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The Business Sector series is a review of Economic outlook and indicators concerning the banking sector for specific quarters in Georgia.

The Business Sector series is a review of Economic outlook and indicators for specific quarters in Georgia.

This comparative analysis report, the second in a series, is part of ADB's regional research and development project on tax administration that analyzes the administrative frameworks, functions, and performance of 21 economies in Asia and the Pacific. The initial version of this report was published in 2014. The primary objective of the series is to motivate governments and revenue officials by sharing knowledge of important developments and trends in tax administration practice and performance, and to identify opportunities to enhance the operation of their tax systems.

Effective pension management, financial education curricula in schools, internationally comparable data on financial literacy and the evaluation of the effectiveness of financial education programs are highlighted in this book. Surveys show that financial literacy levels are typically low around the world, despite the widening access to financial services and the increasing financial risks borne by households in many countries. This suggests that there will be mounting challenges for households and SMEs to invest wisely and effectively as societies age and governments shift away from defined benefit to defined contribution pension schemes. Individuals will increasingly have to make complex financial decisions to plan for their retirement and for a range of foreseen and unforeseen expenditures. All of these developments suggest that financial education should be part of a lifetime process that starts at an early age and is pursued throughout adulthood.

A vibrant stratum of small and medium-sized enterprises (SMEs) is critical for the growth and development of Asian economies. These enterprises generate employment, contribute to investment, participate in value chains, and support innovation. SMEs that seek to sustain and grow their operations, however, face a variety of constraints, many of which are directly related to size. These "size-induced market failures" create a role for public policy intervention. This book focuses on the market failures encountered by enterprises in the key areas of technology and innovation, credit and finance, education and skills, and market access. Obstacles to SME participation in the rapidly expanding regional and global value chains are also examined. The chapter authors examine national and multicountry experiences in South, East, and Southeast Asia.

Effective pension management, financial education curricula in schools, internationally comparable data on financial literacy and the evaluation of the effectiveness of financial education programs are highlighted in this book. Surveys show that financial literacy levels are typically low around the world, despite the widening access to financial services and the increasing financial risks borne by households in many countries. This suggests that there will be mounting challenges for households and SMEs to invest wisely and effectively as societies age and governments shift away from defined benefit to defined contribution pension schemes. Individuals will increasingly have to make complex financial decisions to plan for their retirement and for a range of foreseen and unforeseen expenditures. All of these developments suggest that financial education should be part of a lifetime process that starts at an early age and is pursued throughout adulthood.

Vietnam's fiscal position has deteriorated rapidly in recent years. For example, its budget deficit in 2015 increased 14 per cent to reach 256 trillion dongs (US$11.47 billion), equivalent to 6.1 per cent of its GDP (CafeF, 2016). The country's increasingly precarious fiscal position has been identified by experts as an urgent matter that can generate potential risks for its long-term macro-economic stability (see, for example, Financial Times, 2016; VnExpress, 2015b). It also poses a considerable challenge for Vietnam's new government in achieving socio-economic targets set by the recent twelfth congress of the Communist Party of Vietnam (CPV). If the fiscal imbalance persists or worsens, it will generate serious economic, political and strategic implications for Vietnam. Solving or mitigating the problem, however, will require not only sound economic policies but also political determination to embrace challenging reforms on the part of the CPV. This essay seeks to examine this particular problem and its implications. It provides first an overview of Vietnam's worsening fiscal position and its underlying reasons, and then an analysis of the economic, political and strategic implications that can be expected in the coming years.

This publication reviews recent developments in East Asian local currency bond markets along with the outlook, risks, and policy options. It covers the 10 members of the Association of Southeast Asian Nations and the People's Republic of China; Hong Kong, China; and the Republic of Korea.

In December 2015, compared to the same month of the previous year 2014, the volume of total deposits increased by 24.8% (3 080 mln GEL), while the volume of total loans to the national economy increased by 23.5% (3 074 mln GEL). Taking exchange rates into consideration, the growth rate of the deposits is 5.4% and the growth rate of the loans is 5.8%. In this period, the average interest rate on deposits denominated in foreign currency declined by 0.6 percentage point and on deposits denominated in the national currency increased by 1.1% percentage. Regarding loans, interest rates on loans denominated in foreign currencies declined by 1.1 percentage point and on loans denominated in GEL declined by 0.6% point.

 Detail of Rapture by Jon ReadSince it was published I have taught Kathi Weeks' book The Problem with Work in my Politics and Philosophy of work class. When I introduce the book, stressing that it is written by a political theorist and not, as in the case of many of our readings, by a philosopher, sociologist or historian, I ask the two questions that Weeks asks: namely, why should a political theory consider work? why does work seem to be outside of politics? What I am trying to provoke with these questions is a particular aporia in which work is for many people the central experience of power, authority, control and subjection, but because it is seen as private and natural it is seen as outside of politics, as apolitical. I remember very well a student responding to the second part of the question by saying that work was not political because "no one made you do it." At first I found this formulation strange given all of the ramifications and consequences of not working from homelessness to starvation, but the more I thought about his response the more it made its own particular sense. The compulsion to work, to sell one's labor power, was in some sense mute, unspoken, there was no particular agency or institution in society demanding it, and there was no particular institution or agency in society enforcing it--in part because it is diffuse spread throughout society. Since that day I have tried to think together two intersecting ideas. First, Marx's particular contribution to political thought is to think a new kind of compulsion, one that exceeds force or consent and ultimately the political institutions of society all together. The compulsions that define capitalism, not just in demanding that people go to work, to sell labor power, but the compulsions that dictate the rate and intensity of how that labor power will be put to work, are the structural conditions of capitalist accumulation. These compulsions go on behind the producers backs as Marx put it, are not decided on by anyone in particular. Moreover, while the state, law, and police are necessary conditions of capitalist accumulation, making possible the status of labor power as a commodity, these conditions exceed the state to be disseminated throughout political life. Which brings up the second point, this particular kind of compulsion is, for the most part, not experienced as compulsion but often as freedom, and to the extent that it appears as constraint, as necessity, it does so as a necessity that is not historical or instituted, but a fact of existence. Work, private property, competition, the market, etc. appear to not be institutions but, as Marx puts it, self-evident natural laws. Lastly, or to add a third idea, it is against this background of mute compulsion that the more overt compulsions or constraints of politics stand out. To give a contemporary example, one that I have been thinking about a lot, the short lived and inadequate measure of pandemic lockdown in the US, the few weeks of shutdowns, the few months of mask mandates, the sporadic vaccine requirements, etc., appear to be so intolerable because they were dictated and decided by specific people, but the far more pressing, and often deadly demand, to return to work, to discard unpopular mandates, and to go back to normal is all the more tolerable because it appears to come from no one and to be everywhere. Going back to work, going to stores to buy the things we need and want, is not a dictate or demand, but simply the way that things are. It is for this reason that I was very excited to read Søren Mau's Mute Compulsion: A Marxist Theory of the Economic Power of Capital. Mau takes up a position that is against the tendency in much of twentieth century Marxism which sought the basis for the reproduction of the relations of production in ideology or the state. As Mau says with respect to Althusser, there is a tendency to look for relations of power outside of economic relations, in the school or other various state apparatus. (I should say parenthetically that I am not convinced of this criticism of Althusser. It might describe his most famous essay, but Althusser also examined the way in which ideology was immanent to the relations of production, as for example in the wage relation and the labor contract). In place of this search for the reproduction of the relations of production in some external aspect, in the ideological state apparatuses, capitalist hegemony, or the culture industry, Mau examines the extent to which the capitalist social relations constitute their own conditions of reproduction. This reproduction stems in part from the unity in separation, to use Endnotes term, or as Mau puts it "In this mode of production, proletarians are temporarily connected to the conditions of their life through the very same social relations that ensure their permanent separation from them." Mau insists that he is not dispensing with ideology altogether. As he writes, "Since my aim is to say something about the economic power of capital, I will largely ignore the role played by ideology as well as violence in the reproduction of the capitalist relations of production. I prevent any misunderstanding here, I want to emphasize that this does not mean that I consider these forms of power to be secondary or unimportant."Reading Mau's examination of this mute compulsion made me think of not only the central problem of Marx and capital that I outline above, but how long I had been trying to think about this problem. When one thinks about such a problem long enough one hopefully makes some progress, but that may or may not take place. What does happen, however, is that the world of thinking around you changes, the problems shift as does the world of references and texts. One of the thing that occurred to me is how, twenty years ago, I would have rejected the very turn to think the reproduction of capital from the relations of capital, with no reference to ideology as being "economism." The idea that reproduction of the relations of production necessarily passes through something like the supestructure, through ideology, and the state. To cite a long passage from The Micro-Politics of Capital:In Capital Marx argues that the reproduction of the labor force is a necessary aspect of the perpetuation of the capitalist mode of production. "The maintenance and reproduction of the working class remains a necessary condition for the reproduction of capital" (CI 718/597). Althusser's own investigation into the connection between reproduction and ideology takes its bearings from this point. While both Marx and Althusser argue that any mode of production necessarily must reproduce its subjective and objective conditions, in Capital Marx primarily stresses the physical and biological dimension of the reproduction of subjectivity, the physical reproduction of the working class, and only marginally addresses the political and social dimension of reproduction. Before immediately rushing to conclude that Althusser's analysis is superior, since it includes in the "reproduction of the relations of production" the obedience and subjectification of the worker, it is necessary to pause over Marx's examination of the biological dimension of reproduction. Necessary, because as Althusser claims reproduction is always overdetermined, it encompasses the reproduction of the worker as a biological being, as a skilled and trained worker, and as a docile and obedient subject. The combination of these diverse practices, from the biological demand to consume sufficient food to the reproduction of ideological environments, under the same term would make the term seem hopelessly confused and monolithic, prompting many to reject it. Rather than reject the term "reproduction" almost in advance, it would seem to make more sense to construct its specific problematic from the diverse senses of the term, biological, technical, and political. From this reconstruction it is possible to expose the limits of the term, as well as its specific historicity. Marx argues that for the most part capital can leave reproduction to the "worker's drives for self-preservation and propagation." (CI 718/597) For Marx the reproduction of the biological existence of the worker is not examined as a process, but posited as a fact. It explains, poorly one might add, why the worker shows up for work. It does not answer the question as to why these same drives for self-preservation do not lead to revolt or insurrection. Moreover, Marx's treatment of reproduction, leaves the entire relation between reproductive labor, the work of care and housework, and productive labor, labor performed indirectly for capital, for the most part completely outside of Marx's analysis. Furthermore, by framing the biological reproduction of the working class as the brute confrontation of the worker's drive for self preservation and the capitalists drive for profits, it would appear that class struggle is an almost biological and a-historical struggle for survival. Thus, in considering the dynamic of capitalist reproduction, Marx lapses behind his critique of the supposed natural ground of need underlying classical political economy in the Grundrisse, and the recognition of the need and desire as a conflictual terrain, framed by the simultaneous demand of the capitalist mode of production to produce new needs and to reduce the cost of labor power in Capital. In these later points (covered in the previous chapters) Marx does not reduce history to the interaction of natural laws but recognizes that "nature" is thoroughly historical and "history" is thoroughly natural.This interrelation of nature and history as it relates to the reproduction of life is expounded in The German Ideology. The production of life, both of one's own in labor and of fresh life in procreation, now appears as a double relationship: on the one hand as natural, on the other as a social relationship. By social we understand the co-operation of several individuals, no matter under what conditions, in what manner and to what end…. Thus it is quite obvious from the start that there exists a materialistic connection of men with one another, which is determined by their needs and their mode of production, and which is old as men themselves. This connection is ever taking on new forms, and thus presents a "history" independently of the existence of any political or religious nonsense which in addition may hold men together. In light of this assertion it becomes necessary to read against this biological ground of reproduction. Not in order to purge from Marx any reference to the biological dimension of reproduction, but to locate in this biological dimension not the simple and a-historical conflict of the needs of the working class versus the desires of the capitalist, but the historical transformation of biological existence—what we could call the "biopolitics of capitalism." Marx argues that one of the fundamental differences between the capitalist mode of production and pre-capitalist production is that in the former the conditions of reproduction are mediated by the commodity form and wage rather than directly provided. The capitalist does not feed or care for the worker, at least directly, as in the case of slavery, but provides the abstract conditions for reproduction in the form of a wage. Under formal subsumption, or generalized commodity production, one of the presuppositions of capitalist production is that the conditions for living can and ultimately must be bought in the form of commodities. Which is not to argue that there may not be some forms of pre-capitalist practices of reproduction (small gardens, homecooked meals, children cared for at home, etc.) but that the time constraints imposed by commodity production (the working day) as well as the availability of commodified substitutes work to diminish the role of these practices of reproduction in capital. The process of primitive accumulation "frees" the worker from any communal or hierarchical system that would provide for the conditions of existence, exposing him or her as "naked life" on the market. Of course this "freedom" is at best partial, if not wholly illusory. Since the wage makes possible a new hierarchy between wage work, male work, and the non-waged work of reproduction, female work. The wage and with it the commodity form become the general condition for life and existence. This means that the conditions of the reproduction of existence are subject to the economic constraints and demands imposed by the commodity form. Specifically, one of the ways to increase relative surplus is to make the costs of reproduction of labor, the basic necessities of life, cheaper, increasing the ratio of surplus labor to necessary labor. To be exposed to commodity production for the basic conditions of one's existence is to be ruthlessly exposed to the demand for cheaper commodities."That is a long citation, but like I said, I have been thinking about that book that I wrote twenty-years ago. Mau discusses the book briefly but mainly to criticize it for using the phrase "real subsumption of subjectivity by capital." I am not really interested in getting into that now. It was the early 2000s, Empire had just come out, subsumption was all the craze. It was a different time. I also used to listen to Radiohead and frequently wore a sweater vest over a t-shirt: the past is a foreign country. I am less attached to the idea of real subsumption as having explanatory power as a marker of periodization. It is a term that needs to be explained more than it explains. What I am more interested in is the way in which Marx presented his understanding of capitalism in terms of strict conceptual oppositions from what had come before it, contrasting personal and impersonal domination, unity versus separation, and the way that these conceptual distinctions are maintained and extended into the present in terms of inside and outside, ideology versus economy, and so on. It seems to me that those divisions, the divisions that Marx used to distinguish capital from pre-capitalism, and the divisions internal to Marxist theory increasingly fail us now in the current stage of "absolute capitalism" to use Balibar's phrase. Economic relations, such as selling labor power, are at once material, part of the capitalist relations of production, and ideological, part of its justification. Or, to perhaps repeat what I said above, mute compulsion is both a fact of existence and an ideological justification. 

Part five of an interview with Robert and Joanne Frigoletto. Topics include: His father's dental practice. How dentistry changed between Robert and his father's time. Dentistry and insurance. How Robert got into pediatric dentistry. What it means to Robert and Joanne to be Italian. What it was like when Robert and Joanne moved to Leominster, MA. Finding a church to join. Italian cooking. Discrimination and derogatory ethnic terms. ; 1 ROBERT: How is it different? I guess, I don't know. LINDA: Oh, I guess I'll just give a hint. I remember last time… SPEAKER 1: Yeah, I'm just gonna -- not saying anything different. LINDA: I guess remember last time you had mentioned… ROBERT: Two generations? LINDA: Well, more, more that they established more of a relationship you had thought, your father and his, his customer. Or the patients or whatever. ROBERT: The patients, yeah. LINDA: And by the time you came along it was more a business relationship. SPEAKER 1: Yes, that's what I was gonna say. ROBERT: Yeah, I think the culture changed then, the insurance changed then. SPEAKER 1: Exactly. ROBERT: You know, they weren't paying the bill all the time anymore, I guess. But then I get… SPEAKER 1: It was on a professional level more than… ROBERT: Yeah, it was more of a professional level. LINDA: But can you give me some examples of your father… again, last time you had mentioned that some, some of these people just couldn't afford the bill. ROBERT: Sometimes they bring in the eggs and the, from the chickens, and they'll bring in the chickens. SPEAKER 1: [Laughter] ROBERT: Then they couldn't bring in the eggs. [Laughter] SPEAKER 1: [Laughter] ROBERT: Really, my life, we had eggs for the rest of our lives here, really. SPEAKER 1: [Laughter] ROBERT: But right. My, my dad used to do a lot of work for these -- 50 cents and some dollars. And I remember coming from dental school in '63, when I got out, and I thought I had a hard time 2 learning the fees, they were the same as we were charging in the clinic in Chicago, and that was like three and four dollars a filling. My father had the same fees then. SPEAKER 1: He had clinic fees instead of Boston [buttons]. ROBERT: Instead of Boston places. Yeah, certainly now Boston places and places around here about the same. SPEAKER 1: They're the same because it's all covered by insurance. ROBERT: Yeah, well, different class. So I guess he had a lot of people who are paying him on time, and those people really appreciated the doctor and patient relationship. And a lot of them are friends, and my father used to use a lot of his patients to do work, and… SPEAKER 1: Yeah, I think that was more prevalent then… ROBERT: It was more prevalent in those days where people used to use… SPEAKER 1: And you kind of… ROBERT: … their own group back and forth. But my father used to say -- there's a great quote, "If you keep spending money in town it'll eventually get back to you." That was probably a good -- he always used to tell me that. Keep using the local people in town, and it'll eventually get back to you. LINDA: That sounds good. ROBERT: Yeah, I think that's -- that's a quote that's gonna make the CD. SPEAKER 1: [Laughter] LINDA: Well, if you don't pay extra, I don't know. ROBERT: … out of all the quotes. LINDA: I don't even know about… SPEAKER 1: Yeah, right. We… LINDA: You know, we don't know. ROBERT: Right. We don't know what that means. LINDA: We don't know. ROBERT: Hidden information or whatever, that's the one or two phrase out of all of this.3 LINDA: Oh, but don't be discouraged because, again, I think… ROBERT: Oh, I'm not discouraged. LINDA: … there are more… ROBERT: I'm just talking about it, you know. SPEAKER 1: I think it's just wonderful that it's written down, and especially, and I think I mentioned this last time, in the book that we've done called City in the River, that was one of Fitchburg, the section on the Italian, the Italian section in the book, left out his father. They mentioned the other brothers, the other brother and sisters, but his father was left out. So it's nice that he's gonna be in some archives. ROBERT: I think that was a political… SPEAKER 1: Yeah, there was a … ROBERT: … it was -- for my father being involved in politics a little bit, there was some stuff. But what was… SPEAKER 1: But the Jewish section they mentioned him. There's two doctors… ROBERT: Well, that's because of my mother… SPEAKER 1: … that's Dr. Van and Dr. Phil, they mentioned Dr. Frigoletto in the Jewish part of the book. ROBERT: My mother was such a social being. SPEAKER 1: Well, they mentioned that, that's why she came here. Now… ROBERT: Everybody loved her. She was just huggy. SPEAKER 1: No, but they mentioned her because of your father's instrument on the incumbency, so it was mentioned in that part of the book. ROBERT: [Brilliant] thing. SPEAKER 1: But it's nice to have this in history. Like I say, who knows, great, great, great grandchildren, someday, may wanna find out. ROBERT: Yeah. LINDA: Oh, but it's not -- certainly that, but it's the people that wanna learn about, let's say, the history of Italians or the history of Leominster and Fitchburg. It's really for our reviewing.4 SPEAKER 1: Absolutely. And that's important, I mean, I think the more of us ought to be a little more connected with history somehow. This generation sometimes is not too interested; they're only interested in here and now. ROBERT: And the only -- the other thing that may be interesting was he had a brother and sister that came here from Grandpa, lived here for a while, Lee Marie. SPEAKER 1: Louise… Louise Frigoletto. Grandpa Frigoletto came here from Italy. ROBERT: Grandpa Frigoletto had a brother and sister from Italy who came to Fitchburg for a year or two. SPEAKER 1: A year. Didn't… ROBERT: … and that both of them ended up in California. The last time I was still there, we got to meet them about 15 years ago for the first time. They came out to my daughter's wedding, and we still talk and write letters, and [unintelligible - 00:05:11] see each other probably 'til we die. We found them too late. Wonderful Italian family. SPEAKER 1: Yes. They -- now, his parents have gone off to visit them. I never… ROBERT: The never talked much about it. I knew they went, but, you know, they came home with some pictures and by the end of the week that was it, and I never remember them calling or doing -- and yet we, you know, we went up there and struck up a nice relationship, and to this day we're constantly in touch. But somehow they didn't like they didn't like the area, and what's interestingly, culturally, I think, is that the brother, so I understand, didn't like it here and saw an ad in the Boston Paper from California saying come out and work in our produce farm, and if you spend a year with us and you work hard, we'll give you an acre of land. For five years or three years or some time, and that's what this brother 5 did, and kept getting acres of land, and now -- out in [Los Baños] you'd look like this, as far as you can see, hundreds of acres of produce that he produces… SPEAKER 1: Yeah. LINDA: Mm-hmm. SPEAKER 1: Well, now, do they have Frigoletto, or are they… ROBERT: No, they're Frigolettis… SPEAKER 1: They kept the old… ROBERT: They're the Frigolettis. SPEAKER 1: Frigoletti, right. ROBERT: Hmm. SPEAKER 1: Yeah. LINDA: Oh, yeah, but they would be, right…? SPEAKER 1: Right. LINDA: …. because… ROBERT: Because they left a year or two after Grandpa. My father might've been, you know, five years old or born recently or something like that when they left. And the… SPEAKER 1: But there's a family resemblance. LINDA: Is that…? ROBERT: Oh, I wish. I walked… SPEAKER 1: Watch. He walked like him. ROBERT: I walked into the room in California, and one of the daughters turned around and said, "You look just like Uncle…" SPEAKER 1: Tony. ROBERT: Uncle Tony, who used to be her -- Uncle Tony had died recently just before we got there, right? Showed me pictures of Tony… SPEAKER 1: They're your father's first cousin. ROBERT: My father's first cousin. I looked at the pictures and go, "Wow!" SPEAKER 1: Yeah.6 ROBERT: And I guess one of us, one of the daughters, one of the daughters' daughters who came to the wedding, yeah, and met me for the first time. This Tony used to send her money when she was going to college, was her favorite uncle, you know, always slipping the -- never met me. When she met me she took a breath because she thought Tony came back to her. And she told me that after, just for a second, because you turn around they introduced you, she says, "I took a deep breath because that was my favorite uncle. And he -- and for a second there he was again." So we knew we were the right relatives. SPEAKER 1: [Laughter] LINDA: [Laughter] ROBERT: So that's -- I don't know if that's be of interest to anybody at all. But I think the produce going and being -- and now, doing very well. He says most of the lettuce you get back East comes from us. SPEAKER 1: They made… ROBERT: … big bucks. SPEAKER 1: Big money. LINDA: Wow. SPEAKER 1: They really value the land. ROBERT: Yeah, they'd really lorded it then. LINDA: So getting back to dentistry, how did insurance change the practice? ROBERT: He didn't have that 50 cents and a dollar a week, come and get in do free work as much because all of these poor—and there are poor people who are now on welfare, which is some kind of insurance, right? And insurance paid now some of the things that were deductibles and back pays, but it separated the trust factor, and now we weren't doing so many things for free or discounts or 15 kinds of people, because we don't have to, we would get it from the insurance. But you'd always get less with the insurance with 7 all these complaints about the things you would choose to do and put doubt in people's minds. So now the relationship with the doctor who could do no wrong, which sometimes I guess he did, and insurance company always looking for their stockholders, and they have different goals, so you've got -- poor consumer was in the middle, and the relationships are more business than personal, aren't they now? So that's what happened to medicine. When I heard that medicine sometimes -- a lot of times the insurance companies would figure out the price of an appendectomy, say, and they get this from the auto insurance business. I heard this, and I think it's true that most doctors can do an appendix in 33 minutes, and it'll cost the hospital X amount of dollars, and they figure it out. And that's what you do when you got a big car fix. They say it takes 34 minutes to do this and this is the price you get for it. It doesn't matter if it's complicated or not. Because a car is not a person and doesn't have the history of diabetes or cardiac or whatnot, you know, you replace a windshield in a car, it usually goes pretty much the same way every time, not true with people. So this insurance really got kind of crazy. Now they've come up -- well, this is not even cultural -- well, this is cultural. They've come up with a new thing now, evidence-based medicine that will be coming through -- it's starting to trickle in. If you don't perform, if you don't -- say you come to me with a certain disease, certain problem, and I don't solve it in one of the three or maybe one of the only ways that most people would solve that, the insurance won't pay for it because it's not evidence-based. It has to be proven that that particular way of solving the problem is the way that most people solve it. So that's gonna take all of the 8 entrepreneur out of this. And just what they've done with the drug companies, they stifle some of the research because the people, the drug companies can't get back their dollars. So all the medicines that didn't work out and all the lawsuits they got, so they'd stopped doing a lot of extra research and the progression, and the speed of new things coming out is slower. And the same thing is gonna happen in medicine, I would guess, with evidence-based medicine there's gonna be a stifling. On the other hand the protection of crazy medicine, so you get both sides, don't you? LINDA: You hear much of that…? ROBERT: You get a protection… LINDA: Crazy medicine? ROBERT: I don't know. LINDA: Let's keep it at dentistry. ROBERT: Yeah, at dentistry? Yeah, this is people of all levels, but less and less now. Most dentists are pretty proficient. Yeah, I think in my father's day there was some bad ones around, less skilled ones around. But I don't know of any now, everybody's pretty good. LINDA: So did your father determine procedures as much in the same way you did, or was it, was insurance even determining that for you? ROBERT: Ah, no. I would not let insurance determine that. I would tell the patient the best thing, give them their choices, tell them what the insurance would pay, and if they didn't pick the worst one I'd kinda go along and do it. If they picked the worst procedure I'd tell them go someplace else. I think in my father's day, my father would pick the procedure that he thought the person could afford. That's what you're looking for, remember we said that. LINDA: Mm-hmm. ROBERT: And then give them that procedure rather than letting the patient make up their mind, because I have found that some of the poor 9 people want the best medicine, and some of the richer people don't always want the best medicine. LINDA: How did the instruments change between your father's day…? ROBERT: Surprisingly a lot of the same stuff, but two things that changed the most were the high-speed drill. Let's see, just about in the early '60s when I was getting out of school, they had this air rotor, you know, air-driven turbine rather than the old mechanical thing you saw the string going around turning the pulley. Krrrr-krrrr. SPEAKER 1: Grinding away. [Laughter] ROBERT: Right, and now it's like painting, little brush. I mean, it's really air… air-quick-caning. As you can remember now, going to the dentist, you don't feel the pressure anymore. You just hear the sound. If you forget the sound that'll be all set. The other thing is the plastics, all of the adhesives and the kinds of plastics and fiberglass materials. That was always a boring subject, dental materials, is now the hot subject, because every six months they're improving all of these white fillings, so to speak, which they haven't got yet perfected but they're getting closer every year. LINDA: Oh, wow. SPEAKER 1: And the other thing besides the material, I mean, the procedures they do, the procedures that you do that your father didn't do with children? ROBERT: Ah, yeah, the specialties of -- but that's true in medicine in general, the specialties have become more important and accepted, except you can't get this under the specialist now if you're in an HMO. [Laughter] LINDA: True. True. ROBERT: You might be going back to the generalist because it's less costly. But now we -- my brother and I would say the same thing, we 10 would get referrals from general doctors for problem cases that, to us, were not really problems because we dealt with them every day. And he used to say the same thing, he used to get problem cases that were routine. But we had extra training, and that's what specialists are for. I mean some percentage sometime of his work. LINDA: Did your father deal mostly with problems or maintenance? ROBERT: Father dealt mostly with problems, because a lot of people would come only when they had a problem. Although he was -- he would deal with a lot of six-monthers that were on maintenance. SPEAKER 1: I think it was pretty evenly divided. ROBERT: Yeah. But certainly, for a time in my dental career, maintenance and prevention became really most of my practice. As a pediatric dentist that was -- prevention was really strong, stronger than most practices. And then, now the insurance companies are in now trying to dilute a lot of the preventive things that we're doing in medicine. And the -- what do you call it? SPEAKER 1: Pendulum. ROBERT: The pendulum will swung back because they're gonna get caught ten years down the line with more expensive diseases because they didn't wanna pay for the prevention. SPEAKER 1: I think there wasn't much education when your father was practicing, so people wouldn't… ROBERT: People -- yeah, less television, less news, less -- now you can't do anything because it's out in the news, they tell you every week something new. SPEAKER 1: So a lot of his patients were problems. ROBERT: Yeah, now the drug companies are advertising directly to the consumer. The hospitals are advertising directly to the consumer – never had that 25 years ago. Looked like the doctor make the choice, which hospital to go to, which medicine to use. Now, 11 people go into doctor and say, "I wanna go to hospital A, and I want you to use pill B." SPEAKER 1: I just thought of something that might be important. Your father, Scott, is the… first of all… ROBERT: The dental staff at the Burbank Hospital. SPEAKER 1: Burbank Hospital. That's what you… ROBERT: That's right, yeah. He and Dr. Beckman were… SPEAKER 1: There were no oral surgeon in town… ROBERT: Well, no. SPEAKER 1: … they used to do the oral surgery. ROBERT: My father was -- yeah. My father was [unintelligible - 00:18:01] surgery. SPEAKER 1: Mm-hmm. I think in his other life he would come back as an… ROBERT: Back as an oral surgeon. SPEAKER 1: Yeah. ROBERT: Yeah, I learned a lot of oral surgery from my dad. SPEAKER 1: Uh-huh. ROBERT: And I think he learned by the gut of his -- how do you say that? SPEAKER 1: Pleat of his pants. ROBERT: Pleat of his pants. SPEAKER 1: Mm-hmm. ROBERT: Right. You read about it and then you practice it, huh? LINDA: Then you can just… SPEAKER 1: Confident. ROBERT: Yeah, they were no -- oh, very good. Very good at tooth extractions, and a lot of people would come in. They didn't have root canals in those days, right, so you'd end up taking out the tooth. SPEAKER 1: He wasn't doing major facial surgery. We're talking of… ROBERT: No. Doing internal, oral… SPEAKER 1: Yeah, root canals…12 ROBERT: Yeah. SPEAKER 1: … extractions, yeah. LINDA: Well, I was going to ask you about pulling teeth. It seems as though people back then would just have their tooth pulled… ROBERT: Tooth pulled out and not saved, and nowadays, people are saving their teeth. Maybe years -- in his early practice, how that 70 percent of the people had full dentures, huh. Population maybe over 50 percent certainly… SPEAKER 1: Really? ROBERT: … had full dentures, and now it's down to like 25 percent. And I can remember teenagers coming into his practice when I was there the first few years and saying, "I want all my teeth out," 16, 17 years old, and my father would refuse to do it. And two months later he would tell me he would see them with dentures. LINDA: Now, why would they do that? ROBERT: Because they were here to have it made, they had money to fix them, and someone told them just get them all out of teeth and get dentures, and what a terrible thing. And my father wouldn't do it, and a number of people wouldn't do it, but I guess there were two or three dentists around who would do it. My father says he'd always see those people six months later with dentures. He used to kick them out, "Hang on to these." They'd come in and ask that [unintelligible - 00:19:51]. SPEAKER 1: Again, it's… ROBERT: But I know I used to see a lot of 16-year old kids taking out one tooth at a time, and 8 months later taking out the other one, and a year later another one would go. And I know a couple of people today that are running like that. [Laughter] LINDA: Right. SPEAKER 1: Well, as long as it's a couple that…13 ROBERT: Yeah. Well, see, I'm seeing it now in Florida when I volunteered at an indigent clinic, in Florida, during the winter. Seeing the same thing now with all of the immigrants that have come in over the past 10 years and the minorities. They're really back to the '50s dental education-wise, because these minorities they go and have a toothache and have it taken out, and I see the same thing happening as what's happening back in my early days. LINDA: Now, is that because they don't have the money or the education or both? ROBERT: Both. Both. They come from third world countries, and… you know, we had a couple of dentists in town, they go every year, over to -- where do they go, Bangladesh or something? SPEAKER 1: No, no, no. They go to El Salvador. ROBERT: El Salvador? SPEAKER 1: I think. ROBERT: And he'd see people standing in the line. They walk all night for six, eight hours to be at the clinic early in the morning at the tent to have teeth taken out because they had been suffering with toothaches for months. And there's -- every morning there's a line of people, he would say. SPEAKER 1: Or Colton tells a… ROBERT: He says over there that's all we can do. And I think I mentioned to you last time, you know, people in Colombia who said, "Let's get… let's pool some dollars and get some old equipment and get it over there to the clinic in Colombia, and the Colombian doctor who was working with us in Miami said, "Don't bother, they'll get stolen within 24 hours." LINDA: Hmm. I don't remember you mentioning that. ROBERT: Oh, didn't I? LINDA: I do remember you mentioning Florida. ROBERT: Oh. So you never know.14 LINDA: See? So it's coming back to you. ROBERT: Yeah. We're trying to get a grant passed now. I sent her the stuff, a lady has the clinic, and see if we can get Rotary and Kiwanis and all of those groups involved in helping out some of the poor people in Florida. SPEAKER 1: Yeah. No one wants to do it down there. LINDA: No one wants to… SPEAKER 1: The other day, the dentist don't want to… ROBERT: No, no difference in this, with the county. SPEAKER 1: Yeah. ROBERT: You know, the welfare system is so screwed up, and the fees are so low and the people don't show for appointments. SPEAKER 1: Yeah. ROBERT: And the only way you can do it is if you had a clinic. In fact, tomorrow night there's gonna be a meeting locally in town, and the local dentist society is gonna talk about that with some of the politicians. And I think the only answer is to develop a clinic every so often and have us guys in private practice go volunteer half a day, a week, and have some kind of tax incentive. LINDA: Trying to get people to volunteer is a problem. ROBERT: Well, you gotta give them -- you gotta give them a tax incentive… LINDA: Yeah. ROBERT: … a couple of hundred bucks of a day or something like that, you know. And then -- see, years ago, my father was -- and I just finished the rest of it, I'm doing it all, the school examiner… SPEAKER 1: He asked you. Yeah. You and your father both were school dentists. ROBERT: Right. Yeah. My father was the -- well, they didn't have school dentists anymore; he would just examine teeth. But the program started with a guy named [Bumgardner] who's a living legend. The patient that used to come into my office shaking like this 15 because they were afraid of the dentist. I used to go to Dr. Bumgardner. [Laughter] SPEAKER 1: [Laughter] I actually hear some people say that to this day. ROBERT: To this day. "My parents used to go to Bumgardner." Oh, he must have been… SPEAKER 1: He must have been horrible. [Laughter] ROBERT: So he'd say -- he was the school dentist. He used to take out teeth without Novocainee and did things like that, you know, and just -- I mean, a kid could come in with a sore tooth and just yank it out. LINDA: I can remember you telling me -- I think you told me that you were known as to be more gentle than your father? SPEAKER 1: Yes. ROBERT: Oh, that story, too, yeah. SPEAKER 1: [Laughter] ROBERT: He was pretty rough. [Laughter] But people loved him. SPEAKER 1: Well, he was quick. ROBERT: Yes. If you said ouch he'd say, "Oh, shut up." SPEAKER 1: Well, yeah. Your father worked on me once. And when I said ow, he said, "That doesn't hurt." LINDA: [Laughter] ROBERT: [Laughter] That doesn't hurt. LINDA: You [unintelligible - 00:24:04] went to him once? SPEAKER 1: Once? [Laughter] ROBERT: Well, I told you a story about the first toothache ago was the nearest from the hospital, I guess. SPEAKER 1: That was a story. ROBERT: That was a story, yeah. And I gave him a Novocainee and she said, "Ouch," and I said, "I'm sorry." She said, "Your father would've told me to shut up." I said, "Well, shut up." She says, "Good! I feel more at home now." [Laughter] 16 Then the other guy was Bill Botta, who used to be the head of United Fund here and played tennis with him. He says, "I never found out there was Novocaine until I left your father." Went to another dentist, he said, "Do you want Novocaine?" He says, "What's that?" [Laughter] He says, "Your father, decided -- " he was a big, overweight, burly guy, and I'm sure my dad decided he was strong enough not to take, that he could take the pain, why give him a Novocaine. [Laughter] He says he grew up without Novocaine, and he's well with that, you know. I don't know if it was terrible, but -- actually I don't take Novocaine now. I grew up the same way. [Laughter] SPEAKER 1: And I don't understand that. I cannot imagine not having Novocaine. ROBERT: Well, I used to study how it felt. It would help me practice, really, because I kinda knew what happens. Dang it. SPEAKER 1: I just hope… [laughter] yeah, well, before the war. ROBERT: It wasn't part of my education, but it really is not bad. LINDA: [Laughter] So tell me about… ROBERT: All right. LINDA: Tell me more about your father's connection to Burbank Hospital. ROBERT: He and Dr. Beckman, this other dentist, had decided -- I guess because my father liked these surgeries so much. He's taken out a lot of teeth, people would demand that. Started the dental department, really, the dental staff at Burbank Hospital, and which became… SPEAKER 1: So they had… ROBERT: And to mingle with the medical staff eventually as we, dentists, became accepted as doctors as the years went on. SPEAKER 1: So then they had hospital privileges in the OR. ROBERT: And we had hospital privileges in the OR, right? And I remember when I first got out of school going up with him and he was so 17 good at taking out teeth and so fast. He used to just toss them, and the girls would be running around trying to catch them with a can. [Laughter] And he caught [unintelligible - 00:26:20] mouth extractions on elderly people and senior citizens and then put the dentures right in immediately, and they'd walk out with a full set of teeth. SPEAKER 1: There was a time when both father and son were on the staff together. ROBERT: Together. Right. SPEAKER 1: Yeah, well… ROBERT: We did cases together. And it was part of my training, really, going into pediatric dentistry because I ended up dealing with retarded adults. Probably one of the few pediatric dentists that had six years of general dentistry experience, and then took a lot of retarded people to the hospital, and did fillings and their special equipment to make sure you did rehab in the hospital, at least special, and some medically compromised people. SPEAKER 1: That's what you did. ROBERT: And some apprehensively compromised people, that were adults that we took into the -- or young kids under three or four. In fact, well they're starting to change, to pass the bill in town now, in the state, been at it for three years, I think they'll get it through this year, 23 States out of… SPEAKER 1: Fifty. ROBERT: The 50 that passed it to force the insurance companies to pay for hospital costs for serious dental problems for kids under five years old. LINDA: Oh, good. SPEAKER 1: About time. ROBERT: Which we used to have years ago, and in fact, that's one of the few things Medicaid still covers. But then the insurance companies 18 dropped it. As we hear they dropped circumcision, because that's not treating a disease but preventing. SPEAKER 1: Really. ROBERT: Pennsylvania they had started it and a few states picked it up. The insurance companies are so under the wire now they think of everything they can think of to not, not to pay. Because the dollars are so tight. SPEAKER 1: Don't get sick. Stay healthy. LINDA: [Unintelligible - 00:28:25]. ROBERT: Yeah. Well, they've… they've prepared, they're doing this evidence-based medicine, and some of the insurance companies now want to allow only one clean and fluoride a year for children instead of two, every six months. LINDA: And how long does it take them to make a change like that? Typically speaking. ROBERT: I don't know. I mean, when the change comes out and there's some noise about it, because when they come out with a change they won't pay for it. SPEAKER 1: No, but does it take years, months? ROBERT: I don't know. I started reading about it a year and a half ago, and I hear some insurance companies now are just trickling in. SPEAKER 1: So probably about a year… ROBERT: A couple of years. Yeah, a year or two. LINDA: So there's really no public discourse; it's just immediate, but it comes down… SPEAKER 1: Yeah, they just do it and tell you about it. ROBERT: The public comes when they get hurt later and they wanna make a noise about it. SPEAKER 1: When they found out they're not covered. ROBERT: Like what happened with the HMOs. Many years nothing happened until a few people died. Actually, a few senators' 19 daughters, kids got involved and said, "Dad, you know, this isn't government." Dad said, "Gee, my insurance is still okay, [laughter] I got the big stuff up here in Washington." You know, and then word started to trickle through, and then they started to get after the HMOs. And here's the big thing now about passing a law whether you could sue an HMO or not. What is negligence, what isn't? LINDA: What's going on with the doctors and all of those insurance changes? ROBERT: To clarify with the patient, the pros and cons of both sides and letting the patient know what they want to do, what's available for them and how much money they will get from it, pros and cons of each kind of treatment, what will happen if they don't get treated. And some people say, "Hey, I ain't got any money. Do the treatment that they will pay for, even if it's second class." And the doctor then has to decide -- and a lot of second class, second steps are okay, as long as it's average, good. You don't have to buy a Cadillac every day, right? You can buy a Ford, still get there, but you don't wanna buy last year's junk. LINDA: Well, what if, let's say, the Dentists Association or whatever you call the professional organization, what if they felt very strongly that children should have their teeth cleaned twice a year? And the insurance companies says… ROBERT: We're not strong enough. That would take a decade to change, and we'd need a lot of public support behind it. Unfortunately, the children don't vote, so that's not gonna happen. Now, if it has something to do with adults, like if they took away, maybe root canals, maybe the adults would get it done faster. But things to do with kids don't change too quickly. SPEAKER 1: Not just quick.20 ROBERT: It's the kids they're taking advantage of, what can I say? When you wanna get cheers, who gets -- used to be the kids and the senior citizens got it. Now, the senior citizens, there's so many of us that vote, we're now getting listened to. Especially now with the next group of baby boomers that come along. SPEAKER 1: Very vocal. ROBERT: Very vocal. Runs and goes, gonna vote… SPEAKER 1: My feeling is that somehow in this society we children like they're commodities, aren't people, they're just things, are just -- they have it real tough, children. ROBERT: Yeah, it's terrible. There's a story of a little girl I tried to tickle once, dirty clothes and dirty… and when Medicaid is out, "How many brothers and sisters do you have?" How many sisters or whatever I asked her, and her answer, in two words, told me, the answer was, "Too many." And I couldn't get her to laugh, tickling her, that's how -- she could've been four and a half years old, pretty face, you know, worn out clothes. You could see. And those kinds of kids you just wanna give them a hug and help them out as much as you can. Every week in our office we would, I would say, "We should do something for nothing and we should tell the girls," and it gets me to the end of the week. And we then find someone, you know, we wanna do something for and remind me, and so Fridays we can do it, because they would know a lot about the people sometimes more than I did, in busy days. SPEAKER 1: That sounds more. We just don't like the insurance company… ROBERT: We don't like someone telling me what we can do for nothing. That's one we choose ourselves. But that was always a good exercise. Or if we charge someone some money, they'd come back, they'd say, "Wait a minute," and they'd come back and say, "These people really can't afford it." That's okay. [Unintelligible - 00:33:14] work out something.21 LINDA: Mm-hmm. ROBERT: I always had that nice relationship with my best friend so that we could, so that we could really be helpful to people when we could, on those who needed it. And on the other side of the story where someone comes in, you know, a little kid who came with us with an interpreter, Spanish kid with a toothache, and I said, "How did she get on Medicaid so quickly? She's only been here two weeks, you tell me?" and the interpreter told me, "Oh, we got her on Medicaid before she even left Puerto Rico. She had a toothache in Puerto Rico. And we paid for the flight over." SPEAKER 1: That annoys me. And we don't… ROBERT: So there's, you know, there's two sides to every story. And being a doctor or politician or anybody, a judge, lawyer, boy, you're in the middle of some of this ethical stuff. It's tough to make a decision sometimes. Gotta go with your heart. And sometimes you get in trouble though, with your heart. So sometimes you just pull back and don't do anything; that's not good. SPEAKER 1: It's not good for people. ROBERT: Because what's happening to a lot of medicine now; they're pulling back and not doing it because they're afraid to make the right suggestion. They have a poor doctor in Boston with a basketball player, with Madge… SPEAKER 1: Dr. Madge. ROBERT: Dr. Madge, it's my cardiologist. SPEAKER 1: [Laughter] LINDA: Wow. SPEAKER 1: So I said to him when I… ROBERT: I asked Dr. Madge, "If I had a little irregular heartbeat when I'm playing tennis, what should I do?" He said, "Just play through it." [Laughter] I said, "Thanks a lot, that's pretty…" SPEAKER 1: … before we asked her.22 ROBERT: No, even now. LINDA: Even now? ROBERT: Why are you telling me that? But I'm not sure. He said, "You have to make your decision." LINDA: Uh-huh. ROBERT: It's tough. SPEAKER 1: He lost that case to… ROBERT: No, no, he won it, but two years later. Two years of misery. LINDA: I thought that we're now… SPEAKER 1: … but they took him again. ROBERT: But it's civil. SPEAKER 1: Oh, civil. ROBERT: He still made it. He won the case. I don't know what happened with the civil case. SPEAKER 1: No, I don't know what happened. ROBERT: She wanted the big bucks. SPEAKER 1: Yeah. ROBERT: You know, he said, if she were alive now he would have earned four trillion dollars… LINDA: You know what, I think… ROBERT: … so I don't want part of that. Because you said that if he played basketball he wouldn't die. It's like bringing the [unintelligible - 00:35:40] in and saying if you could change the distributor the car will work. Probably. If you changed the guy's heart, maybe it'll work, maybe it won't. Look at the guy who just got in trouble and he had an artificial heart, and stroke, blood clots. SPEAKER 1: I printed that, Reggie Lewis, I think she was gonna start a third suit, but I haven't heard anything about that. ROBERT: Is that right? LINDA: Haven't heard anything.23 ROBERT: Well, her lawyer keeps going, going and going. He wants to get -- he probably started the case and said, "I won't take anything until we're winning." He's just gonna keep coming up with stuff until they win. LINDA: They had a big negative backlash last time, which I'm sure they weren't prepared for. SPEAKER 1: Yeah. LINDA: So I can imagine they'd keep going now. ROBERT: Me neither. I thought he was finally done. For 12 months he had at least -- remember the first year? He had to take off two months because he had plenty of phone calls from his family, and his life and everything from people, and he just left the city, upside down. SPEAKER 1: You know you can see… I mean, you can see people thinking, "Oh, it's his fault," because you don't get all the information on TV, so… ROBERT: No, you got just what the media wants you to get. SPEAKER 1: Mm-hmm. Yeah. ROBERT: So we wonder how much of this stuff we're hearing about the war is true. We hear only about all our successes, we don't hear about the failures. LINDA: It seems that anytime we do hear about a failure, it's always a mechanical… ROBERT: Brought it down, mechanical, right. Oh yeah, they were there on a training mission. SPEAKER 1: Mm-hmm. ROBERT: Anyways. Boom. Well, here we are spending two hours again. We gotta… LINDA: I know, I'm sorry. ROBERT: This is terrible. SPEAKER 1: No. ROBERT: Look. What other questions you got?24 LINDA: Oh, I want just to cover with the information about your starting your practice, and I seem to remember that you went into the pediatrics floor in [unintelligible - 00:37:26]. SPEAKER 1: He practiced with his dad first. ROBERT: I practiced general dentistry with my dad for six years and found myself doing more and more of the younger population of the practice, and enjoying it, and being successful at it. Probably enjoying it is the main word. Oh, I just enjoy the kids. SPEAKER 1: IE, he is the kid here. ROBERT: IE, I am a kid still. SPEAKER 1: [Laughter] ROBERT: Well, they are the next leaders of the world, and it feels [unintelligible - 00:37:58] time thinking about what they're thinking about, it keeps you young. The body doesn't like that, but the mind that's -- you know the story, "I just got my mind together and now my body is falling apart." And it took 60, 65 years to get to here. [Laughter] LINDA: [Laughter] SPEAKER 1: Anyway, that's when he… ROBERT: So all the parents used to say, you know, I guess -- well, last time the parents used to tell my father, "I don't want go over to your son. He just got out of dental school. But I don't mind if my kids go to your son." So I guess that's why I got the younger population and enjoyed it and did well with them. Because I have magic, it's a hobby, and sleight of hands, so I was always -- to this day, I think, would keep thimbles and cards next to my chair. LINDA: How did you learn that? ROBERT: This 91-year old Sylvia here that we're talking about started me in as a hobby as a kid, and puppets and all that stuff. I think I broke my leg at one point, and that's when I got introduced because I was in a cast for some weeks and nothing to do, and she brought the 25 stuff and happened to like it. But the… you know, one of the many stories of kids is the kid had been to three dentists and with a toothache, four-year old, and screaming and yelling at me and kicking, and me, the dentist, could handle him and finally made their way to pediatric dentist office, my office. And so I looked in the mouth as the kid was screaming and produced a red thimble from his mouth, and the kid stopped crying right away, put his hand to his head, scratched his head and said, "No wonder why that damn thing was hurting." [Laughter] SPEAKER 1: [Laughter] ROBERT: And I had him then, right? [Laughter] Yeah, I said, "Lemme look around some more. You got any more of those in there? Ah, over here," and goes, "Why not. Well, go get rid of that," you know. "I can do that magically, you know. Boom, I got that." [Laughter] LINDA: He's a cute… ROBERT: So probably he said, "No wonder why that damn thing was hurting." [Laughter] SPEAKER 1: They really do… ROBERT: Oh, I've got some great stories, yeah. [Laughter] And sometimes, also, when I used to lecture, I used to tell that story, and nobody would laugh. And I'd look and I'd say, "Come on, guys, wake up. Get a life. Do any of you have any kids, anybody, I mean, kids at all? That's a funny story." LINDA: Even if you don't have kids I think that was… SPEAKER 1: Right. ROBERT: That's a funny story. Because you guys are too serious. I used to tell adults that and get nothing out of it. I tell you, these guys are really too serious. It's like golfers rather than tennis players with dentists. We have a good time. In golf everybody's, "Don't make a sound. Be serious." And I'm throwing clubs around [unintelligible - 00:40:40] I can't understand.26 SPEAKER 1: He used to talk… ROBERT: I can't understand why they take this game so serious. LINDA: So can both of you talk a little bit about being Italian, what it means to you? ROBERT: Other than being proud I'm Italian -- I grew up not knowing there was much difference 'til recently. I got interested in the history of all of this, and yet I think my wife has a different story. SPEAKER 1: That's very recent to him. He just thought of himself as American [laughter] more recently, I think… ROBERT: Yeah, I mean I didn't know there was any difference to… many years SPEAKER 1: We were always -- our family was very into the history of being an Italian, very proud, you know, really proud of everything connected with being Italian, whether it was, you know, where you came from, or the country… ROBERT: Oh, yeah, I was smart enough to marry an Italian. LINDA: … the history. Thank you. The history, the architecture, I mean, we were all -- our family was always -- there were some parts of it. Some were more into the food, some were more into the history, but there was always, you know, you're an Italian American, you know, it's great to be an Italian. So it was just -- although, living where I lived, where we were, talk about a minority, we were really a minority. In the school I went to we were also a minority. And I do remember -- but just in that neighborhood, I don't remember while I was in anywhere else, but there were people who -- now, we were… ROBERT: Who thought you were second-class citizens, right? SPEAKER 1: … we were third generation, and we had some people who were first generation but spoke English thinking that we were second-class citizens because we had those funny-sounding names. ROBERT: First generation of another group, another ethnic group.27 SPEAKER 1: Yeah, of another -- yeah, they're not Italian. Right. And I thought, "Excuse me?" you know, I was born here, my parents were born here… ROBERT: So she experienced some prejudices that I don't remember. SPEAKER 1: Yeah, and in school, too. LINDA: Now, where was this? SPEAKER 1: Boston. The suburb of Boston but it was a very, very predominant Irish, Catholic neighborhood. I went to an Irish Catholic school, so while the nuns were Irish… ROBERT: Irish Catholics… SPEAKER 1: … so the nuns couldn't quite… ROBERT: Well they were Catholics, that's the… SPEAKER 1: You know, they couldn't quite understand, you know, anything. And then we had, maybe, like, two Polish kids, maybe three Italian kids. So we did feel different, but only in that, you know, instance then we were in the rest of the, you know, with my relatives who lived in all over suburban Boston, [unintelligible - 00:43:23], whatever, you know, lived with the -- it wasn't a problem… ROBERT: Which brings up my story, which you're probably waiting for, again, because I must've… SPEAKER 1: That was when I was -- then we moved to another neighborhood in Newton, I don't live there now. ROBERT: When I was in this progressive school and my parents were -- we were family members of a local country club that was limited in the acceptance of people, of members, and I took home a black friend of mine from school for the weekend, grabbed my neighbor, who was Jewish and took him up to play golf and get kicked off of golf course with a black and a Jewish guy. That was in the early '50s. LINDA: And where was this? SPEAKER 1: At the local…28 ROBERT: At a local country club. SPEAKER 1: He was too dumb to even know… ROBERT: I was too dumb to even know that they had restrictions. Right. SPEAKER 1: Sorry, I didn't mean dumb. LINDA: What kind of -- what did they tell you? Was this before you got on the course, or did somebody…? ROBERT: No, no, we were right just -- took him out on the course. Apparently we were coming back close to the clubhouse again on the third hole… SPEAKER 1: Someone saw him. ROBERT: … and the manager came out and told me I had to get off the course. LINDA: Did you ask why? SPEAKER 1: He didn't tell you? ROBERT: I don't remember. Yeah, we left… LINDA: And then? ROBERT: He was the boss, he said, "Get off," I got off. LINDA: But was it clear that he was doing because it was…? ROBERT: Yeah, I guess I knew that -- I figured it out once I was in the car and got home, I guess. I didn't figure it out right on the spot, but I think once I got in the car I figured it out. I didn't even think of checking on it when it went up, because I did the same thing recently, I took a lady on men's day who had Levi's, and you never have to have Levi's up there, same club. [Laughter] SPEAKER 1: Well, they were happy [laughter]. If you knew who was Wednesday… ROBERT: [Laughter] I forgot. I thought Wednesday morning was men's day and then Wednesday afternoon was okay. SPEAKER 1: They don't want pants with Levi's anywhere. LINDA: So it was key to double win.29 ROBERT: There was a double, so-- I got permission… I did get permission to go out on men's day in the afternoon. They said, "If nobody complains, just go out." When I get back in, head of the pro comes up to me and says, "And I heard you want Levi's, too." SPEAKER 1: [Laughter] ROBERT: I said, "I didn't even think to look at that so much." [Laughter] LINDA: All right. What's our next question? How did you feel coming here? I know we talked a lot more about this last time, but how did you feel coming to Leominster after living in -- was it Newton? SPEAKER 1: Mm-hmm. Yeah. I thought this was the end of the earth, [laughter] I thought this was… ROBERT: She said this was the on the other side of orange. [Laughter] SPEAKER 1: No. I thought it was real country. ROBERT: Out there an echo. SPEAKER 1: And I thought when I first came here, well it was late fall, so it was winter by the time we moved in our house and no one welcomed us, and I thought what an unfriendly place. And the ward of the dentist who welcomed us, the one nearest our age was 15 years older than we were, so I thought, "Oh, Lord, there was no one my age." I don't even know if there are any neighbors here. I never saw a face, and it didn't dawn on me that, well number one, it was winter, so people were kind of [unintelligible - 00:47:09] down. Number two was this is a real family community, generations are born and married and stayed here, so they have all extended families living right here. It's not that you're all spread out though… ROBERT: But the lights kept going on in the houses around us. You didn't see any people, but the lights kept going on at night. SPEAKER 1: And there was -- not Leominster, and I told him I thought the city had these houses wired up and they just flipped the switch at night [laughter].30 ROBERT: And the lights used to go because there were no people around us. SPEAKER 1: I thought there were no people. LINDA: And what year was this? SPEAKER 1: I thought it was '63. And then I realized after that, well, number one, it was winter and people weren't so ready, you know, to welcome you. Number two, his name was known in town, so they assumed, I guess that he had tons of friends and family, whereas, he really didn't because he was all the way to school, and his family -- well, because his parents were in Florida, so we had the one aunt and uncle who lived here in town. So I think people just assumed, "Well, we have our huge extended family. They must have theirs," so it was mainly lonely and I thought unfriendly. So it took -- it took a while, then when the thaw came, the neighbors… ROBERT: Spring came and we started raking leaves and we see people around. SPEAKER 1: … come. And then I found out it was a nice neighborhood, and the neighbors were nice, because the snow melted and out they came. But it took a while. I was really thinking, "Oh, boy. What a -- this is awful." ROBERT: There was like about -- we moved up here, right? We were like -- there were three houses up here in this hill, three of four houses, right here the top of the hill, and these people built houses and moved in, I always bring a bottle of wine and welcome them, maybe from the experience that we had. And it was all fine, that's great, whatnot, and then we decided after -- well, never, never heard from them after that. SPEAKER 1: Hmmm. No. People aren't as friendly as they are in the Midwest. Well, I worked… ROBERT: Then we finally said -- oh, great people, Midwest. SPEAKER 1: … people are different.31 ROBERT: Different. Then we decided we're gonna throw a street party. So we opened up our house and we sent a letter out to everybody with the old farm road address, 95 percent of the people showed, right? SPEAKER 1: Mm-hmm. ROBERT: Never heard from them since. That was 15 years ago. Other than the, other than the people who are touching us [unintelligible - 00:49:31] land here. LINDA: Mm-hmm. SPEAKER 1: Well, people are busy. It is different. People -- it's not like when we were kids. I think people are just so busy. ROBERT: When I grew up in the street where we had everybody, had each other's keys and everything when I was in grammar school, high school and whatnot. That street was close. SPEAKER 1: Well, those were your high school, what, home high school friends. ROBERT: Those were my home high school friends, right. But I mean, geez, you know. SPEAKER 1: But I have… ROBERT: We were in each other's houses all the time. Streets were… SPEAKER 1: I don't think… I learned to like the area, but it took a while. It really did. Took quite a while. Probably it was better when my children learns… ROBERT: When we saw the kids enjoying it, then we got to like it better. SPEAKER 1: … yeah, I probably -- great place for children because there was so much available that was close by, where on the city you really had to travel, you know. Here they could do everything within the, you know… ROBERT: Yeah, five-minute ride. Then it wasn't -- it was easy to go to wherever you want to go. Now, if you ever decide to go from Leominster to Fitchburg or across our city. LINDA: I just did.32 ROBERT: 3:30 to 5:30, it'd take you an hour and a half to get from one city to the other. If you're going north, then the south isn't too bad. But we come off the highway, we – every… well Route 13, Route 12, every one of those going north is loaded. SPEAKER 1: Well, I laughed. He told me 30 years ago, "Oh, you just wait," because I complain, I still miss the city. I didn't miss living there, but I wanna be a little bit closer so that I could just run in and take advantage of everything, I missed that. And he kept saying to me thirty years ago, "Oh, just wait. This Leominster is just gonna be a bedroom community to Boston," and I would just laugh hysterically and said, "Oh, my God, no one is coming past Concorde." And… ROBERT: And here we are. SPEAKER 1: Here we are. Yeah. ROBERT: Build the highway and they will come. [Laughter] SPEAKER 1: Yeah. LINDA: So which church did you join? SPEAKER 1: Ah, that's something… ROBERT: She remember one of the… SPEAKER 1: I wasn't used to that. We were in North Leominster and there was a knock at door, and there was this priest standing there and I went, "Well, I've never seen this in my life." No one -- no priest ever knocked on my door before. And it was the pastor from the Italian church in Fitchburg trying to convince me to join his church. My [unintelligible - 00:51:54], "Oh, that's fine, that's…" ROBERT: And we were living in… SPEAKER 1: North Leominster. ROBERT: Leominster. SPEAKER 1: Yeah, and, of course, I came from Boston where you went to church, and whatever neighborhood you lived there and whatever, 33 you know. He wasn't surprised when he came home. He said, "Oh, yeah," you know, but I didn't join that church… ROBERT: No, I said, "But you don't have to feel you have to join." SPEAKER 1: The one that was dear in my life, Lady of the Lake, we lived in North Leominster, that was there, so that was the church I joined. But then when we moved here, my daughter was in public school in first grade, we just moved, and I thought, "Well, yeah, I have to sign her up to CCD classes." So this house had been St. Leo's Parish, which was the Irish church. Well, I thought, well, that's obviously where I have to send her to… ROBERT: Closest church. SPEAKER 1: Well, again, didn't dawn on me that's where, you know, but if I had known, I mean, Saint Ana's was just hop, skip and a jump down the road, I could've signed her up there. But it -- still, it was the '70s now, and I still wasn't thinking, "Oh, well, this is different." And I called the secretary of the church who answered it and asked who it was, and she signed up my daughter, and I thought, "Well, don't you want -- aren't you gonna ask me my name? I haven't been -- don't you want us to join the church?" I never heard of a church that would take a child to CCD if the parents didn't belong to it. And she said, "Well…" in her accent, "… um, well, I thought you might… you might wanna join Saint Ana's church." ROBERT: -Which is the Italian church down the road. [Laughter] SPEAKER 1: I didn't know, this is 1970 whatever, and I said… ROBERT: "What?" SPEAKER 1: Yeah. I said, "What?" ROBERT: Why? SPEAKER 1: I was so befuddled. And I said to him, "I wish I had thought fast enough," I probably would've said, "Well, I'm Protestant anyway, so I don't wanna join any church." [Laughter] My sister was so 34 overwhelmed by that. So I thought, well change comes very slowly out here. [Laughter] ROBERT: Did you know we have the largest Finnish population in the world. LINDA: In the world? SPEAKER 1: No, no. In the United States. ROBERT: In the United States that's -- yeah, that's a Finnish group and we have a sister city in Finland. LINDA: Hmm. I didn't know that there were so many Finns around here. ROBERT: A lot of Finns. They're great people. LINDA: Just like my grandfather is Finnish. ROBERT: Is that right? SPEAKER 1: Oh, really? ROBERT: Oh, I remember in my dad's practice, and then I was… SPEAKER 1: Well, still. ROBERT: Great Finnish people. Wonderful people. SPEAKER 1: They have this pact, signed a pact in Fitchburg, and they still have big gatherings, Finnish gatherings and so forth. Yeah. LINDA: So would you like to speak about anything else? ROBERT: No, I need to have lunch. LINDA: Lunch? SPEAKER 1: Oh, poor dear. LINDA: It's dinner. I don't know… ROBERT: Put something in my tummy before I go play tennis at dinnertime. SPEAKER 1: Every Friday he has to play tennis. Yeah, still have fun. ROBERT: Fun time. SPEAKER 1: What else? What else? I guess just my Italian experiences are a little bit different from his. I think… ROBERT: Yeah, well you grew up in a different place. SPEAKER 1: Yeah. Well, and our family might have been different. We had more traditional meals and we did the traditional Christmas Eve dinner. We did the traditional…35 ROBERT: This reminds me, my mother made homemade raviolis every Thanksgiving and Christmas. SPEAKER 1: Yeah. That wasn't Christmas Eve in an Italian household; you have all fish Christmas Eve… ROBERT: Yeah, if you're like -- there aren't any fish out here. SPEAKER 1: [Laughter] No, that's true. ROBERT: Years ago, but I said the fish was four days old… SPEAKER 1: … when I found that out… found that out… ROBERT: … by the time it swam up the national river. ROBERT: That was true. The first time I bought a fish here I threw it out. I couldn't even eat it. I thought, no wonder he doesn't likes fish. ROBERT: It was after the… SPEAKER 1: He was used to getting it live from the… ROBERT: Oh, that's when I got the live fishes, this meeting with her relatives. They had fresh fish and wow, what a difference. SPEAKER 1: We did have… ROBERT: But we didn't have fish houses around here until, maybe, like three, four or five years after we're married. It moved… SPEAKER 1: Yeah, at least. Yeah. ROBERT: It took the… late '60s. SPEAKER 1: I know your mother. I don't remember your mother ever doing -- she did -- I mean, she baked great pies but never did Italian cookies, Italian version. We did all that Italian stuff at the holidays so we were more… ROBERT: The lady next door did, Vermonti. SPEAKER 1: Oh, wow. You were lucky. ROBERT: She used to bring them over. SPEAKER 1: Oh, wow. The stuff you do with this… ROBERT: With all the onion on them and stuff like that, there were ribbon things? Yeah. Yeah?36 SPEAKER 1: I think they have someone I'm looking for a recipe for that because only our -- a distant relative on the other side made those, and we only had it when we went to her house, not… LINDA: Often you don't… SPEAKER 1: Oh, I would love that. That's the one I'm trying to… ROBERT: Yeah, you've been looking for fill-ins. SPEAKER 1: My children are so into this. ROBERT: We make [unintelligible - 00:56:38], we're the intersect. We have her grandmother's, her mother's… SPEAKER 1: [Unintelligible - 00:56:45]. Yeah. ROBERT: [Unintelligible - 00:56:45]. And we get her up all nights and mix us the stuff and… SPEAKER 1: My father's family were great cooks, and my mother actually cooked like my father's side of the family. There were two different sides, and you could tell the difference. My mother's side cooked one way and my father's side cooked the other way… LINDA: Why? They're from different regions? SPEAKER 1: No. ROBERT: No? SPEAKER 1: From the exact same place, but it seems like the Fridocelli cooked with a little bit more… LINDA: Cooked cuisine. SPEAKER 1: You know, a little more fancy. And then my mother's side, they were a little more peasant, plain… ROBERT: You mean there was merit having both grandma and grandpa from the same city. [Laughter] SPEAKER 1: Well, my four grandparents came from the same… ROBERT: Oh, is that right? SPEAKER 1: Same province. ROBERT: Same province. Yeah. SPEAKER 1: Yeah. But still the cooking was a little different.37 LINDA: Wow. SPEAKER 1: Yeah. And that was it. It was important, and I'm glad my kids still think it's important. It's very important for them to -- and often the Italian are important to them. Even though… LINDA: Now, they didn't marry Italians? SPEAKER 1: My daughter married someone who's half Italian. LINDA: What is her last name? SPEAKER 1: Well, she goes by Frigoletto. Yeah, she kept her name. LINDA: But who did she marry? SPEAKER 1: Peter De Feo. D-E capital F-E-O. And then my son, really, broke with tradition. He married Tamara Taylor. [Laughter] ROBERT: Oh, yeah, but he was going with an Italian. SPEAKER 1: He was going with an Italian… ROBERT: Italian, but she turned out to be too strong for us… SPEAKER 1: [Laughter] LINDA: Oh. SPEAKER 1: So Tamara Taylor… ROBERT: Direct battleship. SPEAKER 1: Actually now… she's a redhead, but delightful. She's Norwegian and Scottish. I thought Taylor was English, but she said Scottish was her blood. And her family, they have traced her family back to the first two boats that came over the Mayflower and the next one. What was the other one? Two names, I forget what it is. ROBERT: I don't know. SPEAKER 1: So they're into the history, too. So now the two of them… ROBERT: Has it anything to do with the Minnon, the Tintin, the Sta. Maria? [Laughter] SPEAKER 1: No. But she's had -- but she's very much into Italian… ROBERT: Wrong group, right? SPEAKER 1: … go back. She was trying to learn the language. LINDA: Mm-hmm.38 SPEAKER 1: She was trying to learn to speak it. LINDA: Oh. ROBERT: She's in [unintelligible - 00:58:57]? That daughter-in law? SPEAKER 1: Boy, no. I forget. Yeah, we were trying to learn all this… ROBERT: New Ireland, I think… I forget. No memory anymore. Kinda learn all these Italian words… SPEAKER 1: The word for parent is genatori. ROBERT: Genatori which is… should be -- parenti's relatives. SPEAKER 1: Right. Yeah, that's… ROBERT: Parents genatoris. SPEAKER 1: Yeah, I can't figure that one out. Right. ROBERT: Yeah. SPEAKER 1: Now you are part Italian? LINDA: My grandmother was Italian, my maternal grandmother. Then she married a Finn. SPEAKER 1: Oh. LINDA: And then my mother married a Yankee, then I married a Swede. SPEAKER 1: So you're all that? ROBERT: Did you watch the Hall of Fame last night? LINDA: No. SPEAKER 1: Oh. ROBERT: There was a cute love story in the war, early '40s… SPEAKER 1: Based on a true story. LINDA: Oh, my goodness… ROBERT: In Italy. LINDA: … need to tell me but… ROBERT: Yeah. And a lot of Italians. They spoke too fast, though. SPEAKER 1: You know, I'm not -- and that was the first time I said that's… ROBERT: But a lot of sceneries were filmed entirely in Italy, and it was about this guy that… SPEAKER 1: But you can buy the tape. It's a Hallmark story, though.39 ROBERT: Yeah. LINDA: It was Love and War. Thank you. SPEAKER 1: Love and War, yeah. ROBERT: Love and War But it was an interest of -- the thing I thought was cute, that I hadn't learn or forgotten, I guess, is that a British soldier, it might be British saying, when he falls in love with this Italian girl that they took him in and saved his life, he says, "We, growing up, we used to call you macaroni heads," from British, from the -- derogatory thing, you know, those Italians, they're macaroni head. He says, "Now I found out how wonderful you people are." [Laughter] He says, "I feel guilty." That was kind of a cute part of the story. LINDA: I think that's sort of true. SPEAKER 1: Yeah. LINDA: In any culture, if you just open yourself up and… ROBERT: Sure. SPEAKER 1: But I -- actually, you must've -- I can remember, in Boston… ROBERT: I don't remember. SPEAKER 1: … he had a lot of this derogatory terms. ROBERT: Well, dego, I remember but I didn't hear -- macaroni I thought was just English, that was an English that was the… SPEAKER 1: Yeah, that was it. What I'm saying is that you did hear -- but then, again, you would hear it for the Irish, you would hear it for the Jewish, you always would hear about derogatory terms for -- at least in the city we get through all the ethnic… LINDA: So tell me what some of them are, you know, what's so politically correct now that you don't really…? At least my children don't know any of the… SPEAKER 1: You know, I don't really… LINDA: … Italian being derogatory… SPEAKER 1: No. Dego, wop…40 ROBERT: Dego, wop. And when in Chicago we used to -- we used to walk back East to look at the watch and, "Watch the dego by," [laughter] and used the word "dego." LINDA: Oh, dego. Where did that come from? SPEAKER 1: I don't know either. ROBERT: I don't know. SPEAKER 1: I don't know either. LINDA: I've never heard dego. SPEAKER 1: I don't either. ROBERT: Like, what? Pollack is Polish? SPEAKER 1: Pollack would be for… ROBERT: Be Polish and… SPEAKER 1: Mic are half… ROBERT: Mic were half for Irish. Right. And we were dego and the wops. So I would be French… SPEAKER 1: No. I don't know where they… ROBERT: Don't know the origins of all of those things… be interesting, which my uncle would've mind. He was such a [unintelligible - 01:01:51]. He was doing the history of words. SPEAKER 1: He was so… ROBERT: After he retired that was his… LINDA: Did he keep his information? ROBERT: Yeah, he's kept it going, and when he died I tried to get it from my aunt. SPEAKER 1: And when he couldn't… ROBERT: I guess she gave it to one his younger teachers. I don't know where it is now. SPEAKER 1: He gave it to another elderly person… ROBERT: Another elderly person and got lost or something. SPEAKER 1: Right, it's gotta be… ROBERT: We even offered to pay her for it.41 SPEAKER 1: Yeah. ROBERT: It was -- yeah, it was just so interesting. SPEAKER 1: He was the professor of Roman languages, so he's doing the… ROBERT: He knew the different languages. SPEAKER 1: … words, whether it came from France… ROBERT: France or Italian or whatnot. SPEAKER 1: We desperately want… ROBERT: I wanted to get a hold of that. SPEAKER 1: We couldn't, we tried. ROBERT: Every time we'd see him, which is like twice a year, that it's, "Oh, I got, you know, twenty… twenty more words…" LINDA: What's his name? ROBERT: Merlino. My mother's name, Merlino. SPEAKER 1: Camillo Merlino. ROBERT: Camillo Merlino. How's that? SPEAKER 1: Yeah. He was the… ROBERT: Protestant Italian. SPEAKER 1: … head of the department at BU… ROBERT: Head of the Roman's languages at BU. And still I didn't get the language. SPEAKER 1: No, he did not inherit that. No, my kids took after my part of the family. We have an air for languages, he struggles so with it. Doing better than I ever… ROBERT: I got so frustrated last night watching that… SPEAKER 1: That was tough, I had… ROBERT: But you said you had a tough time, too. Two years trying to learn words, just to recognize [unintelligible - 01:03:12]. SPEAKER 1: I mean, I think you're doing well… ROBERT: It's got nothing. SPEAKER 1: … trying for all these years. LINDA: I think you have to be immersed in it.42 SPEAKER 1: Mm-hmm. That's true. ROBERT: Yeah, yeah, yeah. Good idea, let's go. [Laughter] SPEAKER 1: That's my mother. ROBERT: Yeah, yeah, yeah, for a month, that's her way of saying we gotta go. SPEAKER 1: But that is no close. ROBERT: [Laughter] SPEAKER 1: Well, before we let you on, could you take another picture of us? LINDA: Oh, yes. I have central… SPEAKER 1: I'd love that. LINDA: … because I almost forgot the camera, too. SPEAKER 1: Oh. LINDA: This was supposed to go over real low. SPEAKER 1: No, we wouldn't hold you to it. I just thought -- I didn't like my plaid shirt, I looked like the… the fire hand. LINDA: He said you'd say amazing things. SPEAKER 1: Yeah. Well, I may -- well, I was that day. Well, I was today, too, but… ROBERT: Guess what? It's four o'clock. SPEAKER 1: It's now four o'clock in the middle of a family interview./AT/jf/jc/es

Background: The prevalence of type 2 diabetes mellitus (T2D) and the number of patients with comorbidities like hypertension, dyslipidemia and cardiovascular diseases are increasing worldwide. Evidence-based medicine uses the best available evidence from systematic research to make decisions about the care of individual patients. The systematisation and appraisal of evidence are done in care guidelines, which in turn aim to guide the application of effective diabetes prevention and care interventions in different age groups and settings. Patients with T2D need continuous and individualised care. They are therefore seen as the ideal target group for the use of digital health interventions like telemedicine. However, heterogeneous patient populations, telemedicine phenotypes and settings hamper the evaluation of digital health interventions. Comparing study results to provide evidence-based recommendations is further complicated by the diversity of applied study designs. Therefore, there is a need for a systematic review of the current state of research while considering the described variability. In line with this aim five research studies were conducted. Objective: The overall objective of this thesis was, to identify current needs of patients with diabetes (publication 1), to systematically analyse the effectiveness of different diabetes prevention and care interventions (publications 2+3) and to evaluate digital diabetes prevention and care interventions (publications 4+5). Material und Method: To analyse current needs of patients with diabetes, three substudies were conducted in the beginning (publication 1). They consisted of a standardised survey of experts to analyse existing chronic care programs, an expert workshop to identify patients' needs and an online survey to prioritise the categorised needs dimensions seen from the perspective of patients and health care providers. Two literature overviews were performed to analyse the best available evidence in diabetes prevention and care. An umbrella review analysed the available evidence to identify effective interventions of blood sugar regulation on cardiovascular risk (publication 2). Study quality was assessed using OQAQ (Overview Quality Assessment Questionnaire). Afterwards, a literature overview aimed to identify effective measures of population-based prevention and communication strategies to provide recommendations for policy makers on how to prevent diabetes in different age groups and settings (publication 3). In a next step, digital diabetes prevention and care interventions were summarised. To evaluate digital health interventions with more than one active function, a study protocol was developed. It describes the evaluation of a hypothetical gamification-based smartphone application for weight loss in overweight and obese adolescents (publication 4). As a last step, an umbrella review (publication 5) systematically analysed the effectiveness of telemedicine interventions in diabetes, dyslipidaemia and hypertension. Potentially relevant records had to analyse the effectiveness of telemedicine on clinical outcomes under real-life conditions in patients with one of the defined target diseases using either a systematic review or meta-analysis based on RCTs. Results of meta-analyses and their subgroup analyses were used to identify effective components or other characteristics (e.g. intensity or frequency of feedback). Overall certainty of outcomes was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tool. Results and Implications: The standardised survey on current care models indicated that a lack of national guidelines, cost-ineffective and non-individualised health care as well as long waiting periods were criticised. Education of patients, communication within the team and with the patient, prevention and health promotion as well as the accessibility of services were significantly more important to patients when compared to health care providers. The identified differences in priorities support the early assessment of these preferences. The umbrella review on the potential of blood sugar regulation for the reduction of cardiovascular risk identified 44 records which were of good quality (OQAQ-median = 17). The results suggest that pharmacological and non-pharmacological interventions have the potential to improve cardiovascular outcomes. When deciding for a certain intervention as well as its intensity, baseline blood pressure and cardiovascular risks of the patient should be considered. Guidelines on cardiovascular prevention should take into account pathophysiological mechanisms as well as individual lifestyle interventions. While effective measures for individual level prevention including physical activity and diet programs were found, available evidence for population-based intervention was scarce and insufficient. The literature overview conducted afterwards identified evidence-based interventions for population-based prevention, including taxation of unhealthy products and specific prevention strategies in certain settings (e.g. kindergartens, schools). These strategies may contribute to the development of policies and governmental regulations for the prevention of diabetes in different age groups and settings. To evaluate a digital mobile health intervention consisting of more than one component, a study protocol for a single-centre, two-arm, triple-blinded, randomised controlled trial following the CONSORT recommendations was developed. The intervention consists of a smartphone application that provides both tracking and gamification elements for lifestyle change. The control group uses an identically designed application, which solely features the tracking of health information. It appears favourable to use RCTs for proof of concept assessments, to evaluate the effectiveness of an app or specific components in controlled settings. The fifth publication of this thesis shows that telemedicine may lead to significant and clinically relevant reductions of HbA1c (≤ -0,5 %) in patients with T2D. The identified reduction rates are comparable to those of non-pharmacological and even some pharmacological interventions. Extracted subgroup analyses showed that certain population and intervention characteristics seem to be associated with improved clinical benefits. This applies to interventions with a rather short duration ( 8,0 %) were identified as population characteristics favourable for clinically relevant improvements of HbA1c. In addition to the characteristics, future updates of guidelines should carefully consider the low levels of certainty as indicated by the low GRADE results. The present thesis provides a systematic overview of effective measures in diabetes prevention and care. Overall, there is a potential for the early and structured assessment of patients' preferences. The systematisation and appraisal of the best available evidence on the effectiveness of telemedicine in patients with diabetes and associated comorbidities revealed areas for the update of present guidelines. There is a need for methodologically robust studies on the effectiveness of telemedicine in specific populations and in consideration of combined digital health components. The results and identified research needs have the potential to motivate future studies.:Inhaltsverzeichnis I Abkürzungsverzeichnis III Abbildungsverzeichnis VI Tabellenverzeichnis VII Liste der entstandenen Publikationen VIII 1 Einführung in die Thematik 1 1.1 Diabetes 1 1.1.1 Epidemiologie 1 1.1.2 Krankheitstypen, Krankheitsstadien und Begleiterkrankungen 2 1.1.3 Diabetesprävention 5 1.1.4 Diabetesversorgung 6 1.2 Evidenzbasierte Medizin 9 1.3 Digitalisierung 14 1.4 Stand der Forschung 15 1.4.1 Unterstützungs- und Versorgungsprobleme 15 1.4.2 Individuelle und populationsbasierte Maßnahmen zur Diabetesprävention 16 1.4.3 Herausforderungen digitaler Diabetesprävention und -versorgung 22 1.5 Zieldefinition und Fragestellung 25 2 Thematischer Zusammenhang und Methodenüberblick 26 3 Individualising Chronic Care Management by Analysing Patients' Needs – A Mixed Method Approach 28 4 Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention 31 5 What should governments be doing to prevent diabetes throughout the life course? 34 6 Efficacy of gamification-based smartphone application for weight loss in overweight and obese adolescents: study protocol for a phase II randomized controlled trial 36 7 Mapping the Evidence on the Effectiveness of Telemedicine Interventions in Diabetes, Dyslipidemia, and Hypertension: An Umbrella Review of Systematic Reviews and Meta-Analyses 38 8 Diskussion und Ausblick 41 8.1 Einordnung der Ergebnisse 41 8.2 Limitationen und Methodenkritik 49 8.3 Wissenschaftliche Kontribution und Ausblick 50 9 Schlussfolgerung 51 10 Zusammenfassung 53 11 Summary 57 12 Literaturverzeichnis 60 13 Anhang 110 13.1 Wissenschaftliche Kontribution der Publikationen 110 13.2 Details zu Publikationen als Erstautor 112 13.3 Volltexte der entstandenen Veröffentlichungen 117 13.4 Curriculum Vitae 198 13.5 Danksagung 199 Anlage 1 200 Anlage 2 202 ; Hintergrund: Die Häufigkeit des Typ-2-Diabetes mellitus (T2D) sowie die Zahl von Patienten mit Begleiterkrankungen wie Hypertonie, Lipidstoffwechselstörungen und kardiovaskulären Erkrankungen sind weltweit ansteigend. Die evidenzbasierte Medizin nutzt die beste verfügbare Evidenz aus systematischer Forschung um Entscheidungen für die individuelle Patientenversorgung zu treffen. Die Aufarbeitung und Bewertung der Evidenz erfolgt in Versorgungsleitlinien, welche wiederum zur Verwendung wirksamer Maßnahmen der Diabetesprävention und -versorgung in verschiedenen Altersgruppen und Settings anleiten können. Patienten mit T2D bedürfen der kontinuierlichen und individualisierten Versorgung. Sie gelten daher als ideale Patientengruppe, um digitale Versorgungsformen wie Telemedizin zu nutzen. Heterogene Patientenpopulationen, Telemedizinanwendungen und Settings erschweren jedoch die Evaluation digitaler Gesundheitsanwendungen. Zusätzlich wird durch die Diversität der angewandten Studiendesigns ein Vergleich der Studienergebnisse, mit dem Ziel evidenzbasierte Empfehlungen zu formulieren, verkompliziert. Es fehlt daher an einer systematischen Aufarbeitung des Forschungsstands unter Berücksichtigung der geschilderten Variabilität. Mit diesem Ziel wurden fünf Forschungsarbeiten angefertigt. Fragestellung: Übergeordnetes Ziel der vorliegenden Arbeit war es, bestehende Unterstützungs- und Versorgungsprobleme von Patienten mit Diabetes zu identifizieren (Publikation 1), die Wirksamkeit verschiedener Maßnahmen der Prävention und Versorgung des Diabetes systematisch aufzubereiten (Publikationen 2+3) und digitale Diabetespräventions- und –versorgungsstrategien zu bewerten (Publikationen 4+5). Material und Methode: Mit dem Ziel, bestehende Unterstützungs- und Versorgungsprobleme von Patienten mit Diabetes zu analysieren, wurden zu Beginn drei Teilstudien durchgeführt (Publikation 1). Diese beinhalteten eine standardisierte Expertenbefragung zu bestehenden Versorgungsmodellen, einen Workshop zur Identifikation von Versorgungs- und Unterstützungsproblemen und die Durchführung einer mehrsprachigen Online-Befragung zur Priorisierung der kategorisierten Problembereiche aus Sicht der Patienten und Leistungserbringer. Zur Analyse der besten verfügbaren Evidenz zur Diabetesprävention und –versorgung wurden zwei Übersichtsarbeiten durchgeführt. Ein Umbrella Review untersuchte die verfügbare Evidenz effektiver Maßnahmen der Blutzuckerregulation auf das kardiovaskuläre Risiko (Publikation 2). Die Studienqualität wurde durch OQAQ (Overview Quality Assessment Questionnaire) bewertet. Im Anschluss hatte eine Literaturübersicht das Ziel, wirksame Maßnahmen der Verhältnisprävention sowie Kommunikations-strategien zu identifizieren, um Handlungsempfehlungen abzuleiten, wie politische Entscheidungsträger in verschiedenen Altersgruppen und Settings Diabetes verhindern können (Publikation 3). In einem nächsten Schritt wurden Ansätze der digitalen Diabetesprävention und –versorgung aufgearbeitet. Zur Evaluation von digitalen Interventionen mit mehr als einer aktiven Funktion wurde ein Studienprotokoll entwickelt. Dieses beschreibt die Evaluation einer (hypothetischen) spielbasierten mobilen Applikation zur Gewichtsreduzierung bei übergewichtigen und adipösen Jugendlichen (Publikation 4). Im letzten Schritt wurde ein Umbrella Review (Publikation 5) durchgeführt, um die Wirksamkeit von Telemedizin bei Patienten mit Diabetes, Lipidstoffwechselstörungen und Hypertonie systematisch zu erheben. Potentiell relevante Forschungsarbeiten mussten die Wirksamkeit (effectiveness) von Telemedizin auf klinische Outcomeparameter unter realweltlichen Bedingungen bei mindestens einer der definierten Erkrankungen in Form von systematischen Übersichtsarbeiten und Meta-Analysen auf Basis von RCTs untersucht haben. Ergebnisse von Meta-Analysen und deren Subgruppenanalysen wurden herangezogen, um effektive Funktionen oder andere Charakteristika (z.B. Intensität oder Häufigkeit von Feedback) zu identifizieren. Um das Vertrauen in den Effektschätzer der Subgruppenanalysen zu bewerten, wurde das GRADE-Schema (Grading of Recommendations Assessment, Development and Evaluation) angewandt. Ergebnisse und Schlussfolgerungen: Die standardisierte Befragung zu verfügbaren Versorgungsmodellen von Patienten mit Diabetes ergab, dass das Fehlen nationaler Versorgungsleitlinien, nicht kosteneffektive und nicht-individualisierte Versorgung sowie lange Wartezeiten häufig bemängelt wurden. Für die befragten Patienten waren im Vergleich zu den befragten Leistungserbringern die Patientenschulung, Kommunikation im Behandlungsteam und mit dem Patienten, die Prävention und Gesundheitsförderung, sowie die Verfügbarkeit der Versorgungsdienstleistungen signifikant wichtiger. Die identifizierten unterschiedlichen Prioritäten zwischen den an der Versorgung beteiligten Akteuren legen nahe, diese Präferenzen frühzeitig zu erfassen. Der Umbrella Review zum Potential der Blutzuckerregulation für Verbesserungen kardiovaskulärer Risiken identifizierte 44 Übersichtsarbeiten mit mehrheitlich guter Qualität (OQAQ-Median = 17). Unter Berücksichtigung unterschiedlicher Endpunkte legen die Erkenntnisse nahe, dass sowohl pharmakologische als auch nicht-pharmakologische Interventionen kardiovaskuläre Endpunkte verbessern können. Die Entscheidung für eine Intervention und ihre Intensität sollte neben dem Blutdruck auch das bestehende kardiovaskuläre Risiko zu Beginn der Behandlung berücksichtigen. Leitlinien im Bereich der kardiovaskulären Prävention sollten sowohl pathophysiologische Mechanismen als auch individuelle verhaltensorientierte Präventionsmaßnahmen einbeziehen. Während im Bereich der Verhaltensprävention wirksame Strategien, wie die Steigerung der körperlichen Aktivität und die Anpassung der Ernährungsgewohnheiten, identifiziert wurden, war die verfügbare Evidenz von populationsbasierten Maßnahmen der Verhältnisprävention im durchgeführten Umbrella Review begrenzt und nicht belastbar. Die im Anschluss durchgeführte Literaturübersicht konnte jedoch belastbare Evidenz zur Verhältnisprävention, wie die Besteuerung ungesunder Nahrungsmittel und spezifische Präventionsmaßnahmen in Settings (z.B. Kindergarten, Schule etc.), identifizieren. Diese Ansätze können dazu beitragen, regulatorische Maßnahmen zur Diabetesprävention in verschiedenen Altersgruppen und Settings zu entwickeln. Zur Evaluation einer mobilen digitalen Gesundheitsanwendung mit mehreren Funktionen wurde ein CONSORT-konformes Studienprotokoll für eine monozentrische, zweiarmige, dreifach verblindete, randomisierte, kontrollierte Studie entwickelt. Die Intervention bestand aus einer Smartphone-Applikation, die "Tracking" und spielerische Anregungen zur Lebensstiländerung verbindet. Die Kontrollgruppe erhielt eine Smartphone-Applikation mit identischem Design, die jedoch ausschließlich Tracking von Gesundheitsinformationen anbietet. Im Rahmen des frühen Wirksamkeitsnachweises scheinen RCTs hilfreich, um die Wirksamkeit einer App bzw. ausgewählter Funktionen klinisch kontrolliert zu testen. Die fünfte Publikation der vorliegenden Dissertation zeigt, dass Telemedizin den HbA1c bei Patienten mit T2D klinisch relevant (≤ -0,5 %) reduzieren kann. Die identifizierten Reduktionsraten sind mit jenen von etablierten lebensstilmodifizierenden und selbst einigen pharmakologischen Interventionen vergleichbar. Extrahierte Subgruppenanalysen legen nahe, dass bestimmte Populations- und Interventionscharakteristika mit einer gesteigerten Wirksamkeit assoziiert sind. Hierzu gehören Interventionen mit relativ kurzer Dauer ( 8,0 %) wurden als Patientencharakteristika identifiziert, bei denen Telemedizin zu klinisch relevanten und signifikanten Verbesserungen des HbA1c führte. Neben diesen Charakteristika sollten zukünftige Leitlinienupdates das geringe Vertrauen in die Effektschätzer, in Form der schlechten GRADE Bewertungen, berücksichtigen. Die vorliegende kumulative Dissertation liefert einen Beitrag zur systematischen Übersicht über wirksame Ansätze der Diabetesprävention und –versorgung. In der Gesamtschau zeigt sich ein Potential für die frühzeitige und strukturierte Berücksichtigung von Patientenpräferenzen. Durch die Aufbereitung und methodische Bewertung der verfügbaren Evidenz zur Wirksamkeit von Telemedizin bei Diabetes und assoziierten Begleiterkrankungen wurden Ansätze für die gezielte Aktualisierung bestehender Leitlinien identifiziert. Es besteht ein Bedarf für methodisch robuste Studien zur Wirksamkeit von Telemedizin in spezifischen Populationen und unter Berücksichtigung der Kombination digitaler Interventionsfunktionen. Die Ergebnisse und identifizierten Forschungsbedarfe haben das Potential, zukünftige Studien zu motivieren.:Inhaltsverzeichnis I Abkürzungsverzeichnis III Abbildungsverzeichnis VI Tabellenverzeichnis VII Liste der entstandenen Publikationen VIII 1 Einführung in die Thematik 1 1.1 Diabetes 1 1.1.1 Epidemiologie 1 1.1.2 Krankheitstypen, Krankheitsstadien und Begleiterkrankungen 2 1.1.3 Diabetesprävention 5 1.1.4 Diabetesversorgung 6 1.2 Evidenzbasierte Medizin 9 1.3 Digitalisierung 14 1.4 Stand der Forschung 15 1.4.1 Unterstützungs- und Versorgungsprobleme 15 1.4.2 Individuelle und populationsbasierte Maßnahmen zur Diabetesprävention 16 1.4.3 Herausforderungen digitaler Diabetesprävention und -versorgung 22 1.5 Zieldefinition und Fragestellung 25 2 Thematischer Zusammenhang und Methodenüberblick 26 3 Individualising Chronic Care Management by Analysing Patients' Needs – A Mixed Method Approach 28 4 Blood Sugar Regulation for Cardiovascular Health Promotion and Disease Prevention 31 5 What should governments be doing to prevent diabetes throughout the life course? 34 6 Efficacy of gamification-based smartphone application for weight loss in overweight and obese adolescents: study protocol for a phase II randomized controlled trial 36 7 Mapping the Evidence on the Effectiveness of Telemedicine Interventions in Diabetes, Dyslipidemia, and Hypertension: An Umbrella Review of Systematic Reviews and Meta-Analyses 38 8 Diskussion und Ausblick 41 8.1 Einordnung der Ergebnisse 41 8.2 Limitationen und Methodenkritik 49 8.3 Wissenschaftliche Kontribution und Ausblick 50 9 Schlussfolgerung 51 10 Zusammenfassung 53 11 Summary 57 12 Literaturverzeichnis 60 13 Anhang 110 13.1 Wissenschaftliche Kontribution der Publikationen 110 13.2 Details zu Publikationen als Erstautor 112 13.3 Volltexte der entstandenen Veröffentlichungen 117 13.4 Curriculum Vitae 198 13.5 Danksagung 199 Anlage 1 200 Anlage 2 202

*This series is the result of an adaptation of a paper presented as part of a seminar on "Theories and Research in International Relations" at Hebrew University, July 2012. Commentaries are welcome to daniel.wajner@mail.huji.ac.il Click here to read Part II of the series In the first article of this series we have introduced the debates on the ontology of power, while in the second one we have presented the main epistemological approaches of the different paradigms. In this third and final article we will deal with methodological schemes for Power Analysis in IR, while indicating areas for possible innovation using the "Arab Spring" cases as illustrations. Power, Outcomes, and what brings them togetherAs we have seen in the last part, the contribution made by Barnett and Duvall with his taxonomy of four dimensions of power is very helpful as theoretical framework; nevertheless, it is still weak to implement as a methodological tool - it is very difficult to distinguish in a real case what is originated through the structure or the actor, as well as to measure if the specificity is direct or diffuse.But the same could be expressed about the majority of the mentioned schemes. In fact, Dahl itself warned about the difficulties of combining variables to compare power relations and argued that it depends on the requirements of the research.1 This complexity is even larger when normative factors are included; for example, despite the proposal of Nye of measuring soft power through polls and focus groups, he also cautioned about the limits of the intangible variables.2 Hurt addresses certain ways of skipping the difficulties in measuring the power of legitimacy, such as examining: the rates of compliance, the reasons given for compliance and for non-compliance, the support given by the centers of Power and the need for legitimacy argument (akin to a counterfactual technique).3 But, once again, no combined power relations framework is presented.In addition, Lukes argues that power depends on the "significance" of the outcomes, namely, in the capacity of affecting the interests of the agents. He refers to two methods: by changing incentives structures (indoctrination) and by influencing interests (subject freedom). However, Lukes confesses that the main question remains open: how to use certain power to shape certain preferences?4In conclusion, in these approaches no power relation mechanism explains, in a measurable way, how material and normative resources are combined to shape power and influence decisions. Therefore, I would like to subsequently suggest a very simple framework that may allow us to implement the knowledge mentioned hitherto to study specific cases in IR.In line with the majority of the authors, in order to make power measurable I consider that we have to divide it in two variables: material power (or simply Power) and legitimation power (or legitimacy). In international politics, the power of an actor is expressed by its military (backed-by-economical) resources, and for the scheme it would receive "high" or "low" values. The legitimacy of the actors, which is based on their capacity to be perceived as norms-compliers and to build consensus around them5, would receive also "high" or "low" values.A power analysis based on the combination of those two variables, as it is shown below in illustration I, leads us to the taxonomy of four types of cases, each one ascribed to an "outcome". It is important to clarify that, for this paper, the outcomes would reflect the domestic situation of the main agent (the State) given an international system; it is a sort of outside-in analysis if we take into account Gourevitch´s second image reversed.6 Further work has to be done to adapt this scheme so as to explain the conduct of the State vis-à-vis other States as well as to include the domestic sphere of legitimacy.The first actor, which has high power and high legitimacy, could describe his situation as "stable"; that means, the actor would overcome the domestic and external challenges without internal changes and high international costs.The second actor, having high power but low legitimacy, is considered to be in a "changeable" situation. Although this actor is capable of overcoming internal and external challenges, due to the fact that it lacks of support from the other actors he could suffer from high international costs and possibly domestic changes.Illustration I – Taxonomy of Power-Legitimacy outcomesPOWERLEGITIMACYHigh PowerLow Power High Legitimacy "STABLE" "PROTECTABLE" Low Legitimacy "CHANGEABLE" "REVOLUTIONABLE" To the third actor, which has low power but high legitimacy, his situation is defined as "protectable". Due to his incapacity to overcome alone the internal and external challenges, this actor may count on the support of other actors to reduce the possibility of domestic changes; otherwise he will suffer from it.The fourth actor, with low power and low legitimacy, is placed in a "revolutionable" situation; that means, this actor is candidate to suffer from internal changes and high international costs at the time he would face challenges.Testing the Power Analysis framework with the "Arab Spring"The phenomenon known as the "Arab Spring", composed of dozens of countries in which massive protests were held, constitutes an outstanding test for the theory. A large quantity of those cases happened in a very short range of time, with all the variety of domestic conditions, reactions from the regime and from the world, as well as different outcomes. This makes those events ideal for the present examination; even though it is just a "sample" of a more deeply study.7Although no State of those that suffered uprisings is considered in a "stable" situation at all, Saudi Arabia and Jordan could be mentioned as good examples of Arab countries that combined high power (relatively, of course) and high legitimacy. Their regimes faced the uprisings from the beginning (mid-January 2011), but were capable of overcoming the internal challenges through a combination of repression and reforms, without suffering changes in their regime and being supported by the international community.Egypt is probably the best representation of a country whose regime kept high power at the moment of facing domestic challenges but received low legitimacy from the world; this "changeable" situation caused drastic changes at the top of the leadership (including the president, ministers, etc), albeit not of the whole regime (still leaded by the Military Council). Syria seems to be in a similar situation; while the power of the regime is still high, the legitimacy is not low enough to bring to major changes due to the sustained support of Russia, China and Iran. As a result, Syria constitutes today an excellent test for the power of legitimacy (and norms) in international politics.Between those countries that experienced a combination of low power and high legitimacy, experiencing a "protectable" situation, it is possible to mention Bahrain. Despite its regime was not capable of overcoming the internal revolts alone, it counted with the support of most of the Arab countries in the repression, and the Western approval of the "regional intervention" leaded by Gulf countries around the GCC. Yemen was in a comparable position, but at the end of 2011 the legitimacy of its regime was reduced when the region and the world understood the necessity to remove the President to maintain the remaining, in what was denominated later "the Yemenite option".Finally, Libya constitutes the case in which the regime was in a "revolutionable" situation, owing to its low Power to contain the rapid domestic rebellion and its low legitimacy after the first days of tremendous repression. The international costs were so high that included a military intervention leaded by NATO (with the endorsement of the Arab League), that led to the total collapse of the regime. It is possible to say that Tunisia was in an analogous situation while it did not need for a civil war and an external intervention to consummate finally a revolution (i.e., the complete removal of the existing regime).ConclusionsThroughout the paper we were able to observe that the ontological, epistemological and methodological discussions about the complex concept of Power maintain their relevance in the main schools of IR, and in some cases even constitute an essential part of their latest developments.At the same time, the inter-paradigmatic efforts of the last decades are demanding new power analysis approaches; that means, theoretical schemes that would embed a combination of the different factors at stake (material and non-material, resources and interactions, agents and structures) to specific cases of study.Deeper examinations of the "Arab Spring" cases need to be implemented so as to confirm the presented findings, as it was previously said. However, these small samples could possibly reveal that the implementation of a framework that combines both material and non-material resources is possible and, even more, desirable, to a better understanding of the devices of power in IR. 1 Robert A. Dahl, "The concept of Power", p.2142 Joseph S. Nye, Soft Power- The Means to Success in World Politics. p.63 Ian Hurt, "Legitimacy and Authority in International Politics". International Organization 53 No2 (Spring 1999), 390-3914 Stephen Lukes, "Power and the Battle for Hearts and Minds", p.4925 This short definition is based on concepts presented in Ian Clark, "Legitimacy in International Society" (London: Oxford University Press, 2005). It includes components both from the structure and the agent.6 Peter Gourevitch, "The second image reversed – the international sources of domestic politics" International Organization 32 No4, (Autumn 1978), 881-911.7 An investigation is "under construction", called "The Arab League and its legitimation role in the Arab Spring". It focuses on the power of the Arab League to yield legitimacy (or not) in six different cases. Bibliography Bachrach, Peter and Baratz, Morton S. "Two Faces of Power". The American Political Science Review 56 No4, (December 1962), 947-952 Baldwin, David A. Paradoxes of Power (NYC: Basil Blackwell, 1989). Barnett, Michael and Duvall, Raymond. "Power in International Politics", International Organization 59, No1 (Winter 2005), 39-75 Berenskoetter, Felix and Williams, Michael J. Power in World Politics. (NYC: Routledge, 2007) Bourdieu, Pierre. Language & Symbolic Power (NYC : Polity Press, 2001) Carr, Edward H., The Twenty Years' Crisis,1919-1939 (NYC: Harper Torchbooks, 1964) Clark, Ian. "Legitimacy in International Society" (NYC: Oxford University Press, 2005) Claude, Inis L., Power and International Relations (New York: Random House, 1962). Dahl, Robert A. "The concept of Power", Behavioral Science 2 No3, (July 1957), 201-215 Haas, Ernst B. When Knowledge is Power (University of California Press, 1990). Finnemore, Martha and Sikkink, Kathryn "International Norm Dynamics and Political Change," International Organization 52, No. 4 (Autumn 1998), 887-917. Foucalt, Michael. Power/Knowledge: Selected Interviews and Other Writings 1972-77 (Brighton: Havester, 1980) Franck, Thomas M., "The Power of Legitimacy and the Legitimacy of Power: International Law in an Age of Power Disequilibrium." American Journal International 88 (2006), 88-106 Gourevitch, Peter. "The second image reversed – the international sources of domestic politics" International Organization 32 No4, (Autumn 1978), 881-911. Guzzini, Stefano, "The Concept of Power: A Constructivist Analysis" Millennium 33 No3, 2005, 495-521. Guzzini, Stefano, "Structural power: the limits of neorealist power analysis", International Organization 47, No3 (Summer 1993), 443-478. Hurt, Ian, "Legitimacy and Authority in International Politics". International Organization 53 No2 (Spring 1999), 379-408 Ikenberry, John and Kupchan, Charles A. "Socialization and hegemonic power", International Organization 44, No3 (Summer 1990), 283-315. Keohane, Robert O. and Nye, Joseph S., Power and Interdependence, 2nd edition (New York: Harper Collins, 1989) Krasner, Stephen D. "Regimes and the Limits of Realism: Regimes as Autonomous Variables", International Organization 36 (Spring 1982), 497-510 Lukes, Stephen. "Power and the Battle for Hearts and Minds", Millennium 33 No3, (2005), 477-493 Mearsheimer, John. The Tragedy of Great power Politics (NYC: Norton, 2001) Morgenthau, Hans J., Politics among Nations, 4th edition (NYC: Knopf, 1967). Nye, Joseph S. Soft Power- The Means to Success in World Politics (NYC: PublicAffairs, 2004) Putnam, Robert. "Diplomacy and Domestic Politics: The Logic of Two-Level Games," International Organization 42, No3, (1988), 427-460 Risse, Thomas. "Let's Argue! Communicative Action in World Politics," International Organization 54 No1 (Winter 2000), 1-40. Schmidt, Brian C. "Competing Realist Conceptions of Power", Millennium 33 No3, 523-549 Walt, Stephen. The Origins of Alliances (Ithaca, NY: Cornell University Press, 1987) Waltz, Kenneth. Theory of International Politics. (NYC: McGraw-Hill, 1979) Weber, Max. Economy and Society: An Outline of Interpretive Sociology. (California: University of Berkeley, 1978. Edited by Guenther Roth and Claus Wittich). Wendt, Alexander. "Anarchy is What States Make of It: The Social Construction of Power Politics," International Organization 46 (1992), 391-425. Wendt, Alexander. "The Agent-Structure Problem in International Relations Theory", International Organization 41/3 (1987), 335-370. Fabian Daniel Wajner is a Research and Teaching Assistant at the Hebrew University of Jerusalem (Department of International Relations) and a Fellow of the Liweranth Center for Latin America Studies.

Tutkimuksen kohteena ovat ne muutokset, joita venäläisessä sanomalehdistössä ja journalismissa tapahtui 1980-luvun lopun poliittisten reformien aikana ja Neuvostoliiton hajoamisen jälkeen. Tutkimus kohdistuu alueelliselle tasolle ja tarkastelee Karjalan tasavaltaa esimerkkitapauksena. Teoreettisesti tutkimus perustuu ajatukseen siitä, että neuvostoyhteiskunta oli epätäydellisesti moderni ja sen modernit piirteet, kuten joukkotiedotus-välineiden runsas käyttö, olivat osaksi pinnallisia rituaaleja ja niiden modernisoiva vaikutus jäi puutteelliseksi yhteiskunnan esimodernien piirteiden aiheuttamien rajoitusten vuoksi. Yksi neuvostojärjestelmän hajoamisen syistä oli se, että järjestelmä ei neuvostoajan erityinen, epätäydellinen modernisaatio ei kyennyt käsittelemään niitä paineita, joita modernisaatiokehitys aiheutti. Tutkimus tarkastelee lehdistön ja journalismin muutosta kolmen eri näkökulman kautta. Niistä ensimmäinen tarkastelee lehdistön rakenteen kehittymistä Karjalan tasavallassa ja yksitäisissä lehdissä tapahtuneita muutoksia. Toinen näkökulma perustuu kyselytutkimukseen, jonka kohteena on eri lehtien yleisö helmikuussa 2000. Kolmantena on journalismin analyysi määrällisen ja laadullisen tekstianalyysin avulla. Neuvostojärjestelmän hajoamisen myötä entinen lehdistörakenne, jossa johtavassa asemassa olivat valtakunnalliset lehdet, hajosi ja alueelliset lehdet tulivat lehdistön tärkeimmäksi osaksi. Alueellisella tasolla muodostui uudenlainen lehtienvälinen kilpailu ja lehdistön moninaisuus. Esimerkiksi Karjalassa venäjänkielisten aluelehtien määrä kasvoi kahdesta yhteentoista ja suomen- ja karjalankielisten lehtien määrä yhdestä kolmeen. Kehitys on ollut samanlaista muillakin alueilla. Lehtien julkaisemisessa eri alueilla havaittujen erojen syinä ovat niin entiset perinteet lehtien julkaisemisessa, kansalaisyhteiskunnan kehitys kuin taloudellinen hyvinvointikin. Kyselytutkimuksen mukaan venäläisten lehtien lukijat ovat selvästi jakautunut iän mukaan sekä vähemmässä määrin sukupuolen mukaan. Skandaalinhakuinen, oppositiossa oleva lehti on osoittautunut menestyksekkäimmäksi lehtityypiksi, kun taas niin vanhat kuin uudet eliitteihin vetoavat "laatulehdet" saavuttavat vain pienen osan yleisöstä. Journalismin muutoksen tarkastelu kahdessa sanomalehdessä osoittaa että toimittajat ovat saaneet journalistisen tekstin tuottamisen selvästi valvontaansa. Neuvostoaikana sanomalehdet olivat täynnä ulkopuolista kirjoittajien juttuja ja lyhyen glasnostin ajan aikana lukijakirjeillä oli keskeinen rooli. Toisaalta, erilaisten tekstuaalisten rakenteiden joukossa professionaali uutismuoto on saanut enemmän suosiota vaikkakin kantaaottamaton monologi ja juttutyyppi, jossa lähteiden siteeraaminen ja toimittajan kommentit on yhdistetty ovat edelleen suosiossa. Ainoastaan pelkästään vierasta puhetta sisältävät tekstit ovat selvästi vähentyneet. Venäläinen journalismi on omaksunut vaikutteita ulkomailta, mistä osoituksena on esimerkiksi se, että Karjalan Sanomat on alkanut muistuttaa länsimaista journalismia nopeammin kuin venäjänkieliset lehdet. Tiedotusvälineillä oli tärkeä rooli neuvostojärjestelmän hajoamisessa ja tämä tutkimus väittää, että tieto ei ollut yksinomaan järjestelmän hajoamisen taustalla vaan suurempi merkitys oli siinä miten tieto neuvostoyhteiskunnassa esitettiin. Kun lehdistö alkoi vuodesta 1985 lähtien toimia entistä paremmin neuvostojärjestelmän perinteiden mukaisesti osallistumalla yhteiskunnan rakentamiseen ja tarjoamalla tilaa erilaisille mielipiteille, se osallistuikin yhteiskuntajärjestelmän hajottamiseen. Järjestelmä ei kyennyt sopeutumaan eriäviin mielipiteisiin. Neuvostoliitossa ei kyennyt kehittymään erityistä journalistista sfääriä vaan journalismi oli sekä poliittisen että kirjallisen toiminnan osa. Neuvostoliiton jälkeisessä oloissa journalistisen sfäärin kehittymismahdollisuudet ovat paremmat vaikkakin monissa Keski- ja Itä-Euroopan maissa läntisen moderni sanomalehti ja moderni uutismuoto ovat kehittynyt nopeammin. Yksi syistä on siinä, että ulkomainen omistus, joka on tuonut muihin alueen maihin mukanaan länsimaisia toimintamalleja ja -tapoja, on jäänyt Venäjällä hyvin vähäiseksi. Lisäksi omaperäisillä journalismin muodoilla on Venäjällä pidempi historia eikä niiden voida odottaa muuttuvan yhtä nopeasti. Myös poliittisen järjestelmän ja kansalaisyhteiskunnan kehityksellä on vaikutuksensa: journalismi, joka perustuu sitaatteihin ja niiden tulkintaan yleisestä näkökulmasta, voi kehittyä vain oloissa, joissa lähdeorganisaatiota ja kommentteja on helposti saatavana, ja joissa vallitsee yleisesti hyväksytty, yhteinen tulkintatapa. Nämä olosuhteet ovat toistaiseksi heikosti kehittyneet Venäjällä. Myös sillä on merkitystä, että vanhan koulukunnan toimittajien parissa uusien kantaaottamattomien ja standardisoitujen muotojen omaksuminen koetaan menetyksenä. Tutkimus antaa mahdollisuuksia ymmärtää lehdistön ja journalismin kehittymistä osana yhteiskunnallista muutosta. Lisäksi tutkimus tarjoaa kokonaiskuvan yhden Venäjän alueen lehdistöstä ja sen kehitykseen vaikuttavista tekijöistä. Tutkimuksesta voi olla hyötyä myös venäläisissä lehdissä mainostaville sekä venäläisiin lehtiin investoiville ulkomaalaisille. ; This study explores the changes which took place in the Russian press and journalism during the period of political reforms (1985-1991) and after the collapse of the Soviet Union. The study is focused on the regional level and uses the Republic of Karelia as a case. With the collapse of the Soviet system, the former press structure with dominant national newspapers collapsed and the regional newspapers, which preserved their circulation better, became the most important part of the press. At the regional level, a new kind of competition and pluralism emerged. For example, in Karelia the number of regional newspapers published in Russian grew from two to eleven and in the number of those in Finnish or Karelian from one to three. The development has been similar in other regions as well. According to an analysis of factors influencing the local newspaper publishing the circulation of local newspapers is higher in areas with the earlier traditions of newspaper publishing, the development of civil society and the economic welfare. Theoretically the study is based on the notion that the Soviet Union was a fake modern society and its modern features, like the extensive use of mass media, were partly rituals with little modernising impact. One of the reasons behind the collapse of the Soviet system was that the peculiar, incomplete modernisation of the Soviet era could not handle the pressures caused by the modernising development. After the collapse of the Soviet system a new round of modernisation is beginning although the collapse of economy and the forced forms of modernisation have also strengthened the traditional elements. The media had an important role in the collapse of the Soviet system and this study argues that it was not only the information itself which assisted in the collapse of the society but that the way in which the media presented that information was also important in discrediting the former system. After 1985, the Soviet media started to realise the traditional slogans of the media's participation in the construction of the society and offering space for various views. In so doing the press actually participated in the destruction of the social system, which was not equipped to adjust to conflicting opinions. Paradoxically, if Soviet journalism had functioned according to the Western journalistic practice of presenting the information in a way which leaves readers in a detached and non-participant relationship to politics, the collapse of the Soviet system would not have been so sudden. In the Soviet Union, no proper journalistic sphere could develop; journalism was an extension of both political and literary spheres. In the post-Soviet conditions the possibilities for its development are better but in many other Central and Eastern European countries the development of Western-type modern newspaper and modern news form has been more rapid. One of the reasons for this is that Russia has so far also remained outside major Western investments in the media sector which in other Central and Eastern European countries has been accompanied with imported formats and models of making journalism. Moreover, Russia has longer traditions in endogenous forms of journalism which could not be expected to change as rapidly. This study explores the changes which took place in the Russian press and journalism during the period of political reforms (1985-1991) and after the collapse of the Soviet Union. The study is focused on the regional level and uses the Republic of Karelia as a case. With the collapse of the Soviet system, the former press structure with dominant national newspapers collapsed and the regional newspapers, which preserved their circulation better, became the most important part of the press. At the regional level, a new kind of competition and pluralism emerged. For example, in Karelia the number of regional newspapers published in Russian grew from two to eleven and in the number of those in Finnish or Karelian from one to three. The development has been similar in other regions as well. According to an analysis of factors influencing the local newspaper publishing the circulation of local newspapers is higher in areas with the earlier traditions of newspaper publishing, the development of civil society and the economic welfare. Theoretically the study is based on the notion that the Soviet Union was a fake modern society and its modern features, like the extensive use of mass media, were partly rituals with little modernising impact. One of the reasons behind the collapse of the Soviet system was that the peculiar, incomplete modernisation of the Soviet era could not handle the pressures caused by the modernising development. After the collapse of the Soviet system a new round of modernisation is beginning although the collapse of economy and the forced forms of modernisation have also strengthened the traditional elements. The media had an important role in the collapse of the Soviet system and this study argues that it was not only the information itself which assisted in the collapse of the society but that the way in which the media presented that information was also important in discrediting the former system. After 1985, the Soviet media started to realise the traditional slogans of the media's participation in the construction of the society and offering space for various views. In so doing the press actually participated in the destruction of the social system, which was not equipped to adjust to conflicting opinions. Paradoxically, if Soviet journalism had functioned according to the Western journalistic practice of presenting the information in a way which leaves readers in a detached and non-participant relationship to politics, the collapse of the Soviet system would not have been so sudden. In the Soviet Union, no proper journalistic sphere could develop; journalism was an extension of both political and literary spheres. In the post-Soviet conditions the possibilities for its development are better but in many other Central and Eastern European countries the development of Western-type modern newspaper and modern news form has been more rapid. One of the reasons for this is that Russia has so far also remained outside major Western investments in the media sector which in other Central and Eastern European countries has been accompanied with imported formats and models of making journalism. Moreover, Russia has longer traditions in endogenous forms of journalism which could not be expected to change as rapidly. The problems with the development of civil society and political system also play a role: journalism based on quotations and interpretation from the universal, commonsense point of view can develop only in conditions in which source organisations and comments are easily available and where a widely accepted common sense point of view exists. These conditions are so far poorly developed in Russia. It is also important that among the old school of journalists the adaptation of detached and standardised forms of journalism has been seen as a loss. There is some evidence that journalism has adopted practices from abroad, for example, the Finnish-language Karjalan Sanomat started to resemble Western journalism more rapidly than Russian newspapers. According to a survey conducted in Petrozavodsk in February 2000 the audience is clearly divided on the basis of age and partly on the basis of gender. The scandalous, oppositional newspaper has proven to be the most popular and successful part of the press, while the old and new "quality", elite-oriented newspapers appeal to only small part of the audience. An empirical examination of journalism in two newspapers indicates that journalists have gained clear control of the production of newspaper text. In the Soviet era the newspapers were filled with articles by outside authors and official texts, while during a short period of glasnost the letters to the editor played an important role. On the other hand, journalistic control has not become complete inside the texts. Among the different textual strategies the professional news form has received more popularity although non-commentary monologue and a news form in which the citations from the sources are mixed with the comments by journalist are still common. Only the texts written solely by outside authors have clearly lost their share in the newspapers. This study explores the changes which took place in the Russian press and journalism during the period of political reforms (1985-1991) and after the collapse of the Soviet Union. The study is focused on the regional level and uses the Republic of Karelia as a case. With the collapse of the Soviet system, the former press structure with dominant national newspapers collapsed and the regional newspapers, which preserved their circulation better, became the most important part of the press. At the regional level, a new kind of competition and pluralism emerged. For example, in Karelia the number of regional newspapers published in Russian grew from two to eleven and in the number of those in Finnish or Karelian from one to three. The development has been similar in other regions as well. According to an analysis of factors influencing the local newspaper publishing the circulation of local newspapers is higher in areas with the earlier traditions of newspaper publishing, the development of civil society and the economic welfare.

My submission (How effectively has the law since 1997 ensured a 'work life balance' for workers with family responsibilities? Answer this question with reference to the relevant statutory materials, case law, legal commentary and social science literature) is essentially about how the law in the UK can be used to help those within the workforce achieve an effective work-life balance, meaning they have ample time and energy to focus on their professional responsibilities as well as their family life and leisure time. This article outlines that despite an apparent long-standing commitment by successive governments to tackle this issue, the legal framework created has largely failed to ensure people have an effective work-life balance. This is especially true for migrant workers who are often exploited within the UK workforce, as well as women, who arguably are not effectively protected by this area of law after pregnancy/early maternity and increasingly are having to find ways to cope with the dual burden of paid work and childcare/homemaking responsibilities. This submission also considers how this area of law has been impacted by the coronavirus pandemic as well as Brexit, both of which have created new challenges and exacerbated existing ones. - Consider these two quotations from UK government White Papers/Consultation documents: "Helping employees to combine work and family life satisfactorily is good not only for parents and children but also for businesses". (Fairness at Work, White Paper, May 1998, para 5). "The proposals in this document will bring benefits for employers as well as employees, by increasing participation in the labour market while also helping people to balance work with their family and personal responsibilities". (Consultation on modern workplaces, May 2011). How effectively has the law since 1997 ensured a 'work life balance' for workers with family responsibilities? Answer this question with reference to the relevant statutory materials, case law, legal commentary and social science literature. Much like the other areas of labour and employment law, the legal framework used to help those in the labour market achieve an effective 'work life balance' has had to adapt to new challenges in society, which has in turn affected the realities of the UK workforce.[1] Primarily, this issue has become increasingly more prevalent since the latter half of the 20th century because of societal and legal changes that have meant the traditional model of a male breadwinner and female homemaker has become increasingly unrepresentative of the UK labour market.[2] The quotations contained in this essay question, although from different UK governments, suggest a firm and longstanding commitment to ensuring employees with familial responsibilities can use the law to achieve an effective work life balance. This essay will discuss and evaluate the various reasons for this commitment. However, it is arguable that since 1997 successive governments have failed to effectively tackle the UK's long working hours 'culture', as well as the ineffective legal framework that seeks to help achieve an effective work life balance.[3] This essay recognises the fact that there have been some positive advancements since 1997 in the statutory entitlements employees have (or can obtain) that afford them greater flexibility at work in order that they can also fulfil their familial responsibilities.[4] Examples discussed later include the introduction of shared parental leave and the laws protecting and promoting the rights of women during pregnancy and early maternity.[5] However, this essay will seek to show how these positive policies have had a limited overall effect in terms of achieving an effective work life balance, especially for women and immigrants participating in the UK workforce.[6] This will involve a statistics-based criticism, employ case law and a feminist theoretical perspective, as well as give general ideas and propositions as to how the law needs to go further to achieve its aims. I will argue that the law is currently tempered too much by fears of damaging businesses or the UK economy as a whole. Furthermore, the impact of coronavirus will be considered, specifically how new problems have emerged and existing issues have been exacerbated.[7] The Development of the Law Concerning Work Life Balance Since 1997: Changes and Problems Although this essay is primarily concerned with the impact of the legal framework developed since 1997, there are some important contextual developments that occurred before this and are worth mentioning. Throughout the 20th century, the UK labour market moved from a laissez faire model to one characterised by increased regulation. This was controversial and different governments varied in their commitment to pursuing greater order in the labour market using the law.[8] This trajectory was reversed in the 1970s and afterwards, wherein the Thatcher government (influenced significantly by the ideas of neoliberalism)[9] pursued policies of de-regulation and privatisation. Moreover, from 1975 until 2020 the legislature of the UK was required to effectively implement EEC/EC/EU law and directives, which has had a profound impact on the labour market.[10] Furthermore, as previously mentioned the advent of feminism meant that more women than ever were entering (or re-entering) the workforce after having children, whereas before they would have been homemakers.[11] In terms of the narrative of legal development this essay's starting point is the introduction of the 'New Labour' government in 1997, led by Tony Blair. This government helped to produce the Fairness at Work white paper, Chapter 5 of which contained a number of 'family friendly policies' aimed at ensuring a more effective work life balance for those with families.[12] The New Labour government had a few reasons behind the implementation of such policies, but primarily they were utilised to increase competitiveness in the market to ensure its prosperity[13] and to implement the 1996 EC Parental Leave Directive.[14] This directive had ambitious aims that even with the margin of appreciation would have been hard for the UK, with its long working hours culture, to achieve. These aims included promoting equal opportunities; flexible working; greater women's involvement in the labour market and; men taking an equal share of the responsibilities associated with family life.[15] Subsequently, Conservative led governments that published the Consultation on Modern Workplaces[16] and Good Work: A Response to the Taylor Review of Modern Working Practices[17] were also driven by rationales based on economic prosperity. It was thought that this would increase productivity, worker loyalty, the quality of work and reduce the costs associated with high employee turnover.[18] The culmination of this narrative, i.e., the current legal framework governing the work life balance people in the UK labour market can achieve, covers a wide range of situations and involves many protected rights. Yet, despite this scope it also has many failings, primarily because it is fragmented and lacks a unified approach. The focus of this area of law on using skilled workers to diversify and increase competitiveness within the market means that often those working in more flexible or atypical employment are denied some of these rights and protections.[19] For example, most women require some level of maternity pay to be able to afford to take maternity leave, yet to qualify for it there must have been 26 weeks of continuous employment before the expected week of childbirth as well as a paycheck of at least £116 a week. So, for women without provisions for maternity pay within contracts and who earn less than this because they are employed on a temporary basis, work in the gig economy or other types of atypical work, statutory maternity pay is unobtainable.[20] Evidence from the Office for National Statistics found that 55% of the people working on zero-hour contracts (one example of atypical work) were women in its report Contracts That Do Not Guarantee a Minimum Number of Hours, which is even more significant because women make up only 46.8% of those employed not on zero hours contracts.[21] By contrast, 87% of men are in full time work.[22] This means that women who are entitled to statutory maternity leave under the Maternity and Parental Leave Regulations 1999 are not always able to take it because the law fails to provide them with an adequate way of surviving financially: the only other option is a very low level of maternity allowance from the government.[23] Additionally, there are many scholars who argue that flexible working for women with family responsibilities is the way forward, yet the right to request this also requires continuous employment of at least twenty-six weeks.[24] Arguably, this is a cyclical issue: more women are in atypical work because it allows the flexibility to fulfil private domestic obligations, but these women lack statutory and contractual protections and so cannot achieve the same type of flexibility in full time, permanent employment which in turn excludes them from fully participating in the labour market.[25] Additionally, the non-profit organisation Trust for London found that migrants were more likely to work "during night shifts and in non-permanent jobs".[26] This means that similarly migrant women who are in types of atypical work, such as zero-hour contract hospitality jobs (which is very common for this demographic), cannot claim maternity pay and cannot have help at home from their husbands who cannot get paternity leave under the Paternity and Adoption Leave Regulations 2002 because this also requires 26 weeks of continuous employment.[27] Of course, because of the numerous, inflexible requirements needed for shared parental leave to be available under the current law this is also not a viable option for immigrant families or women in low skilled or low paid areas of work that are atypical in nature.[28] All of this demonstrates that the law has little interest in human rights or equality as a justification for an effective work life balance, and that this economic focus has resulted in a legal framework that ignores the problems and experiences of these key demographics that make up a significant amount of the population who have both work and family commitments. It will only go so far as not to damage the competitiveness or prosperity of the economy.[29] Furthermore, if those working part time in the labour market or in atypical work wanted to make an application based on the Part Time Workers (Prevention of Less Favourable Treatment) Regulation 2000 because they were being excluded from such rights, they would have to use their own resources and time to make a complaint to the Employment Tribunal. Arguably, this is not a particularly effective form of remediation as it only offers compensation for losses incurred because of this "less favourable treatment" and hear that the employer has been recommended to stop this action.[30] The Impact of EU Law The law concerning work life balance has been significantly impacted by EU law both before and after 1997. Unlike the mainly economic rationales behind the UK law, the EU acknowledges these benefits whilst also having a focus on social equality, equality of opportunity between men and women, the socioeconomic rights of individuals as well as dismantling harmful societally imposed gender roles.[31] This was evidenced clearly by the ambitious Parental Leave Directive.[32] It has influenced both the legal framework of rights concerning workers and employees with family responsibilities as well as UK equality law, as the UK legislature and judiciary is obliged to implement the aims of these directives using domestic law (albeit with a margin of appreciation).[33] However, academic Nicole Busby in her article 'The Evolution of Gender Equality and Related Employment Policies: The Case of Work-Family Reconciliation'[34] has argued that the focuses of the EU are conflicting, "parallel and incoherent".[35] The dual focus of both on improving the market as a whole by using policies to allow more people to be involved and using the law to equalise equality between men and women has resulted in "a patchwork of provisions rather than an overarching framework".[36] This argument is an interesting one that definitely has its merits, especially the characterisation of familial responsibilities as a form of unpaid work because of its significant contribution to society - it re-frames the way these two goals are thought of.[37] Busby argues that this approach means the EU "subordinates gender equality to economic objectives".[38] Additionally, Busby makes agreeable statements about how EU law and the Court of Justice has failed to promote the rights and roles of men in the domestic setting.[39] However, she arguably fails to account for the numerous and ambitious advancements in work life balance law that has been facilitated in the UK by the EU. The examples of directives that have, even in a de jure way, protected women in the UK workforce from discrimination on the basis of pregnancy or maternity and helped to facilitate a more gender-neutral approach to governing parenting responsibilities. For example, section 18(2) of the Equality Act 2010 which protects women from discrimination or dismissal on the basis of pregnancy or related sickness was influenced by the need to implement the Pregnant Workers Directive[40] and the Equal Treatment Directive,[41] which formalised the previous case ruling of Webb v EMO Air Cargo (UK) Ltd by removing the need for a male comparison in cases of discrimination.[42] The Pregnant Workers Directive also influenced the introduction of statutory maternity pay and the Equal Treatment Directive ensures a woman has a right to return to work after maternity leave.[43] However, it is important not to overstate the influence or importance of EU law, especially because of the fact that the UK is due to leave the EU imminently. There is significant statistical evidence that EU law and UK equality law fails to tackle more "surreptitious" forms of discrimination against pregnant women.[44] The Equality and Human Rights Commission found in its report Pregnancy and Maternity Discrimination and Disadvantage: Summary of Key Findings found that ¾ of mothers surveyed said they had a negative/discriminatory experience during pregnancy and maternity leave, 20% said they experiences harassment or negative comments because of pregnancy or flexible working and 11% felt forced to leave their jobs.[45] On the side of employers, 84% said it was in their interests to support pregnant women yet 70% also felt women should declare upfront if they were pregnant and 27% felt the cost of maternity leave put an unreasonable burden on them.[46] Despite this widespread discrimination, only around 1% of claims are brought.[47] This demonstrates how the de facto reality is that both EU and UK law fails to protect women from discrimination due to pregnancy, and remedies for this are few and far between because (like many other aspects of this area of law) there is poor take up of such rights. Furthermore, in 2019 the EU introduced the Directive on Work-Life Balance For Parents and Carers which aims to do everything the current UK legal framework has failed to do: increase the participation of women in the workforce, increase the de facto use of family related leave and flexible working arrangements.[48] This would be incredibly influential in UK law, especially in terms of strengthening paternity rights and moving towards normalising men taking a more active role in familial responsibilities.[49] However, because of Brexit and the fact the transition period will not be extended again, the UK would have to choose to implement this directive,[50] and perhaps they will in the form of the Good Work Plan, which would have various implications in and of itself.[51] The Good Work Plan – Gender Norms and the Legal Framework Beyond Pregnancy and Birth In 2018, the UK government produced the Good Work Plan: Proposals to Support Families,[52] which was responding to the earlier Taylor Review and reiterated the same economic benefits that would be had from helping individuals to achieve a better work life balance.[53] There are definitely benefits to the approach that would be adopted. Recommendation 41 recognises that pregnancy and maternity discrimination remain a problem, and that an inherent cultural shift is needed to change this that the law should support and facilitate.[54] Overall, the idea of a "balance between flexibility and worker protections" sounds positive.[55] Arguably one of the most positive aspects of the Good Work Plan is that it recognises how the rights of atypical workers are often subverted under the current law and the fact that this needs to change. However, the reality is that the EU directive would have gone further because the UK still lacks a fundamental concern for a regulatory framework that is genuinely concerned with the rights of workers and not just the economic benefits of having more women in the workforce. Additionally, it does not directly relate the current law concerning pregnancy/maternity discrimination and an effective work life balance with the subversion of atypical worker's rights, which would be a significant step forward in and of itself.[56] Furthermore, the Trades Union Congress (TUC) has essentially argued that the Good Work Plan does not go far enough.[57] They point out that the reality is that the current legal framework reinforces harmful gender norms that continues to reproduce patriarchal ideas regarding gender roles. They quote an article by Helen Norman ('Does Paternal Involvement in Childcare Influence Mother's Employment Trajectories During the Early Stages of Parenthood in the UK?' which essentially found that "mothers with preschool children are twice as likely to return to employment at nine months and at three years' post-childbirth if the father is involved by sharing or doing the most childcare at these times".[58] This area of law simply does not want to concern itself with supporting mothers in the workforce, which is yet again one of its primary downfalls. This is significant in terms of establishing one of the least talked about but most problematic aspects of the current law concerning work life balance: it has a significant number of statutory rights and protections for during pregnancy and immediately after birth but fails to provide long term support for mothers.[59] This is because the law refuses to tackle the bigger issue of gendered norms in society that would allow women to be more active in the labour market and normalise men taking a more active role in the domestic sphere of life.[60] Shared Parental Leave and the Feminist Perspective Another important and influential source of criticism of the system governing work-life balance is the feminist perspective on how women are disproportionately affected and pushed out of the labour market as a result.[61] Primarily, feminist scholars of sociology argue that women, far from being freed from the oppressive nature of gender norms in society, now have a dual burden.[62] This is because the law concerning work life balance has failed to tackle these gender norms, which means the unpaid labour burdens of the domestic sphere and childcare is still disproportionately placed on women rather than men; women have the burden of paid work as well as those roles "associated with femininity and motherhood".[63] This is because, as this essay has previously mentioned, the law concerning work life balance in both the UK and Europe has failed in substantially tackling these gender norms despite the fact societal changes have significantly decreased the relevance of the male breadwinner and female homemaker model.[64] Moreover, there are feminist scholars who argue that women have poorer long term career prospects because they need to be in part time/atypical employment to manage their familial responsibilities because the law has not created an effective system where they would be able to do this in full time employment.[65] This is another way in which the law concerning work life balance fails to support mothers in a long-term sense beyond pregnancy and its immediate aftermath. However, there has been some argument amongst legal scholars and officials about whether such arguments have been abated by the introduction of Shared Parental Leave in 2014. This new regulation, in theory, "makes it possible for partners to share the entitlement to maternity leave and maternity pay between them".[66] As Grace James put it in her article 'Family-friendly Employment Laws (Re)assessed: The Potential of Care Ethics' this has been added to the existing framework of rights for working parents and reiterates a commitment by the law to dismantling the gender norms that are keeping women from effectively and substantially engaging with the labour market.[67] Despite this, Grace James is right when she points out that this "package of rights" (including shared parental leave) is fundamentally flawed.[68] Firstly, this shared parental leave package fails to deal with the continued discrimination against pregnant women and mothers that statistically feel pushed out of the labour market.[69] Furthermore, the refusal by the law on work life balance to place too much of a financial burden on the employers means that only a small proportion of the workforce are even eligible for this.[70] Both parents must be employees and pass the relevant statutory and common law requirements to be categorised as such, i.e., they must have a contract of employment under s.230 of the Employment Rights Act 1996, be able to satisfy the control test;[71] have their activity be an integral part of the business;[72] as well as the tests of economic reality;[73] mutuality of obligations and;[74] continuity of employment. Beyond these already numerous requirements, both parents also must have earnt at least £390 in thirteen out of the sixty-six weeks of employment.[75] Additionally, as couples are likely to work for different employers there is a great deal of organisational effort that goes into organising shared parental leave.[76] Again, this means that those working in atypical work are automatically not covered by such provisions. Furthermore, the slow uptake on this due to the law's failure to tackle traditional gender roles in society effectively enough has severely limited the de facto effectiveness of shared parental leave in dealing with the problems facing people with work and family responsibilities in the UK.[77] Moreover, this article offers an interesting contextual background about how remedies for people whose employers deny them such rights are limited because of cuts in "legal aid funding and the closure of many legal advice centres".[78] Arguably, this helps us understand how developments outside of the immediate legal framework also affect work life balance in a significant way which need to be remedied in the future if it is to be effective. Jamie Atkinson offers an interesting perspective on shared parental leave in their article 'Shared Parental Leave in the UK: Can it Advance Gender Equality by Changing Fathers into Co-Parents?' by comparing it with similar policies in Nordic countries that have much higher levels of gender equality.[79] To summarise, she argues that generous levels of compensation to parents, flexibility about how the leave is taken, wide reaching eligibility requirements and "other incentives to get the father to take leave" are the most important elements in ensuring the success of such policies (which she measures by the amount of people who make use of it).[80] Although she rightly identifies that these Nordic countries are also not perfect, it provides an interesting perspective for how shared parental leave in the UK can improve on itself to further gender equality.[81] Impact of Coronavirus: Problems Old and New The feminist narrative of women being disproportionately affected by poor regulation of work-life balance in the UK has only been strengthened by the impact of coronavirus.[82] Within the private sphere of unpaid work, women are already doing the majority of this work and school closures combined with millions of people working from home has meant this burden has only grown.[83] In her article 'The COVID-19 Pandemic has Increased the Care Burden on Women and Families', Kate Power cites a statistic that 41% of women currently inactive in the UK labour market are so because of their unpaid care responsibilities.[84] It is very unlikely that the law will recognise this problem or endeavour to solve it, because it is occurring in the private sphere.[85] These are the problems that coronavirus has exacerbated. Additionally, the coronavirus pandemic has created new issues in the UK workforce because many people, most notably women and immigrants in atypical work, have lost their jobs due to the economic downturn and the law has failed to recognise that the issues facing men and women during this pandemic are different in many ways.[86] Women are more likely to be frontline healthcare workers, which additionally will have only increased their already substantial burden in terms of balancing professional work and private life responsibilities.[87] Furthermore, immigrant women (who like all other women are bearing a lot of the economic brunt of this crisis) because of the "'no recourse to public funds' condition stamped on many non-EU visas".[88] Additionally, undocumented women face even more issues because they are fearful of making use of social security or NHS services.[89] The response from the UK government in terms of labour law has failed to account for these differences. Furthermore, arguably this is more evidence of how the law is unconcerned with assisting women beyond pregnancy and childbirth because it demonstrates their unwillingness to get too over involved with the private sphere of life that would bring about a significant change in terms of the position of women within society. Conclusion This essay has demonstrated how UK law since 1997 has failed to ensure an effective work-life balance for those with familial responsibilities, an issue that has disproportionately affected women, as well as immigrants in the labour market. Additionally, it has shown that feminist perspectives are extremely useful in helping us to understand how women are still excluded from the UK workforce because the law refuses to go far enough to tackle harmful gender roles within society.[90] This is because the law is purely concerned with increasing competitiveness in the market and benefiting the economy and so ignores concerns about equality and human rights that EU law has adopted in its own rationales.[91] Women and immigrants in atypical or part time work are therefore often excluded from such benefits and arguably the Good Work Plan does not go far enough in the future to deal with these issues in the same way that perhaps the Directive on Work-Life Balance For Parents and Carers could if Brexit was not happening.[92] Furthermore, whilst the government response to coronavirus has been much more regulatory and helpful than predictions suggested, it has ignored the fact that women and men are experiencing different adverse effects because of the pandemic and worsened the dual burden women have to bear of paid and unpaid responsibilities.[93] [1] Hugh Collins, K.D. Ewing, Aileen McColgan, Labour Law (2nd edition, Cambridge University Press 2019) 398. [2] ibid. [3] Chris Kerridge, 'How can we overcome the UK's long working hours culture?' (People Management, 8 November 2019) accessed 15 November 2020. [4] Collins (n 1), 399. [5] Grace James, 'Family-friendly Employment Laws (Re)assessed: The Potential of Care Ethics' [2016] Industrial Law Journal 45(4), 477. [6] Sarah Dyer, 'Migrant work, precarious work-life balance: what the experience of migrant workers in the service sector in Greater London tells us about the adult worker model' [2011] Gender, Place and Culture; A Journal of Feminist Geography' 18. [7] Kate Power, 'The COVID-19 pandemic has increased the care burden of women and families' [2020] Sustainability: Science, Practice and Policy 16(1), 69. [8] Collins (n 1), 9. [9] Jamie Robertson, 'How the Big Bang changed the city of London for ever' (BBC News, 26 October 2016) accessed 5 December 2020. [10] Maria Koumenta and others, 'Occupational Regulation in the EU and UK: Prevalence and Labour Market Impacts' (Department for Business, Innovation and Skills Final Report, July 2014) accessed 30 November 2020. [11] Pat Hudson, 'Women's Work' (BBC History, 29 March 2013) accessed 25 November 2020. [12] Board of Trade, Fairness at Work (White Paper, Cm 3968, 1998). [13] ibid. [14] [1996] 96/34/EC. [15] ibid. [16] Department for Business, Innovation and Skills, Consultation on modern workplaces (Consultation, first published 16 May 2011). [17] HM Government, Good Work: A response to the Taylor Review of Modern Working Practices (Department for Business, Energy and Industrial Strategy and Employment Agency Standards Inspectorate, 2018). [18] Matthew Taylor, The Taylor Review of Modern Working Practices (Independent Review, Department for Business, Energy and Industrial Strategy, 2017). [19] Conor D'Arcy, Fahmida Rahman, 'Atypical Approaches; Options to Secure Workers with Insecure Income' (Resolution Foundation, January 2019). [20] Collins (n 1), 406. [21] Contracts That Do Not Guarantee a Minimum Number of Hours (Office for National Statistics, 23 April 2018) accessed 30 November 2020. [22] Trades Union Congress, Good Work Plan: Proposals to Better Support Families; TUC Responds to BEIS Consultation' (Consultation Response, 13 December 2019) accessed 7 December 2020. [23] Collins (n 1), 406. [24] Employment Rights Act 1996, section 80(G)(1). [25] Trades Union Congress, Good Work Plan: Proposals to Better Support Families; TUC Responds to BEIS Consultation' (Consultation Response, 13 December 2019) accessed 7 December 2020. [26] Mariña Fernández-Reino, 'Migrants in the UK Labour Market: An Overview' (Trust for London, 17 July 2017) accessed 4 December 2020. [27] Steve French, 'Between Globalisation and Brexit: Migration, Pay and the Road to Modern Slavery in the UK Hospitality Industry' [2018] Research in Hospitality Management 8(1). [28] Shared Parental Leave Regulations 2014. [29] Joanne Conaghan, Kerry Rittich, Labour Law, Work and Family: Critical and Comparative Perspectives (Oxford University Press 2005). [30] Collins (n 1), 425. [31] Nicole Busby, 'The evolution of gender equality and related employment policies: The case of work– family reconciliation' [2018] International Journal of Discrimination and the Law 18(2),105. [32] 96/34/EC. [33] Busby (n 33), 106. [34] ibid. [35] ibid at 105. [36] ibid. [37] ibid at 106. [38] ibid at 120. [39] ibid at 112. [40] 92/85. [41] 2006/54/EC. [42] C-32/93. [43] Collins (n 1), 407. [44] ibid at 404. [45] Lorna Adams and others, Pregnancy and Maternity Discrimination and Disadvantage: Summary of Key Findings (Equality and Human Rights Commission, Department for Innovation, Business and Skills, 2016). [46] ibid. [47] Amelia Gentleman, 'Pregnant? Wait Till the Boss Hears' (The Guardian, 23 June 2011) accessed 1 December 2020. [48] 2019/1158. [49] Rachel Crasnow, Chesca Lord, 'Will the New Radical Work-Life Balance Directive Help UK Parents and Carers? (Cloisters – Employment, 25 June 2019) accessed 5 December 2020. [50] ibid. [51] Department for Business, Energy and Industrial Strategy, 'The Good Work Plan' (Policy Paper, 17 December 2018) accessed 15 December 2020. [52] ibid. [53] Taylor (n 18). [54] Department for Business, Energy and Industrial Strategy, 'The Good Work Plan' (Policy Paper, 17 December 2018) accessed 15 December 2020. [55] ibid. [56] Trades Union Congress, Good Work Plan: Proposals to Better Support Families; TUC Responds to BEIS Consultation' (Consultation Response, 13 December 2019) accessed 7 December 2020. [57] ibid. [58] Helen Norman, 'Does Paternal Involvement in Childcare Influence Mother's Employment Trajectories During the Early Stages of Parenthood in the UK' [2019] British Sociological Association 54(2). [59] James (n 5), 480. [60] ibid. [61] Emily Grabham, 'The Strange Temporalities of Work-Life Balance Law' [2014] feminists@law 4(1). [62] Gaëlle Farrant, Luca Maria Pesando, Keiko Nowacka, 'Unpaid Care Work: The Missing Link in the Analysis of Gender Gaps in Labour Outcomes' (OECD Development Centre, 2014) accessed 2 December 2020. [63] ibid. [64] Mick Cunningham, 'Changing Attitudes toward the Male Breadwinner, Female Homemaker Family Model: Influences of Women's Employment and Education over the Lifecourse' [2008] Social Forces 87(1). [65] Collins (n 1), 422. [66] Collins (n 1), 409. [67] James (n 5), 480. [68] ibid at 478. [69] ibid. [70] Collins (n 1), 410. [71] Established by Yewens v Noakes [1880] 6 QBD 530. [72] Established by Stevenson Jordan v Macdonald and Evans [1952] 1 TLR 101. [73] Stringfellows v Quashie [2012] EWCA Civ 1735. [74] Carmichael v National Power plc [1999] UKHL 47. [75] Collins,(n 1), 410. [76] ibid at 411. [77] James (n 5). [78] Ibid at 485. [79] [2017] International Journal of Law in Context 13(3). [80] Jamie Atkinson, 'Shared Parental Leave in the UK: Can it Advance Gender Equality by Changing Fathers into Co-Parents?' [2017] International Journal of Law in Context 13(3), 361. [81] ibid. [82] Power (n 7). [83] ibid at 68. [84] ibid. [85] ibid. [86] Jenna Norman, 'Gender and COVID-19: The Immediate Impact the Crisis is Having on Women' [2020] British Politics and Policy at LSE. [87] ibid. [88] ibid. [89] ibid. [90] James (n 5). [91] Board of Trade, Fairness at Work (White Paper, Cm 3968, 1998). [92] 2019/1158. [93] Alison Andrew and others, 'How are mothers and fathers balancing work and family under lockdown' (Institute for Fiscal Sciences, 27 May 2020) accessed 12 November 2020.