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

2004 State Child Care Administrators Meeting

Wednesday, July 28, 2004
Washington, D.C.

"Shaping America's Future"

It's an honor to be here with all of you. The work that you all do every day is so important to our nation.

The quality of early child care sets the foundation for school readiness and all future success.

Thank you for all you do to provide our youngest children with the building blocks of literacy and future academic achievement.

My grandmother came to this country when she had 27 children, seeking a better life. She came at a very late age, and never learned English.

When I was a child, she made sure that we had food, clothes, and a roof over our heads. When we needed health care, she either provided that care herself or found a way to pay for the stitches I needed, or the prescription medication my sister or brothers or cousins needed.

We didn't have the type of services and care that you provide. It would have made a tremendous difference.

To help today's children grow to be healthy and self-sufficient members of society, we must work collaboratively to promote good health in all its forms - mental, physical, and spiritual. We all recognize that there is a lot of work to do.

Health is a factor in every aspect of life.

As a nurse and a physician's assistant, and more recently a trauma surgeon and public health director in Arizona, 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.

Now 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 children and their families receive and their ability to understand and use that information is one key to building a healthier America.

Priorities
When President Bush nominated me to be Surgeon General, he asked me to focus on three priorities.

I'm fortunate to work with a leader who understands the importance of health. Both President Bush and Secretary Thompson 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. - What each of us can do in our own lives and communities to make ourselves and our families healthier. Child care serves as an access point for the delivery of health services - including outreach to enroll children and families in reduced or free health insurance such as S-CHIP.

• 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. Millions of children spend their days in child care programs, and we are working to ensure that child care providers are included in state and local emergency preparedness efforts.

  Child care providers need training in the area of emergency preparedness. Child care providers must have a plan of action for emergencies. Let's not forget that child care programs were affected by both the 9/11 and Oklahoma City attacks, and many more are affected by natural disasters each year.

  I want to thank ACF's Child Care Bureau for distributing information about emergency preparedness and encouraging state and local disaster-planning teams to make sure that child care is at the table when the plans are made. This is particularly important because all disasters are local disasters.

  and

• Third, Eliminating Health Care Disparities. As you know, the chronic health conditions that plague our nation are most pervasive in communities of color and immigrant communities.

I am also working hard to improve our nation's health literacy. Most of the preventable diseases that are cutting healthy years off the lives of people in places like where I grew up in Washington Heights, 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.

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.

Further studies show that people of all ages, races, incomes, and education levels are challenged by low 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 here in our nation's capital.

Even the seemingly simple things that we can all do to stay healthy and safe, such as getting regular medical check-ups and eating healthy foods, can be struggles for many families. The reality is that to be able to do these things, we must have a basic infrastructure and understanding of why these choices are important to our health and safety, as well as our family's health and safety.

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

Prevention
Will health literacy help improve the lives of young children and their parents? Yes, it can. We must provide information in clear terms that people can understand and use to make healthy decisions.

As we look at the big picture of health care, there are backward incentives in our health care system. Instead of helping people understand how to stay healthy, we wait for them to get sick and then we spend billions of dollars every year trying to make them healthy again.

That's why President Bush, Secretary Thompson, and I have made prevention a priority.

Solutions
As Surgeon General, prevention comes first in everything I do. It's the vision behind the President's HealthierUS initiative, which is designed educating people about making good choices to keep themselves and their families healthy.

It's also at the vision behind Healthy Child Care America.

Your work with ACF's Child Care Bureau and the Maternal and Child Health Bureau to support Healthy Child Care America has ensured that more states and communities develop linkages between families, child care providers, and health care professionals.

The success of these partnerships is in the fact that more children in child care programs have access to safe physical environments and health services such as medical, dental, and up-to-date immunizations. Thank you for being a part of HealthierUS and Healthy Child Care America. We need your help.

They are both at the heart of health literacy.

Low health literacy has gone largely unrecognized and untreated for too long. Now 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 - from high-text methods like interactive programs and the Internet; to proven low-tech 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.

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.

This is particularly relevant for racial and ethnic populations. Health information campaigns must be developed by individuals with specific knowledge of the cultural characteristics, media habits, and language preferences of intended audiences.

Pill Necklace
I learned this lesson more than 30 years ago, as 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 didn't 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 didn't 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 interpreter…the 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?, What's your value system?" They wanted to know who we were.

Today, Americans are still on a fast track all the time. But that's 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 I'm not sure what I was eating, but I smiled.

And that wasn't 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 wouldn't get washed away.

But underneath the chief's 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 wasn't a drinker. I had learned from my parents' 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 don't know how old she was, maybe 7 or 8. Mind you, in their language, they don't have words for time or days or years. It's sunrise, sundown. Passage of time is related to the crops and the cattle.

So when I saw her walking toward me, I thought, "I'm 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 didn't have running water, so we said, "Go down to the river, wash with this, don't pick at the scabs, let them fall off. Oh, and by the way, take these."

Back in 1969/1970 we only had two antibiotics - 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, "I'll be back in a week or 10 days, and I'll 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 wasn't, 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 you're 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 didn't even consider that the Montagnard people would see a pill as anything other than a pill.

Charge and Closing
Today, we are still grappling with cross-cultural communication. As our country becomes more diverse and enriched with the cultures of the world, we as policymakers, administrators, providers, care takers, and service agencies respond every day to our constituents and communities' needs.

Improving health literacy must be part of our response. It will save lives, save money, and improve the health and well-being of millions of people.

Health literacy is the currency of success for everything I am doing as Surgeon General.

And I need your help. All of us need to work together to improve Americans' health literacy. To prevent disease we must all embrace a culturally competent approach to health and well-being. This applies to everyone involved in child care across our nation - not only the health professionals.

Many of your organizations have capabilities and competencies to bridge the gap so that more children and families will have access to good health information and services. You interact with the families on a regular basis, you know them, and you know their cultures.

Whether it is working with the early care and education community, places of worship, community-based organizations, partnering with community health centers or other provider organizations, health must always be included as a component of child care services.

You are serving people who truly need and appreciate your help.

Your work with children strengthens the American spirit.

I am confident that through your leadership, expertise, and dedication, you will continue to improve the long-term health of children and families. Thank you for your hard work and for your commitment to improving America.

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Last revised: January 9, 2007