Rebecca Onie: What if our healthcare system kept us healthy?

Translator: Timothy Covell Reviewer: Morton Bast

翻译人员: Yilun Zhou 校对人员: Yuguo Zhang

So my freshman year of college

在我大学第一年的时候，

I signed up for an internship in the housing unit

我就在波士顿法律系统的住房部

at Greater Boston Legal Services.

得到了一个实习机会。

Showed up the first day

当我第一天上班

ready to make coffee and photocopies,

准备喝点咖啡，复印东西的时候，

but was paired with this righteous, deeply inspired attorney

我就和Jeff Purcell这个

named Jeff Purcell,

有正义感的律师组成了一组，

who thrust me onto the front lines

他把我从第一天起

from the very first day.

就推到了前线。

And over the course of nine months

在9个月里，

I had the chance

我有机会

to have dozens of conversations

和波士顿低收入家庭

with low-income families in Boston

有许多对话，

who would come in presenting with housing issues,

他们和我谈起住房问题，

but always had an underlying health issue.

但这些问题都有一个潜在的卫生问题。

So I had a client who came in,

我有一个客户跟我说，

about to be evicted because he hasn't paid his rent.

他马上就要被驱逐出住所因为他付不起房租。

But he hasn't paid his rent, of course,

当然他没有付房租，

because he's paying for his HIV medication

不过是因为他要支付艾滋病治疗费用

and just can't afford both.

所以他没法付起两样钱。

We had moms who would come in,

我们的客户中有妈妈，

daughter has asthma,

说她们的女儿有哮喘，

wakes up covered in cockroaches every morning.

每天早上身上爬满蟑螂。

And one of our litigation strategies

所以我们的一个诉讼手段就是

was actually to send me into the home of these clients

把我送到这些人家里

with these large glass bottles.

带着大玻璃瓶。

And I would collect the cockroaches,

然后我用大玻璃瓶来收集这些蟑螂，

hot glue-gun them to this poster board

把他们封起来，

that we'd bring to court for our cases.

然后带到法院。

And we always won

我们总赢

because the judges were just so grossed out.

因为法官法官自己感到恶心。

Far more effective, I have to say,

我想说，这方法

than anything I later learned in law school.

比我在法学院以后学的所有东西都管用。

But over the course of these nine months,

但在那九个月里，

I grew frustrated with feeling

我觉得我们的工作已经太迟了，

like we were intervening too far downstream

并且我被这种感觉所折磨，

in the lives of our clients --

那些人

that by the time they came to us,

到我们这里的时候，

they were already in crisis.

他们已经在危机当中。

And at the end of my freshman year of college,

所以在我大一结束的时候，

I read an article about the work

我读到了关于

that Dr. Barry Zuckerman was doing

巴里·扎克曼博士的工作

as Chair of Pediatrics

他在当儿科主任

at Boston Medical Center.

在波士顿医疗中心。

And his first hire was a legal services attorney

他的第一个工作就是

to represent the patients.

作为律师代表病人。

So I called Barry,

所以我打电话给巴里博士，

and with his blessing, in October 1995

并且在他的帮助下，在1995年十月，

walked into the waiting room

我走进了波士顿医疗中心的

of the pediatrics clinic at Boston Medical Center.

儿科诊所等候室。

I'll never forget,

我永远不会忘记

the TVs played this endless reel of cartoons.

那里的电视不断地播放卡通。

And the exhaustion of mothers

还有母亲的劳累，

who had taken two, three, sometimes four buses

他们也许已经做了2回，3回，有时4回的公交车

to bring their child to the doctor

就为了带她们的孩子来看以上，

was just palpable.

这经历现在我都印象很深。

The doctors, it seemed,

然而，医生似乎

never really had enough time for all the patients,

永远没有足够的时间来看这些病人，

try as they might.

尽管他们很努力。

And over the course of six months,

在6个月里，

I would corner them in the hallway

我在走廊拐角看到他们

and ask them a sort of naive but fundamental question:

问他们一个很简单但基础的问题，

"If you had unlimited resources,

“如果你有无限的组员，

what's the one thing you would give your patients?"

你最想给这些病人什么？”

And I heard the same story again and again,

我听到相同的答复，

a story we've heard hundreds of times since then.

这个答复我已经听到数百遍了。

They said, "Every day we have patients that come into the clinic --

他们说：“每天我们都有病人，

child has an ear infection,

对于耳朵感染的孩子，

I prescribe antibiotics.

我给他们开抗生素。

But the real issue is there's no food at home.

但真正的问题是他们家没有食物。

The real issue

真正的问题是

is that child is living with 12 other people

这个孩子在一个两居室里

in a two-bedroom apartment.

和12个人同居。

And I don't even ask about those issues

所以我甚至就不问这些了

because there's nothing I can do.

因为我什么也做不了。

I have 13 minutes with each patient.

对于一个病人我有13分钟。

Patients are piling up in the clinic waiting room.

病人在诊所等候室堆积。

I have no idea where the nearest food pantry is.

我不知道哪里能弄到吃的，

And I don't even have any help."

我也没有帮助。”

In that clinic, even today,

在那个诊所，每天，

there are two social workers

有两个社会工作者

for 24,000 pediatric patients,

来应对24000个儿童病人，

which is better than a lot of the clinics out there.

这也比其他诊所要强得多。

So Health Leads was born of these conversations --

所以健康领导项目就在这些对话中产生了——

a simple model

一个简单的模型，

where doctors and nurses

在其中医生和护士

can prescribe nutritious food,

可以像开药一样开食物，

heat in the winter

在冬天开供暖

and other basic resources for their patients

以及给病人开其他基本资源

the same way they prescribe medication.

和开药是一模一样的。

Patients then take their prescriptions

然后病人拿着他们的厨房

to our desk in the clinic waiting room

到我们在诊所等候室的桌子前

where we have a core of well-trained college student advocates

在这里我们有训练有素的大学生志愿者

who work side by side with these families

来和这些家庭共同工作

to connect them out

把他们和已有的资源

to the existing landscape of community resources.

连接起来。

So we began with a card table in the clinic waiting room --

所以我们以一个小桌子作为开始——

totally lemonade stand style.

就像一个柠檬汁柜台那样。

But today we have a thousand college student advocates

但现在我们有1000个大学生，

who are working to connect nearly 9,000 patients and their families

来把尽9000患者和家庭

with the resources that they need to be healthy.

和资源联系起来让他们健康。

So 18 months ago

所以18个月前，

I got this email that changed my life.

我收到了一封改变我一生的邮件。

And the email was from Dr. Jack Geiger,

这个邮件是从杰克·盖格博士发来的，

who had written to congratulate me on Health Leads

他祝贺我在健康领导项目上取得的成功

and to share, as he said,

并且像他所说，和我分享

a bit of historical context.

一些历史背景。

In 1965 Dr. Geiger founded

在1965年，盖格博士建立了

one of the first two community health centers in this country,

这个国家两个最早的社区健康中心的一个，

in a brutally poor area in the Mississippi Delta.

在密西西比三角洲最贫穷的地方。

And so many of his patients came in

然后有太多营养不良的病人

presenting with malnutrition

进来

that be began prescribing food for them.

使得他开始给他们开食物。

And they would take these prescriptions to the local supermarket,

然后他们把这些处方带到当地超市，

which would fill them

然后超市提供食物

and then charge the pharmacy budget of the clinic.

并从诊所的药物预算中拿钱。

And when the Office of Economic Opportunity in Washington, D.C. --

当华盛顿特区的经济机会办公室

which was funding Geiger's clinic --

——这个办公室在自助盖格的诊所——

found out about this,

发现这个的时候，

they were furious.

他们很生气。

And they sent this bureaucrat down

并且当他们拍官员

to tell Geiger that he was expected to use their dollars

告诉盖格用这些钱

for medical care --

来提供医疗服务的时候——

to which Geiger famously and logically responded,

盖格发表了著名且有逻辑的回应，

"The last time I checked my textbooks,

“最近一次我看我的教科书的时候，

the specific therapy for malnutrition was food."

书上说营养不良的疗法就是食物。”

(Laughter)

（笑声）

So when I got this email from Dr. Geiger,

所以当我收到盖格的邮件的时候，

I knew I was supposed to be proud

我知道我应该为是这个历史的一部分

to be part of this history.

而感到自豪。

But the truth is

但事实上，

I was devastated.

我很沮丧。

Here we are,

现在是这个情况，

45 years after Geiger has prescribed food for his patients,

当盖格给病人开食物45年后，

and I have doctors telling me,

有医生告诉我，

"On those issues, we practice a 'don't ask, don't tell' policy."

“在那些问题上，我们保持”不许问，不许说“的政策。”

Forty-five years after Geiger,

45年后，

Health Leads has to reinvent

健康领导必须要重新发明

the prescription for basic resources.

开基本资源的处方。

So I have spent hours upon hours

所以我花了很多小时，

trying to make sense of this weird Groundhog Day.

来尝试途理解这个奇怪的土拨鼠节。

How is it that if for decades

我们为什么

we had a pretty straightforward tool for keeping patients,

在几十年前就有一个很直接的手段来让我们的病人

and especially low-income patients, healthy,

特别是低收入病人健康，

that we didn't use it?

但不用？

If we know what it takes to have a healthcare system

如果我们知道什么组成一个健康保障系统，

rather than a sick-care system,

而不是一个疾病治疗系统，

why don't we just do it?

我们为什么不做？

These questions, in my mind,

我认为，这些问题

are not hard because the answers are complicated,

不是因为答案很复杂而变得很难，

they are hard because they require that we be honest with ourselves.

而是因为我们需要对我们自己诚实。

My belief is that it's almost too painful

我的观点是这太痛苦了

to articulate our aspirations for our healthcare system,

来说出来我们对健康系统的渴望，

or even admit that we have any at all.

或者甚至承认我们有一个健康系统。

Because if we did,

因为如果我们这么做，

they would be so removed

那些健康系统就会里

from our current reality.

我们的现实太远了。

But that doesn't change my belief

但这不会改变我的观点：

that all of us, deep inside,

我们所有人在内心深处

here in this room and across this country,

在这个房间里和国家里，

share a similar set of desires.

有一些相同的渴望。

That if we are honest with ourselves

我们如果诚实对待我们自己，

and listen quietly,

仔细倾听，

that we all harbor

我们有

one fiercely held aspiration for our healthcare:

一个强烈的渴望，对于我们的健康系统：

that it keep us healthy.

就是它让我们健康。

This aspiration that our healthcare keep us healthy

这个渴望

is an enormously powerful one.

是一个很强有力的渴望。

And the way I think about this

我是这么认为的：

is that healthcare is like any other system.

健康系统和其他所有系统一样。

It's just a set of choices that people make.

只是人们做的一系列选择。

What if we decided

如果我们决定

to make a different set of choices?

做出一套不同的选择会怎么样呢？

What if we decided to take all the parts of healthcare

如果我们决定吧所有

that have drifted away from us

离我们现实越来越远的部分拿出来

and stand firm and say, "No.

然后坚定地说

These things are ours.

“不，这些是我们的。

They will be used for our purposes.

这些要为我们所用。

They will be used to realize

这些要用来实现我们的

our aspiration"?

希望”又会怎么样呢？

What if everything we needed

如果所有我们需要的

to realize our aspiration for healthcare

来实现我们的渴望

was right there in front of us

就在我们前方

just waiting to be claimed?

等着我们去得到又会怎么样呢？

So that's where Health Leads began.

所以这就是健康领导的起点。

We started with the prescription pad --

我们从处方板开始——

a very ordinary piece of paper --

一个很普通的值——

and we asked, not what do patients need to get healthy --

然后我们不问病人需要什么来变得健康

antibiotics, an inhaler, medication --

——抗生素，呼吸器，药物——

but what do patients need to be healthy,

而是病人需要什么来保持健康，

to not get sick in the first place?

从根本上就不生病？

And we chose to use the prescription

所以我们选择

for that purpose.

以这个目的来开处方。

So just a few miles from here

所以就在几英里外

at Children's National Medical Center,

在儿童国家健康中心，

when patients come into the doctor's office,

当病人进入医生办公室是，

they're asked a few questions.

他们被问到一些问题。

They're asked, "Are you running out of food at the end of the month?

他们被问到：“你在月底还有吃的吗？

Do you have safe housing?"

你有健康的住房吗？"

And when the doctor begins the visit,

并且当医生开始走访，

she knows height, weight, is there food at home,

她知道是否家里有食物，

is the family living in a shelter.

是否有住所。

And that not only leads to a better set of clinical choices,

这不仅导致了更好的临床选择，

but the doctor can also prescribe those resources for the patient,

更能让医生给病人开这些资源，

using Health Leads like any other sub-specialty referral.

在健康领导的指引下。

The problem is,

问题是，

once you get a taste of what it's like

一旦你知道怎样

to realize your aspiration for healthcare,

实现你对健康系统的愿望，

you want more.

你就想要更多。

So we thought,

所以我们想，

if we can get individual doctors

如果我们能让医生个人

to prescribe these basic resources for their patients,

来开这些基本资源，

could we get an entire healthcare system

我们能让整个健康系统

to shift its presumption?

改变吗？

And we gave it a shot.

现在我们在做这个工作。

So now at Harlem Hospital Center

在哈雷姆医疗中心，

when patients come in with an elevated body mass index,

当身高体重指数过高的病人进来时，

the electronic medical record

电子医疗系统

automatically generates a prescription for Health Leads.

自动为健康领导开除处方。

And our volunteers can then work with them

然后我们的志愿者就可以和他们一起工作

to connect patients to healthy food and excercise programs

来把病人和食物及健身项目联系起来

in their communities.

这全在他们的社区里。

We've created a presumption

我们提出了一个新的概念

that if you're a patient at that hospital

就是如果你是一个

with an elevated BMI,

身高体重指数过高的病人，

the four walls of the doctor's office

那么医生办公室

probably aren't going to give you everything

也许不能给你所有

you need to be healthy.

你需要来保持健康的东西。

You need more.

你需要更多。

So on the one hand,

所以与方面，

this is just a basic recoding

这只是一个

of the electronic medical record.

电子医疗基础记录。

And on the other hand,

但另一方面，

it's a radical transformation

这是一个

of the electronic medical record

电子医疗记录的根本的改变

from a static repository of diagnostic information

从静止诊断信息

to a health promotion tool.

到健康促进工具。

In the private sector,

在私人领域，

when you squeeze that kind of additional value

当你把这些额外价值

out of a fixed-cost investment,

从一个固定成本投资中挤出来，

it's called a billion-dollar company.

这是一个十亿美元公司的做法。

But in my world,

但在我的世界里，

it's called reduced obesity and diabetes.

这是减少肥胖和糖尿病的方法。

It's called healthcare --

这是健康保障

a system where doctors can prescribe solutions

——一个系统其中医生可以

to improve health,

开出解决方案来促进健康，

not just manage disease.

而不只是治疗疾病。

Same thing in the clinic waiting room.

同样的事发生在诊所等候室里。

So every day in this country

每天在这个国家

three million patients

三百万病人

pass through about 150,000 clinic waiting rooms in this country.

从150000个等候室里走过。

And what do they do when they're there?

他们在那里做什么？

They sit, they watch the goldfish in the fish tank,

他们坐着，看着鱼缸里的金鱼，

they read extremely old copies

读着很旧的

of Good Housekeeping magazine.

杂志。

But mostly we all just sit there forever, waiting.

但通常我们只是坐在那里，等候。

How did we get here

我们怎样实现

where we devote hundreds of acres and thousands of hours

我们付出几百英里几千小时

to waiting?

等待？

What if we had a waiting room

如果我们有一个等候室

where you don't just sit when you're sick,

在其中你不仅仅坐着，

but where you go to get healthy.

而是在那里就变得健康会怎样？

If airports can become shopping malls

如果机场可以变成商场，

and McDonald's can become playgrounds,

麦当劳可以变成操场，

surely we can reinvent the clinic waiting room.

当然我们可以重新创造等候室。

And that's what Health Leads has tried to do,

这就是健康领导在做的，

to reclaim that real estate and that time

重新利用那片地和时间

and to use it as a gateway

并且把它做成一个过道

to connect patients

来连接病人

to the resources they need to be healthy.

和让他们健康的资源。

So it's a brutal winter in the Northeast,

在东北部寒冷的冬天，

your kid has asthma, your heat just got turned off,

你的孩子有哮喘，但你却没有暖气，

and of course you're in the waiting room of the ER,

当然你在等候室里，

because the cold air triggered your child's asthma.

因为外面的冷风会让你的孩子咳嗽。

But what if instead of waiting for hours anxiously,

但如果不是在等候室里焦急的等几个小时，

the waiting room became the place

而是让等候室变成一个平台

where Health Leads turned your heat back on?

利用这个平台健康领导能让你的暖气重新工作会怎样呢？

And of course all of this requires

当然这需要

a broader workforce.

很多的劳动力。

But if we're creative, we already have that too.

但如果我们有创意，我们已经有了。

We know that our doctors and nurses

我们知道我们的医生和护士

and even social workers

甚至社会工作者

aren't enough,

的力量并不够，

that the ticking minutes of health care

医疗护理的时间

are too constraining.

还太有限。

Health just takes more time.

健康需要更多时间。

It requires a non-clinical army

它需要一个非临床的队伍

of community health workers and case managers

这个队伍由社区健康工作者和特例经理

and many others.

以及其他许多的人组成。

What if a small part of that next healthcare workforce

如果一小部分队伍

were the 11 million college students in this country?

是1100万大学生又会怎么样呢？

Unencumbered by clinical responsibilities,

不受临床责任所限，

unwilling to take no for an answer

不想从那些想压迫病人

from those bureaucracies

的官员口中

that tend to crush patients,

得到不行的答案，

and with an unparalleled ability

并且具备无可匹敌的

for information retrieval

信息收集能力

honed through years of using Google.

且被不断从用谷歌中加强。

Now lest you think it improbable

现在免得你认为

that a college volunteer

一个大学志愿者可以

can make this kind of commitment,

做出这种工作是不可能的，

I have two words for you:

我有两个词给你：

March Madness.

三月疯狂。

The average NCAA Division I men's basketball player

平均一个美国顶级大学生篮球联赛球员

dedicates 39 hours a week to his sport.

每周付出39小时在运动中。

Now we may think that's good or bad,

现在不过我们认为这时好时坏，

but in either case it's real.

这是事实。

And Health Leads is based on the presumption

并且健康领导是基于这样一个事实：

that for too long

已经有太长时间，

we have asked too little of our college students

我们关于学生问的太少了

when it comes to real impact in vulnerable communities.

当谈及脆弱社区的实际影响。

College sports teams say,

高校运动队说，

"We're going to take dozens of hours

“我们要花几十个小时

at some field across campus at some ungodly hour of the morning

在一些校园里的地方，在一些不虔诚的小时，在早上，

and we're going to measure your performance, and your team's performance,

我们要去衡量你的表现和你的团队的表现，

and if you don't measure up or you don't show up,

如果你不来衡量或者不来了，

we're going to cut you off the team.

我们就要把你淘汰。

But we'll make huge investments

但我们会投资大量的钱

in your training and development,

用于你的训练和发展，

and we'll give you an extraordinary community of peers."

并且我们会给你很出色的队友。”

And people line up out the door

门外排队的人

just for the chance to be part of it.

只是为了成为它的一部分。

So our feeling is,

所以我们的感觉就是，

if it's good enough for the rugby team,

如果它对于橄榄球队很好，

it's good enough for health and poverty.

他也对健康和贫困很好。

Health Leads too recruits competitively,

健康领导也用一个很苛刻的条件选拔志愿者，

trains intensively,

给予高强度的训练，

coaches professionally,

专业的训练，

demands significant time,

需要大量的时间，

builds a cohesive team

来筑造一个有凝聚力的团队

and measures results --

并且检测结果 — —

a kind of Teach for America for healthcare.

类似一个为美国而教学的健康保障。

Now in the top 10 cities in the U.S.

现在，在美国的10个

with the largest number of Medicaid patients,

医疗补助患者最多的城市，

each of those has at least 20,000 college students.

每一个人拥有至少 20000 名高校学生。

New York alone has half a million college students.

纽约一个州就有50万大学生。

And this isn't just a sort of short-term workforce

这不只是一种短期的劳动力

to connect patients to basic resources,

来进行把病人和基本资源连接的工作，

it's a next generation healthcare leadership pipeline

它是下一代医疗保健领导的通道

who've spent two, three, four years

那些花了二、 三、 四年

in the clinic waiting room

在诊所等候室

talking to patients about their most basic health needs.

给病人谈论他们最基本的卫生需求的人。

And they leave with the conviction,

他们带着决心离开，

the ability and the efficacy

能力和效率

to realize our most basic aspirations for health care.

来实现我们对卫生保健的最基本愿望。

And the thing is, there's thousands of these folks already out there.

所以，成千上万的人已经到了。

So Mia Lozada is Chief Resident of Internal Medicine

米亚洛是UCSF健康中心

at UCSF Medical Center,

的内科负责人，

but for three years as an undergraduate

但作为在本科的三年里

she was a Health Leads volunteer

她是健康领导的志愿者

in the clinic waiting room at Boston Medical Center.

在波士顿医疗中心诊所等候室工作。

Mia says, "When my classmates write a prescription,

米亚说，"如果我的同学们开了处方，

they think their work is done.

他们就认为他们的工作已经完成了。

When I write a prescription,

当我写了药，

I think, can the family read the prescription?

我认为，家庭可以理解这个处方吗？

Do they have transportation to the pharmacy?

他们能到药房吗？

Do they have food to take with the prescription?

他们有吃的吗？

Do they have insurance to fill the prescription?

他们有保险吗？

Those are the questions I learned at Health Leads,

这些是我在健康领导中学到的，

not in medical school."

而不是在医学院。"

Now none of these solutions --

现在没有任何这些解决方案 — —

the prescription pad, the electronic medical record,

药方，电子医疗记录，

the waiting room,

等候室，

the army of college students --

大学生队伍——

are perfect.

是完美的。

But they are ours for the taking --

但他们是我们的责任 — —

simple examples

简单的例子

of the vast under-utilized healthcare resources

关于大量未充分利用医疗资源的

that, if we reclaimed and redeployed,

如果我们回收和重新调配，

could realize our most basic aspiration

可以实现我们最基本的愿望

of healthcare.

卫生保健。

So I had been at Legal Services for about nine months

所以我一直在约九个月的法律服务

when this idea of Health Leads started percolating in my mind.

当这个健康领导项目被我想时。

And I knew I had to tell Jeff Purcell, my attorney,

我知道我不得不告诉我的律师，杰夫 · 珀塞尔

that I needed to leave.

我需要离开。

And I was so nervous,

我很紧张，

because I thought he was going to be disappointed in me

因为我以为他要将对我失望

for abandoning our clients for some crazy idea.

因为我放弃我们的客户而进行一些疯狂的想法。

And I sat down with him and I said,

他坐下，我说，

"Jeff, I have this idea

"杰夫，我有这种想法

that we could mobilize college students

我们可以调动大学生

to address patients' most basic health needs."

来解决病人最基本的健康需要。”

And I'll be honest,

我是诚实的

all I wanted was for him to not be angry at me.

我只是他不是生我的气。

But he said this,

但他表示，这一点，

"Rebecca, when you have a vision,

"罗贝卡，当你有一个远景

you have an obligation to realize that vision.

你就有义务要实现这一理想。

You must pursue that vision."

你必须追求这一愿景。"

And I have to say, I was like "Whoa.

我不得不说，我就像"哇。

That's a lot of pressure."

这压力很大。”

I just wanted a blessing,

我只想要祝福，

I didn't want some kind of mandate.

我不想要命令。

But the truth is

但事实是

I've spent every waking minute nearly since then

自那时以来我几乎花了醒着的每一分钟

chasing that vision.

追求这一愿景。

I believe that we all have a vision

我相信我们都有一个关于

for healthcare in this country.

这个国家医疗保健的远景。

I believe that at the end of the day

我相信，在一天结束时

when we measure our healthcare,

当我们来衡量我们的卫生保健，

it will not be by the diseases cured,

标准不是被治好的疾病，

but by the diseases prevented.

而是被预防的疾病。

It will not be by the excellence of our technologies

标准不是我们的技术有多好，

or the sophistication of our specialists,

或者我们专家有多专业，

but by how rarely we needed them.

而是我们多么不需要他们。

And most of all,

最重要的是，

I believe that when we measure healthcare,

我认为当我们见此的健康保障是，

it will be, not by what the system was,

标准不是这个系统是什么，

but by what we chose it to be.

而是我们让它变成什么。

Thank you.

谢谢。

(Applause)

（掌声）

Thank you.

谢谢。

(Applause)

（掌声）