 |
By Richard H.
Carmona, M.D., M.P.H., F.A.C.S.
United States Surgeon General
Department of Health and Human Services |
There is no
more pressing public health issue for our nation than improving health
literacy. It touches every aspect of our lives. Health literacy is the ability
of an individual to access, understand, and use health-related information and
services to make appropriate health decisions.
I will do everything in my power to
increase Americans' health literacy while I have the privilege of serving as
Surgeon General. My mission as Surgeon General is to advance and protect the
health and safety of the American people. The quality of the health information
that Americans receive and their ability to understand and use that information
is key to building a healthier America.
America has the best health care
system in the world. At the dawn of the 21st century, medical discovery is
advancing at an unprecedented rate.
Yet Americans have not kept pace in adopting health
behaviors to live longer, healthier lives.
As a nurse and more recently a trauma surgeon and
public health director, I worked alongside my colleagues to convince our
patients and our communities to choose healthy behaviors to help prevent
illness and injury.
But often there was a wall between us and the people we were
trying to serve. It was a wall of confusion and misunderstanding brought on by
low functional literacy skills and, unfortunately, it was sometimes shored up
by our inability as health care professionals to recognize that our patients
didn't understand the health information that we were trying to
communicate.
We
must close the gap between what health care professionals know and what the
rest of America understands.
Priorities
When President Bush and
Secretary Thompson nominated me to be Surgeon General, they asked me to focus
on three priorities. I'm fortunate to work with these two leaders who
understand the importance of health. Two leaders who insist that evidence and
the best science always guide our policy and what I do.
All three of my priorities are very
strongly evidence-based. They are:
First, Prevention. - What each of us can do in our own lives
and communities to make our families and ourselves
healthier.
Second,
and new to the Office of the Surgeon General, Public Health Preparedness. We
are investing resources at the federal, state, and local levels to prevent,
mitigate, and respond to all-hazards emergencies.
Third, Eliminating Health Care
Disparities. The chronic conditions that plague our nation are most pervasive
in communities of color. Most of the preventable diseases that are cutting
healthy years off the lives of people in communities like where I grew up in
Harlem, in New York City, could be eliminated if people had access to better
health information, and understood and acted on that information. Eliminating
health disparities is predicated on increasing health
literacy.
Right
now low health literacy is a problem throughout our nation - from Native
American communities, to rural areas of Appalachia, to our nation's
capital.
Health
Literacy
Our nation's low health literacy is a threat to the health and
well being of Americans and to the health and well being of the American health
care system.
Statistics show that low health literacy adds as much as $58
billion per year to health care costs. More than 90 million Americans cannot
adequately understand basic health information.
You only have to look at the past few
decades to see the impact of low health literacy. It took over 25 years with a
major long-term initiative by NIH's National Heart, Lung, and Blood Institute
to get Americans to know their blood pressure level and seek appropriate
treatment. Despite numerous efforts to eliminate smoking, more than 4,000
American children age 17 and younger will try their first cigarette today. Many
Americans avoid getting appropriate medical check-ups for breast, colorectal,
and cervical cancer, even though these preventive screenings can help them live
longer and healthier lives.
Consider this: A study of English-speaking patients
in public hospitals revealed that one-third were unable to read basic health
materials. Twenty-six percent of the patients could not read their appointment
slips, and 42 percent did not understand the labels on their prescription
bottles.
Among
patients with type 2 diabetes, low health literacy is independently associated
with worse glycemic control and higher rates of complications, including
retinopathy.
Further studies show that people of all ages, races, incomes,
and education levels are challenged by low health literacy. The problem has
grown as patients have been asked to assume more responsibility for self-care
in a complex health care system.
Adequate health literacy is important in secondary prevention,
as ineffective communication between health providers and patients results in
medical errors due to misunderstandings about medications and self-care
instructions.
Compounding the problem is the fact that most patients hide any
confusion from their health care providers, because they are too ashamed and
intimidated to ask for help.
Not every American is a scientist or a health care
professional, and we can't expect everyone to understand what it takes doctors,
nurses, pharmacists, and other health care professionals years of training to
learn. My mechanic doesn't expect me to know how to change the transmission in
my car. And I don't expect him to know how to perform a tracheotomy or to
understand complex medical issues.
There are some simple things that Americans can do to stay
healthy and safe. We can get regular medical check-ups; eat healthy foods; be
physically active every day; and make good choices, like wearing seatbelts
every time we're in a motor vehicle.
These are all very simple - but they all require a
lot of understanding of why these choices are smart choices for our health and
safety, as well as our family's health and safety.
Another simple thing we can do for our
families, and ourselves, and this is part of health literacy, is to better
understand the medicines we're taking. That's the heart of the Be MedWise
campaign that I helped launch.
I issued a prescription that will be posted in pharmacies
across the United States. This prescription is for every American who is
considering taking an over-the-counter medicine. It lists some of the most
important questions that everyone should ask their doctor or pharmacist about
over-the-counter drugs. This may be the most important prescription I've ever
written, as I see it.
Today, 6 out of every 10 medications that people take are
over-the-counter drugs - so-called OTC medicines. These drugs are real
medicines that must be taken responsibly.
Let's look at one reason why health literacy is so
important when it comes to using over-the-counter drugs: over-dosing.
When I was a
practicing nurse and later a doctor, I talked with people every day who thought
that over-the-counter drugs were not serious medications, but that they were
harmless products that they should try at random for a range of symptoms. Well,
we know that's not true. There are more than 100,000 OTC drug products on the
market. As a nation, we take nonprescription medications more today than ever
before.
These
medications are an important part of our health care system, but they are
easily misused. Taking medicines without understanding what their active
ingredients are and what they can do to your body can result in very serious
health problems. Yet thousands of Americans do just that because they have not
been educated about medications.
The Department of Health and Human Services launched a new
campaign to promote proper antibiotic use. Every year when cold and flu season
hits, we hear from so many patients who want an antibiotic to treat their
symptoms, when the reality is that although antibiotics are often powerful
weapons against bacterial infections, they won't help at all against the common
cold or flu or viral conditions of any kind.
This has become a global public health
issue as inappropriate antibiotic use has contributed to an alarming growth of
global antibiotic resistance. It is another problem that can be solved by
increasing health literacy. We're working with state and local health
departments, managed care organizations, and pharmaceutical companies, and we
need help to spread the word about proper antibiotic use with patients and
through organizations' communication channels.
Prevention
Health literacy
is key to secondary prevention. And it may be even more essential to primary
prevention. A health literate individual is more apt to know how to answer the
question "How do I keep myself well?" Right now, low health literacy is one of
the largest contributors to our nation's epidemic of overweight and obesity.
Experience with
my own patients and students indicate that Americans do not understand the
meaning of fat grams, or the impact of caloric intake versus expenditure.
Every morning
people wake up and, while they're sitting at the kitchen table, they read the
newspaper and the cereal box.
Throughout the day they read the nutritional information on
their meals and on their snacks. But do they really understand the information
they're reading? The labels list grams of fat. But do people know how many
grams of fat they should eat in a meal? Or in a day? Or how many is too many?
Or how many is too few?
These are seemingly simple questions, but we're not giving
Americans simple answers.
People are hearing about overweight and obesity. So they're
trying to figure out how much food they should eat. How much is too much? How
much is too little? What constitutes a healthy diet?
They're asking about calories,
carbohydrates, vitamins, and fiber. They're asking about salt, sugar, and
portion sizes.
As
for what our future health professionals learn about nutrition, medical and
nursing students learn more about the pathophysiology of disease than about
answering these questions for their future patients.
Today, poor eating habits and
inactivity erode Americans' quality of life, shorten our lifespan, and burden
our health care system - which is already stretched far too thin.
In the year 2000,
the total annual cost of obesity in the United States was $117 billion. Obesity
is the fastest-growing cause of disease and death in America today. Nearly 2
out of 3 Americans are overweight or obese. That's a 50% increase from just a
decade ago. If we don't do something about it, obesity will shortly eclipse
smoking as the leading cause of preventable death in this
country.
Will
health literacy help us end the obesity epidemic? Yes, it can. We must give
Americans information in clear terms that they can understand and use to make
healthy decisions.
As we look at the big picture of health care, even beyond
obesity, there are perverse incentives in our health care system.
Instead of
helping people understand how to stay healthy, we wait for people to get sick
and then we spend billions of dollars every year trying to make them healthy
again. That's why President Bush, Secretary Thompson, and I have made
prevention a priority.
As Surgeon General, prevention comes first in everything I do.
It's the vision behind the President's HealthierUS initiative, which is
designed to educate Americans about making good choices to keep themselves and
their families healthy.
We are working hard to help Americans develop greater
understanding of the devastating toll that the co-morbidities associated with
overweight and obesity exact on their health, their families, their careers,
and their lives. This understanding is the heart of health
literacy.
Next
Steps
Low health literacy has gone largely unrecognized and untreated
for too long. Awareness is the first step in addressing the problem. Additional
research is also needed to help us understand the problem and find solutions.
We need to ask, "What are the best ways to improve health literacy in
America?"
Some
that I consider promising are the different distribution methods - from
high-text methods like interactive programs and the Internet; to proven
low-tech, high-touch methods like peer-to-peer education that can help increase
health literacy.
The Surgeon General communications that my office issues are
written in plain language that people can understand. As a next step, we are
currently undergoing a review so that we can ensure that the best practices in
health literacy are incorporated into all our
communications.
Health communication alone cannot change systemic problems
related to health - such as poverty, environmental degradation, or lack of
access to health care. But comprehensive health programs must clearly
communicate health information to populations across our diverse nation.
Eliminating
Health Disparities
This is particularly relevant for racial and ethnic
populations, who may have different languages, cultural traditions, or sources
of information.
In these cases, health information campaigns must be developed
by individuals with specific knowledge of the cultural characteristics, media
habits, and language preferences of intended audiences.
More than 30 years ago, I was a young
Special Forces medic in Vietnam. I was a medic and a weapons specialist on an
A-Team. I learned first-hand that how I communicated with a patient and her
family could have direct effects on their health outcomes.
These lessons that I learned in a very
remote area, working with the Montagnard villagers, were lessons I have never
forgotten. Montagnards in Vietnam were more or less analogous to American
Indians here hundreds of years ago. They are wonderful people of great
character and dignity, and their language at that point was only spoken. The
reality was that they had no context to understand some of the messages that we
wanted to give them about their health.
This A-Team that I was a part of had a wonderful
relationship with the Montagnards, and at one point in time when we were
standing down for a couple days from combat operations, we went into the
Montagnard village and did what was called a MEDCAP.
This was very early in my career; I
was just shy of my 20th birthday. By that point in my life, I had already taken
care of gunshot wounds, I had taken care of parasitic diseases, and I had set
up a sanitation system for the village. I didn't realize at the time how
important those lessons would be to me years later. In fact, they are more
important to me today than they were back then, because I now work with very
diverse populations and the unique needs of those
populations.
In
any case, we went into the village to do a Medical Civil Action Program, what
we called a MEDCAP. When you go into the village as Americans, you just want to
run sick call. You want to line everybody up and start diagnosing and treating
their medical complaints.
Well, the Montagnard village leaders didn't want us meeting
anybody or touching anybody until they knew who we were. So we had to sit for a
while with the village chief and his family and get to know each other. We
talked through an interpreter...the Montagnard interpreter. We had learned a
little Montagnard, but not enough to fully converse.
The Montagnard interpreter would field
questions from the village chief. The questions were largely, "Who are you?,
Where are you from?, Are you married?, Do you have children?, What's your value
system?" They wanted to know who we were.
Today, Americans are still on a fast track all the
time. But that's not necessarily the best way to understand what is really
happening with someone, within his or her culture. I sat down and learned that
lesson. I had to share food with the village chief, which I did. To this day
I'm not sure what I was eating, but I smiled.
And that wasn't all. We were in these
thatched huts. They were on stilts, so that when the monsoons came, the water
would run below and the houses wouldn't get washed away. Underneath the chief's
house; buried into the ground, connected with long, thin pieces of bamboo was
this ceremonial wine that fermented through generation after generation.
So we sat in the
middle of the house, and the bamboo straw came up, and we sat in a circle with
the healer and the village chief, and we had to sip this stuff. Well, as soon
as we smelled it, it was enough to just knock us out. And I wasn't a drinker. I
had learned from my parents' bad habits, so I just pretended like I sipped it.
And we sat there for what seemed like an extraordinarily long period of time
drinking this stuff.
And when it was all over, the village healer started to bring
some people in, because we had offered to look at them for conditions that the
healer was not able to treat. And the first person who came up was the
granddaughter of the village chief. I don't know how old she was, maybe 7 or 8.
Mind you, in their language, they don't have words for time or days or years.
It's sunrise, sundown. Passage of time is related to the crops and the cattle.
So when I saw her
walking toward me, I thought, "I'm going to look brilliant." Her arm was
covered with scabs, and I immediately recognized it as impetigo. Even as a
19-year-old Special Forces medic, I was thinking that I was going to look
pretty good with this diagnosis and treatment.
For those of you who have been around
for a while and are practitioners, you remember that we used to have these big
green buckets of Phisohex. They weighed about 10 pounds. So I put some of this
Phisohex in a bottle that the villagers had. They didn't have running water, so
we said, "Go down to the river, wash with this, don't pick at the scabs, and
let them fall off. Oh, and by the way, take these."
Back in 1969/1970 we only had two
antibiotics - penicillin and streptomycin. So I gave them a little bottle of
the PenVK and said, "Take one of these four times a day." There were 28 pills
in the bottle, and I said, "I'll be back in a week or 10 days, and I'll check
up on you when we come through the village."
So I went away, and then came back in about a week.
We went through the whole ceremonial thing again with the food and wine and
talking. Then the little girl was introduced as the first patient. She looked
wonderful. The scabs were coming off her arm.
The village chief thanked me. They
brought me some things. I got a Montagnard bracelet, a Montagnard ring, they
gave me a crossbow, and they made me an honorary member of the family. The
village chief thanked me for all I was doing for his people. And then he showed
me a little box and said, "And we thank you for this gift that you have given
us."
He opened the
box, and there was a necklace of 28 Pen VK pills. Then the interpreter told me
that now when people are ill, they wear the necklace so that it will ward of
the disease.
The
thing is that I thought I was a pretty good communicator. Obviously I wasn't,
and I learned a lot that day. More than 30 years later, I still think of that
and what a valuable lesson I leaned about never assuming that someone
understands what you're talking about.
The Montagnard villagers had no idea
what questions to ask me about the pills. This was the first time that they had
ever seen a pill. To them, it looked like a bead. A medicine bead. So they
treated the vial of pills as a bottle of beads. And to take it four times a
day, there was really nothing in the language to say that.
I wish I could have anticipated the
misunderstanding. As a relative stranger to their culture and their way of
life, I didn't even consider that the Montagnard people would see a pill as
anything other than a pill.
One approach to increasing health literacy is to
train community health workers. They may be called community health advocates,
lay health educators, community health representatives, or, in Spanish,
promotores de salud.
We need these knowledgeable people to serve as connectors
between community members and health care professionals.
As members of the community, they are
able to promote health among groups that have traditionally lacked
understanding about health and the health care system.
Opportunities
For health literacy to
improve, we need health professionals, policymakers, researchers, and the
public to collaborate.
Healthy People 2010, which is the Department of Health and
Human Services' road map for the nation's health, recommends activities to
improve health literacy.
These include building a robust health information system that
provides equitable access; developing audience-appropriate information and
support services for all segments of the population, especially under-served
persons; and training health professionals in the science of communication and
the use of communication technologies.
You should all have copies of the book,
"Communicating Health: Priorities and Strategies for Progress." These are the
action plans to achieving the health communication goals set out in Healthy
People 2010.
Now
that we have set out the priorities, let's ramp up this effort even further.
Many people, even
educated Americans, don't know what a calorie is, or how to burn it. It's our
job to make that kind of health information meaningful, useful, and helpful.
It's time to start looking at a different way to provide nutritional
information.
Maybe we need a point system like some weight-loss programs
use. Maybe we need to help people understand food portions by describing
portion sizes in terms of things people can already relate to.
Already HHS and
the Department of Agriculture are redesigning the Food Guide Pyramid. It may
end up as a food cube, or trapezoid, or a straight line. We don't know
yet.
I don't have
all the answers today, but I'm confident that we can figure this out together.
I want to ask all
health care practitioners to find ways to ensure that your patients understand
what they can do to stay healthy. Offer the information even if they do not ask
the questions.
And
I'll ask the public health educators and communicators to keep following the
science to develop communications that captures people's attention and
imagination. Think outside the box. Use the expertise and materials developed
by organizations and companies to increase health literacy. Develop new ways to
communicate these important messages. Work with colleagues in community health
improvement to reach out to people who have the greatest needs.
By working
together, we can bring the dialogue about health literacy into greater focus
among health professionals and society as a whole. This will advance the
prevention initiative across America.
Health literacy can save lives, save money, and
improve the health and well being of millions of Americans. Health literacy is
the currency of success for everything I am doing as Surgeon General.
I need your help.
All of us - government, academia, health care professionals, corporations, and
communities - need to work together to improve Americans' health literacy. I
know that through our efforts and through our partnerships we will continue
improving the health and health literacy of all Americans.
|
|
