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

Pfizer Sixth National Health Literacy Conference

Friday, September 19, 2003

"Health Literacy: Key to Improving Americanís Health"

It is a pleasure to be here with you today.

I also want to thank Dr. Georges Benjamin for his leadership in public health and on the issue of health literacy in particular. [Georges Benjamin, Executive Director of the American Public Health Association]

There is no more pressing public health issue for our nation than improving health literacy. It touches every aspect of our lives. Your work here will resonate throughout the health care system and across America for years to come.

President Bush, Secretary Thompson, and I are grateful to you for all youíre doing to improve health and health care for all Americans.

Many of you are the power behind the growing body of evidence supporting the need to improve Americansí health literacy. Many of you are also engaged in helping to increase the publicís understanding of health information.

I will also do everything in my power to increase Americansí health literacy while I have the privilege of partnering with you.

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 the key to building a healthier America.

Thanks to many of you here today, 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 didnít 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.


When President Bush and Secretary Thompson nominated me to be Surgeon General, they asked me to focus on three priorities. Iím 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. ó 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. 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 ó

  • From Native American communities,
  • To rural areas of Appalachia,
  • To our nationís capital.
  • 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.

    Our nationís 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. (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 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.

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

    Among patients with type 2 diabetes, low health literacy is independently associated with worse glycemic control and higher rates of complications, including retinopathy.(3.)

    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.

    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.

    Not every American is a scientist or a health care professional, and we canít expect everyone to understand what it takes doctors, nurses, pharmacists, and other health care professionals years of training to learn.

    My mechanic doesnít expect me to know how to change the transmission in my car. And I donít 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,
    • make good choices like wearing seatbelts every time weíre in a motor vehicle.

    These are all very simple ó but they all require a lot of understanding of why these choices are smart choices for our health and safety, as well as our familyís health and safety.

    Another simple thing we can do for ourselves and our families, and this is part of health literacy, is to better understand the medicines weíre taking.

    Thatís the heart of the Be MedWise campaign that I helped launch last week.

    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 Iíve ever written, as I see it.

    Today, 6 out of every 10 medications that people take are over-the-counter drugs ó
    so-called OTC medicines. These drugs are real medicines that must be taken responsibly.

    Letís 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 thatís 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.

    And this week the Department of Health and Human Services launched a new campaign to promote proper antibiotic use. Every year at this time, 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 wonít 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.

    This is another problem that can be solved by increasing health literacy. Weíre working with state and local health departments, managed care organizations, and pharmaceutical companies, and we need your help to spread the word about proper antibiotic use with your patients and through your organizationsí communication channels.


    Clearly 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 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 how many is 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? How much is too little? What constitutes a healthy diet?

    Theyíre asking about calories, carbohydrates, vitamins, and fiber. Theyíre 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 Americansí quality of life, shorten our lifespan, and burden our health care system ó 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. ; tThatís a 50% increase from just a decade ago. If we donít 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.

    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, and their lives. This understanding is the heart of health literacy.

    Pfizer Efforts

    Let me also take a moment to acknowledge Pfizerís contribution to improving public health through their commitment to health literacy and their partnership with our nationís public health associations and federal and state public health agencies to advance health literacy across the nation. 

    Over the past few years, Pfizer has increased its commitment to public health.  For example, the Pfizer Fellowship in Public Health provides junior faculty some financial support and flexibility to study public health challenges and look for new solutions to our most troubling problems.

    In the health literacy arena, Pfizerís commitment is made tangible through this annual conference, as well as by convening the Partnership for Clear Health Communication and developing the Know Your Health Program in diabetes and hypertension. The Know Your Health program is particularly impressive to me in the way that it addresses multicultural issues.

    I thank Pfizer and especially Karen Katen and Pat Kelly for their leadership in this area.

    Next Steps

    These are outstanding efforts and partnerships. We need more organizations to step up and help lead the way as Pfizer has done.

    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 ó 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.

    I am ensuring that the Surgeon General communications my office issues are written in plain language that people can understand. And we are currently undergoing a review so that we can ensure that the best practices in health literacy are incorporated into our communications.

    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, 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 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 20th 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 didnít realize at the time how important those lessons would be to me years later. In fact, 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 didnít 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 interpreterÖthe 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?, Whatís your value system?" They wanted to know who we were.

    Today, Americans are still on a fast track all the time. But thatís 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 Iím not sure what I was eating, but I smiled.

    And that wasnít 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 wouldnít get washed away.

    But underneath the chiefís 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 wasnít a drinker. I had learned from my parentsí 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 donít know how old she was, maybe 7 or 8. Mind you, in their language, they donít have words for time or days or years. Itís sunrise, sundown. Passage of time is related to the crops and the cattle.

    So when I saw her walking toward me, I thought, "Iím 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 didnít have running water, so we said, "Go down to the river, wash with this, donít pick at the scabs, let them fall off. Oh, and by the way, take these."

    Back in 1969/1970 we only had two antibiotics ó 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, "Iíll be back in a week or 10 days, and Iíll 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 wasnít, 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 youíre 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 didnít 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.


    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 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 all segments of the population, especially under-served persons,
    3. training health professionals in the science of communication and the use of communication technologies. (4.)

    You should all have copies of this book, "Communicating Health: Priorities and Strategies for Progress" on the table in front of you. These are the action plans to achieving the health communication goals set out in Healthy People 2010, and I want to thank all of you who provided expertise and technical assistance in developing this book.

    Now that we have set out the priorities, letís ramp up this effort even further.

    Many people, even educated Americans, donít know what a calorie is, or how to burn it.

    Itís our job to make that kind of health information meaningful, useful, and helpful. 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 Guide 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 IĎm confident that we can figure this out together.

    I want to ask all the health care practitioners here today 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 Iíll ask the public health educators and communicators to keep following the science to develop communications that captures peopleís attention and imagination. Think outside the box.

    Use the expertise and materials developed by Pfizer, HHS, and other organizations, and companies to increase health literacy. And 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.

    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. 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 Americansí health literacy.

    Looking around this room, I know that through your efforts and through your partnerships with the President, the Secretary, and me; you will continue improving the health and health literacy of all Americans. Thank you.



    1. Center for Health Care Strategies, Inc. Impact of Low Health Literacy Skills on Annual Health Care Expenditures Fact Sheet. 2003, Sept. See
    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. Schillinger D, Grumbach K, Piette J, Wang F, Osmond D, Daher C, Palacios J, Diaz Sullivan G, Bindman AB. Association of health literacy with diabetes outcomes. JAMA 2002 July 24/31; 288 (4); 475-82.
    4. Healthy People 2010. Department of Health and Human Services.


    Last revised: January 9, 2007