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A Surgeon General’s Opinion: Consumer Directed Healthcare And Health Literacy

In my quest to bring the best possible health advice to the Revolution Health community I am actively pursuing interviews with credible sources. At the top of the list is America’s #1 doctor, the Surgeon General. I recently had the opportunity to sit down with Vice Admiral Richard H. Carmona, M.D., who served as Surgeon General from August 2002 to August 2006. He addressed a range of health issues facing Americans today. I am posting the interview in segments; the following post is part of that series.

Dr. Val: What role could consumer-directed healthcare initiatives play in helping to reduce healthcare costs associated with chronic disease? Is the government doing enough to support this movement?

Dr. Carmona: I think the consumer-driven initiatives struggle for a number of reasons, and the most important one is that we’re a health illiterate nation. Studies show that about one third of our population doesn’t understand the connection between their lifestyle and their health outcomes. Consumer-driven initiatives are predicated on the assumption that the consumer can understand the issue and take appropriate action to change behavior.

Are we doing enough? No. The government could pour all of its budget into patient education, but if the people don’t receive a message that they can understand and act upon, we’re wasting our time. The real challenge for consumer-directed initiatives is to deliver health literate, culturally competent messages that resonate with diverse populations. If I sent a bunch of posters to certain communities with a picture of the Surgeon General saying, “eat less and exercise more” would that change behaviors in that community? No. What we need to do is partner with community leaders, whether it be a priest or a rabbi or a grandmother or a block neighborhood captain – someone who has credibility in that community and work with them and spend the time necessary to change the culture.

The American public wants the best of everything, they want it yesterday, and they don’t want to pay for it. That pretty much characterizes the problem that we have. We see health as a right, we want somebody to give us a card, and if we want to smoke, that’s our right too. There’s this attitude that if we want to drink excessively, that’s our right, and if we want to ride a motorcycle without a helmet, that’s our right (“you can’t tell us what to do”). However, when I crash my motorcycle and I have a head injury and I’m disabled for life, I also expect society to pay for that.

We have to do a better job of improving health literacy so that American people of all socio-economic strata can understand the consequences of the choices that are deleterious to their health and help them to adopt appropriate behaviors that optimize health and wellness. Health literacy is the currency of success for everything we need to do to improve the health, safety, and security of our nation. It’s part of what we include in every project we do at Canyon Ranch Institute, with all our partners.

Dr. Val: And how do we get the message across to them, then?

Dr. Carmona: Boy, people have written books on that one. I’ve been plagued by this question, Val, ever since I came into the office of Surgeon General. I remember one day sitting down with my staff and taking a look at the previous Surgeon General reports. I thought they made pretty good book ends and looked nice in my office, but I wanted to know what we used them for. One staff member said, “Well sir, these have been developed to define the base of knowledge on a given topic and it helps our peers decide what needs to be done. It has a long bibliography and it’s based on science.”

But then other staff told me, “Really these are written for the public, so they’ll understand the information.”

And I thought to myself “I don’t know that any of the ‘public’ that I grew up with could read this.”

So I started a program to help communicate health messages to the American public. The goal was to develop resonant messages that would result in maximal behavior change over time. My advisors told me that the messages had to be written at a sixth grade level. So what we did with every Surgeon General’s Report and every Surgeon General’s Call to Action and other publication – we published the “Peoples’ Piece” to go along with it. It was full of pictures and written like a comic book to facilitate parent-child dialog about health. We also wrote them with cultural sensitivities in mind. The science behind our recommendations doesn’t change, but you have to send out thousands of messages to resonate with people from different cultures and languages – who are all Americans – in order to change their behaviors. So that’s what makes this so difficult.

Dr. Val: How do you get the ‘Peoples’ Piece’ to the people? Do you use the Internet or new media approaches?

Dr. Carmona: Unfortunately it’s often the case that the people who need the information the most don’t have Internet access. But the Internet can be incredibly powerful. For example, Dr. Francis Collins (the head of the human genome project at NIH) helped me with the U.S. Surgeon General’s Family History Initiative. We put our heads together to help people understand the significance of family health history.

We put it on the Internet and also distributed it to libraries, post offices, community centers, and schools. It helped people to create a family health tree to use as a talking point with their doctors. They could remind their doctors that, for example, their aunt and grandmother had breast cancer and then ask if they should be monitored more closely.  Or they could discuss the fact that their uncles and cousins all had heart attacks before age 50. This tool helped people to begin identifying their risks based on a good family history – which busy docs don’t pay enough attention to anymore. When you know your history, genomics becomes valuable. If we can characterize disease, then we can search for potential genetic loci to help explain what’s going on and take a preventive approach to modifying the person’s environment to mitigate risk.

This concept is extraordinarily hard to communicate, but the Family History Initiative helped to make it accessible to people. We released the project at Thanksgiving time – when we knew that families would be together and could discuss their health histories, and it was a resounding success.  Within a week or two we had hundreds and thousands of hits, with people asking for more information.


The Surgeon General series: see what else Dr. Carmona has to say about…

Cost Savings Associated with Preventive Health

Obesity is America’s #1 Health Concern

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Preventing Chronic DiseaseThis post originally appeared on Dr. Val’s blog at

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2 Responses to “A Surgeon General’s Opinion: Consumer Directed Healthcare And Health Literacy”

  1. DrFredric says:

    Dr. Carmona correctly identifies the point that the medical/scientific communities describe genetics in ways that are difficult for ordinary people to understand. However, a larger challenge is there: to transform genetics from a language of death, disease and disability to the language of life and living. After all, our 20,000 genes help define who we are in our normal lives from the time we are born, and before. Why not increase our focus on what’s normal and our genetic potential non-disease traits.

    The last 40 years in computers provides an easy parallel that demonstrates how re-framing language changes use. Computers were once considered too complicated for ordinary people to use. The computer people used specialized languages to develop sophisticated, “serious” applications. Their mindset was that ordinary people would never learn how to use computers, and besides computers were too important to trust to ordinary folk. This was even true in the early days of the personal computer.

    Two major changes took place that revolutionized computers. One was the graphic user interface, which made computers easy to use and somewhat intuitive. The other was the Internet, which suddenly created a reason for people to use computers. Computers help make your life manageable. Today, three year olds use computers.

    Everyone knows they inherit things from their mother and father. And everyone knows at a basic, intuitive level that what they inherit then helps define who they are. “The apple doesn’t fall far from the tree,” “she takes after her mother,” and “talent runs in the family” are three statements that people have been making for a very, very long time.

    We will increase “health literacy” if we emphasize the role of genetics in shaping everyday life.  We will improve lifestyle behavior when we communicate two key points: that DNA does not automatically seal our fate, for living or dying, and that shaping our environment does indeed shape the way our genes behave.

    Shaping the environment is one of Dr. Carmona’s points. If we go beyond disease prevention, which attracts ten percent of our population, to lifestyle enhancement, the ultimate payoff will be better health.

    In the interests of disclosure, I am founder and CEO of AlphaGenics, a company devoted to making genetic information useful to improve everyone’s everyday life.

    Fredric Abramson

  2. sarah4656 says:

    The answer to Dr. Val’s question concerning consumer-driven initiatives is the key to solving a large portion of the problems in our health care system.  I agree with Dr. Carmona that many Americans think they have a right to the best health care in the world, but they are not willing to pay for it.  The democratic candidates promote the idea that unaffordable health insurance is the cause of the high number of uninsured Americans.  This is simply not the case.  Many people can afford to purchase insurance but choose to use their money in other ways.  I personally know many very successful business owners who refuse to purchase health coverage because it is cheaper for them to pay for health care as needed.

    Americans have an innate sense of freedom, which indeed makes compliance with consumer-directed initiatives more difficult.  Health professionals are very proficient in explaining negative lifestyle choices.  Over the past decade, there has been a dramatic increase in the awareness of how lifestyle affects long-term health.  Some changes have occured but we have to find a better way to inspire people to choose healthier lifestyles.

    Sarah E. James Ph.D.



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