The Economist 2020-01-19 · reckons that if AML sells 5,000 of the cars that start at £158,000 at a 15% margin, that would only bring in enough cash to cover £100m in annual interest

Thecontents

[2020-01-19]

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Business

AstonMartinisstuckinidle[Jan16th2020]

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Drivingnowherefast

AstonMartinisstuckinidle

FEWASTONMARTINownersdarepushtheirsportscarstotheedgeoflosinggripinafastcorner.ThesamecannotbesaidofshareholdersinAstonMartinLagonda(AML),whichownstheprestigebrand.Anill-judgedinitialpublicofferingin2018,predicatedonrapidgrowth,hasthecompanycareening.

TheIPOwasanattempttoemulatethesuccessofFerrari,whichfloatedin2015.(ThechairmanofExor,whichhasasignificantstakeinFerrari,alsositsontheboardofTheEconomist’sparentcompany.)TheItaliansupercar-makerenjoys25%operatingmargins,closertowhatLVMHmakesonitsLouisVuittonhandbagsthanwhatDaimlergetsforMercedescars.Ferrari’ssharepricehastrebledsincegoingpublic.AML’s,bycontrast,hasplungedbythree-quarters.Itsmarketvaluenowstandsatjust£1.1bn($1.4bn).Afterturninganoperatingprofitin2017and2018,inNovemberitreportedalossforthefirstninemonthsoflastyear.OnJanuary7ththecompanyissueditssecondprofitwarningsinceJuly.

AMLissellingfarfewercarsthanithoped—20%fewerrelativetoearlyforecastsfor2019,whenaround5,800actuallyrolledofftheproductionline.Thegoalofmaking14,000carsayearby2023looksfanciful.Attemptstomeetit,byinvestinginnewmodels,haveleftAMLwithnetdebtsofaround£900m.Warybondinvestorsaredemandingcouponsashighas15%torefinance£100mabouttocomedue.AstonMartinhaspasteditslogoonhelicoptersandblocksofflats.ButifMaxWarburtonofBernstein,anequity-researchfirm,iscorrectinhishereticalsuggestionthatperhapsthebrandisnotthatstrongafterall,suchnon-autoventuresmayflop.

Aston’slegacyoflosingmoneyisasrichasthatofmakingfastandglamorouscars.Inits106yearsJamesBond’swheelsofchoicehaveenduredsevenbankruptcies.ThistimeinvestorsbetonAMLthankstoacredibleleader—AndyPalmer,ashrewdindustryexecutive—andaplausibleplantoexpanditsrangeofvehicles.IthasalreadylaunchedthreenewGTcars,suitedtolong,comfyjourneys.Nextyearitplanstounveilamid-enginedcar,theValhalla,totakeonFerrari,better-knownforsuchmachines.Andithastaken1,800ordersforitsSUV,theDBX,followinginthetyretracksofBentley,Rolls-RoyceandLamborghini.

EvenifalltheseAMLofferingsprovewildlysuccessful,theymaynotbringinenoughcashtoensureasuccessionofnewmodelsneededtokeepwealthypetrolheadscomingbacktothebrand.PhilippeHouchoisofJefferies,abank,reckonsthatifAMLsells5,000ofthecarsthatstartat£158,000ata15%margin,thatwouldonlybringinenoughcashtocover£100minannualinterestonitsdebts.TheoverallmarketforsportscarsisnotgrowingfastandEvercoreISI,abroker,pointsoutthatrivals’SUVshaveeatenintosalesoftheirothercars.AMLcanexpectthesame.

MrHouchoisreckonsthatAMLneeds£400m-500mtotackleitsdebtsandinvestinitsfuture.Thefirmsaysitis“reviewingitsfundingrequirements”.LawrenceStroll,aCanadianbillionairewhoco-ownsaFormula1team,issaidtobereadytoinject£200mintothebusiness.ApparentinterestbyGeely,aChinesecarmakerthatalsoownsVolvo,Lotusand10%ofDaimler,pushedAML’ssharesupthismonth.Butanyrescuer,shouldonecomeforth,riskslookinglikeanAstonMartinbuyer—stuckowningafast-depreciatingtrophyasset.■

ThisarticleappearedintheBusinesssectionoftheprinteditionundertheheadline"AstonMartinisstuckinidle"

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Booksandarts

Whodotheythinktheyare?[Jan16th2020]





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Johnson

Whodotheythinktheyare?

GRAMMARHASrarelyproducedasmuchpublicacrimonyasinthebattleoverpronounsbeingwagedaroundtheworld.Inoneskirmishin2015,theUniversityofTennesseeofferedguidanceonreferringtonon-binarystudentsonitswebsite,onlyforpoliticalblowbacktoleadtoalegislativebanonspendingpublicmoneytosupportnon-traditionalpronouns.JordanPeterson,acontroversialCanadianacademic,hasrefusedtouseinventedpronounsor“they”inrelationtopeoplewhoidentifyasneithermalenorfemale.Manyfulminatingcommentatorsspypoliticalcorrectnessrunningamokyetagain.

IntothebreachcomesausefulcorrectiveintheformofDennisBaron’swell-timednewbook,“What’sYourPronoun?”MrBaronisalinguistattheUniversityofIllinois,andalongtimescholarofacuriousgapintheEnglishlanguage.Forcenturies,peoplehavewrestledwiththefactthatthereisnouncontroversialpronountorefertoasubjectofunknown,indeterminateormixedgender.

Singularthey,insentencessuchas“Everyonelovestheirmother”,hasbeenderidedasincorrectforalongtime.MrBarontracksthefirstsuchrulingtoa16th-centuryLatingrammar,whichdeclaredthemasculinethemorehonourablegenderthat,wherenecessary,encompassesthefeminine.Inthe18thand19thcenturies,thisviewmadeitswayintoEnglishgrammars:whenreferringtoagenericperson,youshouldsay“Everyoneloveshismother.”

Buttherewerewideholesinthisargument.Proponentsoftheruletreateditasasimplematterofgrammaticalagreement:everyoneisgrammaticallysingular,sorequiresasingularpronoun.Theyispluralandwon’tdo.Torealsticklersforagreement,however,pronounsmusttallyinbothnumberandgender.Generictheyiswrongbynumber,butgenericheiswrongbygender.

Nonetheless,“heincludesshe”wasintextbooks,andso,foratime,proto-feministstriedtotakeadvantagewheretheycould.Lawssayingthateachpersonshouldpay“his”taxesrequiredwomentopay,too.So,19th-centurysuffragistsreasoned,thestatutebooksreferringtoagenericvoteras“he”gavewomentherighttovote.Seeminglyhoistonthechauvinistpetard,defendersofmale-onlysuffragetacticallyretreated:heincludedsheunlessitwouldproducean“absurd”reading—suchasofferingwomenthevote.(Sinceitwasoftenheldthathusbandsvotedintheirwives’interests,SusanB.Anthony,a19th-centuryAmericansuffragist,suggestedthatifawomancommitsmurderherhusbandshouldbehangedinherstead.)

Giventheproblemswithhe,lotsofpeoplehaveinventednew,gender-freepronouns.ThefirstoneMrBaroncouldfind(ofmorethan250intotal)datesto1841:E.Othersuggestionscontinueinasteadystreamuntiltoday.Everyonceinawhile,onefoundatinypurchase.In1884threedictionariesincludedthon,shortenedfromthatone,butitfailedtocatchon.TheSacramentoBee,anewspaper,saidin1920thatitwouldusehirinplaceof“heorshe”,anddidsosporadicallyuntilthe1940s,butittoofadedaway.

The“missingword”,MrBaronsays,is“they”.Peoplehavebeenusingitasagenericsingularinwritingsinceatleast1375,andhavedoubtlessbeensayingitevenlonger.IthasappearedassuchintheKingJamesBible,theworksofShakespeareandthenovelsofJaneAusten.Recently,growingnumbersofstyleguides,includingthoseofTheEconomistandtheAssociatedPressaswellastheChicagoManualofStyle,haveconcludedthatitisoftenthemostpragmaticofasetofimperfectsolutions.

Butallthatcomesasadifferentsingulartheyhascometothefore:torefertoaknownindividualwhoidentifiesasnon-binary,asgrowingnumbersdo,insentencessuchas“Alexforgottheirkeys.”ThisistheincreasinglywidespreadsingulartheythatwasrecentlyrecognisedbytheAmericanDialectSocietyasitsWordoftheDecade.

Thetwousagesarequitedifferent.Theonein“Everyonehastheirownopinion”isactuallyquiteconservative,givenitsage,itsliterarypedigreeandthefactthatmostpeoplealreadysayitincasualspeech.Theyin“Alexforgottheirkeys”is,bycontrast,innovativeandjarringtomany;fortheuninitiated,ittakespracticetouseitconsistently.Andthoughbothfeministsandtransgenderactivistshaveembracedthesingularthey,theyhavedonesofordifferentreasons,andotherissuesstilldividethem.Araremomentofliberationthroughgrammarrisksbeingcaughtupinwider,rancorousculturewars.

ThisarticleappearedintheBooksandartssectionoftheprinteditionundertheheadline"Whodotheythinktheyare?"






TheAmericas

Baseball-madAndrésManuelLópezObradorthrowsmoneyatthegame[Jan16th2020]






Outofleftfield

Baseball-madAndrésManuelLópezObradorthrowsmoneyatthegame

“TRAITOR.YOUAREATRAITOR.”ThatishowEduardoGaleano,aleftistwriterfromUruguay,greetedCheGuevarainHavanaintheearly1960s.TheArgentine’scrimehadbeentoabandonLatinAmerica’sfavouritepastime,football,forNorthAmerica’s.ACubannewspaperhadpublishedaphotoofhimplayingbaseball.Guevara,whosaiditwas“thefirsttimesomeonecallsmeatraitorandkeepsliving”,learnedtoplayinaMexicanprisonwhilejailedwithFidelCastrointhe1950s.

Heisnottheonlyleft-wingleadertohavecaughtthebaseballbuginMexico.AndrésManuelLópezObrador,thecountry’spresident,hasbeenafanaticsincechildhood.Hewontheelectionin2018bypledgingtogotobatforthepoorandvowsto“strikeout”Mexico’s“mafiaofpower”.

Underhisprogrammeof“republicanausterity”,thegovernmenthasslashedspendingoneverythingfromchildcaretomedicines.Baseballisanexception.

InMarchMrLópezObradoropenedanOfficeforthePromotionandDevelopmentofBaseball.Itgot350mpesos($19m)tospotandnurturetalent.Bureaucratsatnon-baseballagencieswereenraged.

Mexico’sconstitutiontellsthegovernmentto“promoteandstimulate”sport.Itdoesnotsaywhichones.MrLópezObradorhascutfundingforFormula1andAmerican-footballevents.Baseball,though,is“morethanasport.Itisafruitfulpassionthatrequireshead,heartandcharacter,”hesaidlastyearattheopeningofastadiuminMexicoCity.Hebecamethefirstpresidentin72yearstothrowanopeningpitch.

MrLópezObradorwantstospreadthegamebeyonditsstrongholdsneartheAmericanborder.Hedreamsthat50Mexicanswillbeplayinginmajorleaguesabroad,afourfoldincrease,bythetimehistermendsin2024.HewantstocombineMexico’stworegionalleaguesintoasingle26-teamcompetition.

BaseballnevercaughtoninMexicoasitdidinCubaandVenezuela.Mexicanbaseball’sbestmomentscamebefore1947,duringtheperiodwhenAmericanleaguesbarredblackplayers.SomeplayedforMexicanteams.DuringthesecondworldwarJorgePasquel,thepresidentofMexico’sleague,wangleddraftdefermentsfromtheAmericangovernmentforAmericanplayersheadingtoMexico.ThatmayhaveencouragedMexicotocontinueaprogrammeunderwhichMexicanworkershelpedthewareffortintheUnitedStates.

ThanksnodoubtinparttoMrLópezObrador’sfandom,attendanceatMexicanBaseballLeaguegamesroseby30%lastyear.InAprilMexicoCitywillhostregular-seasonMajorLeagueBaseballgamesforthefirsttimesince2004.Mexico’snationalteamisoneofsixtoqualifyforthissummer’sOlympicgamesinTokyo.

MrLópezObrador,whois66,saysthathadhisarmyofscoutsbeenaroundinhisyouthhewouldnothavebecomeapolitician.Butpowerhasitsperks.HugoChávez,aleftist(andleft-handedpitcher)whogovernedVenezuelafrom1999to2013,calledthemanagerofVenezuela’snationalteamaftereachgametooffertipsontacticsandselection.MrLópezObrador,whoresiststhetrappingsofpower,maybetemptedtoringuptheMexicanmanager.■

ThisarticleappearedintheTheAmericassectionoftheprinteditionundertheheadline"Baseball-madAndrésManuelLópezObradorthrowsmoneyatthegame"






Briefing

Backpainisamassiveproblemwhichisbadlytreated[Jan18th2020]






Theburdenofbackpain

Backpainisamassiveproblemwhichisbadlytreated

PETEMOOREwas43whenhewokeuponeautumnmorningwithbackpainsoexcruciatingthathestruggledtodresshimself.HisdoctorinRomford,anEnglishtown,referredhimtohospitalforanMRIscan;thisshowedthatsomeofthespongelikediscsthatseparatethespine’svertebraewerebulgingoutoftheslotsintowhichtheycustomarilyfit.Such“slipped”discscanbecausedbyaninjury;buttheyarealsothesortofthingwhichcanjusthappenwithincreasingage.

MrMoorereceivedaprescriptionforopioidstohelphimcopewiththepain;butthepainpersisted,andhefoundhimselfbecomingloopy.Unabletoworkordomuchelse,MrMoore,whohadbeenapainter,sankintodepression.Threeyearsintohisordeal,hesays,hewas“thinkingofendingitall”.

Thecosts,however,havebeenrisingquitequickly—andareenormous.In2013,accordingtoonestudy,$88bnwasspentonmedicaltreatmentsforbackandneckpaininAmerica,notfarshortofthe$115bnspentoncancer(morerecentfigureshavenotbeenanalysedinacomparableway).Agreatdealofthismoneyseems,sadly,todolittlegood.

DoctorsusedtothinkthatbackpainwasalmostentirelytheresultofmechanicaldamagetotissuebeyondthecapacityofX-raystodetect.TheadventofMRIscansshowedthiswasnottrue.Adefinitivephysicalcause—suchasafracture,atumour,pressureonanerve,infectionorarthritis—isfoundin5-15%ofpeoplewithbackpain.Therestisalllabelledas“non-specific”,andthereisincreasingevidencethatitisnotmechanicalinorigin.

Backpain,likeallpain,isexperiencedinthebrainnotthebody;nervescomingintellthebrainthatsomethingisamiss,andthebrainprojectsanappropriatesensationofpain.Researcherswhospecialiseinpainincreasinglybelievethat,inmostcases,chronicpainmeansthatthesystemhasbecomedamagedinsomewaythatkeepsitswitchedon.“It’slikeafirealarmthatgoesoffafterthefirehasbeenextinguished,”saysLucieKnight,apsychologistatapainclinicinStThomas’Hospital,inLondon.Backpainmayalsoberelatedtootheraspectsofaperson’slifenotgoingwell.

Takingthisviewseriouslythrowsintodoubtagreatdealofthemedicaltreatmentofbackpain—muchofwhich,ineffect,seekstosilencethemaddeningsoundofthefirealarmbyputtingoutafirethatisn’tthere.Butitdoesnotofferanobviousmedicalalternative.Somepainmedicines,suchasparacetamol,donotworkatallforbackpain.Opioids,foralltheirreputedanalgesicpotency,offerback-painrelieflittleifanybetterthanoptionssuchasibuprofen.Theircontinueduseoftenmakespainworseratherthanbetter,andishighlylikelytocauseaddiction.

Drugsthatworkedbetteranddidlessharmwouldbeaboon.Buttheyhaveprovedhardtodevelop.Themechanismsinthenervoussystemandbrainwhichgeneratepainarecomplex,andcandoubtlessgowronginavarietyofways,saysSteveMcMahonofKing’sCollegeLondon.Hethinksthatthedevelopmentofdrugsforchronicpainhasapoorrecordbecausethepeopletheyaretriedonhavearangeofdifferentproblems.

Evidenceofineffectivenesshasnotstoppeddoctorsfromwritingprescriptionsforthedrugstheyhave.TheprevalenceofchronicbackpainprovidedahugeexpanseoffertilegroundforthedeceptivemarketingandpoorprescriptionbehindAmerica’sopioidepidemic(seeBartleby).Inmanycountriesdoctorsalsofrequentlyprescribepainkillerscalledgabapentinoids,despitestrongevidencefromtrialsthat,asfarastreatingbackpaingoes,theyoffernobenefits.

Therearealsoalotoftreatmentsforthebackitself.Spinesareinjectedwithcement-likemixturesorfittedwithvarioustypesofmedicalhardware.Vertebraearefusedtogether,discsexcisedortamperedwithinvariousways.Yet—unsurprisingly,ifitislargelythepainmechanismwhichistheproblem—thereisagrowingbodyofevidencethatthebenefitsallthisofferstomostpatientsarelimitedornon-existent.

Evenjustlookingatthebackcausesproblems.Only1-5%ofpeoplewithbackpainhaveaproblemthatrequiresurgenttreatment,suchasaninfectionoratumour;insuchcasesthepainwilltendtobeaccompaniedbyothersymptomstoo,suchasweightloss,feverorincontinence.InAmericaandwesternEuropeguidelinessaythatitisonlywhensuchredflagsarepresentthatapatientpresentingwithbackpainshouldpromptlybegivenanx-rayoranMRIscan.Yetgeneralpractitionersandhospitalsroutinelyignorethis,sending40-60%ofpeoplewithbackpaintobescanned—farmorethantheydid20yearsago.AccordingtoJanHartvigsenoftheUniversityofSouthernDenmarkthereisabroadconsensusthatabout80%ofsuchscansareuseless.

Thatmightbefineifthescansweresometimeshelpfulandneverharmful.Butfewbodiesarecompletelynormal,andlearningofyourparticular“abnormalities”inamedicalsettingandwhilesufferingisalarmingevenifahealthybackmightlookjustasodd.Disc“degeneration”isseeninroughlyhalfofyoungandmiddle-agedadultswithbackpain,butalsoinathirdofthosewithnopainatall.Some40%ofpeoplewithbackpainhavediscprotrusion,aformof“slipped”disc;butsodonearly20%ofpeoplewhoarepain-free.

Bothpatientsanddoctors,though,tendtothinkthatiftheycanseesomethingtheyshoulddosomething.Somesuffererscatastrophisethenewsintotheideathattheyhaveabroken,fragilebackandstartavoidingnormalphysicalactivity—notleast,saysMsKnightofStThomas’,becausedoctorsoftenfailtoexplaintothemthatabnormalitiesare,infact,quitenormal,andthatdegenerationcanbasicallybewearandtear.Thestiffnessandweakeningofthemusclesthisinactivitybringsoftenmakesthingsworse.Anddoctorsmaytakeabnormalitiesasacueforfurthermedicalattention.Manystudieshaveconfirmedthatpatientswhoreceiveunwarrantedimaginginthefirstfewweeksofbackpainaremorelikelytohavesurgeryandunnecessaryfollow-upteststhansimilarpatientssparedthescans—butthattheyenjoynobenefitsintermsofpainreductionorlesseneddisability.

In2011Cigna,anAmericaninsurancecompany,ranafollow-upstudyonpatientswhohadundergoneproceduresinwhichvertebraearestitchedtogetherwithimplantedboltsandbraces.“Spinalfusion”ofthistypeisafrequentlyusedsurgicalresponsetobackpainthatisassociatedwiththedegenerationofspinaldiscs;in2015therewereroughly85,000suchsurgeriesinAmerica.Thecompanyfoundthattwoyearsaftertreatment87%ofcustomerswerestillinpainsevereenoughformedicationorsomeothertreatment;15%hadmoresurgery.

Thisisgoingtohurt

Itallsoundsdepressing.Itneednotbeso.Therearewaysofdealingwithbackpainthatwastemuchlessmoneyandleavepatientslessdistressedandwithagreatersenseoftheirownagency.

MrMoore,thepatientwithwhomthisstorybegan,triedtocometotermswithhisdisablingpainbystartingasupportgroupforfellowsufferers.ApsychologistfromStThomas’,whichhasthebiggestpainclinicinEurope,cametotalktothemabout“gradedexercise”andtheimportanceofpacingthemselveswhengoingoutandabout.“NobodyhadtoldmeIcoulddothesethings,”saysMrMoore.In1996,threeyearsafterbackpainhadcometodominatehisexistence,atwo-weekresidentialprogrammeatthepainclinictaughthimwhatitteachespeopletoday:exercisedaily;acceptflare-upsastemporarysetbacks;don’tgetfixatedonthepain.Learningtokeepgoingthisway“savedmylife”,MrMooresays.

Theprogramme,explainsMsKnight,aimsnottoreducepainsomuchastoaddtolife.Peoplenaturallystruggleagainstthepain,whichmeanstheyareburdenedwiththepainandthestruggletoo.“Ifyoucandropthestruggle,”saysMsKnight,“thenyouhaveyourhandsfreetodomore.”Patientsaretaughthowtograduallyovercometheirfearsofexerciseanddailyactivitiesthatcancausesomepain.Thegoalsthattheystartwithcanbeassimpleascallingafriendandmeetingforacoffee,orattendingawedding.Inatypicalclassoftenpeople,MsKnightsays,oneortwodecidethattheapproachisnotwhattheywant,andmaydropout.Mostofthemtakeawayatleastsomeskillswhichaddtotheirqualityoflife.Oneortwo,likeMrMoore,findtheprogrammelife-changing.

Variouscountrieshavetriedtoencouragepeoplewithbackpaintostayactive,withpromisingeffects.Onesuchcampaign,inAustralia,isreckonedtohaveled

toa15%reductioninthenumberofdoctorvisitsforbackpainanda20%decreaseinrelatedmedicalcosts.Suchcampaignsappeartoworkbestwhentheyprovidepracticaladviceonhowtostayactiveandatworkdespitethepain,andwhenaswellasspeakingtotheafflictedtheyenrollemployers,cliniciansandunionsaspartners.

Activityisnotapanacea,andifleadinganactivelifewithpainisbetterthanwithdrawingfromtheworld,itisstillnotideal.Butinterventionslikethisseemtoofferpeoplemoresuccourthanhighlymedicalisedapproaches.Unfortunately,medicalschools,patientexpectationsandthepoliciesofinsurersandgovernmentsallsustainthelatter.

Allaroundtheworld,familydoctorsarewoefullyundertrainedtotreatcommon,unglamorousconditionssuchasbadbacks.Inmostmedicalcurriculamusculoskeletalconditions,likebackpain,areaminorfeature.Backpainis“notsexy”formedicalstudents,saysChrisMaheroftheUniversityofSydney.Eveniftheyaregoingtobefamilydoctorstheystillwanttohearaboutcuresforcancerandimpressiveformsofsurgery,ratherthanhumdrumstufflikebackpainorpreventingfallsinolderpeople.

Spinalsurgeons,fortheirpart,oftentakeadimviewofevidencethatwhattheydomaybeineffective.Surgicaltrainingisbasedonanapprenticeshipmodel.“Youlearnfromamaster,agreatguru,andyoudowhattheytaughtyou.Youdon’tlearnfromapaperintheBritishMedicalJournal,”saysAndrewCarr,whoheadsthedepartmentoforthopaedicsurgeryatOxfordUniversity.Surgeonsgenerallyconsideranoperationsuccessfuliftheincisionissmall,thingshealnicelyandtherearenocomplications,saysMauritsvanTulderfromVrijeUniversityinAmsterdam.Iftheyeverhearbackfrompatients,thatisusuallyfromthoseforwhomtheoperationworked—whichleadssurgeonstobelievethatitworksmostofthetime.

Thoughresearchonsurgicaloutcomesisbecomingalotmorewidespread,itisstillhardtoconvincesurgeonsthatwhattheyhavebeendoingformostoftheircareersisineffective,saysDrCarr.Itisalsohardtoconvincepatientsthat,whenitcomestotreatment,lessmaybemore.Toldthatthebestthingtheycandoaboutbackpainisexercisetheirbodyandtheirpatience,theyoftenthinktheyarebeingfobbedoff;adelugeofonlinemarketingforineffectivetreatmentsdoesnothelp.Someharanguetheirdoctorsforscansorinjections,orfindanewmorebiddableone.Forabusydoctor,saysRachelleBuchbinderofMonash

UniversityinAustralia,“it’seasiertoprescribeanx-raythanexplainwhyyoudon’tneedone.”

Oncepainbecomeschronic,persuadingsufferersthatthecauseisnotafixablephysicaldefectbecomesmuchharder.GraemeWilkes,aBritishdoctor,saysthathemightspendanhourtellingapatientthatthethingsseenonhisMRImaynotbethereasonsforhisbackpain,andthataspinalinjectionisunlikelytohelp.“Thereasonthey’vegotbackpainisthattheyhavefinancialproblems,maritalproblems,disabledchildren,theyarenotsleepingatnight—notthosechangesintheirMRIscan,”saysDrWilkes.“Andtheygohomeandsomeonesays‘Oh,that’sabsoluterubbishthatyoucan’tgetaninjection,becausemymateatworkhaditandhewasmuchbetterafterwards.Don’tlistentothem,gobacktoyourGPandgetreferred’.”

Butthebiggestreasonwhysomanypeoplewithbackpaingetthewrongtreatmentsisthatgovernmentsandinsuranceplanspayforthem.InAmerica,AustraliaandtheNetherlandshealthplanspayforbackoperationsthatcost$25,000-100,000apiece.Americanplansoftensupportthealternativetherapyofferedbychiropractors.Thereissomeevidencethatthismaydosomegoodinbackpain,buttheresearchispatchyandanybenefitssmallandshort-lived.Yetthesameplanstypicallyofferlittlesupportforphysiotherapytothesameend.Ifatherapyhasbeenacceptedbyaninsurancecompany,oragovernmentschemelikeAmerica’sMedicare,itisveryhardtogetitremoved,evenifevidenceforeffectivenesspersistentlyfailstoturnup.“Oncetheyarein,itishardtotakethemout,”saysDanCherkinfromtheKaiserPermanenteWashingtonHealthResearchInstitute.Themanufacturersofmedicaldevicesareverygoodatlobbyingtogetthemcoveredastreatments.Theyarealso“incrediblyeffective”inmarketingtheirwarestodoctors,saysRichardDeyoofOregonHealthandScienceUniversity.

Backpainisbigbusinessformanysurgeons,doctorsandchiropractors.“Ifwestopdoinglow-valuecare,someentireprofessionshavetochangefundamentallywhattheydo,”saysLorimerMoseleyoftheUniversityofSouthAustraliaafterenumeratingalonglistofineffectivetreatments.Insomesystemscupidityencouragessuchthings.InAmerica,whereproceduresaremorelucrativethantalkingtopatients,anunscrupulousdoctormightprefertospenda15-minuteappointmentgivingapatientaninjectionratherthansomeeducation,justasaharriedonemight.

Othercountrieshavehadsomesuccesswithanapproachcalled“ChoosingWisely”,inwhichdoctorsexplaintopatientstheevidenceontheeffectivenessofvarioustreatmentoptionsanddecidetogetherwhatisbestgiveneachpatient’spersonalgoals(whichcouldrangefromsimplywantingtobeabletoplaywiththeirgrandchildrentocyclingorrunning).InBritaintherehasbeenadeterminedmovetowardstriagewhichassignsback-painpatientstomoreorlessintensivetreatmentdependingonthecomplexityoftheirproblems.InAustraliasomeemergencyroomshavestartedsendingsomeback-painpatientsbroughtinbyambulancestraighttophysiotherapists,whichavoidsasignificantamountofhospitalisation.

Choosingpoorly

ButwhenprofessionalassociationsinAmericaurgeddoctorstotakeuptheChoosingWiselymodeltheircampaignmadealmostnodifferencetoback-paintreatment—perhapsbecausedoctorswereundernoobligationtochange,saysDrDeyo.NorhasachangeintheadviceprovidedbytheAmericanCollegeofPhysicianshadanygreateffectasyet.In2017thecollegestoppedrecommendingmedicationasaninitialresponsetobackpain,suggestinginsteadacupuncture,yoga,tai-chiandpsychologicaltherapiesaimedatreducingstress,allofwhichhavebeenshowntoreducepain-relateddisability.Insurershavetakennote,withsomenowcoveringsomeormoreofthesealternatives.Thatwillmakeiteasierfordoctorsmovedtochangetheirpracticetodoso.

Anotherapproachmightbetonudgedoctorsincrementally,ratherthantochangetheirpracticesonceandforall.TweakingtheinterfaceoftheelectronicsystemsdoctorsusetoorderMRIssothatittakesthemlongertoplaceanorderhasbeenshowntoreducethenumberofunnecessaryscans.Addingapop-upreminderexplainingwhyimagingisfrequentlyunnecessaryhasalsoshowneffects.

Driversforsuchchangearehardtocomebyinpartbecause,asDrMahersays,

backpainislargelyinvisible.Peopledonotdiefromitandthereareno“back-painsurvivors”tospearheadlapel-ribboncampaignsforchange.Fewnationalmedicalplansevenmentionbackpain.Sufferersareoftenviewedasimpostors,ortoldthatitisallintheirheads.Thoughotheraspectsofapatient’slifedoimpederecoveryfrombackpain,manypeoplecannoteasilytakecontroloverthecontextoftheirlife,stilllessthecontentoftheirheads.Thelackofalobbyaccountsinpartfortheabsenceofmoreimpressiveprojectstomovebeyondmedicaldevicesanddrugs.

In2018DrBuchbinderwasoneoftheauthorsofaseriesofstudiesonbackpainpublishedintheLancetwhichtheypitchedtothejournalinthehopethatsummarisingthedebacleinrichcountrieswouldwarndevelopingcountriesnottofollowsuit.Butwhentheresearchersbegantocompilethedata,shesays,theydiscoveredthatinpoorcountriesthehorsehadalreadybolted.InIndia,Brazil,China,Nepal,Iranandotherdevelopingcountriesdoctorsarealreadyprescribingdrugs,injectionsandX-raysforsimplebackpain.InsomeurbanareasofIndiaandAfricaopioidscanbeeasilyboughtfromtheroadsidechemistswheremanypoorpeoplegofirstforachesandpains.

MrMoore,forhispart,hasnottakenpainmedicationsince1997.Tokeephispainatamanageablelevel,hestartshisdaywithstretchingathomeforhalfanhour,followedbyanhourandahalfatthegym.Andheleadsafulllife.■

Correction(January16th2020):AnearlierversionofthisarticlestatedincorrectlythatMrMoore’sdoctorwasinPeterboroughandthathewasgivensteroidinjections.

ThisarticleappearedintheBriefingsectionoftheprinteditionundertheheadline"Backpainisamassiveproblemwhichisbadlytreated"






Financeandeconomics

Emergingeconomiesareexperiencingaprolongedproductivityslowdown[Jan16th2020]






Notjustafirst-worldproblem

Emergingeconomiesareexperiencingaprolongedproductivityslowdown

HOWDOMODERNinnovationsstackupwiththoseofthepast?Someeconomists,suchasRobertGordonofNorthwesternUniversity,arguethatdriverlesscars,3Dprintersandsoonpaleintoinsignificancecomparedwiththefruitsofpreviousindustrialrevolutions,suchasmassproduction(seeFreeexchange).That,theythink,explainsaprolongedproductivityslowdowninAmericaandotherricheconomiesthatthefinancialcrisisdeepened.

Butwhatabouteverywhereelse?Developingcountriesare,bydefinition,somedistancefromthetechnologicalfrontier.Oneconsolationoftheirpositionisthevastbacklogofpastinnovationsthatremainforthemtoexploitmorefully.Theirgrowthdependsmoreonimitationthaninnovation.AcountrywheremostpeoplestillridescootersdoesnothavetoworryifthenextTeslafailstoarriveonschedule.

TheInstituteofInternationalFinance,athink-tank,believesthatemergingmarketsnowsufferfromavariantofthe“secularstagnation”thathauntstherichworld.OxfordEconomics,aconsultancy,arguesthatemergingmarketshavelostbothvolatilityandvigour,consigningthemto“gratingstability”.CapitalEconomics,anotherconsultancy,predictsthatinthecomingdecade,“thewidespreademerging-marketcatch-upgrowthofthepasttwodecadeswillcometoanend”.Inmostoftheemergingmarketsittracks,GDPperpersongrewless

quicklylastyearthaninAmerica.Imitationissupposedtobeeasierthaninnovation.Butevenasleadingeconomiesarefindingithardertobreakapath,manyoftheirfollowershavelosttheirwayentirely.

Howdidthishappen?Whentheylookattherichworld,someeconomistsworrythatbigfirmshaveittooeasy.Withoutstiffcompetition,theyhavelittleincentivetoinnovateorinvest.Butwhentheylookatthepoorworld,someworrythatbigfirmsnowhaveittoohard.Inasurveyofover15,000companies,theWorldBankshowsthatlargefirmsinpoorcountriestendtobemoreproductiveandmorelikelytoexportthantheirsmallerrivals.Inthepast,thesefirmshavebeenimportantconduitsforimprovedknow-howandtechnologiesacquiredfrompartnersandrivalsabroadandpassedontosuppliersandimitatorsathome.Butthe“routestotechnologytransferarenarrowing”,thebankpointsout,thankstorisingprotectionismandthehaltintheexpansionofglobalvaluechains.

Alackoftechnologytransferisonlypartoftheproblem,however.Halfoftheslowdowninlabour-productivitygrowthinrecentyearsreflectsnotafailuretoimitatebutafailuretoaccumulate:weakinvestmenthasleftlabourwithtoolittlecapitaltoworkwith.ThisshortfallininvestmentexplainsalltheproductivityslowdowninSouthAsia,theMiddleEastandnorthAfrica,andtwo-thirdsofthatinEuropeandCentralAsia.Thatisaseriousproblem,butalsoareassuringlyconventionalone.Insofaraslowcapitalspendingstemsfromalackofcreditorconfidence,itiseasyenoughtoimagineareversaloncefinancialwoundshealandanimalspiritsrevive.

Perhapsthesimplestexplanationfortheproductivitybustliesintheboomthatprecededit.Forfiveextraordinaryyears,punctuatedbytheglobalfinancialcrisis,Chinaenjoyedexceptionalgrowththatpulledcommodity-exportersbehindit.ThatverysuccesslefttheAsiangiantwithlessroomforfurthercatch-upgrowth,contributingtoitsinevitableslowdown.Itsgrowthhasalsobecomemoreself-containedandlesscommodity-intensive.

ThechangingpaceandpatternofChina’sgrowthprovedadisasterforthemanydevelopingeconomiesthatexportcommodities,especiallyinLatinAmericaandtheMiddleEast.Theirproductivitygrowthhascollapsed.Butinotherdevelopingeconomies,claimsofsecularstagnationandtheendofcatch-upgrowthseemexaggerated.Theirproductivitygrowthisclosetoits25-yearaverageandstillcomfortablyabovethatoftherichworld.Itisslowonlyincomparisonwithahandfulofyearsbeforeandaftertheglobalfinancialcrisis.

InaWorldBankpublication25yearsagoLantPritchett,nowatOxfordUniversity,emphasisedthatcatch-upgrowthwashistoricallyquiterare.Yes,imitationshouldbeeasierthaninnovation(andreturnstoinvestmentshouldbehighwherecapitalisscarce).Butotherfactorsoftengotintheway.Afterall,ifpoorcountriesreliablygrewfasterthanrichones,therewouldnotbesomanypoorcountriesstillaround.The“dominantfeature”ofmoderneconomichistorywasnotconvergencebetweenrichandpoorcountries,wroteMrPritchett,but“divergence,bigtime”.

Thepastdecade,forallitsdisappointments,hasbuckedthathistoricaltrend,iflessimpressivelythanthedecadebeforeit.Foremergingeconomies,the2010swerealet-down.Buttheywerestillthesecond-bestdecadeofthepast50years.■

ThisarticleappearedintheFinanceandeconomicssectionoftheprinteditionundertheheadline"Emergingeconomiesareexperiencingaprolongedproductivityslowdown"






MiddleEastandAfrica

HowtogetbeeraroundCongo,acountrywithhardlyanyroads[Jan18th2020]






Followthebottle

HowtogetbeeraroundCongo,acountrywithhardlyanyroads

THEBARGE,weigheddownbyhalfamillionbottlesofbeer,pullsoutintothemiddleoftheCongoriver.Atitstip,breezyrumbamusicdriftsoutofasmallradioandagroupofyoungmensitaroundgrumblingaboutthehardshipsoflifeonboard.“Westayonthisboatuntildeath,”claimsonesailor(pictured,right).Inreality,thecrewspendsatotalofonlysixmonthsonthebargeayear—althoughtheriskofitsinkingisnottrivial.LadenwithbeerbelongingtoBracongo,abrewery,theboatistravellingfromKinshasa,thecapitaloftheDemocraticRepublicofCongo,tothecityofBandundu,387km(240miles)upstream.

OmarBarcat,thebarge’sowner,hasbeenrunningafleetoffivecargoshipsfor20years.Hepredictsthatvariousapparatchiks,somewieldingKalashnikovs,willintercepttheboatatseveralpointsalongtheriver.Theywilltrytoextortpayoffsthatamounttoaround$500.Unrulysailorsareanotherproblem.Farawayfromtheirbossesbackinthecapital,theyaresometimestemptedtostop

offinvillagesandvisitfriends.Occasionallytheydrinkbeerstheyclaimhaveexplodedorbroken(whichcanleadtoworsemisdemeanours).“Buttheyknowthatifanyoneiscaughtdoingthathewillimmediatelybefired,”hesays.

MuchisatstakeforMrBarcatandforBracongo.Thebrewery,ownedbyCastel,aFrenchfirmthatoperatesacrossAfrica,hasbeencompetingwithBralima,ownedbytheDutchcompanyHeineken,forcustomersinCongofor70years.Bothbrewerieshavebeenaroundsincecolonialtimes;unlikemostfoodstuffsinCongo,beerislocal.Andyetthedifficultyforbothcompaniesisgettingbottlesfromthefactorytothebar.

Congoisnotaneasycountrytogetaround.Chinahasthreemetresofroadpercitizen;Congohasthreecentimetres.Onlyfouroutof26provincialcapitalshaveroadsthatreachKinshasa.Somevillagesaresoisolatedthattheystilluseacurrencythatwasabolishedin1997.Itisnosurprisethat,intheeast,thegovernmenthaslittlecontrolandthepeopleinpowerarethosewithguns.Millionshavefledtheviolencethereoverthepast20years.

FormostpeopletheonlywaytotravellongdistancesistogoonboatsthatplytheCongoriveranditstributaries.Allthebeersthatreachthecountry’sdense,forestedinteriorwillhavebeenshippeduptheriver.ThejourneyonMrBarcat’sboatwilltakeaweek.IftheroadsinCongoweremadeoftarmacinsteadofundulatingmudandsand,thenthebeerswouldreachBandunduinlessthanaday.Buttherustingcarcassesofoverturnedvehicleslanguishinginditchesserveasareminderofwhatcanhappenifthatjourneyisattemptedbyalorrywithaheavyload.

In2019Bracongohadtheedgeoveritscompetitor:itprovided53%ofbeersinthecountry,comparedwith47%fromBralima,accordingtothebrewery’sownstatistics.InKinshasathetwocompaniesracetoloaduptruckseachmorning.“Wetryhardtogeteverythingoutby7.30am.Bralima’slorriesleavebetween7.30amand8am,”saysTeddyJuniorMena,headofBracongo’sdistribution.“AndwearealsotryingtogetabeertoeverylastvillageinCongo,”headds.

Indeed,despitethecountry’sabysmalinfrastructure,beergetseverywhere.Liketherumbamusicwhichisblastedfromfuzzyspeakersateveryrun-downbar,itisoneofthefewthingsCongolesecanrelyon.Tounderstandhowonebrewerygetsitswarestothirstycustomers,yourcorrespondentembarkedonaseriesofvoyages.

TheCongorivertracesahugearcacrossthecountryfromthesouth-east,throughthecityofKisangani,pastKinshasaandoutintotheAtlanticOcean(seemap).Itisboththesecond-longestriverinAfricaandthedeepest.Ifitsroaringwatermasswasturnedintoenergythroughhydroelectricdams,itcouldlightupmostofthecontinent.

KingLeopold’sghost

Forcenturiestheriverhasservedasatraderoute—forbetterandforworse.KingLeopoldIIofBelgium,whoranCongoashispersonalfieffrom1885to1908,forcedarmiesofvillagerstoharvestivory,taprubberandloadthesepreciouscommoditiesontoboats.Wiveswereheldhostagetoensurethattheirhusbandssubmittedtoforcedlabour.Thosewhodidnotworkhardenoughwerekilledordismembered.Countlessvillagershiddeepintheforesttoavoidenslavement.Fishingandsubsistencefarmingcollapsed.Deathsfromstarvationanddiseasesoared;birthsplunged,sincesomanycoupleswereseparated.Byoneveryroughestimate,Congo’spopulationfellbyhalf,from20mto10m,

between1880and1920.

Leopold’smisruleattractedglobalcondemnation.In1908theBelgiangovernmentprisedCongofromhisgripandruleditsomewhatlessatrociouslyuntil1960,whenitbecameindependent.MobutuSeseSeko,amilitarydespot,re-christenedthecountry“Zaire”in1971.InKongo,alocallanguage,thismeans“theriverthatswallowsallrivers”.ThenamechangedbackwhenMobutuwasoverthrownin1997.

Todaytheriverisasourceofpride.Photosoffishermenincanoesontheriverarestampedacrossthecountry’sbanknotes.Justaftersettingout,MrBarcat’sbargepassesamansittingastridefourfloatingtreetrunks,boundtogetherwithrope.Usingasingleoar,heguideshisvesseltowardstheportwherehewilltrytosellthewood.HehasprobablytravelledfromMbandaka,acityintheheartoftheCongobasinrainforest,some586kmupstream.Ifso,hewillhavespenttwoweekspuntingdownawidestretchofmurkywaterthatishometohundredsofcrocodiles.

AfteraweekMrBarcat’sbargereachesBandundu.Fromhere,asinMbandaka,smallervesselscarrythebeerstotinyvillagesonthebanksoftheriver.AttheportinMbandaka,Christine,a40-year-oldbarowner,picksup70cratesofbeerfromtheBracongodepot.Shetravelstothecitytwiceamonthononeofthesesmallervesselstocollectbeersforherbarandtoselltootherbartenders.Thetripsaretough:shehastosleepoutondeckintherainandthemuggyheat.“Weareexposedtoalltheelements,”shesighs.

Itisnottheonlysignthatthisvesselisnotentirelyriver-worthy.Fiston’slistofpassengers,presentedtotheofficialattheharbour,hasonly15namesonit.Iftheboatgoesdownandmorethan15peoplesurvive,hewillhavenoproblemswiththoseincharge.Creativeaccountinglikethismakesitalmostimpossibletoknowhowmanypeopledieintherivereachyear.

Soonaftertheboatstartsoff,thesmellofmarijuanawaftsdownfromtheupperdeck,nicknamed“TheUnitedStates”,because“it’sashighasyoucangoinlife”,apassengerexplains.Below,peoplehuddlearoundsmokystovesandsharesaucepansofriceandstew.Oldmennestledownforthenightundertheircoats.Passengersstepoverthemtogettothetoilet,whichisaholeinthedeckandabucketofriverwater.

Inoneofthefourcabinsavailabletopassengers,yourcorrespondent’sbedisasaggingfoammattresssupportedbyslabsofplywoodwithagrubbymosquitonethangingoverit.Sleepiselusive:thegeneratorissoloudthatitishardtodozeoff.

Thenextmorningbleary-eyedpassengersshuffle,onebyone,tothebackoftheboat,clutchingtoothbrushes.Awomanfriesdoughballsandsellsplasticcupsofsugaryteaforbreakfast.Anargumentbreaksoutbetweenthecaptainanda

coupleofyoungmen.AgroupofboysontheUnitedStatesdeckleanovertogetabetterviewoftheruckus.Angel,apeanutvendor,wagsoneofherfingersandshoutssomethinginLingala,alocallanguage.Suddenlyeveryonecheers.Adrunkmanblowsawhistle.“Oneoftheboyswaswindingupthedriver,”Christineexplains.“Butthatwomanputhiminhisplace.”

Çasentlabière,Dieuqu’onestbien

Yourcorrespondentgetsoff,gratefulfordryland,atavillagecalledLolanga.Christinewillcontinueontheboatforthreemoredays,toitsfinalstop,alargervillagecalledAkula.Itislessthan350km—aboutasfarasNewYorkisfromWashington,DC,ajourneyofaroundfourhoursinacar.EachroundtriptakesChristinejustoveraweek.Shedreadsit,butknowsthatherbarwillnotsurvivewithoutbeer.

Christine’stravailsarepassedontohercustomers.HerbeerscostathirdmorethanthoseinKinshasa,at$1.80.Shehastofactorinher$60boatticketandthemoneyshepaysafriendtorunherbarwhensheisaway.Herprofitsareslim.Shedoesnotmakeenoughmoneytosave,shesays,butenoughtosurvive.

FormanyCongolese,potenthome-brewsofferbettervalueformoneythan

factory-madebeer.Oldladiesproducebucketsoffizzingmoonshineinthebacksoftheirhouses.Onedrink,calledMbandule,or“turnyourmindupside-down”,ismadefromafermentedcerealcropandisparticularlypopularintheeast,orwiththoseseekingcheapoblivion.Aglasscostsjust30cents.

Beerisastatussymbol,observesMrMena,likeowningamobilephone.Thetwooftengotogether,helaughs:“Nowadayspeopledrinkabeerwiththeirphoneinonehand.”Rumbamusicians,too,aresponsoredbydifferentbeercompanies;whenWerrason,afamousone,switchedsponsorfromBracongotoBralimain2005,hepromptedgaspingheadlines.

Partlyasaresult,beersalesinCongodonotreflectthestateoftheeconomy,whichshrankby1.5%in2019.AccordingtoBracongopeoplearedrinkingmorebeerthaneverbefore.“Evenwedon’tunderstanditsometimes.Thisdryseason[ApriltoAugust]wehavesomeofthebiggestfiguresever,”saysMrMena.

Since2010Bracongohasstartedtopromotedifferentkindsofbeerstodifferentslicesofthepopulation.Thosewithoutjobsinevitablypickthecheapestinthemarket:smallbottlesoftheweakestbrewcalledBeaufort.Youngpeopletendtogoforlighterlagers,saysFlorentMuteba,headofBracongo’scommercialanalysis.Farmersandstreetvendorsseemtolikemaltydarkales.Clever,aspirationalmarketingandHerculeanlogisticshelpexplainwhythecompanymanagestosellalcoholevenwhenpeoplearegettingpoorer.(Itsaddictivequalitiesprobablyhelp,too.)

OnthejourneybacktoMbandaka,thistimeonawoodencanoewhichthreatenstocapsizeasapriestandhisfriendsgetonboard,yourcorrespondentstopsinatinyriversidevillage.Hereawomancomplainsthatthenearestpharmacyisathree-hourboattripaway.Gettingantibioticsquicklyisimpossible,butgettingbeerisnot—justnextdoortoheranoldman,Garus,sellslarge,warmbottlesofdarkale.Fishermenpooltheirday’searningstobuythem.Thereisnoelectricity,butGarusturnshisstraw-roofedhouseintoabaratnight,usingtorchestolightit.Hetoopumpsrumbamusicoutofabattery-poweredradio.“Peopleheredrinkbeertoforgettheirworries,tode-stress,”heexplains.

MrBarcatwouldbeoutofbusinessifCongohadproperroads.Politicianskeeppromisingtobuildthem,butsomehowneverdo.MrBarcatjokesthathewillbeabletoretirecomfortably;hisbargesalsotaketheemptybottlesbacktoKinshasaonthereturnjourney,sohemakesmoneybothways.TheriverwillremainCongo’smainarteryforyearstocome.Andpoorpeoplewillcontinuetoclubtogethertobuyoneofthefewcolonialrelicsthatnearlyeveryoneloves:clear,refreshing,temporarilyworry-dispellingbeer.■

ThisarticleappearedintheMiddleEastandAfricasectionoftheprinteditionundertheheadline"HowtogetbeeraroundCongo,acountrywithhardlyanyroads"





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Graphicdetail

Thegreatglobalhousingfolly[Jan17th2020]

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Theweekincharts

Thegreatglobalhousingfolly

OurcoverstorythisweekexaminestheWest’sdamagingobsessionwithhousing.Atrilliondollarsofdudmortgagesblewupthefinancialsystemin2007-08;butacreepingdysfunction,createdoverdecades,hasbeenjustaspernicious.Asourten-pagespecialreportexplains,muchoftheblamelieswithwarpedpoliciesdatingbacktothesecondworldwar.Toolittleisbuiltinthrivingcities:regulationsandNIMBYismkeephousingsupplyshortandhousepricesandrentshigh.Thatmakesithardforworkerstomovetowherethemostproductivejobsare,andsohamperseconomicgrowth.Soaringhousingcostshavecreatedgenerationalaswellasgeographicalinequalities.Andhousinghasbecomebyfartheworld’sbiggestassetclass,dwarfingequities,commercialpropertyandallthegoldevermined.

Inmostcountriesforwhichtherearereliablefigures,backpainisthetopcauseofdisability,measuredbytheaggregatenumberofyearslivedinpoorhealth.Thatburdenisdecreasing,butonlyveryslowly.Thecostshavebeenrising

quickly,andareenormous.Yetmuchofthemedication,scanningandsurgerydoespatientslittleifanygood.Formostbackpain,ourleaderargues,thebesttreatmentsarenon-medical:keepmoving,stayactiveandbepatient.Theproblemmaynotevenbeinthebackatall,butinthebrain’spain-signallingsystemorinstress.

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