Remarks as prepared; not a transcript

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

It is a pleasure to be here with you today.  I want to thank Dr. Lindberg for his outstanding leadership of the National Library of Medicine.  And I want to thank NLM for being a strong partner in the Office of the Surgeon General’s efforts to advance and protect the health and well-being of the American people.

At our September meeting, we discussed the need to improve Americans’ health literacy.  Not long after that discussion, in consultation with the Secretary, he charged me with health literacy as an additional priority for 2004.  This is a great assignment. 

I agree with the Secretary’s assessment that 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.  The Secretary and I have discussed that health literacy is the ability of an individual to access, understand, and use health-related information and services to make appropriate health decisions. 

Success of the three priorities that the President and the Secretary assigned to me when they nominated me to be Surgeon General—prevention, public health and emergency preparedness, and eliminating health disparities—is predicated on improving health literacy. 

Right now low health literacy is a problem throughout our nation—

• From Native American communities,
• To rural areas of Appalachia,
• To the Great Plains,
• To urban areas, including our nation’s capital.

There is no more pressing public health issue for our nation than improving health literacy.  It touches every aspect of our lives.

NLM and Health Literacy

NLM’s health literacy activities reflect the Library’s strong commitment to serving all of our nation’s citizens.  I’m pleased that NLM has extended its outreach from the original focus on health care professionals, researchers, and medical librarians to include patients, their families, and the general public. 

Increasing the public’s access to health information will increase Americans’ health literacy.  Through outstanding websites such as MEDLINEplus, PubMed, the Household Products Database, the new SeniorHealth.gov, and others, NLM is encouraging healthy lifestyles and disease prevention.  I am particularly impressed with the wide range of NLM-sponsored outreach initiatives, especially those that focus on minority and underserved communities. 

The Hispanic outreach projects in the Lower Rio Grande Valley of Texas are strong examples of the innovative approaches taken by NLM, including the project that supports the work of "promotoras de salud" to improve the health status of people living in the Colonias.

In addition, NLM’s new "Listening Circle" initiative shows that the Library is leading the way to meet with Native American communities on an informal, collegial basis to improve communication; explore ideas, needs, and capabilities; and develop new collaborations.  The "Listening Circle" project is consistent with the Administration’s commitment to community-based consultation and partnership. 

Dr. Lindberg and the NLM staff are to be congratulated on these innovative efforts.  Your work in the area of health literacy will resonate throughout the health care system and across America for years to come.  Many of you are the power behind the growing body of evidence supporting the need to improve Americans’ health literacy.  Many of you are also engaged in helping to increase the public’s understanding of health information.

This is critically important work.  As a former 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.

Costs of Low 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.  (1.)

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.)

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. 

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. 

Health Literacy and Pregnancy

This is especially relevant in the area of pre-pregnancy and pregnancy.  Next week I will participate in a live television show on the Discovery Health channel.  This is the second year that Discovery Health has broadcast this 10-hour program to follow deliveries in three U.S. hospitals.  The program is called Birth Day Live!, and I will focus much of my on-air time on steps that Americans can take to prevent birth defects. 

It’s a great opportunity to increase health literacy for the millions of Americans who will watch the show live and then in repeat broadcasts throughout 2004.

Behind the scenes, I will have the opportunity to talk with the doctors, nurses, and students at Sharp Mary Birch Hospital for Women in San Diego about how we can all better address the problems that can sometimes lead to pre-term births and preventable birth defects.

The steps that women can take to reduce their baby’s risk of birth defects and developmental disabilities require a lot of understanding.    That is why I’m working so hard to focus some of our health literacy efforts on mothers- and fathers-to-be. 

A health literate woman is more apt to know to ask and answer the questions:

• "How do I keep myself well?"
• "How do I plan for a healthy pregnancy?"
• "How much folic acid do I need to consume?"
• "When should I see a health care professional about prenatal care?"

These are seemingly straightforward questions, but we’re not giving Americans straightforward answers.

As health professionals, we’re trained to maintain a certain emotional distance from our patients.  Yet there will always be patients who move into our hearts and stay forever.  Years after completing my training rotation through the neonatal intensive care unit, few sights tug at my heart more than a tiny newborn hooked up to very complex machines because he or she was born prematurely or with a birth defect.

Birth defects affect 150,000 new babies in our nation every year, and are the leading cause of infant death in the United States.

Some racial and ethnic groups are affected more than others.  Today, more than 25% of African American women and more than 30% of American Indian women receive no prenatal care in the first trimester. 

While we are ensuring access to prenatal care, we must also do a better job of ensuring that all American women recognize the importance of prenatal care and follow the advice they’re given.  This is part of health literacy.

In 2001, preterm birth affected over 476,000 infants.  That’s 1 in 8 babies born in this country.   The complications of preterm birth also cause death, disability, and tremendous sorrow for many American families.

We must rededicate ourselves to ensuring that all children have a healthy start in life.  There are two critical steps.  First, we can and must do better at preventing birth defects.  That includes understanding why preterm labor occurs and how to prevent it.  Preterm birth increased from 9% of deliveries in 1980 to 12% of deliveries in 2002.  This is a growing public health problem that we must address.  Second, we must keep working until we know what causes all birth defects and how to prevent them. 

Birth Defects Prevention and Research

While the causes of most birth defects are unknown, genetics, risky behaviors, and environmental factors can each play a major role. HHS supports research into each of these factors that may contribute to birth defects.

We already know that simple preventive measures can help reduce the risk of many birth defects.  For example, vaccinations against measles, mumps, and rubella prevent birth defects by reducing the risk of a pregnant woman becoming infected with these diseases that can increase her baby’s risk of being born with deafness, developmental disabilities, heart defects, and blindness. 

Thanks to high rates of immunization, these infections are now rare occurrences in America. 

Proper nutrition can also help reduce the risk of birth defects.  Serious defects, including
spina bifida and anencephaly, can be prevented when women get 400 micrograms of folic acid each day.  Two thirds of women in the United States do not consume enough folic acid.  All women of reproductive age should consume folic acid because nearly half of pregnancies in the United States are unplanned, and birth defects can start early in pregnancy, before many women even realize that they are pregnant. 

All health professionals must continue to get the word out about the importance of folic acid before and during the earliest weeks of pregnancy.    Encouraging women to not consume harmful substances during pregnancy is also critical to preventing birth defects.

Women who are pregnant or planning a pregnancy should not drink alcohol, smoke, take any illegal drugs, and should consult a healthcare professional before taking any medicine—prescription or over-the-counter. 

A woman who smokes during pregnancy has a 40% higher rate of delivering a low birthweight baby.(3.) And this isn’t a hypothetical concern—in 2002, 11% of pregnant women in America smoked.  That translates into 450,000 babies who were exposed to nicotine, tar, and other harmful chemicals.(4.)

We must remember, there is no safe amount of smoking.  There is no safe cigarette during pregnancy or at any other time in life.

These are health literacy messages that are simply not reaching all women when they need them most.

Understanding and Reducing Preterm Births

We also need to expand our study of another source of death, disability, and tremendous sorrow for American families: preterm birth.  Today, when families ask why their baby was born early, most of the time, the only answer the doctor can give is ... we don’t know. 

We must redouble our efforts to find causes of preterm labor.  We need to look at where the needs are greatest.  For example, why do African Americans have the highest rate of premature birth?  Premature birth is leading cause of neonatal mortality and morbidity in African-Americans.  It is the second-leading cause of infant death among all Americans, of all races. 

The good news is that science is moving forward quickly and may soon offer additional ways to prevent preterm births.  Research supported by the National Institute for Child Health and Human Development and the March of Dimes is elucidating the causes, and the next big health literacy campaign aimed at women of childbearing age may very well be about steps that can be taken to prevent pre-term labor.

Modern medicine is already doing so much to help ensure healthy pregnancies and healthy babies.  Just 50 years after Watson and Crick discovered DNA, scientists are screening more and more genetic information and targeting appropriate interventions to help people avoid physical and mental conditions and diseases years before their first symptoms would have otherwise appeared. 

Prenatal testing can already identify neural tube defects, many congenital heart defects, tumors, and other serious birth defects that can be surgically treated in-utero or soon after birth.  Treatments that save, sustain, and enhance new life are accomplished through technologies that were not even dreamt of when most of us in this room were born.

The nation will see some of the latest technologies at Sharp Mary Birch Hospital on "Birth Day Live!"

Next Steps

Whether in the area of preventing birth defects, cardiovascular disease, drowning, or highway crashes, we need to ask what are the best ways to improve health literacy in the American population.  Some that I consider promising are the different distribution methods—from high-tech 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 from the Office of the Surgeon General.

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. 

To increase health literacy, we need all health professionals, policymakers, researchers, and the public to collaborate.  Healthy People 2010, which is the HHS "road map" for the nation’s 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,

   and
   

3. training health professionals in the science of communication and the use of communication technologies.  (5.)

Now that we have set out the priorities, let’s ramp up this effort even further.  I’m asking all health care professionals to find ways to ensure that their patients understand what they can do to stay healthy.  Sometimes that means offering the information even when patients don’t ask the questions.  And I’m asking public health educators and communicators to keep following the science to develop communications that captures people’s attention and imagination.  Think outside the box. 

With these partnerships, 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, and 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 the Library’s continued help.  All of us — government, academia, health care professionals, corporations, and communities — need to work together to improve Americans’ health literacy. 

Through NLM’s 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. 

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References:

1. Center for Health Care Strategies, Inc. Impact of Low Health Literacy Skills on Annual Health Care Expenditures Fact Sheet. 2003, Sept. See http://www.chcs.org/resource/hl.html
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. Journal of the American Medical Association. 1995 Dec 6; 274(21):1677-82.
3. Centers for Disease Control and Prevention. 
4. Centers for Disease Control and Prevention. 
5. Healthy People 2010.  Department of Health and Human Services.

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Last Revised: April 27, 2004

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