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The human body has 37 trillion cells. If we can work out what they all do, the results could revolutionise healthcare

Pioneered by the Human Cell Atlas consortium, our understanding of the human body is about to be transformed – and with it, the way we treat and prevent…

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Priscilla Chan and Mark Zuckerberg with Moshe Biton (right) and Aviv Regev (left). The Chan Zuckerberg Initiative is one of the major funders of the Human Cell Atlas. Chan Zuckerberg Initiative, CC BY-ND

The average body contains about 37 trillion cells – and we are in the midst of a revolutionary quest to understand what they all do. Unravelling this requires the expertise of scientists from all different backgrounds – computer scientists, biologists, clinicians and mathematicians – as well as new technology and some pretty sophisticated algorithms.

Where once a primitive microscope, essentially little more than a magnifying glass, would reveal a new cell directly and viscerally – in the same way that Antonie van Leeuwenhoek discovered sperm in 1677 – today it is analysis on a computer screen which brings us such revelations. But it’s just as wonderful.

This type of research is hard in all sorts of ways – from the science itself to the sociology of large teams working on it – but the pay-off can be huge. It certainly was for a consortium of 29 scientists who set out to determine which types of cells make up the lining of the trachea, or windpipe – and stumbled upon a new type of cell that could transform our understanding and treatment of cystic fibrosis.

The first time the team – co-led by Aviv Regev at the Broad Institute of MIT and Harvard – came across these cells, they were looking at an analysis of 300 cells in the trachea of mice. Three cells didn’t seem to correspond to anything that had been seen before. Had it been just two, they might have dismissed it as an outcome of noise in the data – but three strange cells warranted a closer look.

In lab banter, they became known as the “hot cells”. The scientists repeated the experiment several times, and it soon became clear they really had stumbled upon a new type of cell in the trachea.

This story is part of Conversation Insights
The Insights team generates long-form journalism and is working with academics from different backgrounds who have been engaged in projects to tackle societal and scientific challenges.

As it turned out, another team from the US and Switzerland had independently found the same thing. The two teams learnt of each other’s work by chance at a seminar in 2017. “It was one of those beautiful moments in science,” recalled Moshe Biton from the Broad Institute team, “when two groups found the same results separately.”

Both groups confirmed that these new cells exist in the human airways as well as in mice and, after meeting up, agreed to publish their two papers side-by-side. These new cells had not been noticed before, simply because they are so rare – they make up around 1% of cells in the airway. But that doesn’t mean they’re unimportant. When the two teams looked in detail at what made these cells stand out, they came across something astonishing.

One of the genes active in these new-found trachea cells turned out to be CFTR – the “cystic fibrosis transmembrane conductance regulator” gene. This gave their work a whole other level of meaning because mutations in this gene cause cystic fibrosis.

Exactly how this disease is caused by the inheritance of a dysfunctional version of the CFTR gene has been a mystery ever since the link was discovered in 1989. Cystic fibrosis is a complex disease, usually beginning in childhood, with symptoms often including lung infections and difficulty breathing. There are treatments but no cure.

Now it seems possible that the key to understanding the cause could lie in working out what these newly discovered cells do, and what happens to these cells if the CFTR gene is defective. The research continues.

But already from this discovery, and other research using similar methods, there is the sense that our understanding of the body’s cells is being transformed by a piercing new combination of biology and computer science. And this is where even more game-changing discoveries are about to be made.

The diversity of human cells

Every one of the 37 trillion-or-so cells in your body is unique to some extent. Types of cell are determined by the particular proteins they contain – so only a red blood cell has haemoglobin, for example, and a neuron contains different proteins from an immune cell. No two cells in the body contain exactly the same amounts of each protein.

The immune system is especially complex. It comprises many types of cells categorised by their core function – T cells, B cells and so on. But there are also countless subtle variations of these T cells and B cells. We don’t even really know how many variants there are – but if we could understand what they all do, we would better understand the immune system. This in turn would enable us to design new medicines to help the immune system to, for example, better fight cancer.

Image of a human cell using super-resolution microscope
A human natural killer cell pictured using Stimulated Emission Depletion (STED) microscopy. Ashley Ambrose and Daniel M Davis, Author provided

One kind of immune cell that my research team at Manchester University studies is called the natural killer cell. There are about a thousand of these immune cells in each drop of your blood, and they are especially good at detecting and killing other cells that have turned cancerous or have become infected with a virus. Again, not all natural killer cells are alike. One analysis has estimated that there are many thousands of variants of this immune cell in any one person.

In 2020, my research lab carried out an analysis which suggested that variants of natural killer cells in blood could be organised into eight categories. While their different roles in the body aren’t yet fully understood, it’s likely that some are especially adept at attacking particular kinds of virus, others are better at detecting cancer, and so on.

Other types of immune cell can be even more varied. Evidently, our component cells are as diverse as the human beings they make up, and understanding how such complex populations of cells work together (in this case, to defend against disease) is a vital frontier.

Using the language of algorithms

To penetrate this complexity, the diversity of human cells must be translated into the language of algorithms.

Imagine a cell contains just two kinds of protein, X and Y. Every individual cell will have a specific amount of each of these two proteins. This can be represented as a point on a graph where the level of protein X becomes a position along the x-axis, and the level of protein Y its location along the y-axis.

One cell may contain a high amount of protein X and a little of protein Y (which can be revealed by a flow cytometer showing that the cell stains with a high amount of one antibody and a low amount of another antibody). This cell can then be represented as a point placed far along the x-axis and a little way up the y-axis.

Illustration of cell identification process. Manon Chauvin via Wikimedia, modified, Author provided

As each cell takes up a position on the graph, those with similar levels of the X and also the Y protein – likely to be the same type of cell – appear as a cluster of points. If thousands or millions of cells are plotted in this way, the number of discrete clusters that emerge tells us how many types of cells there are. Also, the number of points within a cluster tells us how many cells there are of that type.

The wonderful thing is that this form of analysis can reveal how many kinds of cells are present in, say, a sample of blood or a tumour biopsy, without being guided in any way about which cells we are expecting to find. This means that unexpected results can turn up. A cluster of data points might appear with unexpected properties – implicating the discovery a new kind of cell.

Of course, cells need more than two coordinates to describe them. In fact, over the last decade, a type of analysis – known as single-cell sequencing– has been developed to measure the extent to which individual cells use each of the 20,000 human genes it contains.

Which ones out of all the 20,000 human genes a particular cell is using – called the cell’s transcriptome – can then be analysed to create a “map” of different cells. We can’t imagine cells represented on a graph with 20,000 axes, but a computer algorithm can handle this analysis in just the same way it would one with only two variables. Similar cells are positioned close together, while cells using very different sets of genes are far apart.

Algorithms to do this are borrowed from other fields of science, such as those used in analysing social networks. Then we get to spend days, if not years, mining the output, deciphering what the map means: how many types of cells there are, what defines their differences, and what they do in the body?

Right now, this endeavour is happening on an unprecedented scale thanks to the Human Cell Atlas consortium – leading to all kinds of discoveries about the human body.

The Human Cell Atlas

In October 2016, Regev and Sarah Teichmann from the Wellcome Sanger Institute organised an event in London for around 100 world-leading scientists to discuss how to chart every cell in the human body. The elevator pitch was to assemble something like Google Maps for the body: “We know the countries and main cities, now we need to map the streets and buildings.”

A year later, they had drafted a specific plan – to first try to profile 100 million cells from different systems and organs, using different people around the globe. Thousands of scientists in over 70 countries from every inhabited content have joined the consortiu since – it is an especially diverse community, as it should be for such a huge global scientific endeavour.

Large gathering of scientists
First meeting of the Human Cell Atlas team in London, 2016. Thomas Farnetti/Wellcome, CC BY-ND

In many ways, this bold new ambition is a direct descendant of the Human Genome Project. By sequencing all the human genes contained in each human cell, officially completed in April 2003, all sorts of genetic variations have been linked to increased susceptibility to a specific illness.

However, genetic diseases manifest in the specific cells where that gene is normally used. So, crucially, an analysis of genes alone isn’t enough – we also need to know where in the human body these disease-causing genes are being switched on.

The Human Cell Atlas is bridging this gap between abstract genetic codes and the physicality of the human body. We’ve already seen one example of how important this is – the discovery of the cystic fibrosis gene being used by a new, rare cell. Another example comes from what happens during pregnancy.

Unlocking the secrets of pregnancy

For many years, we have known that the immune system is intimately linked with pregnancy. For example, some combinations of immune system genes are slightly more frequent than would be expected by chance in couples who have had three or more miscarriages. While we don’t yet understand why this is, working it out might be medically important in resolving problems in pregnancy.

To tackle the issue, a consortium of scientists (co-led by Teichmann as part of the Human Cell Atlas project) analysed around 70,000 cells from the placenta and lining of the womb from women who had terminated their pregnancy at between six and 14 weeks.

The placenta is the organ where nutrients and gases pass back and forth between the mother and developing baby. It was once thought the mother’s immune system must be switched off in the lining of the womb where the placenta embeds, so that the placenta and foetus aren’t attacked for being “alien” (like an unmatched transplant) on account of half the foetus’s genes coming from the father. But this view turned out to be wrong – or too simple at the very least.

We now know, from a variety of experiments including this analysis, that in the womb, the activity of the mother’s immune cells is somewhat lessened, presumably to prevent an adverse reaction against cells from the foetus, but the immune system is not switched off. Instead, the immune cells we met earlier, natural killer cells, well known for killing infected cells or cancer cells, take on a completely different, more constructive job in the womb; helping build the placenta.

The scientists’ analysis of 70,000 cells has also highlighted that all sorts of other immune cells are also important in the construction of a placenta. What they all do, though, isn’t yet clear – this is at the edge of our knowledge.

Scientist talking at meeting
Muzlifah Haniffa at the Human Cell Atlas launch meeting in 2016. Thomas Farnetti/Wellcome, CC BY-ND

Muzlifah “Muzz” Haniffa is one of the three women who led this analysis. As a physician and scientist, she sees the body from two perspectives on an almost daily basis: as a computational analysis of cells on a screen, and as patients who walk through the door. Both as stones and the arch they make.

Right now, these two views don’t easily mesh. But in time, they will. In the future, Haniffa thinks the tools doctors use on a daily basis – such as a stethoscope to listen to a person’s lungs, or a simple blood count – will be replaced by instruments that profile our body’s cells. Algorithms will analyse the results, clarify the underlying problem, and predict the best treatment. Many other physicians agree with her – this is the coming future of healthcare.

What this could mean for you

Babies are now routinely born by IVF, organ transplants have become common, and overall cancer survival rates in the UK have roughly doubled in recent years – but all these achievements are nothing to what’s coming.

As I’ve written about in The Secret Body, progress in human biology is accelerating at an unprecedented rate – not only through the Human Cell Atlas but in many other areas too. Analysis of our genes presents a new understanding of how we differ; the actions of brain cells give clues to how our minds work; new structures found inside our cells lead to new ideas for medicine; proteins and other molecules found to be circulating in our blood change our view of mental health.

Of course, all science has an ever-increasing impact on our lives, but nothing affects us as deeply or directly as new revelations about the human body. On the horizon now, from all this research, are entirely new ways of defining, screening and manipulating health.

We are already accustomed to the idea that our personal genetic information can be used to guide our health. But a quieter – almost secret – revolution is also under way and it may have an even bigger impact on the future of healthcare: deep analytics of the human body’s cells.

In the future a whole cloud of health information will be available to you, if you want to delve into it. Shutterstock

One day, a watch that can measure a few simple things about your body will be seen as a laughably primitive tool. In the future, maybe within ten years or so, a whole cloud of information will be available – including an analysis of your body’s cells – and you will have to decide how much you want to delve into it. This revolution in human biology will equip us individually with new powers – and we will each need to decide for ourselves if and when to deploy them.

You may, for example, one day visit your doctor with something abnormal on your skin – a rash, itch, or something else. The doctor may then take a small sample of your skin, or perhaps a blood sample, and from a complete cell-by-cell analysis of what’s there, be able to precisely diagnose the problem and know the best treatment. Indeed, some of this might even be automated. Further into the future, if the equipment needed to do this gets small and cheap enough, perhaps the analysis could be done by yourself at home.

Diseases will also be more frequently predicted before any symptoms are present at all. Of course, this is one of the most vital missions of science: to stop human disease before it even begins. For some illnesses, this has been achieved already – with vaccines, clean water and improved sanitation. Now, with the human body opening up to us through computational analysis of cells, genes and more, new ways of pre-empting disease are emerging. We are compelled to seize this new opportunity – yet in practice, there are challenges and unintended consequences to contend with.

Take a familiar example: the idea of the body-mass index, a value derived from a person’s weight and height. This is used to label us as underweight, normal weight, overweight or obese. It’s useful as it indicates an increased risk of health problems arising, such as type 2 diabetes, and steps can be taken to reduce the likelihood of this occurring. But the label itself can also trigger other sorts of problems relating to a person’s self-worth, and how society views obesity and human diversity.

Difficult decisions about how you live

Every one of us is susceptible to some disease or other, to some extent. So as science progresses and we learn more and more about ourselves, we will surely all find ourselves drowning in data about ourselves, awash with estimates and probabilities that play games with our mind and our identity, and require us to make difficult decisions about our health and how we live.

It seems feasible, for example, that the state of a person’s immune system, analysed in depth, could help predict the symptoms they are likely to have if infected with the Sars-CoV-2 virus, for example. Markers of immune activity might even correlate with a person’s mental health. One analysis concluded that particular pro-inflammatory secretions from immune cells (called cytokines) are found at higher levels in people who are depressed.

Read more: Coronavirus: we must step up research to harness immense power of the immune system

As we learn about the composition and status of the human body, this will inevitably establish new ways of assessing health. And it may very well help resolve problems in pregnancy too, as we’ve seen. But there are problems here too – if an analysis suggests a chance of a problem, say 50%, how would you act on this information if the medical intervention that could help has its own risks too?

There is seemingly no end to how the metric analysis of the human body will lead to important but complex new health decisions. Angelina Jolie famously acted on genetic information when she had both of her breasts surgically removed in 2013, and later her ovaries and fallopian tubes, following a genetic test which established that she had inherited a particular variation in a gene known as BRCA1. Crucially, she had been given a very high – 87% – chance of developing breast cancer. In general, risks and probabilities about our health are much less clear than this.

So the question arises, how are we to act on all this new information? What if something has been identified that means your risk of developing an autoimmune disease or cancer is one in six in the next ten years? Would it be different if it was one in four? At what point would you decide to take medicine as a precaution, or undergo surgery, knowing that they also carry their own risks? And would this knowledge in itself make you feel ill? Would your identity be affected?

I don’t have the answers – but that’s the point. As this new science progresses, each of us will have to decide how much we really want to know about ourselves.

For you: more from our Insights series:

To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. Subscribe to our newsletter.

This article is an edited extract from Daniel M. Davis' new book The Secret Body (Vintage paperback, 2022). Davis is also the author of two previous books The Beautiful Cure and The Compatibility Gene. He receives research funding from The Medical Research Council, Cancer Research UK, Wellcome, GSK and Bristol Myers Squibb. He tweets at @dandavis101

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Rand Paul Teases Senate GOP Leader Run – Musk Says “I Would Support”

Rand Paul Teases Senate GOP Leader Run – Musk Says "I Would Support"

Republican Kentucky Senator Rand Paul on Friday hinted that he may jump…

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8 hours ago

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March 10, 2024

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Rand Paul Teases Senate GOP Leader Run - Musk Says "I Would Support"

Republican Kentucky Senator Rand Paul on Friday hinted that he may jump into the race to become the next Senate GOP leader, and Elon Musk was quick to support the idea. Republicans must find a successor for periodically malfunctioning Mitch McConnell, who recently announced he'll step down in November, though intending to keep his Senate seat until his term ends in January 2027, when he'd be within weeks of turning 86. 

So far, the announced field consists of two quintessential establishment types: John Cornyn of Texas and John Thune of South Dakota. While John Barrasso's name had been thrown around as one of "The Three Johns" considered top contenders, the Wyoming senator on Tuesday said he'll instead seek the number two slot as party whip. 

Paul used X to tease his potential bid for the position which -- if the GOP takes back the upper chamber in November -- could graduate from Minority Leader to Majority Leader. He started by telling his 5.1 million followers he'd had lots of people asking him about his interest in running...

...then followed up with a poll in which he predictably annihilated Cornyn and Thune, taking a 96% share as of Friday night, with the other two below 2% each. 

Elon Musk was quick to back the idea of Paul as GOP leader, while daring Cornyn and Thune to follow Paul's lead by throwing their names out for consideration by the Twitter-verse X-verse. 

Paul has been a stalwart opponent of security-state mass surveillance, foreign interventionism -- to include shoveling billions of dollars into the proxy war in Ukraine -- and out-of-control spending in general. He demonstrated the latter passion on the Senate floor this week as he ridiculed the latest kick-the-can spending package:   

In February, Paul used Senate rules to force his colleagues into a grueling Super Bowl weekend of votes, as he worked to derail a $95 billion foreign aid bill. "I think we should stay here as long as it takes,” said Paul. “If it takes a week or a month, I’ll force them to stay here to discuss why they think the border of Ukraine is more important than the US border.”

Don't expect a Majority Leader Paul to ditch the filibuster -- he's been a hardy user of the legislative delay tactic. In 2013, he spoke for 13 hours to fight the nomination of John Brennan as CIA director. In 2015, he orated for 10-and-a-half-hours to oppose extension of the Patriot Act. 

Rand Paul amid his 10 1/2 hour filibuster in 2015

Among the general public, Paul is probably best known as Capitol Hill's chief tormentor of Dr. Anthony Fauci, who was director of the National Institute of Allergy and Infectious Disease during the Covid-19 pandemic. Paul says the evidence indicates the virus emerged from China's Wuhan Institute of Virology. He's accused Fauci and other members of the US government public health apparatus of evading questions about their funding of the Chinese lab's "gain of function" research, which takes natural viruses and morphs them into something more dangerous. Paul has pointedly said that Fauci committed perjury in congressional hearings and that he belongs in jail "without question."   

Musk is neither the only nor the first noteworthy figure to back Paul for party leader. Just hours after McConnell announced his upcoming step-down from leadership, independent 2024 presidential candidate Robert F. Kennedy, Jr voiced his support: 

In a testament to the extent to which the establishment recoils at the libertarian-minded Paul, mainstream media outlets -- which have been quick to report on other developments in the majority leader race -- pretended not to notice that Paul had signaled his interest in the job. More than 24 hours after Paul's test-the-waters tweet-fest began, not a single major outlet had brought it to the attention of their audience. 

That may be his strongest endorsement yet. 

Tyler Durden Sun, 03/10/2024 - 20:25

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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.

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11 hours ago

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March 10, 2024

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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.

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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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Beloved mall retailer files Chapter 7 bankruptcy, will liquidate

The struggling chain has given up the fight and will close hundreds of stores around the world.

Published

16 hours ago

on

March 10, 2024

By

It has been a brutal period for several popular retailers. The fallout from the covid pandemic and a challenging economic environment have pushed numerous chains into bankruptcy with Tuesday Morning, Christmas Tree Shops, and Bed Bath & Beyond all moving from Chapter 11 to Chapter 7 bankruptcy liquidation.

In all three of those cases, the companies faced clear financial pressures that led to inventory problems and vendors demanding faster, or even upfront payment. That creates a sort of inevitability.

Related: Beloved retailer finds life after bankruptcy, new famous owner

When a retailer faces financial pressure it sets off a cycle where vendors become wary of selling them items. That leads to barren shelves and no ability for the chain to sell its way out of its financial problems. 

Once that happens bankruptcy generally becomes the only option. Sometimes that means a Chapter 11 filing which gives the company a chance to negotiate with its creditors. In some cases, deals can be worked out where vendors extend longer terms or even forgive some debts, and banks offer an extension of loan terms.

In other cases, new funding can be secured which assuages vendor concerns or the company might be taken over by its vendors. Sometimes, as was the case with David's Bridal, a new owner steps in, adds new money, and makes deals with creditors in order to give the company a new lease on life.

It's rare that a retailer moves directly into Chapter 7 bankruptcy and decides to liquidate without trying to find a new source of funding.

Mall traffic has varied depending upon the type of mall.

Image source: Getty Images

The Body Shop has bad news for customers  

The Body Shop has been in a very public fight for survival. Fears began when the company closed half of its locations in the United Kingdom. That was followed by a bankruptcy-style filing in Canada and an abrupt closure of its U.S. stores on March 4.

"The Canadian subsidiary of the global beauty and cosmetics brand announced it has started restructuring proceedings by filing a Notice of Intention (NOI) to Make a Proposal pursuant to the Bankruptcy and Insolvency Act (Canada). In the same release, the company said that, as of March 1, 2024, The Body Shop US Limited has ceased operations," Chain Store Age reported.

A message on the company's U.S. website shared a simple message that does not appear to be the entire story.

"We're currently undergoing planned maintenance, but don't worry we're due to be back online soon."

That same message is still on the company's website, but a new filing makes it clear that the site is not down for maintenance, it's down for good.

The Body Shop files for Chapter 7 bankruptcy

While the future appeared bleak for The Body Shop, fans of the brand held out hope that a savior would step in. That's not going to be the case. 

The Body Shop filed for Chapter 7 bankruptcy in the United States.

"The US arm of the ethical cosmetics group has ceased trading at its 50 outlets. On Saturday (March 9), it filed for Chapter 7 insolvency, under which assets are sold off to clear debts, putting about 400 jobs at risk including those in a distribution center that still holds millions of dollars worth of stock," The Guardian reported.

After its closure in the United States, the survival of the brand remains very much in doubt. About half of the chain's stores in the United Kingdom remain open along with its Australian stores. 

The future of those stores remains very much in doubt and the chain has shared that it needs new funding in order for them to continue operating.

The Body Shop did not respond to a request for comment from TheStreet.   

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