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PRESIDENT’S
MESSAGE

Health Literacy:

A Social Determinant of Health

By Rodolfo Molina, MD, 2021 BCMS President

Part 1. Historical Perspective and Definition
Greetings all. This opening article, proposed in two parts, marks the in question, is known as
beginning of my stewardship of the Bexar County Medical Society as “health literacy.”
your President. I feel it’s the duty of our Board to remain mindful of What is health literacy, prin-
our mission and statements: …. “the organization that serves and rep- cipally, and how do we measure
resents the member physicians of Bexar County in providing quality it? In a 2010 review, Berkman et al. acknowledged that the definition
health care for their patients and the public. Vision: To make Bexar of health literacy has had its own evolutionary track, meaning differ-
County a healthier community.” With that being stated, I plan to ent things to different groups. When defined more broadly as the con-
humbly steer a course that does not lose sight of our mission and vision stellation of numerical and reading skills needed for interfacing with
and at all times is ready to accept critique, ideas, and worthy comple- health care structures as a patient, low literacy has had a clear relation-
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ments on how I’m doing. This two-part article deals primarily with ship with poorer health outcomes in the last few decades. The defi-
our Vision statement; making Bexar County a healthier community. nition continues to evolve as technology provides greater access to
The first part will ground us with a historical perspective on health lit- health information, and we become more focused on access and less
eracy and the second part takes us into actionable ideas on how to pro- appreciative of the skills needed for interpretation of that information.
ceed in making our community healthier. Let me begin by telling you We must therefore also embrace a more environmentally framed con-
this true story. ceptual model that takes into account the role of language, culture,
In the winter of 1847-48, a typhus epidemic broke out in a northern education, and social capital. Nevertheless, its measurement relies on
area of Prussia inhabited mainly by a largely poor Polish population. using tools and questionnaires for literacy that remain a work in
Fearing a scandal as the situation in this minority community grew progress. For our purpose, we will use the following accepted defini-
more dire, the Prussian government sent, as was tradition, an outsider tion for health literacy from the Institute of Medicine (IOM): “The
to assess the situation. A young, junior pathology lecturer at the degree to which individuals have the capacity to obtain, process, and
Charite Hospital in Berlin, Rudolf Virchow, arrived at the province understand basic health information and services needed to make ap-
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known as Upper Silesia on February 20th. The 26-year-old left three propriate health decisions.” If you are seeing patients like mine, you
weeks later on March 10th, 1848. He later proclaimed that these were understand that for a chronically ill patient to achieve those metrics
the most important three weeks of his career for they had been “deci- as defined by the IOM is very difficult.
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sive” in shaping his ideas of his life’s work. Virchow in his final analysis stated, “Education, freedom and wel-
The first part of his report dealt primarily with geographical, an- fare can never be fully attained from the outside, in the manner of a
thropological, and social characteristics of the province. He went on present, but from the people’s realization of their needs.” Virchow was
to describe housing conditions, level of education, diets, drinking pat- underscoring the importance of a public education policy that pro-
terns as well as popular medical beliefs and practices of the population. motes a desire for a healthy society. Achieving strong health literacy
He certainly wrote about typhoid, but he made a point of writing across the general public requires both a top down approach (politi-
about the epidemic as it related to other endemic diseases such as pul- cians, policies, caregivers) and bottom up grassroots (our patients) ap-
monary tuberculosis, measles, and dysentery. He refers to these dis- proach if we wish to prioritize and succeed in this effort.
eases of the indigent as “crowd” or “artificial” diseases, caused by To be continued.
bacteria, but spread by individual susceptibilities and social determi-
nants such as poor housing, sanitation, diet, and working conditions. Rodolfo (Rudy) Molina MD MACR FACP is a Practicing Rheuma-
Does this sound familiar? tologist and 2021 President of the Bexar County Medical Society.
Virchow believed in social reformation within medicine as a neces-
sity for better health: treating a pathology without context was and References
remains insufficient. He used the term “Social Medicine” to describe 1. Taylor, R., Rieger, A,. Medicine as Social Science: Rudolf Virchow On The Typhus
his ideas on how best to address disease. Epidemic in Upper Silesia. International Journal of Health Services, Vol. 15,
No. 4, 1985.
Virchow’s observations remain relevant to our discussion of health
2. Berkman, N. D., DeWalt, D. A., Pignone, M. P., Sheridan, S. L., Lohr, K. N.,
170 years later. Broadly speaking, when discussing social factors that
Lux, L. et al. (2004). Literacy and health outcomes: Summary. In AHRQ evi-
influence health today, there are many. However, one that has carried dence report summaries. Agency for Healthcare Research and Quality (US).
multiple definitions in the past and becomes of paramount impor- 3. Kindig, D. A., Panzer, A. M., & Nielsen-Bohlman, L. (Eds.). (2004). Health
tance in the time of a pandemic when information is scarce and always literacy: a prescription to end confusion. National Academies Press.

8 SAN ANTONIO MEDICINE • January 2021