Remarks as prepared; not a transcript.

Vice Admiral Richard H. Carmona, M.D., M.P.H., FACS
United States Surgeon General
U.S. Department of Health and Human Services

2005 Indian Health Service Combined National Councils Meeting

Monday, February 28, 2005
8:30 a.m.
San Diego, California

"Putting Our Patients First: Making the Connections, Meeting the Challenges"

Thank you, Captain Yost, for that kind introduction. [USPHS Captain David Yost, M.D.]

It is an honor and privilege to be here with you today.

It has been about two-and-a-half years since I became the Surgeon General, and I feel like I've aged in dog years. I've crisscrossed the country dozens of times, and spoken to Americans about the public health issues of our time.

And the truth is, I love it. But it wasn't so long ago that I was a regular guy in Arizona, working as a trauma surgeon, a college professor, hospital executive, and law enforcement officer.

I was pretty happy with my life. I worked with some of the best people around, and was able to save lives and care for people from a variety of backgrounds, including members of the Tohono O'odham, Pasqua Yaqui, and other tribes in southern Arizona.

But then a very unexpected nomination came from President Bush asking me to serve as the U.S. Surgeon General.

I couldn't believe it. Here I was, a high school drop-out, born and raised in a poor section of New York City, and the President of the United States was asking me to help him and his team improve the health and well-being of all Americans.

It's an honor to again serve my country, to give back some of what I had been given, to care for people on a broader level than I have ever done before. It's given me the opportunity to speak with people like you; true and dedicated professionals trying to help your communities understand and use the best health information we have available today.

My mission is your mission.

It's an honor to be here with you, and I'm going to take this opportunity to ask for your help.

My mission as Surgeon General is to protect, promote, and advance the health and safety of the Nation. It's a big job.

United States Public Health Service Commissioned Corps
All of you, and each and every one of the 6,000 Public Health Service Commissioned Corps officers across the nation and the world to deliver care, especially in response to health emergencies, and are advancing health science through their research.

It is an honor to serve with you and all these outstanding officers.

When President Bush nominated me to be Surgeon General, he asked me to focus on three priorities. I'm fortunate to work with a leader who understands the importance of health, who insists that evidence and the best science always guide our policies 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 ourselves and our families healthier.
  • Second, and new to the Office of the Surgeon General, as none of my 16 predecessors had to deal with these issues: Public Health Preparedness.
  • The third priority I'm focusing on relentlessly is Eliminating Health Care Disparities.

I am also working hard to improve our nation's health literacy. Most of the preventable diseases that are cutting healthy years off the lives of people in places like where I grew up 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.

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.

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.

Further studies show that people of all ages, races, incomes, and education levels are challenged by low health literacy.

Even the seemingly simple things that we can all do to stay healthy and safe, such as getting regular medical check-ups and eating healthy foods, can be struggles for many people.

The reality is that to be able to do these things, we must have a basic infrastructure and understanding of why these choices are important to our health and safety, as well as our family's health and safety.

Health literacy is the ability of an individual to access, understand, and use health-related information and services to make appropriate health decisions.

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.

I'm asking public health educators to keep following the science to develop communications that capture people's attention and imagination. We're also training community health workers to help increase health literacy among groups that have traditionally lacked understanding about health and the health care system.

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 in culturally competent ways.

Pill Necklace
I learned this lesson more than 30 years ago, as a young Special Forces medic in Vietnam. I was a medic and a weapons specialist on an A-Team. I learned first-hand then that how I communicated with a patient and her family could have direct effects on their 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 are 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 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 twentieth birthday. By that point in my life, I had taken care of gunshot wounds already, I had taken care of parasitic diseases, I had set up a sanitation system for the village, and I didn't realize at the time how important those lessons would be to me years later.

In fact, those experiences 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 MED CAP. 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 their 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.

But 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, 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 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 an invaluable 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.

Today, we are still grappling with cross-cultural communication. We are a diverse nation, enriched with many cultures, and we must respond every day to our communities' and patients' diverse needs. This is particularly important in the work you are doing to eliminate health disparities.

After caring for people in Indian Country, I became convinced that nowhere in the United States are health disparities more manifest.

We all know that is true. It is why one of President Bush's top priorities is to eliminate health disparities.

He didn't just charge me with reducing health disparities. He said we will eliminate health disparities.

Now, we all know how difficult this is to do.

Differences exist among specific population groups along a number of key measures.

American Indians and Alaska Natives alone have a number of health differences that are difficult to overcome — including:

  • The incidence of diabetes is more than twice that of whites, and are much more likely to have diabetes-related complications such as kidney disease and amputations;
  • American Indians and Alaska Natives suffer disproportionately from depression and substance abuse;
  • Oral disease rates in American Indians and Alaska Natives are two to three times worse than those of the non-Indian population.
  • Unintentional injuries are rising to crisis proportions in Indian communities.

We obviously have a lot of work to do.

So where should we begin? To start, we must never again look at the health gap as:

  • A "Native American problem."
  • A "Latino problem."
  • An "African American problem."
  • An "Asian American problem."
  • It is an American problem that demands an American solution.

It will take an American solution that includes understanding how different cultural practices can, and should, be a part of a person's overall medical care.

It includes doing everything we can to ensure that the people who need it most have access to good health care.

Together, we can accomplish this.

I appreciate that as part of the IHS plans, Rear Admiral Grim ensured that IHS would develop a Health Literacy Plan of Action.

Health literacy is the currency of success for everything I am doing as Surgeon General. And I need your help. All of us need to work together to improve Americans' health literacy. To prevent disease we must all embrace a culturally competent approach to health and well-being.

IHS Successes
In fact, we are already working toward this goal with the best rural health care delivery system in the world, the Indian Health Service.

While there is still much work that needs to be done, we need to celebrate IHS' successes, including:

  • Since 1973, infant mortality has decreased by 64 percent, and maternal mortality has decreased by 75 percent.


  • All Indian Health Service and tribally operated hospitals, most large clinics, and many smaller clinics have received accreditation from the Joint Commission on Accreditation of Healthcare Organization, Accreditation Association for Ambulatory Health Care, or the HHS' Centers for Medicare and Medicaid Services.

And if imitation is the sincerest form of flattery, you should feel pretty good about yourselves. Indigenous populations in countries around the world have begun to use our Indian healthcare model to help their own populations.

That is outstanding! I want to thank each of you for your leadership and perseverance.

As we work toward eliminating health disparities, we also have to take responsibility for our own actions, and work to prevent the onset of the chronic diseases we are addressing today.

Right now we've got it backwards. We wait years and years, doing nothing about unhealthy eating habits and lack of physical activity until people get sick.

Then we spend lots of money on costly treatments to make them well, often when it is already too late.

Rear Admiral Grim's leadership in developing and championing IHS' Health Promotion and Disease Prevention Initiative is going to make a difference for generations of families in Indian Country.

If you need a reason to get involved, remember this: today, 40 percent of American Indian children are overweight. 40 percent! If this continues, we will have an entire generation of overweight, sick adults. We cannot allow this to happen.

There are programs available to all of you to help teach children and adults of every age what steps they can take to live a healthier, prevention-oriented lifestyle. And the best place to start is with yourself: I encourage you to sign up for the pedometer challenge by putting in 10,000 steps per day. If you have not signed up, you can stop by the Health Prevention / Disease Prevention booth to pick up your pedometer.

Learn how healthy lifestyle habits can be incorporated into your own daily habits.

Investigate how your own culture encourages living a healthy lifestyle, and encourage your elders and families to embrace these ideas and make it a part of the future. We have the knowledge and the experience to help people live healthier lives.

We now have a responsibility to teach this, and help the Circle of Life continue for generations to come.

The Year of the Healthy Child
People say that children are our future. I say that children are also our present. They are today. Their dreams are today's dreams. Their hopes are today's hopes. Their needs are today's needs.

Because of that, we cannot put off their needs until tomorrow. We cannot overlook them when they are falling behind.

To help today's children grow to be healthy and self-sufficient members of society, we must work together to promote good health in all its forms — mental, physical, and spiritual.

The prosperity and future of our nation rest upon the health and well-being of ALL our children.

The good news is that 82 percent of our nation's 70 million children are in very good or excellent health.

  • Childhood immunization rates are at an all-time high.
  • Our children are less likely to smoke and less likely to give birth as teenagers.

These are important gains in pediatric health. But we still have some troubling problems. That is why this year I will be taking a hard look at ways to improve the health of children both domestically and internationally.

By improving the holistic health of our children, we can ensure a healthier population for the next generation.

"The Year of The Healthy Child" is the most comprehensive agenda ever set forward by a U.S. Surgeon General for a single year.

It includes all aspects of a child's life — body, mind, and spirit — starting with prenatal care and going through the developmental stages of childhood and adolescence.

I will need your help to achieve the objectives of the agenda, across all sectors of society.

A healthy child begins before birth, so we will highlight steps that women should take to keep themselves healthy, especially when they are considering becoming pregnant. This includes a healthful diet, exercise, and eliminating tobacco use and alcohol consumption.

We are also highlighting the contributions and the role of fathers. Every person has to come to the table to ensure the health and well-being of every child.

Last week, I participated in BirthDay Live! on the Discovery Health Channel, and explained how every mom- and dad-to-be can help prevent the preventable birth defects and premature birth that continue children.

We took care of a lot of moms and babies at Sharp Mary Birch Hospital right here in San Diego.

One of the areas that we focused on was preventing birth defects.

Last week, I issued a new advisory to warn pregnant women to abstain from alcohol to eliminate the chance of giving birth to a baby with any of the harmful effects of the Fetal Alcohol Spectrum Disorders, or FASD.

Fetal Alcohol Spectrum Disorders are the full spectrum of birth defects caused by prenatal alcohol exposure.

The spectrum may include mild and subtle changes, such as a slight learning disability and/or physical abnormality, through full-blown Fetal Alcohol Syndrome, which can include severe learning disabilities, growth deficiencies, abnormal facial features, and central nervous system disorders.

This warning updated a 1981 Surgeon General's Advisory that suggested that pregnant women limit the amount of alcohol they drink.

We must prevent all injury and illness that is preventable in society, and alcohol-related birth defects are completely preventable.

We do not know what, if any, amount of alcohol is safe.

But we do know that the risk of a baby being born with any of the fetal alcohol spectrum disorders increases with the amount of alcohol a pregnant woman drinks, as does the likely severity of the condition. And when a pregnant woman drinks alcohol, so does her baby. Therefore, it's in the child's best interest for a pregnant woman to simply not drink alcohol.

In addition, studies indicate that a baby could be affected by alcohol consumption within the earliest weeks after conception, even before a woman knows that she is pregnant.

For that reason, we recommend that women who may become pregnant also abstain from alcohol.

Thanks to our ever-increasing body of scientific knowledge we are now able to identify more and more causes of premature births and birth defects.

And we must use this knowledge, not for knowledge's sake, but for the sake of the health of children everywhere.

The issue of alcohol use during pregnancy is not just hypothetical for IHS professionals.

The reality is that more than three times as many women in Indian Country as in the general population report drinking alcohol during pregnancy.

You can address this problem, and I encourage you to continue educating women about how alcohol can hurt their baby.

In addition to pre-pregnancy and pregnancy, we are also focusing attention this year on every aspect of a child's life. We will address — among other things — breastfeeding, on-time immunizations, oral health, drug and alcohol use prevention, mental health issues, child abuse prevention, healthy indoor environment, youth violence prevention, and safe teen driving.

We will also continue working on many other issues related to child health, including:

  • Child Injury. More than 5,000 children die and 90,000 are permanently disabled each year by motor vehicle injuries, drowning, burns, suffocation and choking, firearm injuries, falls, poisoning, and other preventable injuries. As a trauma surgeon, I treated thousands of children whose injuries could have been prevented with child safety seats, seatbelts, helmets, smoke alarms, pool alarms, and other simple measures.

  • Overweight. One of every seven kids is overweight. We must teach our children to enjoy healthy foods and be physically active for at least 60 minutes a day. Not only sports, but simple things like taking the stairs, riding their bikes, and just getting out and playing. In the 1960s, just over 4 percent of kids were overweight. Today, 15 percent of our children are overweight — that's over 9 million children. And the problem doesn't go away when children grow up. Nearly three out of every four overweight teenagers will become overweight adults. Our children deserve much better than a lifetime of expensive and potentially fatal medical complications associated with excess weight.

  • Child abuse. While we should equip our children to face threatening situations, we must also prevent the abuse that hurts so many children. In March, I will convene some of the best minds in criminal justice, medicine, child welfare, and education at a Surgeon General's Workshop on the Prevention of Child Maltreatment to help end this scourge.

  • Mental health. Every year, 5 to 9 percent of American children have a serious emotional problem. President Bush said, "Americans must understand and send this message: mental disability is not a scandal — it is an illness. And like physical illness, it is treatable, especially when the treatment comes early." Despite investments that have led to many effective treatments for mental illness, many American children are not benefiting. We will work to correct that injustice.

  • Indoor environment. One in five schools in America has indoor air quality problems. Each year four million American children have asthma attacks, making this lung condition a leading cause of emergency room visits and missed schooldays. Last month I convened the first-ever Surgeon General's Workshop on Healthy Indoor Environment and began collaborations with engineers, designers, architects, and builders to improve the air in schools and other buildings across America.

We will also focus on the child's growing mind. Through my "50 Schools in 50 States" Initiative, we are working with school districts and other partners to encourage students to stay in school.

In addition, we will encourage more students, especially minorities, to focus on excelling in math and in the hard sciences, areas in which the United States is falling behind.

Finally, we will focus on spirit. The enthusiasm of children and teens is often overlooked in their communities. We must work to harness their energy and partner them with local and national organizations to promote volunteerism, civic responsibility, and patriotism.

We can ensure the best possible health, and the greatest productivity and independence for every child.

And I hope that you will join me in this effort.

I need you — your expertise, your experience, and your passion.

We are already working with the American Academy of Pediatrics, the March of Dimes, The YMCA, NASA, SAFE KIDS, the Department of Education, and numerous other partners.

Charge and Closing
In closing, thank you for the wonderful work each and every one of you do to care for and improve the health of American Indians and Native Alaskans each and every day.

We need those of you who are health care professionals to continue looking for ways to ensure that people understand what they can do to stay healthy. Offer the information even if they do not ask the questions.

Use the expertise and materials that have been developed by the Department of Health and Human Services, other agencies, organizations, and companies to increase understanding of health information.

Work with colleagues in community health improvement to reach out to people who have the greatest needs.

For those of you in academia, consider teaching health literacy as a competency in your classes.

And for those of you who are researchers, consider your projects from the angle of health literacy.

We can all help bring the dialogue about health literacy into greater focus among health professionals and society as a whole.

Health literacy can save lives, save money, and improve the health and well-being of millions of Americans.

And if you ever doubt whether your work matters, consider this: the cost of failing to prevent chronic disease and injury is about much more than dollars and cents.

It's about a mother who can no longer provide for her children. It's about a child who can no longer ask a father for advice.

It's about real human costs: millions of American lives lost each year to smoking-related and obesity-related diseases, families devastated by alcohol abuse, and children whose lives are cut tragically short because of completely preventable injuries.

Let's keep working on increasing prevention and improving health literacy, particularly for the newest generation.

Let me leave you with this thought: we must always keep improving the scientific process with fresh ideas and a fundamental commitment to serving humanity.

Please keep thinking imaginatively and critically. Keep educating, innovating and collaborating.

I look forward to working with you in the months and years ahead. I am honored to join you in your efforts. Let’s explore together how taking advantage of our diversity, how embracing cultures can help people take action to make themselves healthier. Thank you.


Last revised: January 8, 2007