Remarks as prepared; not a transcript

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

American Medical Association House of Delegates Meeting

Saturday, June 14, 2003

"Health Literacy in America: The Role of Health Care Professionals"

Thank you, Dr. Coble, for that kind introduction. [Yank D. Coble, Jr., M.D., President of the American Medical Association]

It is a pleasure to be here with you today. My friend and colleague Julie Gerberding will speak to you next week. Julie and I were residents together many years ago at the University of California at San Francisco.

Now she is doing a tremendous job leading the CDC.

Another HHS colleague of ours, Jerry Hauer, will be here on Monday. Jerry has been instrumental as Acting Assistant Secretary for Public Health Emergency Preparedness in improving the nationís capacity to respond to terrorist attack or natural disaster.

You will address many topics during this meeting, and your work here will resonate throughout the health care system and across America for years to come.

As physicians, we know first-hand that the American health care system faces a number of challenges.

President Bush, Secretary Thompson, and I are grateful that you are standing shoulder-to-shoulder with us in our efforts to modernize Medicare and in our work to reform medical liability.

Despite all the challenges, our goal is always the same: to promote and protect the health and well-being of our patients and our communities. Itís the oath we swore; itís the reason we practice.

Today I will address a topic of particular relevance to the practice of medicine, to the
AMA, and to every aspect of health and health care in America: health literacy.

Thanks to you and your colleagues, we have the best health care system in the world. As we enter the 21st century, medical discovery is advancing at a rate unequaled in any previous era.

Yet Americans have not kept pace in adopting health behaviors to live longer, healthier lives.

As physicians, we struggle to convince our patients and our communities to choose healthy behaviors that will help prevent illness and injury.

Too often we are forced to rely on good medicine to undo peopleís bad choices.


As Surgeon General, Iím fortunate to be able to work with two leaders who understand the importance of health. Two leaders who insist that evidence and the best science always guide policy.

President Bush and Secretary Thompson asked me to concentrate on three priorities as Surgeon General. All three priorities are evidence-based.

They are:

  • First ó Public Health Preparedness. As physicians, we must strengthen our medical response systems. President Bush and Secretary Thompson have invested
    $9.2 billion in emergency preparedness at the state and local levels.

    As physician leaders, you should be emergency first responders in your communities.

    I rolled up my sleeve and was vaccinated against smallpox this spring. You should also consider who at your hospital should be vaccinated. As weíve just seen with SARS and possibly now with monkey pox, any infectious disease can and will impact the medical community if our personnel and facilities are not prepared.
  • Second ó Health Care Disparities. Itís intolerable that in a nation as wealthy as ours, there are people who cannot get the right care at the right time.
  • Third, Prevention ó what each of us can do in our own lives and communities to make ourselves and our families healthier.

Health Literacy

Right now, thereís a widespread problem that is seriously impacting our progress in these three priority areas: low health literacy.

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

Today, low health literacy is a threat to the health and well-being of Americans and to the health and well-being of the American medical system.

Low health literacy costs the health care industry $73 billion a year in misdirected or misunderstood health care services. More than 90 million Americans cannot adequately understand basic health information. (1.)

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 NIHís 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 might help them live longer.

Is the problem that people donít know, donít want to know Ö.. or just donít care?

Perhaps one answer is that they are unable to understand and use the health information available to them.

Consider this: A recent study of English-speaking patients in public hospital revealed that one-third were unable to read basic health materials.

  • 26% of the patients could not read their appointment slips, and
  • 42% did not understand the labels on their prescription bottles. (2.)

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

The greatest challenges are among the elderly and in communities of color, like where I grew up in Harlem, New York.

And low health literacy is a problem all over the nationó

  • From Native American communities in the Southwest,
  • To rural areas of Appalachia,
  • To the South Side of Chicago.

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 can result 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 doctors, because they are too ashamed and intimidated to ask for help.

Letís face it, most of us men wonít even stop to ask for directions when weíre lost in a new city, let alone when we have a health question.


Health literacy may be even more essential to health promotion, particularly as we address issues of primary prevention.

A health literate individual is more apt to know how to answer the question "How do I keep myself well?"

Low health literacy is one of the largest contributors to our nationís epidemic of overweight and obesity.

Experience with my own patients and students indicates 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 theyíre 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 theyíre 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 too few?

These are seemingly simple questions, but weíre not giving Americans simple answers.

People are hearing about overweight and obesity. So theyíre trying to figure out how much food they should eat. How much is too much?

Theyíre asking about calories, carbohydrates, vitamins, and fiber. Theyíre asking about salt, sugar, and portion sizes.

Years ago as young medical students, you and I learned more about the pathophysiology of disease than we learned about answering these questions for our future patients.

Today, poor eating habits and inactivity erode Americanís quality of life, shorten our lifespan, and burden our health care system ó which is already stretched far too thin.

Now America has an epidemic of obesity. 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. ; tThatís a 50% increase from just a decade ago!

Will health literacy help us end the obesity epidemic? Yes, it can.

And weíre up against a deadline: More than 300,000 Americans die every year from illness related to overweight and obesity. Thatís nearly 1,000 people every day, one every 90 seconds.

Not every American is a scientist or a doctor or a health care professional, and we canít expect them to understand what it took us years of training to learn.

I know that my mechanic doesnít expect me to know how to change the transmission in my car. And I shouldnít expect him to know how to perform a tracheotomy.

But what we can do ó what we must do ó is 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.

Thatís why President Bush, Secretary Thompson, and I have made prevention a priority. As Surgeon General, prevention comes first in everything I do. Itís the vision behind the Presidentís HealthierUS initiative.

The prevention initiative 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, their quality of life, and their lives.

This understanding is the heart of health literacy.

AMA Efforts

In 1998, the American Medical Association became the first national medical organization to adopt policy recognizing that limited patient literacy affects medical diagnosis and treatment.

The AMA Foundation has since been working to raise awareness of health literacy within the health care community.

Educational materials are available to you, your office staff, and your patients. And on Monday, the AMA Council on Medical Education and AMA Foundation will host a health literacy seminar.

I thank you for your leadership.

Next Steps

These are good efforts, because the problem has gone largely unrecognized and untreated for too ling. Awareness is the first step in addressing the challenge of low health literacy.

Additional research is needed to help us understand the problem.

What are the best ways to improve health literacy in America?

Different distribution methods ó from high-text methods like interactive programs and the internet; to proven low-tech, high-touch methods like peer-to-peer education can help increase health literacy.

I am ensuring that the Surgeon General communications my office issues will be written in plain language that American people can understand.

However, health communication alone cannot change systemic problems related to health ó 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.


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, as a Special Forces medic in Vietnam, I learned first-hand that how I communicated with a patient and her family could have a direct effect on my patientís health. Itís a lesson Iíll never forget.

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.

I wish I could have anticipated the misunderstanding. As a relative stranger to their culture and their way of life, I didnít even consider that the Montagnard people would see a pill as anything other than a pill.

One approach to 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.

The largest program to use the community health worker model in the United States was established by the Indian Health Service in 1968.

This program was developed to help bridge cultural, linguistic, geographic, and socioeconomic gaps between people and resources.

Currently, about 1400 community health representatives work with tribally managed or Indian Health Service programs in the more than 550 federally recognized American Indian and Alaska Native communities. (4.)


For health literacy to improve, we need health professionals, policymakers, public officials, researchers, and the public to collaborate on a range of activities.

Healthy People 2010, which is the Department of Health and Human Servicesí "road map" for the nationís health, recommends activities to improve health literacy. These include:

  1. building a robust health information system that provides equitable access,
  2. developing audience-appropriate information and support services for specific health problems for all segments of the population, especially underserved persons, and
  3. training of health professionals in the science of communication and the use of communication technologies.

Letís ramp up this effort even further.

Many people, even educated Americans, donít know what a calorie is, or how to burn it. We donít even use the metric system in America. Except in science and medicine.

Itís our job to make health information meaningful, useful, and helpful.

For example, maybe itís 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 pyramid. It may end up as a food cube, or trapezoid, or a straight line. We donít know yet.

I donít have all the answers today, but we can figure this out together. Iíll be talking about health literacy over the next year as part of our prevention initiative.

You can improve health literacy in your community. In every interaction with your patients and their families, look 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 AMA, the Department of Health and Human Services, and 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.

With your partnership, 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.

The ability to access, understand, and use health-related information and services is critical to the success of my three priorities: improving emergency preparedness, and eliminating health disparities, and preventing disease.

Thatís why health literacy is the currency of success for everything I am doing as Surgeon General. And I need your help.

All of us ó government, academia, health care professionals, corporations, and communities ó need to work together to improve health literacy.

Looking around this room, I know that through your individual efforts; and through your involvement with AMA and your partnerships with the President, the Secretary, and me; you will continue improving the health and health literacy of every American.

Thank you.



  1. Kirsch I, Jungeblut A, Jenkins L, Kolstad A. Adult literacy in America: a first look at the results of the National Adult Literacy Survey. Washington: Department of Education (US), National Center for Education Statistics; 1993.
  2. Williams MV, Parker RM, Baker DW, Parikh NS, Pitkin K, Coates WC, Nurss JR. Inadequate functional health literacy among patients at two public hospitals. JAMA 1995 Dec 6; 274(21):1677-82.
  3. Healthy People 2010. Department of Health and Human Services.
  4. Albright A, Satterfield D, Broussard B, Jack L, Mikami J, Perez G, Perez Rendon A. Diabetes community health workers. 2003.

Last revised: January 9, 2007