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Health Literacy: Time for a new question

What causes disease?
For 200 years,  Western medicine has worked from the idea that health is the absence of disease. 
The overarching question for medicine and healthcare has been What causes disease?  And despite
the name, healthcare has always been about treating disease. Early on, care and research focused 
on germs and infectious disease; later , following the research, focus shifted to genes and risk factors 
for chronic disease. Although it is now widely accepted that health is more than the absence of 
disease,  Public Health, and even the relatively new field of Health Promotion, still maintain a steady 
focus on reducing disease risk factors. It’s time for a new question.
  Prerequisite for Health:
  • Peace
  • Shelter
  • Education
  • Food 
  • Income
  • Stable eco-system
  • Sustainable resources
  • Social justice
  • Equity
                      Ottawa Charter
Research has answered, in broad terms, the centuries old question. 
The roots of disease grow deeper and earlier than germs or genes and 
risky lifestyles. It is well-established that health and disease originate in early development, in the “zero to three”, prenatal to preschool period. The 
combination of Nature (genes & germs) and nurture (early parenting and environment) in the earliest months and years of life establish the foundation
for all that follows:  how susceptible we are to disease, how resilient we are,  
and further, how we learn, make friends, cope with challenges, and get
what we want. 
Research breakthroughs have  given health a new broader meaning that is
 expressed and accepted more internationally than in the US.  See the
Ottawa Charter  and the World Health Organization’s Health Promotion Glossary (1998)
It is now clear that health and disease originate in early development; and that health, like disease,
develops over time and its trajectory can be influenced, especially during fetal and early child 
development and other critical periods of development. That understanding demands that we flip 
the overarching question to ask, What causes health? And to flip the concentration of resources from
end of life care to maternal and child health promotion.
What causes health literacy?
Most health literacy research has taken place in US academic medical centers under the old overarching 
question asking, What is the role of low literacy in disease? It is important to note  that this research
also uses an outdated understanding of literacy as reading ability. This line of research has established
that few Americans understand medical terminology and nearly all of us have difficulty following complex
medication regimens and navigating the complexities of healthcare and insurance. 
If we start with the new overarching question: What causes health?, then a more actionable  question for 
health  literacy promotion is What will empower this person to use information and services for health?  
The answer, that which empowers a person to use information and services for health, is health literacy.   
Better information is necessary, but rarely sufficient. Look to the Prerequisites for Health (above) to see 
other factors necessary to develop  health and health literacy.
Antonovsky A. (1996). The salutogenic model as a theory to guide health promotion Health Promotion
International 11 (1);11-18
Halfon N, Larson K, Lu M, Tullis E & Russ S. (2014). Lifecourse Health Development: Past, Present and Future.
Maternal Child Health Journal 18:344-365.
Nutbeam, D. (2008). The evolving concept of health literacy. Social Science & Medicine, 67, 2072-2078.
Shonkoff, J. P., & Phillips, D. (2000). From neurons to neighbourhoods. The Science of Early Childhood 
Development,: National Academy Press: Washington DC.

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