22 March 2008

"Flush tissue with stool": the problem of low health literacy in Canada

All Canadians must have the tools to take responsibility for their own health and the health of their loved ones. This includes access to up-to-date and accurate health-related information as well as the tools required to understand and use this information. ~ How low literacy can affect your health (Canadian Council on Learning)

Last January I wrote about a particularly atrocious example of patient information, a poop test brochure, which, among other things, advised the reader to "flush tissue with stool." Have you ever tried flushing a toilet using a stool, let alone trying to repeat the step "on the next two subsequent bowel movements?" It's not easy, let me tell you.

Every time some hapless patient is forced to struggle through the opaque vocabulary and convoluted syntax of the Coloscreen brochure published by Helena Laboratories in Beaumont, Texas, you can almost see the illiteracy ratio and mortality rate starting to rise on the charts. Whoever wielded the applicator stick that smeared this rank prose specimen into print has a lot to answer for, as has the Winnipeg health clinic that decided it was appropriate to give to patients [1]. For we have become a country of the reading challenged, where even Robert Service's unpretentious, galumphing strophes, which my Grade 4 class once recited with pleasure, are becoming artifacts of another age. For school kids hooked on Halo and Twitter, The Cremation of Sam McGee will soon be as obscure as Horace's Alcaics; although I see that someone has posted a video of McGee on YouTube. Perhaps this will become a trend: literary works preserved for the print-allergic population as YouTube presentations — bardic recitation in the digital realm. An abomination like the poop test brochure is not the kind of challenge we really want. A health brochure's business is to communicate important facts that will help guide a person to make good health decisions. How did we reach such an impasse: that we can produce neither texts that communicate nor readers who comprehend them?

A vision for a health literate Canada
This month another study is bringing bad news about Canadians' ability to read. "Low health literacy is a serious and costly problem," says a recent report from the Canadian Public Health Association. A vision for a health literate Canada was released on March 3, 2008. A CPHA Expert Panel found that a majority (more than 55%) of Canadian adults do not have the skills to understand information about their own health or to make daily health-related decisions. The low levels of health literacy in Canada are "critical" and a countrywide strategy is needed to solve the problem.

The panel's findings were drawn from a 2003 analysis of 23,000 Canadians by the Canadian Council on Learning, which offers its own take on the problem in a March 6 report on its website, How low literacy can affect your health. See also another CCL report dated February 28, 2008, Health literacy in Canada: a healthy understanding.

Videosphere vs. Graphosphere
What is the nature of this literacy problem, which is certainly not unique to Canada? It seems likely that Fahrenheit 451's flame throwers will never be required. As young people's desire to read is assiduously burned off in what Régis Debray calls the era of the videosphere, and as cultural and political discourse becomes increasingly infused by and confused with the ruminant world of the cartoon or the video game, elites will not crease their linen worrying about proletarian revolution. In a typically quirky but thought-provoking essay published in the New Left Review [2], Debray laments the loss of the graphosphere, the era of printing that made possible the Enlightenment and progressive social change. In his schema this passing age is being replaced by the era of the image, the videosphere, in which the book is knocked off its pedestal and replaced by widescreen, gridlinked digital culture. Debray offers an arresting image of the possible political consequences of the drift from the printed word to digital prattle:
A practical example: to find out what is going on one has to watch TV, and so stay at home. A bourgeois house arrest, for beneath "a man’s home is his castle" there always lurks, "every man for himself." The demobilization of the citizen begins with the physical immobilization of the spectator.
Very much like Ray Bradbury's dystopia. And today's video-capable mobile devices could act like a digital equivalent of ankle bracelets to keep our minds virtually immobilized. According to Debray, the Internet, its access devices, and the jet plane are good for internationalization, but they are lethal for progressive politics and international solidarity. They enlarge the sphere of individual relations but privatize them at the same time; they particularize even as they globalize. And it is the isolated, atomized individual who makes the ideal consumer and the credulously passive subject of the state.

A digression: lexemes and publishing extremes
Strange, then, that even as some thinkers mourn the loss of literacy and the end of solidarity, consumers at all levels of the literacy scale are buying extraordinary amounts of reading material, some of it even subversive of the ruling order. I find it difficult to reconcile the massive size of the English-language publishing industry and the continuing problem of low literacy. To illustrate, a brief note by Daniel Soar in the London Review of Books for 7 Feb 2008 cites the annual turnover of the British publishing industry as £2.8 billion. That's 900,000 books flying off British bookshop shelves every day, or one book for every nine loaves of bread sold in the UK. A lot of bread, however you look at it. In Canada book sales are healthy as well. The overall value for Canadian consumer book sales for 2006 was $1.59 billion. The Association of American Publishers reported that U.S. publishers had net sales of $25 billion in 2007. Book sales were up 3.2% over 2006, with a compound growth rate of 2.5% per year since 2002.

The average person has never been so well educated. Look at the size of an adult's working vocabulary today. According to the linguist David Crystal [3] it's 50,000 words. That represents the average adult's active vocabulary in present-day Britain. The estimate of passive vocabulary (words that can be recognized but would not be used in speech or writing) is roughly 25 per cent larger. Modern vocabularies are simply enormous. There are approximately 400,000 lexemes (actually differing words, not including various forms of the same word) in the Oxford English Dictionary which make up Modern English vocabulary. A reasonably well-educated person with a working vocabulary of about 50,000 words is thus actively employing about 12 per cent of the word stock of the language. By comparison, Shakespeare was working with a word stock of 150,000 lexemes. The size of his vocabulary is approximately 20,000 lexemes. This means that Shakespeare was using something over 13 per cent of the total word stock available to him. That total was probably much higher than his contemporaries, and it was certainly well ahead of the linguistically conservative King James Bible, which has only 8,000 lexemes. But it's extraordinary to think that the average educated working person in most English-speaking countries has a larger active vocabulary than the Bard himself. Obviously social status plays an important role here, something that Crystal does not discuss. Those buyers of books and users of dictionaries are less likely to be from the low-income strata of society.

Health literacy facts
But let's get back to the facts about health literacy. Whatever we may think of Debray's lofty theorizing and the remarkable vocabularies of the average adult, the fact remains that four out of ten Canadians still struggle with low literacy. And we have solid research to show how this affects the health of Canadians. What do we now know about the state of health literacy in this country?
  • 11.7 million working age residents of Canada (55%) are estimated to lack the minimum level of health literacy needed to effectively manage their health information needs. (CCL, 2007)

  • When seniors are added, an estimated 14.8 million may be without adequate health literacy skills. An estimated 88% of respondents 65+ fell below Level 3 on the Health Literacy Scale, which is considered the minimum level of proficiency required to meet the demands of modern day life including those posed by health information. (CCL, 2007).
  • Canadians aged 16 to 65 who rate their health as excellent or very good have the highest levels of proficiency in health literacy. People who rate their health as fair or poor have the lowest levels of proficiency. People with the lowest health literacy skills are more than three times as likely to report fair or poor health. (Outcomes from the National Symposium on Health Literacy, CPHA, 2008)
  • A recent American study examined mortality rates of a group of 3,260 adults over age 56 in four metropolitan areas and found that those with inadequate and marginal health literacy levels had a 50% higher mortality rate over a five-year period than those with adequate skills. Low health literacy was the top predictor of mortality after smoking, and was a more powerful variable than both income and years of education. (Outcomes from the National Symposium on Health Literacy, CPHA, 2008)

Dr. Irving Rootman, chair of CCL's Health and Learning Knowledge Centre and co-chair of the expert panel, provides the following grim statistics in his PowerPoint presentation: Health Literacy and Public Health [PPT]:
  • Over 800 studies have found that health-related material for patient education far exceeds the reading levels of the average adult.
  • A recent study of health information websites in Canada, the U.K. and Australia found that the content of all sites was written at a higher level than recommended by literacy organizations. The lowest level was grade 11.

  • Low health literacy is a barrier to effective self-management of chronic disease. A review of randomized control trial studies found that 62% of patients with lower reading skill levels were unable or unwilling to engage in self-management.

Despite the excellent work of CPHA and CCL, I'm afraid I don't have much hope that our literacy rates will greatly improve without serious social change. After all, quickly sending their own clear message about the depth of their commitment to such change, the Conservative government wasted no time in cutting nearly $20 million from adult literacy programs back in 2006. The unerringly empathetic John Baird, the minister overseeing the cut, explained at the time: "I think if we're spending $20 million and we have one out of seven folks in the country that are functionally illiterate, we've got to fix the ground floor problem and not be trying to do repair work after the fact." Funny, but I thought doing gimcrack repairs was the government's answer to most of Canada's social problems — either that or just cutting costs and programs outright, at least the type that don't get noticed at a G8 summit. One of Harper and Co.'s bright ideas for fixing the ground floor problem of health literacy has been to cut the Canadian Health Network website, which specializes in plain-language consumer health information. By the way, CHN has a good article on Canadian health literacy: Beyond words: the health-literacy connection. But you'd better look now, because whether you can read or not, it won't be available from CHN come April Fool's Day.

The role of the media
The media aren't much help either. For all their health beats, ambulance chasing, and obesity scares, by excluding or marginalizing other perspectives — notably, a more explicitly political analysis of the origins of illness — the media play a significant part in actually narrowing public debate about health, illness and medicine, and they are not helping to fix Mr. Baird's ground floor problem either. A Social Science and Medicine article [4] that looks specifically at Canadian newspapers goes on to conclude:
The absence of any discussion about social gradients in health indicates that newspapers do not find the central observation driving the population health perspective in public policy newsworthy. Even the stories that we have classified as being concerned with the social environment largely fail to discuss broad issues of the welfare state in relation to health—housing and housing policy, child development and related issues of education and child care, the social relations of work environments (as opposed to exposures to physical hazards), community design and urban infrastructure, etc. Implicit in the obsession with issues of health care is the notion that this aspect of the welfare state is singularly important to maintaining and improving human health. Debates as to whether investments in the health care sector come at the expense of investments elsewhere within the welfare state (in education, housing, income supplementation, etc.) rarely appear in Canadian newspapers. Newspapers appear to do little to advance levels of critical health literacy on broad determinants of health in Canada.
A tissue of equivocations
If we are to avoid the bourgeois house arrest of Régis Debray's isolated, passive consumers of the videosphere, we must not approach the issue of health literacy in passive isolation. It is well known that the determinants of literacy include: education, early childhood development, aging, living and working conditions, personal capacity/genetics, gender and culture [5]. These are basically the same as the social determinants of health. Literacy should be framed within an empowering paradigm that highlights opportunities and choices for people. Unfortunately, the way the media deal with the issue has been devoid of empowerment. The blatant fostering of disease-laden imagery (e.g., “stamping out the epidemic of illiteracy”) is one such counterproductive example. It is not helpful either when literacy is promoted — wittingly or unwittingly — as the predominant solution to Canada’s economic woes. What the public often gets from journalists and politicians is a tissue of equivocations.

Literacy or the lack of it should not be separated off from its social context. Nor can the solution to poor literacy be found in some bureaucratic, gimcrack program. Perhaps John Baird was right. We should stop throwing money into programs that are not truly connected to broader efforts to change the determinants of health. But he is wrong to think that anything will change without a radical program to reduce social and economic inequity in Canada.

Like the problem of homelessness in Canada, the baleful reality of illiteracy has been studied very thoroughly. As many experts familiar with the facts will admit, we have known for years what the reports are telling us over and over again. Is it any surprise, for example, to be told that "daily reading appears to be a strong determinant of health literacy?" Good heavens, Francis Bacon was saying that "reading maketh a full man" four centuries ago.

The recommendations of the most recent report are what one might expect: we need a comprehensive, coordinated, cooperative, and integrated pan-Canadian strategy on health literacy, involving all levels of government. We also need educators, bureaucrats, and health professionals who are able to communicate in plain language [6]. And, as always, more research is required. There is nothing new here. Rather than more paper, Canadians need leadership that is truly responsive to people's needs, with the political will to increase social inclusion, reduce income disparities, and uphold everyone's right to equitable health care, housing, education, and employment opportunity. As the Expert Panel conclude, "The question is: are we willing as a country to make the investment that is required to create a health literate Canada?"

Test your health literacy (from the Canadian Council on Learning website)

Can you correctly answer this example question?

Imagine your child is 11 years old and weighs 85 pounds. According to the chart below, how many 80 mg tablets of Tempra can you administer to your child in a 24-hour period and in what dosage?


1. Rootman I. Health literacy: where are the Canadian doctors? CMAJ. 2006 Sep 12;175(6):606.

2. Debray R. Socialism: a life-cycle. New Left Review. 2007 Jul-Aug;46:5-28.

3. Crystal D. The stories of English. London: Penguin; 2004.

4. Hayes M, Ross IE, Gasher M, Gutstein D, Dunn JR, Hackett RA. Telling stories: news media, health literacy and public policy in Canada. Soc Sci Med. 2007 May;64(9):1842-52.

5. Rootman I, Ronson B. Literacy and health research in Canada: where have we been and where should we go? Can J Public Health. 2005 Mar-Apr;96 Suppl 2:S62-77.

6. Stableford S, Mettger W. Plain language: a strategic response to the health literacy challenge. J Public Health Policy. 2007;28(1):71-93.

Health literacy reports
Canadian Council on Learning.

Health literacy in Canada: A healthy understanding, February 2008. This report reveals that daily reading outside of work is associated with higher health literacy scores.

Health Literacy in Canada: Initial Results from the International Adult Literacy and Skills Survey (IALSS), September 2007. Provides Canadians with a country-wide snapshot of health literacy.

Canadian Public Health Association.

A Vision for a Health Literate Canada, February 2008. The CPHA Expert Panel on Health Literacy found a majority of Canadian adults do not have the skills needed to respond to daily health information demands. Low health literacy is associated with poor health and the Panel estimates that the situation in Canada is critical.

The Ontario Health Promotion E-Bulletin of 20 March 2008 provides an excellent list of Canadian resources on health literacy.

Recent articles in mainstream media on health literacy
The Toronto Star, March 4, 2008 Alarm raised on health literacy, by Meghan Ogilvie, http://www.thestar.com/living/article/309115

CBC March 4, 2008 Canadians illiterate about health, report says, http://www.cbc.ca/health/story/2008/03/04/health-literate.html

I like to think that when I fall,
A rain-drop in Death's shoreless sea,
This shelf of books along the wall,
Beside my bed, will mourn for me.

Robert Service, Bookshelf

16 March 2008

Storm and strife as the Canadian Health Network approaches the chopping block

It is not in the storm nor in the strife
We feel benumb'd, and wish to be no more,
But in the after-silence on the shore,
When all is lost, except a little life.

Lord Byron, On hearing Lady Byron was ill

With a pair of sqawkingly incongruous dangling participles, the Canadian Health Network (CHN) has announced its own demise and its absorption by another government website:

Beginning April 1, 2008, Canadians will be able to access timely, trusted and credible public health information through a single source — the Public Health Agency of Canada’s Web site at www.publichealth.gc.ca. Accessed by over 10 million visitors a year, we invite you to bookmark this Web site as a valuable and unique source for information on healthy living, disease and injury prevention.
In their haste to liquidate this last vestige of independent, community-based health information from the government's official web presence, some faceless committee also succeeded in mutilating the English language as part of their dirty work. As if that wasn't depressing enough, there is now little doubt that the voices of nearly 4,000 Canadians who have signed a petition pleading for the CHN's preservation will be ignored. But we can still shout up a storm until the end of March, when, the Friends of CHN website informs us, Liberal Health Critic Robert Thibault will present the petition to the House of Commons, requesting that Parliament rescind the funding cut and immediately restore full, stable funding for the Canadian Health Network.

Much more fluid in its syntax was the succinct form letter I received from Tony Clement, the Minister of Health, with its admission that the decision to "terminate" the Canadian Health Network was "difficult, and was by no means arrived at without thoughtful consideration." But, as always, there are "other equally important health priorities that require government funding." Yes, like the one billion dollars a year that our military adventure in Afghanistan is costing us and the frightful, ongoing costs of caring for all the Canadian wounded, of whom we hear remarkably little in the media. The Minister likes the idea of providing health information through "a single, consolidated website." Somehow that is supposed to ensure that "more Canadians will have access to quality and trusted health information." I would very much like to know how dumping the CHN is going to provide more people with information.

And as the Social Justice Librarian justly pointed out in a recent post, "it’s one thing to take away a really great consumer health resource. It’s another to take it away and leave a pointer referring people to another resource that is virtually useless for the same type of information seeking!" A query of both the Public Health Agency of Canada and the Health Canada websites provided no comprehensible results to a question she and a student posed concerning the relationship between abortion and breast cancer. By contrast, when CHN and MedlinePlus were consulted, they offered reliable, consumer-friendly information when searched with the same key words.

The quality of that service does not seem to have been of great concern to my MP, James Bezan (Selkirk-Interlake). In his response to my complaint about the axing of CHN he pleaded lack of funds. "The Conservative Government has had to make decisions as a result of cuts to spending made in the previous government's ... budgets." That's it. Blame it on the Liberals. Mr. Bezan assures me that "moving from three sites to two will result in saving $7 million per year" — enough to keep the Afghanistan "mission" going for about two days. I am to "rest assured that PHAC will work with CHN in the transfer of information ... wherever possible." The last two weasel words, of course, mean that exactly nothing is promised.

Nothing in Mr. Bezan's letter makes me feel rested or assured. In closing he respectfully counsels me once again to "rest assured that Canadians will continue to have access to the important healthcare information they need." The importance and the need, we can all rest assured, will be determined solely by our wise leaders in Ottawa, whose "thoughtful consideration" has burdened the country with an $18-billion defence budget, the highest level of military spending in inflation-adjusted dollars since the Second World War.

Even if you're feeling benumbed, please sign the Save the CHN petition and write to the Minister of Health and your Member of Parliament.
Augustus was sensible that mankind is governed by names; nor was he deceived in his expectation, that the senate and people would submit to slavery, provided they were respectfully assured that they still enjoyed their ancient freedom.

Edward Gibbon, The decline and fall of the Roman empire, Chapt. 3.

10 March 2008

Oh Brother: the Ontario health minister joins the Soggy Bottom Boys

... nearly blowed us into shivers and smithers. ~ Charles Dickens, Our Mutual Friend, Bk. 4, Chapt. 13

Ontario's health minister, George Smitherman, was singing his own version of Man of Constant Sorrow last month. He made a bad mess worse when he responded to criticism of the treatment of the elderly in the province's nursing homes by blurting out that he was prepared to don an adult diaper — and use it — to justify his government's policies. Not surprisingly, this singular outburst didn't sit well with an outraged public. Advocates for the improvement of personal care homes have complained for years that standards are poor, that homes are understaffed, and that private companies such as Extendicare endanger patients by pressuring their employees to cut costs.

The Ontario Association of Non-Profit Homes and Services for Seniors says seniors in nursing homes should be getting at least three hours of personal care; it says the average in the province is now about 2.5 hours a day. The Canadian Union of Public Employees (CUPE), which represents many nursing home workers, says the standard should be 3.5 hours. Many studies have shown that without proper staffing and adequate standards the quality of care plummets. Front-line nursing home staff in Ontario report that residents are sitting in deplorable conditions. Incontinence products are often kept under lock and key, and many homes are directing staff to change residents only when the product is 75% soiled.

On February 27, two long-term care workers used four bottles of water to fill an adult diaper at a CUPE press conference in Toronto. They wanted to show how much urine had to be in a diaper before care aides were allowed to change it under current legislation. With stunning insensitivity Smitherman said in response that he was ready to test out an adult diaper to show criticism was unfounded. “I’ve got one of these incontinence products — albeit a new one, not the ones that tend to appear at committee — on my desk and I’m really giving this matter very serious contemplation,” Smitherman said. It wasn't only critics of the Liberal government who were angry. There were loud calls for the minister's resignation, even within his own caucus.

Wags and cynics sharpened their quills. March 1st's National Post published an imaginary Smitherman diary entry, with entries like this:

Major confession, diary. I tried out an incontinence diaper today. It was so ... freeing. I had three large coffees ... and then I sat through a three-hour meeting with a bunch of bureaucrats. No pee breaks! It was so much more efficient. Made a bit of a stumble at lunch, though, by having the side dish of asparagus. Won't make that mistake again! I think this will really help in my discussion with the nurses' union. Five hours seems to be the limit before things get a little soggy. I think I'll publicly float the idea tomorrow. Right after I shoot up an eight-ball of smack to get a better feel for drug addiction.
Of course, an apology followed immediately. "I wasn't trivializing the matter," Smitherman said. "I take it really, really seriously." Not surprisingly, the minister couldn't be reached for comment afterwards; but his "diary" entry gives us some insight into why:
After I came in from my night on the streets yesterday morning, Dalton [Premier Dalton McGuinty] called and ordered me to apologize for the diaper "stunt." I explained that I only thought it would gain a better understanding of the issue, but he wouldn't listen. "Also, George," he said, "please tell me you weren't wearing one in my office the other day. Because I thought it smelled like asparagus, if you catch my drift." I told him my cellphone was cutting out and I hung up.
Sam Solomon, writing in his blog Canadian Medicine, adds that this isn't the first time that "Furious George" has run off at the mouth:
Speaking about new building plans suggested by some hospital boards in Ontario, Mr Smitherman dismissively referred to the expensive proposed upgraded facilities as "Taj Ma-hospitals."

His most famous outburst was featured on Stephen Colbert's American parody politics talk show in 2005. Talking to none other than an assemblage of the Ontario Association of Optometrists, Mr Smitherman called optometrists "a bunch of terrorists, and I don't negotiate with terrorists." "Bravo, sir," Mr Colbert said. "Optometrists are a menace. You have to be careful with a group that gets their kicks blowing air into our eyeballs."
Smitherman’s bizarre antics were dismissed by Sid Ryan, president of CUPE's Ontario chapter, who said the minister completely missed the point. The problem isn’t the products, but the cruel reality that residents in long-term care facilities are forced to wear soiled diapers through the night and sometimes up until noon the next day. “If the minister wants to play silly games, well then, let him put on a diaper and sleep in it all night long and come into the legislature and wear it up until 12 o’clock,” Ryan told the Canadian Press.

Could the problems so clumsily dealt with by Ontario's health minister be related to the fact that in Ontario 60% of all publicly funded long-term care beds are in for-profit institutions, as compared with 15% in Manitoba [1]? There is ample research to show that public investment in not-for-profit, rather than for-profit, delivery of long-term care results in more staffing and improved care outcomes for residents [1,2]. Instead of experimenting with adult diapers, perhaps Mr. Smitherman should try absorbing some of these important statistics. There are a lot of excellent health libraries within throwing distance of the Ontario legislature.


1. McGrail KM, McGregor MJ, Cohen M, Tate RB, Ronald LA. For-profit versus not-for-profit delivery of long-term care. CMAJ. 2007 Jan 2;176(1):57-8.

2. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, Ronald L, Cvitkovich Y, Beck M. Staffing levels in not-for-profit and for-profit long-term care facilities: does type of ownership matter? CMAJ. 2005 Mar 1;172(5):645-9.

06 March 2008

Misconstrual of the month: naked librarians and involving buns

There must be a copy editor job vacancy at the office of Library review. How else to explain the driving sleet of slips, flubs, gaffes, muffs, typos, punctuation misfirings, and hair-raising solecisms in an article that appears in the most recent issue? With an effusive application of that endearing élan and derring-do of the "librarians rule" school to my professional bailiwick, two South Africans work up a mighty sweat as they trample hard over the conventions of English prose and punctuation in their contribution, The naked librarian: health librarians in the modern era [1].

Little more than a collection of boilerplate truisms and trite exhortations, this essay is a roll-up-your-sleeves call to action, a perky if not always entirely coherent ramble through the usual library science banalities, starting with that most hackneyed of clichés from the last couple of decades. Care to guess what it is? A phrase so familiar that we now hear it being solemnly intoned by bakers, candlestick makers and undertakers: "The only constant is change."

That, of course, is the famous quotation from Isaac Asimov. Nothing to misconstrue there. But back to our scantily attired article. For the next five pages we are marched out into the cold courtyard and put through a vigorous drill of platitudes and commonplaces:

Health information professionals have to envision the future and plan from there. We have to get rid of outdated ideas and revolutionize our way of thinking. Shrugging off the old coat of the stereotypical librarian, we must start off in our envisioned future, as 'naked librarians' turning into brand new and constantly evolving [sic].
After a laundry list of the challenges and obstacles, most of them "huge," facing health libraries in the "modern era," we are exhorted to "use the digital age" and "proactively anticipate the future implications." Once we have done all that "we will be educated in the latest technical lingo and sound just like computer scientists." (Now I know why I became a librarian.) But look at what else our naked chefs are cooking up: "One of the less mined (as yet) areas for us to explore and conquer, is how to make raw data available to everyone." Not even half-baked? Instead of worrying about a post-Google world we are exhorted in a memorably mixed metaphor to "step up to the plate, accept these challenges and go with the flow."

Now perhaps I'm being overly critical when I say that we librarians have really had enough of this. As Candy Hillenbrand wrote in her take on librarianship in the 21st century, "Desperate to slough off the old limiting stereotypes of the stern bespectacled cardigan-clad shushing controller of books, librarians are clamouring to convince themselves, each other and the wider community that there is far more to the humble librarian than meets the casual eye" [2]. Are we so hankering for attention that only disrobing ourselves in public will suffice?

Just what is this fixation on ripping off our tweedy garments and emerging unclad into the light, like Blake's Glad Day? Is some kind of mass psychosis making us want to run through the streets in puris naturalibus? I saw a sign the other day advertising evening classes in pole dancing. Is this part of some larger social pathology? Or have librarians been infected by the myriads of spores invisibly rising from the piles of discarded print materials in our denuded workplaces? What next? When the clothes are gone should we move on to trichotillomania? Please, let us put a stop to this depilatory process, expose the abuse, and doff this tired metaphor once and for all.

But back to the rapidly unravelling Steyn and de Wee. In the last section of their article they offer what I'm sure is meant to be an edifying quote from a newspaper column by Shelley Howells [3] that appeared five years ago in the New Zealand Herald. All very cute and fluffy in a condescending way, Howells' piece is an example of what has become a standard mass-media treatment of librarians. We are secret nonconformists, wise as serpents and clever as foxes. We are wily, rebellious and twee — not a stitch left of our old encumbrances. Here is Howells' opening sentence, as quoted by Steyn and de Wee:
Librarians rock. That reputation that they have involving buns, sensible shoes and shushing people is merely a cunning ruse, developed over centuries, to conceal their real lives as radicals, subversives and providers of extreme helpfulness.
At this point, having ploughed my way dutifully through the entire article, I had become accustomed to its many textual difficulties. I was beginning to understand the challenges faced by the squinting exegetes of the Dead Sea Scrolls. For here I was, rubbing my eyes in confusion. There was something very wrong with the passage. How to figure out the thats? What exactly were those buns? And how did involving buns relate to naked librarians? Flushed with curiosity, I decided to check the original newspaper article, hoping its text had not disappeared into the Internet Gehenna of 404 not-found error pages. I was lucky this time and found it. Here is what Shelley Howells actually wrote:
Librarians rock. That reputation they have involving buns, sensible shoes and shushing people is merely a cunning ruse, developed over centuries, to conceal their real lives as radicals, subversives and providers of extreme helpfulness.
The sharp-eyed among us will note immediately that in the original text there is no that after reputation. Oh what a difference one word can make! When I first read the sentence, Steyn and de Wee's slipshod insertion of the extraneous that in their quotation had thrown me off completely. It put a spanner in the syntactical works, so to speak, leading this innocent reader to think librarians' buns were being described in the same way as their shoes — with an adjective. The extra that altered the sentence's focus and led me to think impure thoughts. Was involving a typo for involuted? What would such buns look like? But then I was brought up short by the non-tensed verb phrase shushing people. It didn't seem to fit with the two previous attributes which I thought I was being told librarians possessed.

My apologies to those of you who aren't grammar buffs, but I have to get technical here. After seeng Howell's original text I was finally able to parse the sentence to my satisfaction. Buns is the object of the gerund involving, which may also be described as a non-tensed verb phrase with -ing participle. Buns is not the object of the verb have. Involving is the first word of a participial defining relative clause which tells us that which the reputation of librarians involves. It is not a participial adjective, as in these examples: dangling participles, burning buns, flaming idiots. For more information on all things participial, see the Cambridge grammar of English [4].

Confused by now? I certainly was. Dangled enough participles for today? I'm ready to hit the showers.

But Steyn and de Wee aren't finished yet. Feel the goosebumps rise as you thrill to their final rallying cry: "Let us shrug off our 'clothes' and get into the new gear of the future! ... From naked librarian to formidable information force."

Oh dear. It's -25 outside and I don't want to dangle for long. This radical subversive and provider of extreme helpfulness would much rather stay indoors and fully clothed, thank you.


1. Steyn C, de Wee JA. The naked librarian: health librarians in the modern era. Library review. 2007;56(9):797-802.

2. Hillenbrand C. Librarianship in the 21st century - crisis or transformation? Australian library journal [serial on the Internet]. 2005 [cited 2008 Mar 4];54(2):[about 5 p.]. Available from: http://www.alia.org.au/publishing/alj/54.2/full.text/hillenbrand.html

3. Howells S. The secret life of tattooed and belly-dancing librarians. New Zealand herald [serial on the Internet]. 2003 Nov 28 [cited 2008 Mar 4]. Available from: http://www.nzherald.co.nz/section/story.cfm?c_id=5&objectid=3536464

4. Carter M, McCarthy M. Cambridge grammar of English: a comprehensive guide. Cambridge: Cambridge University Press; 2006.

03 March 2008

Missing the obvious, Part 2: slapdash database grocery lists masquerading as articles in medical journals

Six months after
a "research letter" entitled World Databases of Summaries of Articles in the Biomedical Fields was published by Falagas et al. in the Archives of Internal Medicine, a politely-worded demolition of that pretentious excresence has appeared in the same journal's issue of 14 Jan 2008. I vented much less diplomatically about Falagas et al. last July, shortly after it had been published. What was it that raised my hackles and got my goat? Without even nodding in the direction of a library, Dr. Falagas and his team (it actually took more than one person?) sat around a computer one day, scribbled a straggly list of a few databases "based on our previous knowledge" and a few they happened to come across in Google, and by some unattested miracle got their sophomoric effort published in one of the world's most important medical journals. Imagine Will Ferrell and Jon Heder doffing their figure skates and heading for the Moulin Rouge.

I groused at some length about how this inept and unscientific approach not only missed the obvious but apparently escaped any intelligent peer review. I made reference to the well-known Murphy's Law definition of an expert as a person who avoids the small errors while sweeping on to the grand fallacy. Unfortunately, in Falagas' farrago even the small errors were hopelessly compounded, and he swept irreversibly on to something approaching Grand Guignol.

With their letter
subtitled "Getting the whole picture," Dr. Isobel C. Hoskins of CAB International and her two co-authors shine some welcome light on this Carnaval des spectres. With laudable courtesy and restraint — something I wouldn't be capable of under any circumstances — they list "some important omissions" from Falagas' shabby compendium of health databases: Global Health, CINAHL and PsycINFO, to name a few. They tactfully correct one of the grossest errors: "Readers should also be aware that the published list of additional databases includes hosts for databases such as Dialog and EBSCO rather than the databases themselves." As if his dilettantish approach wasn't bad enough, even Falagas' mistakes have errors. His misbegotten enumeration of database hosts omits OVID, for example. Hoskins et al. conclude by finally attempting the right thing and pointing to a health library website. They could have done better than supply a list of public health databases (CINAHL is not included), but in this weak suggestion Hoskins et al. are at least providing a hint to the readers of the Archives that it's all right to go beyond the input of colleagues and the Google prompt when looking for medical resources on the web.

In his two-paragraph reply, festooned with no less than four self-referential footnotes, Dr. Falagas welcomes the valuable input of "our colleagues." In a tone approaching that of a pronouncement from the Holy See he asserts his strong belief "that the availability of lists of databases ... is useful to researchers, clinicians, and other health care professionals." And he's not just whistling Gaieté parisienne. He goes on to puff more of his grocery lists, all of them published in major medical journals. And there are others he hasn't cited. This bloke pumps out more research than kicks at a cancan show (I count 298 PubMed citations to date). An extraordinary accomplishment considering that he seems not to have do-si-doed across the threshold of a library in his entire career. My question is: why doesn't he leave the choreography of knowledge-based information resources to those who know how to dance?

Before I get my petticoats into a real knot, I will briefly mention another of Falagas et al's forays into the world of databases and search engines
this time in a paper unaccountably published in FASEB Journal comparing PubMed, Scopus, Web of Science, and Google Scholar. Did anyone at FASEB edit this article or even look at the contents? A reading of the first clause of its first sentence is not encouraging: "The development along with the spread of the World Wide Web (WWW) represents an informational [sic] revolution ..." There is much more where this comes from as the article develops and spreads. "In conclusion, scientific databases of biomedical information are frequently used by both clinicians and researches [sic]. In this article, we compared the content and various practical aspects in [sic] the utility of the main databases of biomedical scientific information. We found that PubMed remains an important source for clinicians and researchers ..." And on they go in this manner for five densely printed pages without a single original thought, spinning in all directions, legs lifted and twirling. Zoot alors! Kick. Kick. Kick.