The U.S. Health Disadvantage and Why It Matters to Business – Community Health and Economic Prosperity

OVERVIEW

A thriving economic system requires a wholesome workforce. Ongoing public well being threats—like habit, weight problems, and rising midlife mortality amongst working-age Individuals—create obstacles for companies to have a wholesome workforce. This chapter exhibits how an internet of social and financial circumstances contributes to poor well being and connects the well being and prosperity of on a regular basis folks to a aggressive economic system.

Introduction

Many Individuals imagine they get pleasure from higher well being than folks in different rich nations and have entry to the very best healthcare system on this planet. Neither assumption is true. On common, folks in america have poorer well being—shorter lives and extra sickness—and expertise better well being inequity (avoidable variations throughout teams) than their counterparts in different rich nations. In america, the distinction in how lengthy Individuals dwell and the way wholesome they’re, amongst varied teams (similar to racial/ethnic or revenue teams), is bigger than that of populations in lots of different rich nations, and that distinction is widening with time. Moreover, many Individuals can’t totally entry the U.S. healthcare system, together with 28.9 million non-elderly Individuals who lacked medical health insurance in 2019. An individual’s means to obtain high quality healthcare in America will not be common, whilst america spends extra on healthcare than some other nation. The hole between U.S. spending on healthcare and that of different rich nations has widened over time. In 2018, healthcare expenditures have been 2.6 instances larger in america ($10,586 per particular person) than the common of healthcare expenditures of member nations of the Organisation for Financial Co-operation and Growth (OECD) ($3,994 per particular person) (). The excessive degree of U.S. spending on healthcare is ineffective, inefficient, and dear. OECD nations that spend much less on healthcare than america have more healthy populations and better life expectations.

The paradox of poor well being in a rustic that spends much more on healthcare than some other nation is partly defined by the dearth of entry to healthcare, however is extra totally defined by the truth that well being is about extra than simply healthcare. The circumstances that form well being are outdoors the clinic—the place folks dwell, develop, be taught, work, and age—and never contained in the clinic, the place clinicians and employees do their work. In actual fact, healthcare is estimated to account for less than 10–20% of well being outcomes. The takeaway for employers is evident: The well being of staff and the prices of their healthcare are formed by the circumstances by which staff dwell and return to after work—of their houses and neighborhoods. At present’s enterprise leaders can play a significant position within the lives of their staff, customers, and group members. By investing within the well being and well-being of communities throughout the nation, companies have the potential to vary the trajectory of wellness for generations to come back.

The well being of Individuals is significant to people, households, communities, companies, the economic system, and nationwide safety. U.S. employers depend upon a wholesome workforce to maximise productiveness and decrease healthcare prices. In a worldwide market, an unhealthy workforce and excessive healthcare prices put U.S. companies at a aggressive drawback with companies positioned in nations with more healthy folks. Inhabitants well being additionally impacts the patron market, whereby the demand for nonessential services and products suffers when households are scuffling with diseases and far of their disposable revenue is required for medical bills.

The time period “U.S. well being drawback” refers back to the decrease well being standing of Individuals and the distinctiveness of america amongst populations of rich nations. Though leaders in public well being and drugs have been involved in regards to the penalties of an unhealthy inhabitants, the results are more and more drawing the eye of enterprise leaders, economists, and public officers. At present’s enterprise leaders are involved in regards to the bigger financial impacts of a workforce that’s dying prematurely, affected by excessive charges of illness and incapacity, and producing excessive healthcare prices. The U.S. well being drawback threatens the nation’s world competitiveness and nationwide safety, in addition to the hopes and prospects of future generations.

Scope of the U.S. Well being Drawback

In 2018, information retailers reported that U.S. life expectancy (how lengthy a new child can count on to dwell) was reducing for the primary time in generations. The reviews grew out of research from the Facilities for Illness Management and Prevention that U.S. life expectancy had decreased for 3 consecutive years. This information highlighted the reversal of a longstanding pattern of accelerating life expectancy for a lot of the previous century¹
as a result of enhancements within the circumstances that form well being and to advances in drugs and medical care. Nevertheless, this isn’t the information story in different rich nations, the place life expectancy continues to extend.

• The downturn within the well being standing of Individuals will not be new. For a lot of the 20 th century, U.S. life expectancy had been among the many highest on this planet, and for a few years exceeded the common life expectancy of individuals dwelling in different rich nations (i.e., member nations of OECD). The U.S. well being drawback emerged within the Nineteen Eighties, when the rise in life expectancy in america slowed down, growing extra slowly than in different OECD nations (). By 1998, the rise fell under the OECD common. By 2005, the 15-year survival price of 45-year-old White ladies in america was lowest amongst 12 comparability nations. In 2015, U.S. life expectancy ranked final amongst industrialized nations (), and this pattern continues. The latest decline in U.S. life expectancy stems from a rise in deaths amongst working-age adults (25–64 years of age); the chance of demise amongst this inhabitants has typically elevated since 2010 (). U.S. staff are additionally much less wholesome and extra prone to die sooner than staff in different rich nations. Kids born in america are heading in the right direction, on common, to die sooner than kids born in different rich nations.

• The U.S. well being drawback extends past decrease life expectancy. The prevalence of poor well being circumstances, from diabetes to alcohol-related automotive crashes, is larger in america than in different rich nations, which has clear implications for U.S. healthcare prices, labor productiveness, and labor availability. Six of 10 Individuals have no less than one persistent situation and 4 of 10 have two or extra persistent circumstances, together with 18% of Individuals 18–44 years of age and 50% of Individuals 45–64 years of age. Some research have reported that Individuals are feeling much less wholesome and are experiencing a decline in psychological well being and growing charges of despair (primarily amongst adolescents and younger adults). In the meantime, participation by U.S. males within the labor drive has plummeted from a excessive of 86.4% in 1950 to an estimated 68.2% in 2020. Though elevated participation within the labor drive over time by U.S. ladies has made up for a few of the decline in males’s participation, ladies’s labor drive participation has declined from a peak of 60.2% in 2000 to an estimated 57.4% in 2020²
  ).

• The U.S. well being drawback impacts a lot of the inhabitants. The upper (worse) age-specific demise charges in america drive the shorter (worse) life expectancy. These worse demise charges have an effect on younger, middle-aged, and older folks; men and women from infancy to 75 years of age; and all races and social courses. For instance, the demise price amongst non-Hispanic White Individuals is decrease (higher) than charges amongst most minority and low-income Individuals. Nevertheless, the demise price of non-Hispanic White Individuals is larger (worse) than the demise price of non-Hispanic Whites in different rich nations. The demise price amongst U.S. White men and women in all ages group youthful than 55 ranks sixteenth or seventeenth (worst) out of 17 peer nations. Excessive-income Individuals, folks with medical health insurance, school graduates, and people with more healthy behaviors additionally fare worse than their counterparts in different rich nations: These Individuals even have larger toddler mortality, extra persistent illnesses, and decrease life expectancy.

• The U.S. well being disadvantages are numerous. In contrast with populations in different rich nations, Individuals throughout revenue ranges and racial/ethnic teams endure and die at larger charges from a broad vary of illnesses and accidents—together with coronary heart, lung, and kidney illness; weight problems; diabetes; automotive crashes; drug overdoses; and shootings—and from adversarial delivery outcomes (e.g., toddler mortality), adolescent being pregnant, and HIV and AIDS.

These outcomes persist regardless of America’s massive investments in healthcare, which vastly exceed the degrees by which different nations spend money on their very own healthcare methods. Except circumstances change, estimates recommend that the U.S. well being drawback will proceed to worsen, because it did in the course of the coronavirus pandemic of 2020. The coronavirus was particularly harmful to folks with current persistent circumstances and subjected Individuals to the well being issues from the financial downturn introduced on by the pandemic.

Explaining the U.S. Well being Drawback

The query of why Individuals dwell shorter lives and have poorer well being than folks in different rich nations could be defined by how america differs from different rich nations in 5 areas:

• Public insurance policies and spending: Public insurance policies and spending set the context for the opposite 4 variations. Well being and high quality of life are linked to many U.S. public insurance policies and private ideologies that affect these insurance policies, together with (a) America’s strategy to governance and the decentralized affect of the states and (b) Individuals’ distinctive issues in regards to the dimension of presidency, the quantity of regulation, ranges of taxation, gun rights, and different points that have an effect on public insurance policies—particularly, the generosity of social welfare packages and investments in training, housing, and public well being and different social wants.

• Social and financial components: Earnings and training are among the many most necessary social and financial components associated to well being. In contrast with different rich nations, america has larger ranges of revenue inequality, poverty, little one poverty, single-parent households, divorce, and incarceration. The US has misplaced its management place in training, rating twenty fourth in science and studying and thirty eighth in math, behind such nations as Vietnam, Estonia, and Slovenia.

• Social and bodily environments: The constructed surroundings in U.S. cities, suburbs, and rural and tribal areas is designed for cars fairly than pedestrians, cyclists, and public transit; and Individuals are uncovered to better situations of violence and residential segregation than their friends in different rich nations.

• Particular person behaviors: In contrast with their friends in different rich nations, Individuals have decrease charges of smoking³ and drawback ingesting, however they devour extra energy per particular person, are much less prone to fasten seat belts in automobiles, have extra motorcar crashes involving alcohol, usually tend to personal firearms, and are extra possible to make use of and misuse medicine.

• Healthcare: In contrast to different rich nations, america doesn’t supply common entry to healthcare. The U.S. healthcare system struggles with deficiencies in high quality, fragmentation, and poor coordination of care; and it ranks poorly in comparison with healthcare methods in different rich nations. Lastly, medical health insurance in america is usually tied to employment. When employment is disrupted, similar to that brought on by the coronavirus pandemic, many staff lose their medical health insurance protection, typically at a time of excessive want.

Decrease spending on social providers might also contribute to the U.S. well being drawback. Main investments in social, financial, and environmental growth within the Thirties and Nineteen Sixties haven’t been replicated in latest a long time. Between 1962 and 2017, the share of federal spending on social and financial investments (e.g., in training) decreased by 59%. Throughout the identical interval, spending on packages that present direct money switch and healthcare-related prices (e.g., Medicare and Medicaid) elevated by 162%. Spending extra on healthcare doesn’t essentially result in higher well being. In actual fact, populations in nations that prioritize spending on social providers over spending on healthcare have larger life expectancy. The identical is true throughout america, the place populations in states that dedicate a big proportion of their budgets to social providers have larger life expectancy.

Extra lately, analysis consideration has centered on one other element of the reason. Racism and bias is more and more recognized as an necessary contributing explanation for poor well being outcomes for such inhabitants teams as folks of colour in america. Structural, cultural, and interpersonal racism and bias have been proven to have an effect on well being, wealth, and well-being by socioeconomic, psychosocial, coverage, and alternative pathways, which are sometimes intertwined. For instance, residential housing segregation, unequal remedy throughout the felony justice system, and lack of entry to credit score and capital have the impact, individually and collectively, of concentrating poverty, limiting entry to high quality training, and limiting employment and financial alternatives. Every of those contributes to poorer well being outcomes. Racism and bias within the analysis and remedy of illness additionally contributes to poorer well being outcomes.

The relationships amongst these areas are complicated. Though healthcare is necessary when individuals are ailing, analysis exhibits that unhealthy behaviors (e.g., smoking, lack of bodily exercise) contribute considerably to illness and demise. Some research attribute 40% of U.S. deaths to unhealthy behaviors, which, in flip, are influenced by the bodily and social environments. Individuals could make selections from solely the choices which are out there to them; they can not eat effectively if wholesome meals usually are not out there or stroll to the shop or park if the neighborhood will not be secure. The bodily surroundings—or the constructed surroundings—consists of parks, housing, and transportation sources. The social surroundings consists of the connections, networks, folks, and establishments by which individuals work together (e.g., faculties, employers, banks, libraries, and group facilities). These interactions can both promote or harm well being. Well being-promoting circumstances embrace social help, security, and social connection. Well being-damaging circumstances embrace social isolation, discrimination, segregation, and trauma.

Social and financial components—similar to training, revenue, and poverty—rank among the many most influential drivers of well being, as a result of socioeconomic sources allow folks to pursue wholesome behaviors, dwell in neighborhoods with fascinating bodily and social environments, and entry healthcare. In an economic system that relies on a talented and educated workforce, like america economic system, high quality training could also be a very powerful driver of well being and financial alternative.

Choices on public insurance policies and spending significantly affect the opposite 4 areas. Insurance policies (or lack of insurance policies) can decide an individual’s alternatives and whether or not gaps in alternatives shrink or develop. Choices which are made by authorities and the personal sector on the nationwide, state, and native ranges decide whether or not

• The surroundings is wholesome and secure, together with clear air and water; a constructed surroundings that promotes bodily exercise; entry to wholesome meals, high quality and inexpensive housing, dependable transportation to jobs, training, and providers; and a social surroundings that is freed from violence, trauma, and discrimination;

• Insurance policies are instituted to encourage wholesome behaviors, together with avoiding smoking and misuse of alcohol and different medicine;

• Individuals have entry to inexpensive, high-quality healthcare; and

• The social and financial standing of American households—similar to kids’s training, entry to jobs with a livable wage, and revenue and financial savings—permits them to afford the circumstances that form good well being.

Many Individuals, together with these in middle- and low-income households, and particularly racial/ethnic minorities, have confronted extended durations of financial stress, wage stagnation, and decreased social mobility (the shortcoming to climb the financial ladder). These mounting stresses, which could be mitigated by higher insurance policies, contribute to poor well being. The coronavirus pandemic of 2020 exacerbated and accelerated these financial and social stressors.

Why Does the U.S. Well being Drawback Matter to Companies and the Economic system?

The U.S. well being drawback has main implications for companies and employers because of the adversarial results on the well being of staff and their dependents. Employers share the burden as persistent illnesses, similar to weight problems and diabetes, develop in prevalence within the workforce and amongst dependents. This poor well being generates prices for employers, similar to better healthcare bills; whereas larger charges of incapacity (as outlined by the Social Safety Administration), absences for sickness and medical appointments (for themselves and dependent members of the family), and presenteeism (i.e., working whereas sick) generate oblique prices that scale back workforce productiveness and contribute to declines in labor drive participation. For instance, the common full-time employee with diabetes misses an estimated 5.5 workdays per 12 months; unplanned absences for this illness value U.S. employers $20 billion yearly in misplaced productiveness. The oblique prices of diabetes to employers might strategy $90 billion per 12 months ().

Many American corporations are discovering that there are financial advantages within the alternative to handle the very important circumstances required for well being (Boxes 1.1a and 1.1b). Poor training, unstable housing, and meals insecurity have an effect on the well being standing of staff and their productiveness on the job. In a knowledge-based economic system, companies already perceive the worth of an informed and expert workforce, however the bigger well being advantages of training is probably not totally appreciated—neither is the worth tag for gaps in training. Employees with much less training or revenue usually tend to have persistent diseases and issues, larger healthcare prices and extra absenteeism and presenteeism. Even the flexibility to conduct handbook labor, similar to lifting packages or climbing stairs, varies by degree of training (). Decrease revenue provides to psychological misery, an necessary consideration in an period of accelerating deaths from drug use, drawback alcohol use, and suicide. The opioid epidemic, a phenomenon with far much less influence on companies in different nations,⁴ prices U.S. employers billions of {dollars} per 12 months in healthcare prices and misplaced productiveness.

BOX 1.1AWHAT ARE VITAL CONDITIONS FOR HEALTH, WEALTH, AND WELL-BEING?

Our means to outlive and thrive—as people, establishments, industries, and whilst a nation—relies on having a constant set of very important circumstances, similar to clear air, honest pay, humane housing, early training, routine healthcare, and different pragmatic requirements (see ). The standing and high quality of the very important circumstances form every particular person’s means to realize his or her very best well being, wealth, and well-being. Everybody—together with the general public, personal, and nonprofit sectors and people, households, and communities—has a task to play in assuring the very important circumstances, equitably, for all Individuals.

When any of the very important circumstances will not be met, a wide range of threats predictably come up. These threats drive demand for pressing providers that folks going through adversity may want briefly to regain their very best well being, wealth, and well-being (Box 1.1b). If providers are unavailable or insufficient, the results of unmet very important circumstances could also be devastating to people, households and communities, and the prices, that are appreciable, are borne by society. Everybody pays.

The Seven Important Circumstances

The altering states of those very important circumstances and pressing providers form the prospects for folks and locations throughout america, now and for generations to come back.

Individuals don’t have any say within the very important circumstances that they inherit from their predecessors. On the similar time, folks right now can remodel present and future very important circumstances, for higher or for worse.

Observe: Belonging and Civic Muscle kinds the core of the opposite parts as a result of it’s each an important situation unto itself and a sensible capability expressed by each different sort of work. Graphic of the seven very important circumstances is customized with permission from WE within the World, on behalf of the WIN Community, Rippel Basis, and Nicely Being Belief.

BOX 1.1BA DEEPER LOOK AT THE VITAL CONDITIONS

The very important circumstances that form every particular person’s means to realize his or her very best well being, wealth, and well-being are outlined in better element (in teal). When a number of very important situation is unmet, the demand for pressing providers will increase (in orange). Unmet very important circumstances could be devastating to people, households, and communities and generate prices which are borne by all of society. Though the dearth of a selected very important situation doesn’t lead to a selected pressing want, the adversity that outcomes from a number of very important circumstances being unmet can create any variety of pressing wants, a few of that are illustrated right here. Belonging and civic muscle (in blue) is each an important situation and element of every very important situation. When belonging and civic muscle are sturdy, assuring the very important circumstances turns into simpler.

Like financial and social standing, geography additionally performs a task in well being. At present’s enterprise leaders should think about the disparate dwelling and well being circumstances to which their staff return on the finish of their workday. The very important circumstances in staff’ neighborhoods—from the standard of housing and ingesting water to the quantity of inexperienced house to situations of racial segregation—have an effect on well being on the worksite and the price of healthcare. Totally different circumstances in numerous neighborhoods imply that two staff on the similar firm could have completely different instructional and financial alternatives, group helps, well being statuses, illness dangers, and life expectations—for themselves and their kids.

The underside line is evident: Companies have an financial curiosity in enhancing the very important circumstances in staff’ neighborhoods and in working with group companions to take care of or create an surroundings that’s wholesome and secure. The identical circumstances that form well being are additionally the options that allow employers to draw and retain proficient staff. Such circumstances embrace good faculties, sources for sports activities and bodily actions (e.g., parks, playgrounds), trendy, environment friendly infrastructure (high quality inexpensive housing, broadband Web entry, transportation), and wholesome social environments (e.g., lack of segregation and violence). Companies have highly effective incentives to behave to enhance the very important circumstances that form well being (Box 1.2).

The decline in U.S. well being transcends the enterprise surroundings and impacts the nation’s economic system. For instance, state and native economies endure when poor well being and dwelling circumstances make it tough to draw new industries or drive corporations to relocate, taking jobs with them. The identical adversarial circumstances that have an effect on the well being of a group additionally stifle upward mobility and the well-being of communities, creating circumstances for social discord, crime, and violence. Lack of upward mobility and related revenue inequality are expensive to the economic system. The U.S. well being drawback places the nation at a aggressive drawback within the world market, as U.S. corporations compete with abroad corporations that get pleasure from a more healthy, extra productive workforce and decrease healthcare prices per capita. The rise in U.S. healthcare prices locations unsustainable financial pressures on public payers (e.g., Medicare, Medicaid), employers, and sufferers who battle with out-of-pocket bills, whereas reductions within the well being of the working-age inhabitants and reductions in participation within the labor drive place financial pressures on companies themselves. The U.S. well being drawback has even raised nationwide safety issues, as navy leaders encounter a excessive prevalence of weight problems and different well being issues in active-duty personnel and future recruits.

Conclusion

The U.S. well being drawback started to emerge within the Nineteen Eighties. Though this chapter focuses on the decline in life expectancy as a sign of that drawback, the contributors to that decline are powerfully necessary. Will increase in illness (e.g., weight problems and diabetes) and substance misuse, which exceed that of peer nations, and substantial disparities within the very important circumstances of well being (significant work, secure surroundings, high quality training, and humane housing) represent pathways to diminished participation within the labor drive, poorer well being, and early demise. To enhance the nation’s well being, wealth, and well-being, Individuals should remodel the deprived communities by which too many dwell, develop, be taught, work, and lift households. As demonstrated within the subsequent chapter, well being occurs in communities and is basically pushed by circumstances outdoors the healthcare system that compromise well being, restrict alternative, and shorten life. Kids pay a very excessive value for these poor circumstances, and right now’s kids are tomorrow’s staff and nationwide leaders. They’re the following technology of lecturers, medical doctors, enterprise leaders, and navy personnel. If the U.S. well being drawback of right now will not be mounted, by strengthening communities and increasing alternatives, then the long run inhabitants—and workforce—will virtually definitely be burdened with better illness, decrease productiveness, larger prices, and shorter lives. The U.S. well being drawback is a risk to the enterprise group and the nationwide economic system.

BELDEN INC.: Pathways to Employment

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	Group Problem | The staggering ranges of drug habit in native communities throughout america has prompted greater than a well being disaster. The financial influence of treating drug habit is a burden on households and companies. For these addicted, the flexibility to maintain a job is tough and will get tougher over time, and those that handle to carry a job are much less productive. For Belden, Inc. (Belden) one thing needed to change.
	State of affairs | Belden has been a member of the Richmond, Indiana, group since 1928. Because the second largest employer in Wayne County and a worldwide chief in specialty networking options, Belden is a revered American firm and pleased with its security file and powerful workforce. Belden requires all job candidates have a drug-free background and move drug screening. If employed, staff should proceed to be drug-free. Belden employed greater than 500 folks at its Richmond plant. Almost one-third of those staff have been set to retire inside 5 years. On the similar time, the labor pool for manufacturing staff was declining, simply as buyer demand was growing. The place would the brand new hires come from?
	Motion Taken | Regardless of an inflow of functions, many potential staff have been turned away. “We discovered the pre-employment drug display screen failure price was steadily growing—between 10 to fifteen%,” stated Paul Mottershead, vp Company Communications. In response to Mottershead, when the information have been introduced to Belden’s Board of Administrators, one member requested Chief Government Officer John Stroup: “For those who’re not going to do one thing about this, who’s?” With help from high management, Belden convened a crew to work with group companions to handle the drug use drawback amongst its applicant pool. “We’re not a healthcare knowledgeable and wanted to depend on the experience of [others] to develop, implement, and evolve [a] program,” Mottershead stated. Companions included Centerstone Indiana, Meridian Well being Companies, Ivy Tech Group Faculty, Manpower Richmond, and habit specialist Dr. Mitch Rosenthal. Collectively, they constructed the Pathways to Employment Program, which launched as a pilot in February 2018 and gives 18 months of help to candidates who’re employed by Belden. Via this system, Belden provides rehabilitation and a job to candidates who fail the pre-employment drug check however conform to enter this system. In this system, a healthcare supplier assesses staff and locations them into one in every of two teams—low danger or excessive danger for substance use dysfunction. From there, staff obtain personalised, evidence-based rehabilitation remedy, throughout which they work in such positions as cleansing, stock, and different roles that don’t pose a danger to their security or the security of others. Drug assessments are carried out virtually weekly for the primary 8–16 weeks. Staff should stay drug-free to work in larger danger positions, like a machine operator. Staff who fail a drug check are launched and supplied with group sources to assist them with substance misuse. Nevertheless, if staff are forthright a few relapse earlier than failing a check, they get a second probability. By 2019, 34 staff had entered this system—12 have been in machine working roles, 12 left this system, and 10 have been in decrease danger roles. This system prices a mean of $6,000 per low-risk worker and as a lot as $26,000 per high-risk worker. This system can be out there to present staff who’re searching for assist with habit issues. Based mostly on the constructive response, Belden developed a blueprint for different organizations to develop related packages and started providing this system in 2020 at two different U.S. services.
	Key Takeaway | Belden wanted to rent folks to provide merchandise to fulfill enterprise calls for and the expectations of shareholders. All teams—enterprise, authorities, and the healthcare system—labored collectively to handle the necessity. Having a job is a essential a part of sustaining a drug-free life-style; filling a job is essential to enterprise success. Belden helped with each and is sharing its learnings with different corporations, organizations, and communities.

1

A lower in life expectancy of this length has not occurred because the worldwide influenza pandemic of 1917–1918.

2

An estimated 62.5% of women and men mixed participated within the labor drive in 2020 (). Precise month-to-month labor drive participation reached a low of 60.2% in April 2020, because of the influence of the coronavirus pandemic, earlier than rebounding barely to 61.5% in June 2020.

3

Larger charges of smoking a long time in the past might also be contributing to at present excessive U.S. demise charges from tobacco-related diseases.

4

A rise in opioid prescribing has been noticed in different nations (e.g., Australia, Canada, Denmark, Finland, Germany, Sweden, United Kingdom), however no nation has skilled a rise in drug overdose deaths similar to america.