I'm Kevin Fiscella. I'll briefly talk about the role of social disadvantage and population health in the United States today. Let's start with what social disadvantage is. Paula Braveman and colleagues define social disadvantage as unfavorable social, economic, or political conditions that some groups of people systematically experience based on their relative position in social hierarchies. There are numerous examples of socially disadvantaged groups. These include, to name a few: people with low income, low education, those who are unemployed, minority and racial ethnic populations, those who have non-English language proficiency, those who are disabled, those who are formerly incarcerated, and many others. To understand population health, we need to understand health disparities. Braveman and her colleagues define health disparities as systematic, plausibly avoidable health differences adversely affecting socially disadvantaged groups. Let's look at some specific examples of health disparities. Let's start with the first of the IOM measures of population health, life expectancy from birth. The US has actually made significant progress in closing black, white disparities in life expectancy. As you can see from the chart, we've gone from a gap of around seven years down to roughly three years. Now let's look at some bad news. Disparities in life expectancy based on income have conversely grown significantly beginning in 1980. We see these for women, now a gap between the most affluent and least affluent women are close to 14 years. For men, a similar gap, close to 13 years. As you can see from the graph, there's been a divergence among all groups for both sexes. These disparities in life expectancy by income closely mirror growing disparities in income that began emerging in 1980 or so. As you could see from this graph, the top one percent are claiming a growing portion of income, while the bottom 50 percent are actually losing ground. Let's look at disparities and well-being. Here we see a similar pattern among all the racial and ethnic groups, blacks have the lowest rates of well-being. Similarly, well-being rises steadily as income grows in the United States. Those with the highest income experiencing the highest level of well-being and those with the lowest incomes experiencing the least well-being. What about obesity? Here you see trends in obesity over time by education. Those with a high school education or less, have the highest rates of obesity, while women with a college education have the lowest rates. Although rates have risen steadily among all three groups. For men, disparities by education were relatively narrow in 2000, and these have widened since that time with steady rises in all three groups, but the least rise among those men with college education. What about disparities in other addictive behaviors? What do we see there? Let's start with smoking. As I mentioned in an earlier talk, the US has achieved remarkable progress in reducing its smoking rates. Unfortunately, what we see is a divergence by income in smoking rates. That whereas there were relatively small differences between the least and most educated citizens in the United States, we now see a divergence by education, with those with less than a high school education having the highest rates and those with a college education, the lowest rates. We see a very similar pattern when we look at alcohol. This graph shows deaths among whites, the gaps between white males with less than a high school education, shown in the black bars, are now strikingly higher than those with college education, shown in gray at the end. Whereas there were disparities in the early '90s, those disparities are strikingly larger in the present. A very similar pattern holds for white females in the United States. The fifth of the IOM's measures for population health is unintended pregnancy. Unintended pregnancy rates show similar patterns that we've seen before with gaps between poor and more affluent women growing over time, but in more recent years beginning to narrow somewhat. Again, access to long acting reversible contraceptive methods accounts for these declines among all groups and recent narrowing in these disparities. Racial ethnic disparities in teen pregnancy have also steadily declined, with the largest drop seen among Blacks Latin and Native American women. Again improved access to highly effective reversible methods of contraception combined with declining rates of sexual activity, contribute to these improving trends in teen pregnancy in the United States. To recap, in terms of social disadvantage and population health in the United States, disparities and behavioral risk factors represent one key pathway from social disadvantage to health disparities. The national context of growing income inequality and stagnant wage growth for the bottom half of the population contribute to health disparities through thwarted human need for [inaudible]. Public health successes related to declining racial disparities in life expectancy, unintended pregnancy and teen pregnancy show that progress, at least in some cases, is possible despite this context.