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Health Literacy

[H]ealth 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”

--Surgeon General Richard Carmona (2003)

The one panacea that nearly all Americans believe in is individual choice. There's no social or political or economic ailment that we think can't be cured with a devolution of more decision-making authority to the individual. Hence our love of free-market economics, and our obsession in bioethics with "autonomy."

Both of these obsessions are animating our most recent attempts to restrain our skyrocketing health care costs. If we can only give individuals more "say-so" over their health care, costs will plummet and quality will go up. Despite the rich supply of international examples demonstrating that a modern society can get better health outcomes for less money when the government takes a more active role in insuring all its citizens' health care, and in monitoring its quality, we Americans find it easy to dismiss such examples in favor of our home-grown cure-all: more individual choice. MSAs, defined-contribution plans, more effective advertising of doctors' and hospitals' performance histories, private Social Security accounts, direct-to-consumer drug advertising -- all these policies and more are designed to provide information to the health-care consumer so that they can make the decision for themselves, and by doing so, improve health-care quality and lower its cost to boot.

Ah, panaceas. Hope does spring eternal.

No doubt that individual choice, in some if not most contexts, is the best possible aspiration we can have. The problem with aspirations is that sometimes they don't match up with reality. The fact is, many people (including myself) just aren't well-enough informed (for many different reasons) to exercise the kind of individual choice that we believe will cure all our health care ills. Some observers have noted this problem, and have curiously referred to it as a lack of health care "literacy."

A 29-year-old African-American woman with three days of abdominal pain and fever was brought to a Baltimore emergency department by her family. After a brief evaluation she was told that she would need an exploratory laparotomy. She subsequently became agitated and demanded to have her family take her home. When approached by staff, she yelled “I came here in pain and all you want is to do is an exploratory on me! You will not make me a guinea pig!” She refused to consent to any procedures and later died of appendicitis.

This vignette comes from a report issued by the National Academies Press called "Health Literacy: A Prescription to End Confusion." The authors are rightly concerned that although "health consumers" are being asked to make ever-more complicated choices, "over 300 studies have shown that health information cannot be understood by most of the people for whom it was intended...." The vignette is misleading because it suggests that health literacy comes down to teaching everyone the meaning of the word "exploratory." But this general illiteracy isn't the real problem. The real problem is that each of us is being asked to make more and more complicated decisions that are difficult for even the most highly educated among us to make. A few weeks ago I asked for some information from an insurance company about an HSA. Heath Savings Accounts are all the rage these days as a way to "empower consumers" to "take control" of their own health-care spending decisions. When I got the information in an email, I couldn't understand it. Sorry. I know, I have an MD; I'm about to get a JD; I've been around and seen some things. But this HSA stuff was just plain confusing.

It's a testament to the power of our belief in individual choice that the report's authors blithely assume that our health illiteracy can be corrected (usually by another beloved American panacea, education). Another possibility -- that these 300 studies reveal the inherent limits of our individualist approach to solving all our health-care problems -- isn't considered.

Perhaps you'll get a sense of how futile correcting our collective "health illiteracy" might be when you read some of the report's specific "visions" for a health-literate America:

  • everyone has the opportunity to improve their health literacy.

  • people are able to accurately assess the credibility of health information presented by health advocate, commercial, and new media sources.

  • health practitioners communicate clearly during all interactions with their patients, using everyday vocabulary.

  • rights and responsibilities in relation to health and health care are presented or written in clear, everyday terms so that people can take needed action.

Ok, and no one should ever sleep late, the Cubs should win all their games, and the stock market should go up continuously forever. Anyone who pays any attention at all to the real world will realize that these visions are either utopian, or they're trite and silly.

Robert M. Fineman's overly-indulgent review of this report in this week's New England Journal of Medicine says more than its author seems to know. "Although it is a minor point in a review of this outstanding contribution to the public health literature, I believe that an almost Talmudic-length commentary is needed to describe the assessment, policy development, assurance (implementation and evaluation), infrastructure, and capacity-building activities and resources needed to end the confusion regarding health literacy in the United States today." Since "ending the confusion" would amount to describing how normal human beings might be remade into superhuman health care consumers, I suspect the commentary would have to be a lot longer than even the Talmud.

You won't find me holding my breath waiting for the "health literacy" crowd to produce any such thing.




happiest of birthdays! (except for those to come!).