Health Illiteracy Is Nothing New iIn America. But the Pandemic Magnifies How Troubling It Is

Posted on August 3rd, 2020 | By Eve Glicksman

nurse showing a tablet to an older woman


A Michigan library had to ask patrons to stop microwaving books to kill the coronavirus after noticing returned books with scorched pages. The Cleveland Clinic issued a public warning about the danger of using vodka concoctions as a hand sanitizer when recipes started to circulate.

Then came the surge of calls to poison control centers about bleach. The Centers for Disease Control and Prevention had to double-down on warnings not to drink it or rinse food in it.

Fear of covid-19 is exposing a lack of health literacy in this country that is not new. The confusion is amplified during a health emergency, however, by half-truths swirling in social media and misinformed statements by people in the public eye.

One in five people struggle with health information, says Michael S. Wolf, director of the Center for Applied Health Research on Aging at the Feinberg School of Medicine at Northwestern University.

“It’s easy to misunderstand [medical information],” says Wolf, who is also founding director of the medical school’s Health Literacy and Learning Program. Some will be too ashamed to say so while others won’t realize they missed a critical detail.

The people most likely to have low health literacy include those dying in greater numbers from covid-19: older adults, racial and ethnic minorities, nonnative English speakers, and people with low income and education levels.

“Covid has brought to fore the vast inequities in society,” says cardiologist Jared W. Magnani, associate professor of medicine at the University of Pittsburgh School of Medicine. If you don’t understand words such as “immunocompromised” or “comorbidity,” for instance, you miss cautionary information that could save your life.

But low health literacy cuts across all demographics, stresses Alison Caballero, director of the Center for Health Literacy at the University of Arkansas for Medical Sciences. “Given the right headache or stress about a sick child, [gaps in comprehension] can happen to anyone. When you don’t feel well, you don’t think as clearly.”

Health literacy is not about reading skills or having a college degree. It means you know how to ask a doctor the right questions, read a food label, understand what you’re signing on a consent form, and have the numeric ability to analyze relative risks when making treatment decisions.

“None of this is intuitive,” Wolf says.

Magnani has patients who don’t believe they have high blood pressure because their lives aren’t stressful. Or respond with “Great news!” when he tells them a test result was “positive.” He was lead author of a statement from the American Heart Association about overcoming health literacy barriers to improve patient outcomes.

“Most health care doesn’t occur in the exam room,” Magnani says. Misunderstandings over hospital discharge or medication instructions can undo the best medical care. Yet, nearly 1 in 3 of the 17,309 people in a study by researchers from the Agency for Healthcare Research and Quality (AHRQ) responded that instructions from a health provider were “not easy to understand.”

Wolf says he was surprised during a study on reading prescription labels by how many high school graduates could not follow medication instructions. “Being able to read the label doesn’t mean you can interpret it,” he says. “Take two pills, twice daily” was frequently misunderstood. Replacing the awkward wording with “Take two in the morning and two at bedtime” would solve that, Wolf says. Health-care professionals “need to meet people where they’re at.”

Health literacy is the best predictor of someone’s health status, some physicians maintain. Decades of research consistently link low health literacy to poorer medical outcomes, more hospitalizations and emergency room visits, and higher health-care costs. The less literate often experience higher mortality rates for heart disease and more foot amputations if diabetic. And you are less likely to wear sunscreen, maintain an optimal weight and take other health-preventive measures if your health literacy is low.

Anatomy knowledge is another gap.

To avoid misdiagnosis, Philadelphia internist Melissa G. Schiffman says she has to weigh each patient’s comprehension when they discuss symptoms. They may tell her they have kidney pain but the discomfort is lower in their back and more consistent with back strain, she says. Or a patient may be embarrassed to say “testicles” and complains of groin pain, she says.

Explaining medical risk and probability is another challenge.

“ ‘Why did you prescribe this? It says it hurts your kidneys,’ ” Schiffman will hear from a patient. “They may not understand that only a very small percentage of people may get a stated side effect.” Then there are people with heart attack symptoms who don’t go to the ER because they think covid-19 risk is worse, she says.

Over 3,000 studies found that health education materials far exceed the eighth-grade reading level of the average American, too. Beyond not using plain language (“joint pain,” not “arthritis”), texts assume the patient knows more than they do. Telling people to sanitize surfaces to kill the coronavirus means little if you don’t tell them what to use and how to do it, Caballero says. “What does it mean to practice good respiratory hygiene?” she asks. “These are not actionable instructions.”

“People don’t want to look dumb, but patients should never feel embarrassed to ask any question,” Schiffman says. “It’s not in anyone’s interest.”

Poor health literacy is no longer viewed as just the patient’s problem. The AHRQ created the Health Literacy Universal Precautions Toolkit to help physicians communicate more clearly. The American Medical Association and the National Institutes of Health recommend that patient education materials be written at no higher than a sixth-grade level. More instruction materials are using pictures and diagrams that can be easier to follow than text.

Doctors are encouraged to employ the teach-back technique, meaning the doctor asks the patient to repeat what they’ve heard rather than simply asking, “Do you understand?”

Magnani goes a step further to try to identify patients who need help. When teaching, he says, “I tell trainees that when they ask a patient if they have questions and there are none, it may be an indication that the patient doesn’t know how to ask questions.”

In addition, “health care is becoming a harder test,” Wolf says. Health billing and insurance options can be impossible to navigate. We have an aging populationwith more chronic conditions and cognitive decline. And more is being asked of patients such as testing their own blood sugar or blood pressure.

“The health-care system has not done its job for diverse stakeholders,” says Wolf about providing health information within everyone’s grasp. “We can’t put this [burden] in the lap of the patient.”

Is Telework’s Recent Success Proof That Agencies Should Be Moved Out of Washington?

Posted on August 3rd, 2020 | By Ian Smith

One Senator said recently that the fact that many federal employees have been doing their jobs successfully during the COVID-19 pandemic via telework is clear evidence that federal agencies do not need to be located in Washington, DC.

Senator Joni Ernst (R-IA) said in a recent hearing, “During the COVID-19 pandemic, many of our federal workers have successfully done their jobs remotely, showing us that they don’t necessarily need to be in Washington to do their jobs. I think this bolsters my argument that we can and should move more jobs out of Washington…”

She was making a pitch for a bill that she introduced last year which would facilitate moving federal agencies out of Washington, DC. The Strategic Withdrawal of Agencies for Meaningful Placement (SWAMP) Act (S. 2269) would create a competitive bidding process that allows states, cities, and towns across the country to compete to be an agency’s new home.

Specifically, the bill would:

  • Repeal the section of the U.S. Code that requires federal agencies and departments to be located in Washington, D.C.
  • Prohibit agencies currently headquartered in the Washington, D.C. area from entering into new lease agreements, making significant renovations to their existing locations, or beginning construction on new facilities in the area.
  • Exempt the Executive Office of the President, the Department of Defense, and all other national security-related agencies that must be in close proximity to Congress and the White House.

Ernst said that the bill would distribute future agency headquarters over geographically diverse areas of the nation to help ensure agencies focus on the stakeholders.

In a statement about the bill, Ernst said, “Instead of housing federal agencies in swampy D.C., let’s move them outside the Beltway and closer to the folks who know the needs of their states, farms, and businesses best. And in the process, we will see more job creation and greater opportunities for communities across the country—not just in D.C.”

Ernst’s bill is not the first to propose moving federal agencies out of Washington. Perhaps the most aggressive legislation introduced recently would move most federal agencies outside of the DC area. Introduced by Senator Josh Hawley (R-MO), the Helping Infrastructure Restore the Economy (HIRE) Act (S. 2672) would move 90% of the positions in 10 executive departments to other states.

The efforts to relocate federal agencies were emboldened in Congress when the Agriculture Department relocated two of its agencies to Kansas City, MO.

“We’re excited to announce ERS and NIFA’s new, permanent home in downtown Kansas City, Missouri and provide clarity on commute times and work-life balance for our employees,” USDA Secretary Sonny Perdue said in a statement last October.

Whether or not any of these other efforts in Congress to relocate agencies will come to fruition remains to be seen.

© 2020 Ian Smith. All rights reserved. This article may not be reproduced without express written consent from Ian Smith.


McDonald’s, Marriott franchises didn’t pay COVID-19 sick leave. That was illegal. – Center for Public Integrity

Posted on August 3rd | By Alexia Fernández Campbell 

Lucie Joseph started to feel sick on April 28 as she rang up customers at a Shell gas station in Delray Beach, Florida.

Joseph said her boss wouldn’t give her time off without a doctor’s note. But the owner of the gas station, Sun Gas Marketing and Petroleum, didn’t offer her health insurance, so she didn’t go to the doctor. Joseph, a single mother with a 10-year-old son, kept working — seven more shifts over 10 days.

Joseph’s symptoms worsened, so she decided to get tested for COVID-19. On May 9, Joseph learned she had tested positive, and a nurse told her to quarantine. Over the next six weeks Joseph tested positive twice more and texted the results to a manager. As instructed, she didn’t return to work until she had two consecutive negative tests. On June 15, however, she was fired.

“I was stunned,” said Joseph, who showed the Center for Public Integrity images of the text messages with her employer and a document indicating she’d tested positive for COVID-19.

Joseph, who earned $13 an hour, didn’t realize she had a legal right to job protection. She eventually was paid two weeks’ wages, but even this violated the law: She should have been paid as soon as she went into quarantine.

Two months before Joseph was fired, President Donald Trump signed the Families First Coronavirus Response Act, which requires certain small- and medium-sized businesses to pay a worker’s full salary for two weeks if they become infected with COVID-19 and prohibits businesses from firing employees for taking leave.

But Joseph didn’t know about the law until she consulted a lawyer. Many other workers are equally uninformed.

Meanwhile, hundreds of U.S. businesses have been cited for illegally denying paid leave to workers during the pandemic, according to documents Public Integrity obtained through a Freedom of Information Act request. As of June 12, nearly 700 companies had violated the law’s paid-leave provisions and owed back wages to hundreds of employees, according to Labor Department records. Violators include six McDonald’s franchises and the owners of Comfort Suites, Courtyard by Marriott and Red Roof Inn franchises.

In all, the businesses owe $690,000 in unpaid wages to 527 employees, who are not identified in the documents. Most of the workers are low-wage earners in the construction, hotel and food industries. It’s likely many more companies have broken the law because workers such as Joseph aren’t aware of their rights and therefore haven’t filed complaints. The Trump administration hasn’t made a point of educating them.

“Workers with low wages are most in need of paid leave,” said Tanya Goldman, a former Labor Department policy advisor who’s now an attorney at the Center for Law and Social Policy, a nonprofit focused on advancing anti-poverty policies. “They literally cannot afford to stay home and take a sick day if they get COVID.”

Eileen Arslan, comptroller for the Courtyard by Marriott franchise in Fort Walton Beach, Florida, which was cited for a violation, said hotel staff members were confused at first about who was covered under the new law. But as soon as they heard from the Labor Department, they paid the employee the wages owed. Red Roof Inn’s corporate office said they were trying to track down the employee involved, but didn’t give further comment. The corporate office for Comfort Suites did not respond to request for comment.

Joseph is now receiving unemployment pay while looking for work. She’s preparing to sue Sun Gas, claiming it broke the paid-leave law. “Bosses need to know that we’re human, that we have family too,” Joseph said.

Sun Gas owner Richard Vogel did not respond to requests for comment about why Joseph was fired.

Congress is considering another stimulus bill that would extend paid sick days to workers not covered under the current law, such as health-care workers, first responders and employees at companies with more than 500 workers. Establishments with fewer than 50 workers are exempt if they show paid leave would seriously hurt their businesses.

But the bill is tied up in the Senate as Republicans and Democrats fight about how much aid to give workers.

‘I need to eat’

About a third of U.S. workers don’t receive paid time off from their employers. Most of them work in low-wage jobs. Others, such as Joseph, get only one or two days of paid time off a year. Others get a bit more, such as Angely Rodriguez.

Rodriguez, who works as a cashier at a McDonald’s restaurant in Oakland, California, gets up to five sick days a year under state law. But that wasn’t enough to pay her bills while she recovered from COVID-19.

Rodriguez was one of 11 employees at the McDonald’s in the East Bay neighborhood of Temescal who tested positive for the coronavirus in late May. Forced to quarantine, Rodriguez asked if she could get paid while she recovered at home. Probably not, her boss said, adding that she would check with her supervisor. Rodriguez said she never got a response.

Rodriguez, who earns $14.14 an hour, didn’t realize she had the right to get paid for two weeks during quarantine.

“Imagine living here without any money,” Rodriguez said in Spanish. “I can’t stay in my home if I don’t pay the rent, and I need to eat and send money to my family.”

Click here to download the document obtained by the Center for Public Integrity through a Freedom of Information Act request.

Rodriguez and five co-workers are suing the franchise owner, VES McDonald’s, for allegedly breaking local labor laws, including a temporary Oakland ordinance that requires employers to give workers two paid weeks off if they get sick during the pandemic.

Rodriguez said she eventually was paid for 60 hours but is owed another 20. The company said it eventually paid all workers in mid-June who asked for leave, according to court records.

Rodriguez’s employer, McDonald’s franchise owner Valerie Smith, did not respond to a request for comment. In court documents, her lawyers said the franchise has complied with the law.

A spokesperson for McDonald’s Corp. said the company asks employees who are sick to stay home.

“We’re confident the vast majority of restaurant employees impacted by COVID-19 are getting paid sick leave through existing franchisee and corporate policies, the Families First Coronavirus Response Act, CARES Act and state and local regulations, and McDonald’s USA requires its franchisees to comply with all applicable laws and regulations,” the spokesperson wrote.

Angely Rodriguez Lambert, center, strikes with her fellow co-workers at a McDonald’s restaurant in Oakland, California. The group was demanding two-weeks of paid quarantine for sick workers and personal protective equipment for those who continued on the job. (Courtesy of Fight for $15 and a Union)

Rodriguez and Joseph are the types of workers the Families First law was supposed to help: low-income earners who aren’t paid if they are sick or don’t get enough paid leave to quarantine for at least two weeks.

The law also guarantees working parents 10 weeks off at two-thirds pay if a worker’s child-care provider closes because of the pandemic. Employers get a tax credit to cover the cost.

Data from the Labor Department’s Wage and Hour Division, which enforces the paid-leave law, shows that businesses with a large number of low-wage workers are breaking the law more often than others.

Most of the violators are construction and renovation companies, hotels, restaurants, grocery stores and manufacturers. According to the Labor Department, about a dozen companies are repeat violators, including a McDonald’s restaurant in Salem, New Jersey, and the Broward Children’s Center near Fort Lauderdale, Florida. The owner of the McDonald’s in Salem did not respond to a request for comment. The child-care center said it’s complying with the law and declined to comment further.

The U.S. Postal Service has the most violations — 57. It owes workers nearly $100,000, Labor Department records show.

Workers fight for sick leave

Sandra Capkovic, who delivers mail in the Tampa, Florida, area, told Public Integrity a supervisor denied her request for 10 weeks of paid leave to take care of her 7-year-old son, whose babysitters have been unavailable during the pandemic. Capkovic said her supervisor told her the paid-leave law covers only parents whose children’s schools and day-care facilities are closed, and she would have to use the 10 days of annual leave she had accumulated. The Families First law covers working parents whose “child care provider” is unavailable, but doesn’t specify whether that includes babysitters.

Capkovic said she didn’t file a formal complaint because she didn’t know if her supervisor had violated the law.

A spokesperson for the postal service said the agency began educating employees about their rights as soon as the law was signed by the president.

“Significantly, the number of violations cited (57) is a very small fraction of the Postal Service workforce, which is comprised of more than 630,000 employees,” she wrote.

Two former Labor Department officials said the 692 paid-leave records obtained by Public Integrity likely reflect only a fraction of employers who are breaking the law.

“It’s very challenging for an employee, in a time of increasingly high unemployment and instability in the labor market, to have the courage to make a complaint,” said Michael Hancock, an employment lawyer at the firm Cohen Milstein in Washington, D.C., and an assistant administrator for policy in the Wage and Hour Division during the Obama administration.

‘Irresponsible’ enforcement

The Wage and Hour Division has fielded more than 250,000 calls since the paid-leave law went into effect, and about 25 million people have visited its website. The division did not respond to questions about the number of complaints filed or investigations that remain open.

Violation data obtained by Public Integrity suggests investigators are not conducting companywide audits, Hancock and Goldman said. All but a dozen of the 692 violations involved just one employee at one company. Labor experts say that’s a sign federal investigators are not checking to see if other workers at a company were illegally denied leave.

“They literally cannot afford to stay home and take a sick day if they get COVID.”

Tanya Goldman, attorney at the Center for Law and Social Policy

Hancock called this one-off enforcement strategy “irresponsible.”

Goldman said the division should do more to educate workers and employers about the law because many may not know about the temporary paid-leave benefit.

Congress set aside $15 million for the Labor Department to spend on advertising and program administration. But the agency didn’t launch a major outreach campaign until mid-July — more than three months after the law was signed.

Of the six workers who spoke to Public Integrity, only one was aware of the law at the time it could have been of help.

The Labor Department has defended its enforcement of the paid-leave benefits. Investigating individual complaints — instead of conducting companywide audits — allows staff to quickly resolve cases that could otherwise take months, said Edwin Nieves, a spokesperson for the Wage and Hour Division (WHD).

“[The division’s] response has been swift and comprehensive,” he wrote in a statement to Public Integrity. “WHD has simultaneously addressed the need to provide information to the American workforce about their rights and benefits available under the Families First Coronavirus Response Act (FFCRA) and the need to enforce the new law to ensure workers get the protections they need and deserve.”

Fighting paid-sick leave

The coronavirus aid bill introduced by the House of Representatives in March would have created the nation’s first paid sick-leave program. The bill would have allowed paid time off to anyone who earned income in the previous 30 days before becoming sick with coronavirus or needing to take care of a family member.

Then the lobbying began.

On March 12, a day after the bill was introduced, the U.S. Chamber of Commerce warned lawmakers not to pass a universal paid-leave program.

Later that evening, the National Association of Manufacturers sent Congress a similar message.

The International Franchise Association said the paid-leave measures would force chain stores to lay off workers.

In the end, more than 800 companies and organizations lobbied Congress and the Trump administration on the Families First bill, according to the Center for Responsive Politics.

By the time the legislation passed the House on March 14, it looked much different than the bill introduced three days earlier. The paid-leave program excluded employees of companies with more than 500 workers, or about half the U.S. workforce. It also excluded health-care workers and emergency responders, and gave the Labor Department authority to exclude businesses with fewer than 50 employees.

After the federal paid-leave program went into effect in April, the Labor Department further narrowed the group of workers eligible for the benefit. It ruled, for example, that hospital janitors and cafeteria workers were also unprotected because of the law’s exclusion of health-care providers.

The interpretation incensed former Obama Labor Department officials, who charged the Trump administration in an op-ed with “undermining the health and welfare of workers and their families.”

It’s unclear if the coronavirus legislation lawmakers are negotiating will restrict, expand or leave the program untouched.

In the meantime, Joseph is looking for work. Her dream of owning a home seems farther away than ever.

“This is a big hit,” she said. “It’s hurting me, not being able to work.”

Peter Newbatt-Smith and Kristine Villanueva contributed to this report.