When you say that health literacy is a mostly downstream issue does that 
assume that health literacy (in the context of interactions with health 
services) is only an issue if the other determinants are involved? For 
example, I may be a highly educated, well-to-do, white, anglosaxon, man 
(are there more stereotypes I can use?). But faced with a particular 
health issue my health literacy may be impacted by my vulnerability as a 
patient, the complexity of the health issue, the communication skills of 
the health provider, the amount of information I am given, my relationship 
to the illness etc. The social determinants are certainly going to change 
the nature of that interaction but it's not always going to be clear how 
or why. . . is it? 

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