“Thank goodness you are here!” the assistant said as soon as she saw me arriving down the dimly lit hallway at 3:30 in the morning of a dreadfully cold, drizzly day. “Room 338. Be careful in there…” As I was approaching the room, my nostrils cringed at the smell of excrement and vomit. Yellow tape had been placed at the entrance of the room to keep people from accidentally stepping in a large pool of dark-red blood. The body of a man, mid-fifties, was lying lifeless on the floor, belly up, mouth open, eyes rolled back. He had a cachectic look, yellow skin on bones, with an unusually large and protruding abdomen. There were bloody handprints all over. He must have been trying to get help, holding on to the white walls for balance, just to fall down onto the linoleum floor, blood gushing out of his mouth and his bowel. It seemed like the man had practically exsanguinated. But how did that happen? What and who was responsible for such a gruesome death?
Earlier that night I had been called to examine another body.
The body belonged to a woman in her early sixties but seemed much older than her chronological age. As I removed the white sheet covering her, the smell of necrosis became unbearable. The assistant had warned me to wear a surgical mask and I did, but it wasn’t enough to keep the pungent and rotten odor of decaying flesh out of the back of my throat. Her entire body was dotted with abscess-like nodules, all exuding green pus and blood from a central cavity, which reminded me of lacerated, infected gunfire wounds. The woman’s eyebrows were furrowed, the corners of her lips bent downward, her face hopelessly frozen in an unsettling expression of pain. I wondered if I should have attempted to straighten the nasolabial folds and the angles of the mouth to give her in death the peace she must not have had in life. I extended my arms and reached for her cheeks, but my blue-gloved hands hesitated and, instead, slid down her face in a caress that she could not feel.
Who would do something like this? Something so cruel and seemingly deliberate?
The final call came at 5 a.m. I put my warm coat on while looking outside of the small window in the coffee room. I felt a shiver creep up my back as dawn tried to crawl out from behind a thick curtain of clouds. The thought occurred to me that even the bright and powerful light of the sun will fail to shine if it’s met with too many obstacles. I left my bitter cup of coffee on the beat-up plastic table in the room, and with that thought in my mind, I walked down a few flights of stairs to get to the first floor. What now? I wondered.
When I turned the corner of another long hallway, I saw the assistant waving at me: “Over here!”
I approached her slowly and deliberately. “Tell me what happened.”
“We were told by a neighbor that this woman was found at the bottom of the concrete staircase of her apartment complex with her head split open. Not sure if there was foul play involved, but we wanted to notify you because your name was found in her file. You knew her from previous encounters. She was going blind, based on your notes. We wanted to notify you that she has expired. Would you like to call her family?”
I had written in my notes that this 58-year-old woman was diagnosed with tuberculosis of the eyes. Her condition went untreated due to lack of access to medical care. As a result she lost her eyesight, leaving her unable to work, drive, make a living, or walk around safely. In fact, she ended up tripping and tragically falling down the stairs, which resulted in fatal injuries.
This is not the script for a gory horror movie. These stories are but three of literally thousands of accounts of people dying because our market-based system denies access to needed health care services. That one night’s first case was a 54-year-old man with end stage liver disease. He died of a massive esophageal varices rupture. The second was a 65-year-old woman with untreated breast cancer that metastasized to the skin. What all these cases have in common is lack of health insurance and, therefore, lack of access to needed medical care. All three cases resulted in the disease process wreaking havoc on the bodies, the lives, and the families of those unfortunate individuals and on the health care system itself.
I am a physician who has spent decades taking care of people from all walks of life, from all socioeconomic levels, and from different racial and ethnic backgrounds. One thing became very clear very quickly: Lack of access to health care kills people.
As much as I love practicing medicine, I find myself at odds with a system where health care is seen as a privilege or a commodity and not as a human right.
The right to health care has long been recognized in many countries around the world. Although demands for universal health care and “Medicare for All” were crucial issues during the 2020 presidential campaign, the United States has not warmed up to the idea of health care as a right.
A wealthy ranch owner once came to see me as a patient. He told me that health care is a privilege and not a right. “Health care is like a TV set,” he said. “If you have the money, you buy it. If you don’t, you have to do without it.” I felt mystified by his lack of social consciousness. I wondered what could have been fueling that type of thinking.
After all, the idea of health care as a right had already been articulated a long time ago by prominent figures in American history. Franklin Delano Roosevelt, thirty-second U.S. President, in his January 11, 1944 State of the Union address famously proclaimed: “We have accepted, so to speak, a second Bill of Rights under which a new basis of security and prosperity can be established for all regardless of station, race, or creed. Among these are…the right to adequate medical care and the opportunity to achieve and enjoy good health; the right to adequate protection from the economic fears of old age, sickness, accident, and unemployment… All of these rights spell security. And after this war is won, we must be prepared to move forward, in the implementation of these rights, to new goals of human happiness and well-being.”
FDR’s death kept this second Bill of Rights from being implemented. Eleanor Roosevelt, however, took her late husband’s work to the United Nations (UN). Mrs. Roosevelt became the drafting chairperson for the UN’s Universal Declaration of Human Rights (UDHR), the milestone document in the history of human rights. Drafted by representatives with different legal and cultural backgrounds from all regions of the world, the declaration codified our human rights, including the essential right to health (Article 25). This declaration was proclaimed by the United Nations General Assembly in Paris on December 10, 1948, and has been translated into over five hundred languages.
Prior to the Roosevelts’ achievements, the Constitution of the World Health Organization issued a statement: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” These words were written in 1946, seventy-five years ago.
Why then, seventy-five years later, are these words still controversial? Why are we so far away from fulfilling the fundamental human right to health care? Why, seventy-five years later, is it still so painfully common to hear stories of poverty, disease, and demise?
Chris, age 37, came to the emergency department with severe facial pain and unbearable headaches. He was admitted to the hospital for a bad sinus infection. He was discharged home with a diagnosis of adenocarcinoma of the maxillary sinuses. “Home” was a trailer, where he lived with his mentally ill brother. They both needed a lot of help, but they had no parents, no relatives, and no health insurance. Chris didn’t have enough money to afford the much-needed pain medications. He was asked to try applying for Medicaid in a state that didn’t even support Medicaid expansion.
The principle of health care as a basic human right has been widely accepted and supported by secular and religious leaders, medical and health associations, and human rights and political organizations, which have all put forward official position statements on this matter.
At the convention of the Medical Committee for Human Rights held in Chicago in March 1966, Dr. Martin Luther King, Jr. declared: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
Alex, 49 years old, had a strong family history of colon cancer. He died of metastatic colon cancer because he could never get insurance. Without insurance, he had no way to access lifesaving screening procedures. Louise, a 38-year-old mother of three, ended up in a wheelchair, her joints painfully destroyed by untreated rheumatoid arthritis. Ashley, 52 years old, lost her job and her health insurance. She couldn’t afford to pay for her annual mammograms and found herself ensnared by the double death grip of breast cancer and mounting medical debts.
These stories of catastrophic health outcomes make the position statement of Amnesty International urgent and necessary: “We believe that health care is a right, not a privilege or a commodity. Everyone in the United States has the human right to health care. Reform measures should ensure that every person has access to comprehensive, quality health care. No one should be discriminated against on the basis of income, health status, gender, race, age, immigration status or other factors… Health care is a public good, not a commodity”(“Health Care").
Jim, a 58-year-old construction worker with diabetes and hypertension, told me how, after suffering a major heart attack that required bypass surgery, he ended up losing the little he owned, including the roof over his head, to escalating medical bills. He became homeless. “I didn’t need much,” he told me. “All I ever wanted was a job, a decent home, and a nice couch to sit on and watch football games on Sundays. Was that too much to ask?”
The American Medical Student Association has clearly articulated the need for universal health care: “In a time when thousands of people lose their health insurance every day, when health care is becoming elusive to even well-to-do Americans, and when any person is just one pink slip away from becoming uninsured, it becomes clear that health care for all is not just important to achieve, but imperative. At its root, the lack of health care for all in America is fundamentally a moral issue. The United States is the only industrialized nation that does not have some form of universal health care (defined as a basic guarantee of health care to all of its citizens). While other countries have declared health care to be a basic right, the United States treats health care as a privilege, only available to those who can afford it… Americans purport to believe in equal opportunity. Yet, in the current situation, those who do not have health care are at risk for financial ruin and poorer health, both of which disadvantage them in society and thereby do not give them equal opportunity… The Declaration of Independence states there are certain ‘inalienable rights,’ including life, liberty, and the pursuit of happiness. If Americans believe in an inalienable right to life, how can we tolerate a system that denies people lifesaving medications and treatments? Similarly, if Americans believe in an inalienable right to the pursuit of happiness, how can we allow millions of dreams to be smashed by the financial and physical consequences of uninsurance”(“The Case")?
Regrettably, not everybody shares the same views:
In 2011 Dr. Rand Paul declared: “If I’m a physician in your community and you say you have a right to health care, do you have a right to beat down my door with the police, escort me away, and force me to take care of you? That’s ultimately what the right to free health care would be. If you believe in a right to health care, you’re believing in basically the use of force to conscript someone to do your bidding”(ProCon.org).
As Ben Shapiro, JD, put it: “Morally, you have no right to demand medical care of me. I may recognize your necessity and offer charity; my friends and I may choose to band together and fund your medical care. But your necessity does not change the basic math: Medical care is a service and a good provided by a third party”(ProCon.org).
Mike Rosen, MBA, agreed: “If someone is indigent, we don’t let him die on the sidewalk outside a hospital. We treat that person, as we should. We’ll even send an ambulance to get him. But whether the money to pay for this comes from taxpayers, private benefactors or by shifting the cost to other patients, it’s still charity. Health care isn’t a right. Neither are food stamps, housing subsidies or welfare. They’re all charity”(ProCon.org).
How did we get here?
The writings of William Graham Sumner, a famous and influential social scientist who taught social sciences at Yale, had a profound effect on America in the last three decades of the nineteenth century. He was a supporter of free markets and coined the term “forgotten man.” The definition of the forgotten man was one who is coerced into helping the man at the economic bottom.
Sumner believed in social Darwinism. He thought that men could not abolish the natural law of “survival of the fittest.” They could only interfere with it and, in so doing, produce the “unfit.”
Sumner’s ideology was based on the notion that the population was increasing geometrically but resources were increasing arithmetically. “Civilization has a simple choice,” Sumner stated, “liberty, inequality, survival of the fittest, or not-liberty, equality, survival of the unfittest. The former carries society forward and favors all its best members; the latter carries society downward and favors all its worst members”(Sumner). Based on Sumner’s principles, it was inferred that government assistance would interfere with the natural selection of the free market. Sumner’s ideology epitomized capitalism and was widely accepted by most Americans at the time.
Arguments against health care as a human right include opposition to socialized medicine, anti-welfare sentiments, antisocialism, concerns about limited resources, and the unaffordable costs of universal health care. All this goes hand in hand with the support for free markets and the for-profit health care industry, and even the claim that universal health care would be unconstitutional as it calls for unacceptable interference of government into the lives of its citizens.
Supporters of the idea of health care-as-commodity use the same paragraphs of the Declaration of Independence, the Constitution, and the Bill of Rights invoked by the supporters of health care-as-human right to make their case against it. In fact, the health care-as-commodity advocates claim that a careful reading of these historic documents does not reveal any intrinsic right to health care, food, or shelter. The line of defense against health care as a right is that the unalienable rights cited in the Declaration of Independence are life, liberty, and the “pursuit”—not the “guarantee” or the “delivery”—of happiness; the Preamble to the Constitution speaks of “promoting” the general welfare, not providing it; the Bill of Rights delineates a series of fundamental rights that individuals possess by nature and that government shall not infringe, and free health care is not one of them because it would imply wealth redistribution. No one in a free society should have a “right” to anything that forces someone else to work and provide for them.
The idea that people have a right to health care is therefore seen as inimical to legitimate American liberties. Government-sponsored medical care with a top-down approach is regarded as violating the individual rights to freedom guaranteed by the Constitution. Health care, therefore, should be treated as a service and, just like food and shelter, should best be provided through voluntary and mutually beneficial market exchanges.
“Health care…is not important,” emphatically declared Philip Barlow (Barlow).
A 22-year-old aspiring ballerina asked me: “Doctor, are you sure there is nothing that can be done for me anymore? How can that be? What’s going to happen now? Will I die? How’s that possible? I haven’t done anything wrong. I want to be a ballerina. I am a ballerina. I’ve been training hard for it and then all this happened. I was dancing one day, and I noticed that something was off. I couldn’t get through my choreography without stumbling, but I waited a long time to see a doctor because I had no health insurance and no money. Then it got worse. I can hardly walk now, and my head hurts all the time. They said the cancer has spread everywhere. How can that be? Can you do something for me?”
I have to assume that Mr. Barlow, his family, and all of his friends have been blessed with strong health. I assume they have lived their lives blissfully untouched by the havoc that disease can bring upon people’s lives, including the inability to work, provide for themselves and their families, and be productive members of society.
As a physician I am guided by the two universal principles of the Hippocratic Oath: protection of patients from harm and injustice. Not providing patients with health care is both harmful and unjust, clearly a violation of the Hippocratic Oath. Furthermore, treating health care as a commodity makes health contingent upon financial abilities, a reality strongly in contrast with the ideals of fairness and equal opportunities at the core of the American Dream. In fact, there is nothing more fundamental to pursuing the American Dream than good health.
Many arguments against health care as a right have made an impression on me for their lack of social conscience. I’d like to share a few, as they starkly articulate the opinions of the opposition in ways that I could not fully capture by just paraphrasing them (ProCon.org):
“People no more have a right to health care than they have a right to education, food, or clothing… When Americans began looking upon rights as some sort of positive duty on others to provide them with certain things, that was when the quality of health care in America began plummeting. That was what Medicare and Medicaid were all about—the so-called right of poor people and the elderly to health care.” (Jacob G. Hornberger, JD)
“Rights are not about giving you something for free; they are about protecting natural liberties from those who would take them away from you. For instance, the Second Amendment guarantees the right to bear arms. It does not, however, say that you get guns for free if you don’t have one.” (John Campbell, MBT)
“People sometimes argue in favor of a universal human right to health care by saying that health care is different from all other human goods or products. It is supposedly an important precondition of life itself. This is wrong: There are several other, much more important preconditions of human existence, such as food, shelter, and clothing. Everyone agrees that hunger is a bad thing (as is overeating), but few suppose there is a right to a healthy, balanced diet, or that if there was, the federal government would be the best at providing and distributing it to each and every American… There is no right to health care any more than there is a right to chicken Kiev every second Thursday of the month.” (Anthony Malcolm Daniels, aka Theodore Dalrymple, physician and author)
“A true national health care system, along the lines of Britain or Canada, would have advantages and disadvantages over what we have now. But one advantage that it doesn’t offer is to free us from the need to think about our health care in the cold logic of dollars and cents, rather than warm and fuzzy altruistic ideals. Health care cannot be a right, full stop; it has to stop before we run out of wallet.” (Megan McArdle, MBA)
Despite spending far more per capita on health care than any other country, the U.S. has some of the poorest health indicators in the industrialized world. This record can be attributed to a great extent to the very notion that health care is a commodity, a privilege for those who can afford it rather than a fundamental human right. With a system that values profits over people, should we be surprised that health care costs continue to spiral out of control for ordinary Americans while insurance companies and pharmaceutical companies accumulate sensational profits? Should we be surprised that uninsured citizens resort to using emergency rooms for all their medical needs, causing billions in wasteful spending each year? Should we be surprised that health issues, neglected due to lack of access to needed services, result in disease progression and preventable hospitalizations, further escalating the cost of care?
The blind support of the free-market principle in health care and the refutation of universal health care based on the fear of “running out of wallet” are, paradoxically, what is causing the country to run out of wallet. In an environment where the right to health care is denied to large segments of the population, and where even people with health insurance are denied needed services, are left with huge bills to pay, and cannot afford the cost of care, the current health care system will continue to be overwhelmed.
People can live without a gun. People can live without a TV. People can live without chicken Kiev every second Thursday of the month. But people cannot live without their health. Therefore people will continue to crowd the emergency departments. They will continue to get sick and require medical attention and hospitalization, often because of preventable illnesses. How could so many highly educated people blatantly miss this basic fact that when people are sick, and their children are sick, and their parents are sick, they will try to gain access to health care in whatever way possible? They will skip their lunch, but they’ll wait for hours for their turn to be seen by a health care professional. And who is absorbing the costs generated by this system? Charity, apparently, has not been enough to curb the financial losses.
In fact, charity care, defined as the unbilled and uncollected expenses that hospitals write off for patients who can’t pay for services, accounts only for a small percentage of the total value of uncompensated care provided yearly (Hidden Costs).
Furthermore, being “financially indigent” or “medically indigent” is no guarantee that the individual applying for charity care will be approved to receive it. There are a variety of state-based laws and regulations relating to charity care. To complicate matters, each Hospital District can determine its own eligibility guidelines and application procedures. Accessing charity care is not easy. In addition to that, many patient advocates and social service providers have also reported that even when their clients qualify for charity care, they don’t receive it ("Access Denied").
Jaime, 23 years old, developed shortness of breath, fever, and gum bleeding. He was diagnosed with acute leukemia and, after being stabilized, was lost to follow-up due to lack of financial aid. I don’t know what happened to him, but I cannot assume that he’s still with us.
The alarmingly high and growing ranks of the uninsured with ensuing uncompensated care leads to an unsustainable economic situation that will, sooner or later, deal a fatal blow to an already broken health care delivery system.
So what’s next?
Keeping uninsured people from using emergency departments would appear to be the only unstated solution, the one the opponents of universal health care secretly believe in but cannot openly articulate because this position would be too politically incorrect. The opponents of universal health care are not working on any alternative plans that would guarantee basic health care services to those who cannot afford private insurance. Charitable interventions cannot cover the costs generated by the current system. They are not enough to provide people in need of medical care with a reliable safety net. So what solutions are the opponents of universal health care offering to this crisis of majestic proportions?
I have listened to arguments and speeches; I have read posturing articles about freedom, liberties, and unalienable rights as well as think pieces about fancy economic theories and the insignificance of people’s lives; I have paid careful attention to grievances, fears, and concerns; but I have not heard any articulation of a plan offering solid solutions.
The believers in the “survival of the fittest” philosophy don’t want solutions. They’d rather have people stay home and die, and this is the unspoken, ugly truth. The poor, the sick, the disabled don’t matter to them; the poor, the sick, the disabled are “unwilling to provide for themselves,” so why should anybody else provide for them? The poor, the sick, the disabled have no worth. The victims are blamed for their predicament and don’t deserve any help and consideration. They are the “unfits” Sumner talked about and should be forgotten and left behind to die while the rest of society moves on.
This way of thinking is unmistakably intertwined with eugenics, which was adopted by the Nazis to justify their treatment of Jews, disabled people, and other minority groups. Sadly, eugenics seems to be alive and well, finding intended or unintended support in the current health care system in America.
For those who are concerned about “running out of wallet,” for those who talk of health care as a privilege and therefore have no concern for the health needs of their own fellow citizens, the COVID-19 pandemic blisters as an example of how a health care crisis has disastrous consequences for everybody, in every sphere of life. Beyond health and beyond the unthinkable number of deaths, we’ve experienced dramatic job losses in practically every industry and sector, such as tourism, travel, transportation, leisure and hospitality, entertainment, construction, personal services, food and clothing manufacturers, self-employed workers, mining, oil and gas extraction, and so on and so forth.
Loss of jobs disrupts lives. Many younger people have dropped out of the job market and have had to defer their dreams. Long-term unemployment for workers older than 50 may turn into permanent job losses. Many of my patients have reported lack of income, financial instability, food insecurity, inability to pay rent, causing escalating levels of anxiety and depression. When I asked Mark, a 59-year-old hotel worker, how he was doing after being laid off, he answered, “I’m staying hungry.”
“I went from being able to pay rent and bills to basically no income,” said Martha, my 38-year-old patient, mother of two. Martha was already working two jobs to make ends meet. She did not know how she could possibly manage to put food on her table and keep a roof over her children’s heads. Martha was anxiety-ridden and could barely talk in full sentences during the office visit, her voice fragmented by the spectrum of total catastrophe.
A recent study commissioned by the International Chamber of Commerce examined trade data across thirty-five industries in sixty-five countries to explore the economic impacts of unequal vaccine distribution (Goodman). The study concluded that the continued pandemic in poor countries will have a negative impact on industries that are dependent on suppliers around the world, such as automotive, textiles, construction, and retail. Therefore equitable distribution of vaccines is in every country’s economic interest, especially those that depend most on trade. Unequal access to COVID-19 vaccines will pose universal problems. Clearly all economies are connected. No economy, however strong, will be spared from the effects of the virus until the pandemic is brought to an end everywhere. If the leaders of the wealthiest nations fail to ensure that people in the developing world gain access to vaccines, they will end up damaging their own countries’ economic interests. Sharing vaccines with poor countries is not simply a form of charity; it’s a self-preservation strategy.
The meaning of Dr. King’s statement, “We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly,” has never been so striking. Dr. King’s message is a stark reminder of how interconnected human beings are, and how health, economy, and justice are profoundly intertwined.
In the book Dying of Whiteness, physician and author Jonathan Metzl interviewed many white men who voiced a willingness to die, literally, rather than embrace laws that would give minorities or immigrants more access to health care, even if it helped white men as well.
A 41-year-old uninsured Tennessee cab driver dying of liver damage caused by hepatitis C stated: “Ain’t no way I would ever support Obamacare or sign up for it. I would rather die… We don’t need any more government in our lives. And in any case, no way I want my tax dollars paying for Mexicans or welfare queens.”
What that cab driver’s statement highlights, among others, is how bias and prejudice lead to devaluing the lives of others. Ultimately this is what the problem boils down to: Independent from any consideration of limited resources, political affiliation, anti-socialism, free market ideologies, and irreconcilable philosophical differences, if we don’t believe in our hearts and minds that all human beings have the same intrinsic value, equal standing in society, and therefore the same rights; that all human beings are deserving of dignity and respect by virtue of being human beings, then we will continue to allow, tolerate, and promote inequalities at all levels, even to our own detriment.
Valuing human life plays a critical interpersonal and societal role.
If Sumner’s ideology of social Darwinism and survival of the fittest were to be true, we would be wired solely to dominate others and not to respond to their needs and sufferings. The survival-of-the-fittest philosophy conveniently overlooks the fact that being born into privilege or being born into deprivation is not a choice nor is it a designator of “fitness.”
In this system people not only have the misfortune of being born into poverty and hardship, but they are blamed for it.
When one of his daughters died at age 10, Charles Darwin started to develop deep insights about the place of suffering and compassion in human experience. That led him to argue, in The Descent of Man, that sympathy is our strongest instinct, sometimes stronger than self-interest. Darwin argued that sympathy would spread through natural selection, for “the most sympathetic members would flourish best and rear the greatest number of offspring.”
The survival of our species depends on mutual aid, as shown by a wealth of research on human behavior. Human beings have survived as a species because they have evolved the capacities to care for those in need and to cooperate. Humans have developed the most complex and interdependent society of any creature on earth, where empathy and compassion have emerged as powerful forces of unity and progress.
There won’t be any shortage of crime scenes if society continues to allow its privilege to override its conscience, if so many civilized people are willing to live in comfort, both physical and moral, while letting everybody else struggle with poverty and disease.
Talking about the prospect of universal health care, 27-year-old Devin, who voted for Trump in 2016, said: “If you have a sick community, you have a sick workforce, you have sick people. You have death. You have low productivity from it. So I think that as a step back from all of it, then yes, health care I think should be a right”(Scott).
A society that doesn’t take care of the vulnerable is a society that loses tremendous human potential. Liberty without security and opportunity is not a tenable option in a democratic society.
There are rights to which we are entitled simply by virtue of our humanity, independent from our culture, religion, race, nationality, or economic status.
Health care is a basic human need. Health care is necessary for human thriving; therefore health care is a fundamental human right. Promoting and sustaining human health is a moral obligation for every society that believes in the inherent value of human life.
Fifty-eight-year-old Paula would be walking and talking with no impediments now if a devastating stroke didn’t take away her speech and leave her with significant motor deficits.
Access to health care would have allowed her to be treated for diabetes and hypertension, therefore preventing the stroke. Paula would still be a productive and happy member of our society. Instead she’s doomed to a life of sickness, disability, and pain. Tell me how this is not a crime.
Access Denied: Washington’s Charity Care.”
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*"Crime Scenes" was previously published in the Atherton Review, Vol 107.