challenges to health promotion in modern society - … challenges to health promotion in modern...
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Challenges to Health Promotion in Modern Society
Dennis Raphael, PhD School of Health Policy and Management
York University
Keynote Address at Health Promotion Research: An International Forum
Trondheim, Norway, August 6, 2012
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Today’s Presentation • Health promotion faces various challenges • These challenges are wrought by globalization
and weakening of concepts of universalism and solidarity
• Effects of these changes are mediated by the form of the welfare state
• Social democratic welfare states can best resist these challenges
• There are means of moving the health promotion agenda forward
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Key Health Promotion Principles
• Provide prerequisites of health • Build healthy public policy • Create supportive environments • Strengthen community actions • Develop personal skills • Reorient health systems
• Source: WHO (1986). The Ottawa Charter for Health Promotion.
Geneva: WHO
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Affinities between the Prerequisites and Social Determinants of Health
• Ottawa Charter: peace, shelter, education, food, income, a stable eco-system, sustainable resources, social justice, and equity.
• SDOH: The Canadian Facts: income and income distribution, education, unemployment and job security, employment and working conditions, early childhood development, food insecurity, housing, social exclusion, social safety network, health services, Aboriginal status, gender, race, and disability
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The Nordic Concept of Level of Living I
• “The command over resources in terms of money, possessions, knowledge, psychological and physical energy, social relations, security, and so on by means of which the individual can control and consciously direct her conditions of life.”
• Source: Sten Johansson (1970) cited in J. Kvist et al. (2012). Changing Social Equality: The Nordic Welfare Model in the 21st Century. Bristol UK: The Policy Press.
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The Nordic Concept of Level of Living II Johansson’s nine components of well-being:
• Health • Employment • Economic
resources • Knowledge and
education • Social integration
• Housing and neighbourhood
• Security of life and property
• Recreation and culture • Political resources
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HP in Wealthy Developed Nations
• Finland, Norway, and Sweden have emerged as leaders in health promotion
• Australia, Canada, and UK continue to provide conceptual contributions to HP with rather less to show for it in terms of health-promoting public policy
• The Continental nations do a rather good job of supporting health independent of explicit commitments to health promotion
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The Nordic HP Situation • Finland
– National Action Plan to Reduce Health Inequalities 2008‒2011 (2008)
– Socially Sustainable Finland 2020: Strategy For Social And Health Policy (2011)
• Norway – The Challenge of the Gradient (2005) – National Strategy to Reduce Social Inequalities in
Health (2007) • Sweden
– Objectives for Public Health (2003) – Closing the Gap (2010)
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The Liberal HP Situation
• Australia – Taking Preventative Action (2010)
• UK – Choosing Health (2004) England – Fair to All, Personal to Each (2004) Scotland
• Canada – Report on the State of Public Health in Canada
2008: Addressing Health Inequalities – A Healthy, Productive Canada: A Determinant of
Health Approach
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The Continental Situation • France
– Health promotion remains ‘hindered by a system still very centred on curative care and a lack of political consideration for health determinants’
• Germany – The German approach to explicit health promotion
appears to be embedded within a behavioural approach.
• Belgium – Belgium does not have a ‘global comprehensive
policy framework’ to address the social determinants of health.
Source: Raphael, D. (in press). The political economy of health promotion: Part 1, national commitments to the provision of the prerequisites of health. Health Promotion International.
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The Modern Welfare State I • Welfare state is a nation in which organized
power is used to modify the play of market forces in by narrowing the extent of insecurity by enabling individuals and families to meet certain social contingencies; third, by ensuring that all citizens, regardless of status or class, are offered the best standards available in relation to a certain agreed range of social services.
• Source: Briggs, A. (1961). The Welfare State in Historical Perspective.
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The Modern Welfare State II • “The welfare state can also be seen as a
capitalist society in which the state has intervened in the form of social policies, programs, standards, and regulations in order to mitigate class conflicts and to provide for, answer, or accommodate certain social needs for which the capitalist mode of production in itself has no solution or makes no provision.”
• Source: Teeple, G. (2000). Globalization and the Decline of Social Reform, p.15
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The Welfare State is a Choice, not an Economic Imperative
Source: M. O’Brien. The Myth that Entitlements Destroy a Nation’s Growth, Busted in One Chart. The Atlantic, July 11, 2012.
GDP Growth since 2000
S oc i a l
S pe n d i n g
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Distinctiveness of the Scandinavian Welfare State
• Ideological inspiration: Equality • Dominant institution: The State • Emphasis on full and paid employment • Universalism of supports and programs • Support for gender equity • Greater extent of decommodification • Strong labour activation policies
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Figure 5. Poverty Rates in Families with Children, Selected OECD Nations by Welfare State Type, Mid 2000s
2117
171616
161515
1312
1212
109
86
54
43
10
0 5 10 15 20
United StatesSpain
PortugalIreland
GermanyItaly
CanadaNew Zealand
GreeceLuxembourg
AustraliaNetherlands
United KingdomBelgium
SwitzerlandFranceAustriaNorwayFinlandSweden
Denmark
Nat
ions
Poverty Rates
Source: Organisation for Economic Cooperation and Development. (2008). Growing Unequal? Income Distribution and Poverty in OECD Countries. Paris: OECD.
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Figure 4. Gini Coefficients of Income Inequality, Selected OECD Countries, by Welfare State Type, Mid-2000s
0.2320.234
0.2580.265
0.2690.2710.271
0.2760.276
0.2810.2980.301
0.3170.3190.321
0.3280.3350.335
0.3520.381
0.385
0.0 0.1 0.2 0.3 0.4
DenmarkSweden
LuxembourgAustriaFinland
BelgiumNetherlandsSwitzerland
NorwayFrance
GermanyAustriaCanada
SpainGreeceIreland
New ZealandUK
ItalyUSA
Portugal
Nat
ion
Gini Coefficient of Income Inequality
Source: Organisation for Economic Cooperation and Development. (2008). Growing Unequal? Income Distribution and Poverty in OECD Countries. Paris: OECD.
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Figure 3. Total Public Expenditures as Percentage of GDP, Selected OECD Nations, 2007
28.4
27.3
26.4
26.3
26.1
25.2
24.9
24.8
23.1
21.6
21.3
20.8
20.6
20.5
20.1
18.5
18.4
16.9
16.3
16.2
16
0 6 12 18 24 30
FranceSwedenAustria
BelgiumDenmarkGermany
ItalyFinland
PortugalSpain
GreeceNorway
LuxembourgUK
NetherlandsSwitzerland
New ZealandCanada
IrelandUSA
Australia
Nat
ion
Source: OECD Social Expenditure Database, http://stats.oecd.org/Index.aspx?datasetcode=SOCX_AGG
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Figure 7. Public Expenditure on Childcare and Early Education Services as Percentage of GDP, Selected OECD Nations, by Welfare State, 2005
0.1
0.20.2
0.3
0.3
0.4
0.40.4
0.4
0.4
0.4
0.5
0.6
0.7
0.8
0.8
0.91.0
1.0
1.2
0.6
0.0 0.2 0.4 0.6 0.8 1.0 1.2
GreeceCanada
Sw itzerlandAustriaIreland
USAGermanyAustraliaPortugal
LuxembourgSpain
NetherlandsUK
ItalyNew Zealand
Norw ayBelgiumFinland
Sw edenFrance
Denmark
Nat
ions
Percentage of GDP
Source: OECD Family Database (2010). Available at www.oecd.org/dataoecd/45/27/37864512.pdf
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Decommodification • “Essentially, it is the extent to which
individuals and families can maintain a normal and socially acceptable standard of living regardless of their market performance” (p.4).
• Source: Eikemo, T. A. and Bambra, C. (2008) The welfare state: a glossary for public health. Journal of Epidemiology and Community Health, 62, 3–6.
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Decommodified Security Ratio • Provision of three types of income:
– (i) replacement income for the risks of old age, unemployment, sickness and disability plus survivors’ pensions;
– (ii) reimbursements and benefits in kind: costs of health care, family allowances, housing benefits; and
– (iii) allowances and benefits in kind paid as part of measures to combat social exclusion (income support, etc.).
– Menahem, G. (2010) How Can The Decommodified Security Ratio Assess Social Protection Systems? LIS Working Paper No. 529. Luxembourg Income Study, Syracuse.
21 Source: Menahem, G. (2010). LIS Working Paper No. 529, How Can the Decommodified Security Ratio Assess Social Protection Systems?
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Figure 9. Infant Mortality Rates, Selected OECD Nations by Welfare State Type, 2007
6.75.0
4.84.8
4.24.1
3.93.9
3.83.8
3.73.7
3.73.6
3.43.13.1
2.72.5
1.8
3.7
0 1 2 3 4 5 6 7
USACanada
New ZealandUK
AustraliaNetherlandsSw itzerland
GermanyFrance
DenmarkSpain
BelgiumAustria
ItalyGreecePortugal
IrelandNorw ayFinland
Sw edenLuxembourg
Nat
ions
Infant Mortality Rates/1000
Source: OECD (2010). Health at a Glance: OECD Indicators. Paris: OECD.
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Figure 8. Life Expectancy at Birth, among Selected OECD Nations, 2007
78.178.4
79.179.4
79.579.579.5
79.779.8
80.080.1
80.2
80.780.8
81.081.081.0
81.481.4
81.9
80.2
74 75 76 77 78 79 80 81 82
United StatesDenmarkPortugal
LuxembourgUK
GreeceFinlandIreland
BelgiumGermany
AustriaNew ZealandNetherlands
CanadaNorw ay
SpainFrance
Sw edenAustralia
ItalySw itzerland
Nat
ions
Life Expectancy at Birth
Source: (2009c). Life Expectancy. In Health at a Glance 2009: OECD Indicators. Paris: OECD.
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Changing Welfare States: Retrenchment?
• Most obvious in liberal political economies – England – Canada – USA
• Also apparent in Nordic nations – Norway – Sweden – Finland
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Increasing Inequality and Poverty?
Source: OECD (2011). Divided We Stand: Why Inequality Keeps Rising. Paris: OECD
26 Source: OECD (2011). Society at a Glance: OECD Social Indicators. Paris: OECD
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Declining Adequacy of Social Assistance Benefits
Source: Kuivalainen, S. and Nelson, K. (2012). Eroding minimum income protection…
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Growing Income Inequality
Source: Fritzell, J. et al. (2012). Income inequality and poverty…
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Growing Relative Poverty
Source: Fritzell, J. et al. (2012). Income inequality and poverty…
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Challenges Related to Immigration
• Presents employment and integration challenges
• Can leads to split in left party solidarity • Manifests in different nations in different
ways (see next slide) • Requires education efforts but more
important is successful integration and employment strategies
• Source: Finseraas, H. (2012). Anti-immigration attitudes…
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Growing Strength of Centre-Right and Nationalist Political Parties?
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Immigration Presents a Threat to Left Solidarity in Nordic Nations
Source: Finseraas, H. (2012). Anti-immigration attitudes, support for redistribution and party choice in Europe. In Changing Social Inequality. Bristol UK: Policy Press.
Percentage of Voters Jointly Supporting Redistribution and Restrictive Immigration Policy,
2008
16
41
22
7
0
10
20
30
40
50
Denmark Finland Norway Sweden
Perc
enta
ge o
f Vot
ers
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Defining Support for the Welfare State
Source: Jaegar, M. (2012). Do we all (dis)like the same welfare state?
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Identifying Support for the Welfare State
Source: Jaegar, M. (2012). Do we all (dis)like the same welfare state?
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Many of these challenges are related to economic changes
wrought by economic globalization and increasing
corporate influence upon public policymaking
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Globalization and its Discontents?
Source: Labonte, R., & Schrecker, T. (2007). Globalization and social determinants of health: Introduction and methodological background. Part 1 of 3. Globalization and Health, 3(5).
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The effects of these changes are mediated by the form of
welfare state regime
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Source: Saint-Arnaud, S., & Bernard, P. (2003). Convergence or resilience? A hierarchial cluster analysis of the welfare regimes in advanced countries. Current Sociology, 51(5), 499-527.
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Social democratic regimes are best situated to resist these
challenges; Liberal regimes the least able
40 Begg, I. et al. (2008). Is Social Europe fit for globalization? A study of the social impact of globalisation on the European Union. Brussels: European Commission.
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. Figure 9.4 Factors Contributing to the Extent of Health Inequalities and Willingness to Tackle Them
Source: Raphael, D. (2012). Tackling Health Inequalities. Toronto: CSPI.
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Electoral Behaviour – 1946-1990s
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Growing Strength of Centre-Right and Nationalist Political Parties?
• Finland: Centre-Left Coalition • Norway: Red-Green Coalition • Denmark: Centre-Left Coalition • Sweden: Centre-Right Coalition
• Numerous authors, however complain of
weakening of social democratic resolve and this is especially the case in liberal nations
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Figure 2. Union Density among, Selected OECD Nations, 2008
7.711.9
14.318.318.618.919.1
20.420.8
24.027.127.1
33.437.4
51.953.3
67.567.6
68.3
28.9
0 10 20 30 40 50 60 70
FranceUSA
SpainSwitzerland
AustraliaNetherlands
GermanyPortugal
New ZealandGreece
United KingdomCanadaAustria
ItalyLuxembourg
BelgiumNorwayFinland
DenmarkSweden
Na
tion
s
Percentage of Workforce that are Members of Unions
Data Source: Organization for Economic Cooperation and Development (2010). Trade Union Density. Available at http://stats.oecd.org/Index.aspx?DataSetCode=UN_DEN
Trade Union Strength
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Figure 1. Collective Agreements Coverage among,Selected OECD Nations, 2008
13.030.0
32.035.0
48.060.060.0
62.063.0
72.080.080.0
82.085.0
90.092.0
95.096.0
99.0
82.0
0 10 20 30 40 50 60 70 80 90 100
USANewZealand
CanadaUK
SwitzerlandAustralia
LuxembourgPortugalGermany
NorwaySpain
ItalyNetherlands
DenmarkGreeceFinland
SwedenFrance
BelgiumAustria
Nat
ions
Percentage of Workforce Covered by Collective Agreements
Source: Venn, D. (2009). Legislation, Collective Bargaining and Enforcement: Updating the OECD Employment Protection Indicators, OECD Social Employment and Migration Working Papers, No. 89, Paris: OECD
Figures for Ireland are from Ireland: Industrial Relations Profile, EIRO, 2009, available at http://www.eurofound.europa.eu/eiro/country/ireland.pdf.
Collective Agreement Coverage
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Civil Society Coalitions I
Percentage of Non-profit Work that is Unpaid Voluntary Activity, mid 1990s
76
6150 49
3932
01020304050607080
Sweden Norway UK Finland USA Australia
Per
cent
age
of A
ctiv
ity
Wijkström, F. (2004). The Role of Civil Society. The Case of Sweden in International Comparison. Stockholm: The Stockholm School of Economics.
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Civil Society Coalitions II Voice versus Service Focus in Non-profit Sector Work,
mid 1990s
107
61 58
3021
11
0
20
40
60
80
100
120
Sweden Norway UK Finland Australia USA
Rat
io o
f Voi
ce v
s. S
ervi
ce
Act
ivity
Wijkström, F. (2004). The Role of Civil Society. The Case of Sweden in International Comparison. Stockholm: The Stockholm School of Economics.
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Social Democratic Welfare States: Finland
• Finland has been a success story of how an agrarian society was transformed in the course of half a century into a well-developed welfare state with an educated population and high-tech industries.
• Future challenges of the Finnish welfare state are similar to those of other European nations, an aging population, economic instability, increased inequality, globalization, and migration.
• Sustaining the Finnish welfare state is chiefly a matter of commitment and determination.
• Source: Mikonnen, J. (2012). Finnish Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI.
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Social Democratic Welfare States: Norway • Norwegian public health policy approach is radical in
its emphasis on upstream measures and intersectoral collaboration.
• These principles represent a revitalization of universal and structural measures in line with the social democratic welfare state model.
• Universal welfare measures are seen as more important than contributions from the health sector in reducing social inequalities in health.
• It is born from a conviction that the social democratic welfare state project should be sustained.
• Source: Fosse, E. (2012). Norwegian Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI.
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Social Democratic Welfare States: Sweden • Changes observed in public policy approaches have
been inspired by neo-liberal ideas on the role of government, acceptance of growing income inequalities, retrenchment of the welfare state, and an emphasis on the importance of individual choice.
• Health equity should be a goal across the left-right spectrum in a country with a strong egalitarian legacy.
• Since the political majority will not change soon, public health advocates need new strategies to bring politicians on board.
• Source: Backhuns, M. and (2012). Swedish Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI.
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Liberal Welfare States: Australia • Economic inequities in Australia have increased
with worrying signs of a growing divide between haves and have-nots in Australian society.
• Concerted policy action is required to use progressive taxation and other revenue-raising methods to ensure funding for redistributive policies.
• Leadership is required to create the political will to institute a systematic approach to reducing inequities.
• Source: Baum, F. et al. (2012). Australian Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI
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Liberal Welfare States: UK • Despite a raft of policy measures designed to reduce
health inequalities, health inequalities remain high on policy agendas throughout the UK.
• By the time Labour left office in 2010, health inequalities continued to widen triggering some despair within the health inequalities community.
• Scholars have called for stronger links between academics and policy-makers to co-produce research; engage in public health advocacy and work with communities; and promote awareness of the actors and forces influencing policies.
• Source: Smith, K. and Bambra, C. (2012). British and N. Irish Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI.
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Liberal Welfare States: Canada • Health inequalities are being driven by the country’s
expending fewer resources toward citizen support than most other OECD nations.
• Continuing evidence of a decline in relative population health and stagnating or increasing health inequalities can be expected.
• Canada’s unwillingness to promote citizen economic and social security are troubling with little sign this situation will improve in the near future.
• Source: Raphael, D. (2012). Canadian Experiences. In D. Raphael Tackling Health Inequalities: Lessons from International Experiences. Toronto: CSPI.
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Resiliency Factors • SD Welfare state: Path dependency • Central governance • Proportional representation • Union strength • Strength of civil society • Nordic values of equality • Buy-in of the middle class
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Nordic Nations: Immediate Challenges
• Integrating immigrants • Counterbalancing corporate influence • Resisting lure of right-wing parties • Responding to welfare state fatigue? • ???
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What about the Conservative and Latin welfare regimes?
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Implications for Health Promotion • Need for continued education and public
awareness as to the importance of health promoting public policy (hear Toba Bryant on Thursday)
• Need for a political economy lens that considers how issues of power, influence, and economics shape the making of health promoting public policy
• Identifying of barriers to the making of health promoting public policy provide means means of overcoming these barriers (hear me tomorrow)
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Implications for Health Promotion Research
• Need to systematically research the political economy of health promotion
• Study citizen attitudes and values towards redistribution, health, and health promotion
• Examine the forces that oppose health promotion and the public policies that support it
• Evaluate the impacts of governments’ policies on the health and well-being of citizens and the extent of health inequalities
• Put special focus on the situation of immigrants
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Conclusions and Take Away Messages • Nordic welfare state appears to be the best
means of promoting health and quality of life • Challenges to promoting the health and well-
being of citizens can be addressed but only if they are accurately identified.
• “Don't it always seem to go That you don't know what you've got 'Til it's gone They paved paradise And put up a parking lot -- Joni Mitchell, Big Yellow Taxi, 1970
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Dennis Raphael
This presentation and other presentations and related papers are available at:
http://www.atkinson.yorku.ca/draphael
[go to the library there]