine injury. This increased dependency on the very institutions that had caused the problem in the first place: the medical/scientific establishment.

The rise of crime drove the small businesses out of the city. They had barely survived the lockdowns, but they certainly could not survive the crime epidemic. This undermined the tax base of the city and allowed the criminals to take further control.

The same cities became sanctuaries for the waves of migrants sacking the country, and partisan mayors actually used tax dollars to house these invaders in high-end hotels in the name of having compassion for the stranger. Citizens were pushed out to make way for rampaging migrant hordes, as incredible as this seems.

But with that, of course, crime rose ever further, inciting citizen anger and providing a pretext to bring in the police state in the form of the National Guard, now tasked with cracking down on crime in the transportation system.

What’s the next step? It’s probably already here: mass surveillance and censorship, plus ever-expanding police power. This will be accompanied by further population movements, as those with the means to do so flee the city and even the country and leave it for everyone else to suffer.

As I tell the story, all of this seems inevitable. It is not. It could have been stopped at any point. A wise and prudent political leadership could have admitted the error from the beginning and called on the country to rediscover freedom, decency, and the difference between right and wrong. But ego and pride stopped that from happening, and we are left with the consequences.

The government grows ever bigger and civil society ever less capable of managing itself in large urban centers. Disaster is unfolding in real time, mitigated only by a rising stock market and a financial system that has yet to fall apart completely.

Are we at the middle stages of total collapse, or at the point where the population and people in leadership positions wise up and decide to put an end to the downward slide? It’s hard to know. But this much we do know: There is a growing pocket of resistance out there that is fed up and refuses to sit by and watch this great country be sacked and taken over by everything it was set up to prevent.

Tyler Durden Sat, 03/09/2024 - 16:20

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Another beloved brewery files Chapter 11 bankruptcy

The beer industry has been devastated by covid, changing tastes, and maybe fallout from the Bud Light scandal.

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Before the covid pandemic, craft beer was having a moment. Most cities had multiple breweries and taprooms with some having so many that people put together the brewery version of a pub crawl.

It was a period where beer snobbery ruled the day and it was not uncommon to hear bar patrons discuss the makeup of the beer the beer they were drinking. This boom period always seemed destined for failure, or at least a retraction as many markets seemed to have more craft breweries than they could support.

Related: Fast-food chain closes more stores after Chapter 11 bankruptcy

The pandemic, however, hastened that downfall. Many of these local and regional craft breweries counted on in-person sales to drive their business. 

And while many had local and regional distribution, selling through a third party comes with much lower margins. Direct sales drove their business and the pandemic forced many breweries to shut down their taprooms during the period where social distancing rules were in effect.

During those months the breweries still had rent and employees to pay while little money was coming in. That led to a number of popular beermakers including San Francisco's nationally-known Anchor Brewing as well as many regional favorites including Chicago’s Metropolitan Brewing, New Jersey’s Flying Fish, Denver’s Joyride Brewing, Tampa’s Zydeco Brew Werks, and Cleveland’s Terrestrial Brewing filing bankruptcy.

Some of these brands hope to survive, but others, including Anchor Brewing, fell into Chapter 7 liquidation. Now, another domino has fallen as a popular regional brewery has filed for Chapter 11 bankruptcy protection.

Overall beer sales have fallen.

Image source: Shutterstock

Covid is not the only reason for brewery bankruptcies

While covid deserves some of the blame for brewery failures, it's not the only reason why so many have filed for bankruptcy protection. Overall beer sales have fallen driven by younger people embracing non-alcoholic cocktails, and the rise in popularity of non-beer alcoholic offerings,

Beer sales have fallen to their lowest levels since 1999 and some industry analysts

"Sales declined by more than 5% in the first nine months of the year, dragged down not only by the backlash and boycotts against Anheuser-Busch-owned Bud Light but the changing habits of younger drinkers," according to data from Beer Marketer’s Insights published by the New York Post.

Bud Light parent Anheuser Busch InBev (BUD) faced massive boycotts after it partnered with transgender social media influencer Dylan Mulvaney. It was a very small partnership but it led to a right-wing backlash spurred on by Kid Rock, who posted a video on social media where he chastised the company before shooting up cases of Bud Light with an automatic weapon.

Another brewery files Chapter 11 bankruptcy

Gizmo Brew Works, which does business under the name Roth Brewing Company LLC, filed for Chapter 11 bankruptcy protection on March 8. In its filing, the company checked the box that indicates that its debts are less than $7.5 million and it chooses to proceed under Subchapter V of Chapter 11. 

"Both small business and subchapter V cases are treated differently than a traditional chapter 11 case primarily due to accelerated deadlines and the speed with which the plan is confirmed," USCourts.gov explained. 

Roth Brewing/Gizmo Brew Works shared that it has 50-99 creditors and assets $100,000 and $500,000. The filing noted that the company does expect to have funds available for unsecured creditors. 

The popular brewery operates three taprooms and sells its beer to go at those locations.

"Join us at Gizmo Brew Works Craft Brewery and Taprooms located in Raleigh, Durham, and Chapel Hill, North Carolina. Find us for entertainment, live music, food trucks, beer specials, and most importantly, great-tasting craft beer by Gizmo Brew Works," the company shared on its website.

The company estimates that it has between $1 and $10 million in liabilities (a broad range as the bankruptcy form does not provide a space to be more specific).

Gizmo Brew Works/Roth Brewing did not share a reorganization or funding plan in its bankruptcy filing. An email request for comment sent through the company's contact page was not immediately returned.

 

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