Sonia Shah: 3 reasons we still haven't gotten rid of malaria

翻译人员: Guangqiu Shen 校对人员: Tingting Zhao

So over the long course of human history,

在漫长的人类历史中，

the infectious disease that's killed more humans

疟疾是

than any other is malaria.

致死率最高的传染性疾病。

It's carried in the bites of infected mosquitos,

它由受感染的蚊子叮咬传播，

and it's probably our oldest scourge.

可能是人类最古老的灾难了。

We may have had malaria since we evolved from the apes.

从人猿时代起疟疾可能就已经存在了。

And to this day, malaria takes a huge toll on our species.

直至今天，疟疾已经夺去了许多许多人的生命。

We've got 300 million cases a year

每年有3亿人疟疾患者，

and over half a million deaths.

其中有超过50万人死亡，

Now this really makes no sense.

这真让人匪夷所思。

We've known how to cure malaria

自17世纪起，

since the 1600s.

我们就已经知道如何治疗疟疾。

That's when Jesuit missionaries in Peru

耶稣会传教士在秘鲁

discovered the bark of the cinchona tree,

发现金鸡纳树的树皮。

and inside that bark was quinine,

金鸡纳树树皮中的奎宁可以治疗疟疾，

still an effective cure for malaria to this day.

这种方法至今有效。

So we've known how to cure malaria for centuries.

所以，我们知道如何治疗疟疾已经有几个世纪的时间了。

We've known how to prevent malaria since 1897.

从1897年开始，我们就知道如何预防疟疾。

That's when the British army surgeon Ronald Ross

那时英国军队外科医生罗纳德-罗斯

discovered that it was mosquitos that carried malaria,

发现了是蚊子传染疟疾，

not bad air or miasmas, as was previously thought.

而不是之前认为的空气质量或雾霾问题

So malaria should be a relatively simple disease to solve,

所以，疟疾应该是一种容易攻克的疾病，

and yet to this day, hundreds of thousands of people

但直到今天，仍然有成千上万的人

are going to die from the bite of a mosquito.

因为被一只蚊子叮咬而丧命。

Why is that?

为什么呢？

This is a question that's

这是一个很长时间以来

personally intrigued me for a long time.

一直在困惑我的一个问题。

I grew up as the daughter of Indian immigrants

我来自一个印度移民家庭，

visiting my cousins in India every summer,

每年夏天，我会去印度看望我的表兄弟姐妹们，

and because I had no immunity to the local malarias,

因为我对当地的疟疾没有免疫力，

I was made to sleep under this hot, sweaty mosquito net every night

每晚我不得不睡在那种非常闷热的蚊帐里，

while my cousins, they were allowed to sleep

但我的表兄弟姐妹们却可以被允许

out on the terrace and have

在露台上睡觉，

this nice, cool night breeze wafting over them.

享受从他们身上吹佛而过的舒爽夜风。

And I really hated the mosquitos for that.

因为这个，我特别痛恨蚊子。

But at the same time, I come from a Jain family,

但与此同时，我也是来自一个耆那教的家庭，

and Jainism is a religion that espouses

耆那教是一个极其信奉

a very extreme form of nonviolence.

非暴力形式的宗教。

So Jains are not supposed to eat meat.

所以，耆那教徒不吃肉。

We're not supposed to walk on grass,

不能在草地上走，

because you could, you know,

因为那样的话

inadvertently kill some insects when you walk on grass.

你无意中会杀死一些昆虫。

We're certainly not supposed to swat mosquitos.

当然，我们也不能打蚊子。

So the fearsome power of this little insect

所以，这小小的昆虫所拥有的如此可怕的力量，

was apparent to me from a very young age,

在我很小时候就令我印象深刻，

and it's one reason why I spent five years as a journalist

而这也是为什么我作为一名记者

trying to understand, why has malaria

花了五年时间去尝试了解

been such a horrible scourge for all of us for so very long?

为什么疟疾会成为人类持续的灾难。

And I think there's three main reasons why.

我认为主要有三个原因，

Those three reasons add up to the fourth reason,

这三个原因共同导致第四个原因，

which is probably the biggest reason of all.

而这第四个可能就是其中的主导因素。

The first reason is certainly scientific.

第一个原因是科学相关的。

This little parasite that causes malaria,

这种引起疟疾的小小的病原寄生虫，

it's probably one of the most complex

可能是人类已知的最复杂

and wily pathogens known to humankind.

最狡猾的病原体之一。

It lives half its life inside the cold-blooded mosquito

它生命的一半时间生活在冷血动物――蚊子体内，

and half its life inside the warm-blooded human.

另一半生命则生活在恒温动物――人类体内。

These two environments are totally different,

这是两种完全不同的环境，

but not only that, they're both utterly hostile.

而且它们在两种环境下都是有害的。

So the insect is continually trying to fight off the parasite,

因此，昆虫不断试图击退寄生虫，

and so is the human body continually trying to fight it off.

人类的身体也不断地尝试抵抗它。

This little creature survives under siege like that,

这种小小的生物体正是在这种围困下生存下来，

but not only does it survive, it has thrived.

而且还在蓬勃发展。

It has spread. It has more ways to evade attack than we know.

它拥有超过我们想象的更多方法来逃避攻击，继而传播蔓延。

It's a shape-shifter, for one thing.

就某一方面而言，这是一种蜕变。

Just as a caterpillar turns into a butterfly,

就像一条毛毛虫变成一只蝴蝶，

the malaria parasite transforms itself like that

疟疾寄生虫在其生命中有7次

seven times in its life cycle.

这样的蜕变。

And each of those life stages not only looks totally different from each other,

各个生命阶段不只形态迥异，

they have totally different physiology.

而且都有完全不同的生理状态。

So say you came up with some great drug

所以，当你找到一种很强大的药物

that worked against one stage of the parasite's life cycle.

来对抗这种疟疾寄生虫生命周期的某一个阶段，

It might do nothing at all to any of the other stages.

但对其他生命阶段可能完全无效。

It can hide in our bodies, undetected,

它隐藏在我们的体内，不被发现，

unbeknownst to us, for days, for weeks,

瞒着我们，几天、几个星期、

for months, for years, in some cases even decades.

几个月、几年，有时甚至是几十年。

So the parasite is a very big scientific challenge to tackle,

所以这种疟疾寄生虫对科学研究而言形成巨大挑战，

but so is the mosquito that carries the parasite.

携带疟疾寄生虫的蚊子也如此。

Only about 12 species of mosquitos

只有大约12种的蚊子

carry most of the world's malaria,

携带了世界上大部分的疟疾，

and we know quite a bit about the kinds of

我们知道

watery habitats that they specialize in.

它们擅长生活在有水的栖息地。

So you might think, then, well, why don't we just

所以，你可能会认为，

avoid the places where the killer mosquitos live? Right?

我们可以避开蚊子滋生的地方，对吧？

We could avoid the places where the killer grizzly bears live

我们可以不接近凶猛灰熊的住地

and we avoid the places where the killer crocodiles live.

也可以远离凶悍鳄鱼的活动区域。

But say you live in the tropics

但如果你生活在热带地区

and you walk outside your hut one day

某天你在自家的房屋外面走

and you leave some footprints in the soft dirt

脚印留在了

around your home.

门口的泥土上。

Or say your cow does, or say your pig does,

又或是你的牛或猪在土中留下了一些蹄印，

and then, say, it rains,

然后，下雨了，

and that footprint fills up with a little bit of water.

那些印记里积满了水。

That's it. You've created the perfect

就这样，你已经为那些疟疾蚊子

malarial mosquito habitat that's right outside your door.

在你家门口打造了完美的栖息地。

So it's not easy for us to extricate ourselves from these insects.

所以说，我们要摆脱这些昆虫并不容易。

We kind of create places that they love to live

我们生活，

just by living our own lives.

其实也在为它们创建合适的生活环境。

So there's a huge scientific challenge,

所以，这对科学来说是个巨大挑战，

but there's a huge economic challenge too.

对于经济来说，也同样是一个巨大挑战。

Malaria occurs in some of the poorest

疟疾发生在地球上那些最贫穷的

and most remote places on Earth,

和最偏僻的地方，

and there's a reason for that.

这是有原因的。

If you're poor, you're more likely to get malaria.

如果你很穷，你更有可能患上疟疾。

If you're poor, you're more likely to live

因为你的贫穷使你更可能生活

in rudimentary housing on marginal land that's poorly drained.

在贫瘠偏远地区简陋的房屋中，那里的排水往往不好，

These are places where mosquitos breed.

也正是是滋生蚊子的好地方。

You're less likely to have door screens or window screens.

你不太可能有门或窗户的屏障。

You're less likely to have electricity

你不太可能有电

and all the indoor activities that electricity makes possible,

所有通过电力所产生的室内活动都不太可能有，

so you're outside more.

所以你会更多在户外待着，

You're getting bitten by mosquitos more.

更多地被蚊子叮咬。

So poverty causes malaria,

所以说贫穷导致疟疾。

but what we also know now is that malaria itself

但我们也知道

causes poverty.

疟疾本身也会导致贫困。

For one thing, it strikes hardest during harvest season,

一方面，疟疾爆发最严重的时间是在收获季节，

so exactly when farmers need to be out in the fields

说以正当农民要在田地里收割庄稼的季节

collecting their crops, they're home sick with a fever.

他们经常会发烧生病在家。

But it also predisposes people to death

当然这也容易引起其它疾病

from all other causes.

最终导致死亡。

So this has happened historically.

所以，过去我们已经有能力

We've been able to take malaria out of a society.

将疟疾从人类社会中铲除。

Everything else stays the same,

但其他一切却仍保持不变，

so we still have bad food, bad water, bad sanitation,

我们的食品安全、饮用水安全以及公共卫生都没有改善

all the things that make people sick.

所有这些都会让人生病。

But just if you take malaria out,

但是，只要你清除了疟疾，

deaths from everything else go down.

其它因素致死的情况也会减少。

And the economist Jeff Sachs has actually quantified

经济学家杰夫-萨克斯对这一问题导致的社会影响

what this means for a society.

进行过量化分析

What it means is, if you have malaria in your society,

这意味着，如果有疟疾存在，

your economic growth is depressed

社会经济增长

by 1.3 percent every year,

会因为这一种疾病

year after year after year, just this one disease alone.

每年减少1.3%，

So this poses a huge economic challenge,

这必然带来巨大的经济挑战。

because say you do come up with your great drug

因为即便你有好的药品

or your great vaccine -- how do you deliver it

或者强大的疫苗

in a place where there's no roads,

但对于一个车都不通

there's no infrastructure,

没有基础设施

there's no electricity for refrigeration to keep things cold,

没有电力制冷来低温保存物品

there's no clinics, there's no clinicians

没有诊所，也没有临床医生的地方，

to deliver these things where they're needed?

你如何把它们发送到那里去？

So there's a huge economic challenge in taming malaria.

所以，在制服疟疾时我们面临巨大的经济挑战。

But along with the scientific challenge and the economic challenge,

在面临科学和经济挑战时，

there's also a cultural challenge,

我们还面临文化方面的挑战，

and this is probably the part about malaria

这大概是疟疾

that people don't like to talk about.

让人们常常讳莫如深的那个方面。

And it's the paradox that the people

悖论在于：世界上疟疾最多的地方，

who have the most malaria in the world

也是疟疾最不受重视

tend to care about it the least.

最不被在乎的地方。

This has been the finding of medical anthropologists again and again.

医学人类学家的发现已经一次次的证明过这一点。

They ask people in malarious parts of the world,

他们问世界上疟疾流行地区的人们，

"What do you think about malaria?"

"你怎么看疟疾这件事?"

And they don't say, "It's a killer disease. We're scared of it."

他们不会说，"它是一种致命的疾病。我们害怕它。”

They say, "Malaria is a normal problem of life."

他们说，"疟疾是一个正常的生活问题"。

And that was certainly my personal experience.

那的确也是我的亲身经历。

When I told my relatives in India

当我告诉我在印度的亲人们

that I was writing a book about malaria,

我正在写一本关于疟疾的书

they kind of looked at me like

他们看我的眼神，

I told them I was writing a book about warts or something.

好像我写的是一本关于瘊子之类的书。

Like, why would you write about something so boring,

仿佛在问，那么无聊的话题，你也写啊！？

so ordinary? You know?

这太平常了，知道吗？

And it's simple risk perception, really.

它真是一个简单的风险认知。

A child in Malawi, for example,

比如，有一个来自马拉维的小孩，

she might have 12 episodes of malaria before the age of two,

两岁之前就已经得过12次疟疾，

but if she survives,

但是，如果她活下来了，

she'll continue to get malaria throughout her life,

她的一生都将不停地患上疟疾，

but she's much less likely to die of it.

但因此致死的可能性会越来越小。

And so in her lived experience,

所以在她的生活里，

malaria is something that comes and goes.

疟疾不过是为来来去去的访客。

And that's actually true for most of the world's malaria.

对于世界上大部分的疟疾来说的确是这样的。

Most of the world's malaria comes and goes on its own.

世界上大部分的疟疾都是自己来自己去。

It's just, there's so much malaria

只是，疟疾病例如此之多

that this tiny fraction of cases that end in death

一起起致死的病例加起来，

add up to this big, huge number.

也就累积成巨大的数字。

So I think people in malarious parts of the world

所以，我认为在世界上疟疾流行地区的人们

must think of malaria the way

看待疟疾的态度

those of us who live in the temperate world

就和我们这些生活在温带地区的人们看待

think of cold and flu. Right?

感冒和流感一样。对吧？

Cold and flu have a huge burden on our societies

感冒和流感对我们的社会和我们的生活

and on our own lives,

造成了巨大的负担，

but we don't really even take

但我们并不会

the most rudimentary precautions against it because

考虑采取一些哪怕是最基本的防范措施，

we consider it normal to get cold and flu

因为我们认为它们只不过是普通的疾病，

during cold and flu season.

就像在感冒和流感季节中常见的感冒和流感一样。

And so this poses a huge cultural challenge in taming malaria,

所以，这对驯服疟疾带来了巨大的文化挑战。

because if people think it's normal to have malaria,

因为，如果人们认为患上疟疾是正常的，

then how do you get them to run to the doctor

那么，你怎么能让他们跑到医生那里

to get diagnosed, to pick up their prescription,

去治疗，开处方

to get it filled, to take the drugs,

拿药

to put on the repellents, to tuck in the bed nets?

用上驱蚊用品，躺到蚊帐中去呢？

This is a huge cultural challenge in taming this disease.

这的的确确是一个巨大的文化挑战。

So take all that together.

所以把这些因素都凑在一起，

We've got a disease. It's scientifically complicated,

我们可以说，

it's economically challenging to deal with,

疟疾在医学上很复杂，在经济上的挑战也不好处理，

and it's one for which the people who stand

那些最该关注此疾病的人们

to benefit the most care about it the least.

却对它不加重视

And that adds up to the biggest problem of all,

这所有一切加总起来，就导致了最大问题，

which, of course, is the political problem.

当然，就是政治问题。

How do you get a political leader to do anything

政治领导人要怎样

about a problem like this?

才能为这类问题做一些什么呢？

And the answer is, historically, you don't.

答案是，从历史上看，不能。

Most malarious societies throughout history

在整个历史上，大部分疟疾流行的社会

have simply lived with the disease.

就是简单地和这种疾病共存。

So the main attacks on malaria have come

所以疟疾面对的主要攻击来源于

from outside of malarious societies,

外部社会因素，

from people who aren't constrained

来自于那些

by these rather paralyzing politics.

不受制于此类瘫痪政治的人们。

But this, I think, introduces a whole host of other kinds of difficulties.

但我觉得这一点必然会导致一系列各式各样的问题。

The first concerted attack against malaria

第一次针对疟疾的协力防治

started in the 1950s.

开始于20世纪50年代，

It was the brainchild of the U.S. State Department.

耗费了美国国务院不少心血，

And this effort well understood the economic challenge.

在此期间也充分考虑了经济面临的挑战。

They knew they had to focus on cheap, easy-to-use tools,

他们知道必须着眼于便宜、 便捷的工具，

and they focused on DDT.

所以着力使用了滴滴涕（译者注：DDT，一种杀虫剂）。

They understood the cultural challenge.

他们也理解了文化面临的挑战。

In fact, their rather patronizing view was that

事实上，当时的观点十分照顾病人，人们认为

people at risk of malaria shouldn't be asked to do anything at all.

不能向处于感染疟疾风险之中的人们提什么要求，

Everything should be done to them and for them.

只要为他们采取一切可能采取的措施就行了。

But they greatly underestimated the scientific challenge.

但他们大大低估了科学所面临的挑战。

They had so much faith in their tools

他们对他们的工具如此有信心

that they stopped doing malaria research.

以至于他们停止了对疟疾的研究，

And so when those tools started to fail,

因此，当这些工具失败的时候，

and public opinion started to turn against those tools,

公众的舆论开始反对，

they had no scientific expertise to figure out what to do.

而他们没有专业的科学知识可以应对这些。

The whole campaign crashed, malaria resurged back,

整个运动残败，疟疾又死灰复燃、卷土重来了，

but now it was even worse than before

而且甚至比先前更猛烈

because it was corralled into the hardest-to-reach places

因为它已经以最难控制的形式，

in the most difficult-to-control forms.

抢占了我们最难接触到的地方。

One WHO official at the time actually called that whole campaign

那时一位世界卫生组织的官员称那整个运动是

"one of the greatest mistakes ever made in public health."

"在公共卫生领域所做犯过的最大错误之一"。

The latest effort to tame malaria started in the late 1990s.

1990年代后期，新一轮驯服疟疾的运动启动了，

It's similarly directed and financed primarily

它的指导和经济支持

from outside of malarious societies.

仍然来源于疾病肆掠的社会之外。

Now this effort well understands the scientific challenge.

这次努力很好的理解了科学所面临的挑战，

They are doing tons of malaria research.

他们做了无数的疟疾研究。

And they understand the economic challenge too.

他们也很了解经济面临的挑战，

They're focusing on very cheap, very easy-to-use tools.

主要集中在便宜、易用的工具上。

But now, I think, the dilemma is the cultural challenge.

但是却遇上了文化方面的困境。

The centerpiece of the current effort is the bed net.

目前主要的努力是利用蚊帐，

It's treated with insecticides.

它是用杀虫剂处理过的。

This thing has been distributed across the malarious world

这个蚊帐已在疟疾流行地区

by the millions.

发放了数百万件。

And when you think about the bed net,

当你想到蚊帐时，

it's sort of a surgical intervention.

它就像某种外科手术。

You know, it doesn't really have any value

你知道，除了有助于防止疟疾外，

to a family with malaria except that it helps prevent malaria.

它对一个已经患上疟疾的家庭来说真的没有任何意义。

And yet we're asking people to use these nets every night.

我们还会要求人们

They have to sleep under them every night.

每晚都必须睡在蚊帐当中，

That's the only way they are effective.

这是唯一有效的途径。

And they have to do that

他们不得不这样做

even if the net blocks the breeze,

即便这些蚊帐挡住了风，

even if they might have to get up in the middle of the night

他们有可能不得不

and relieve themselves,

在深夜起床透透气，

even if they might have to move all their furnishings

他们可能需要移动他们所有的家具

to put this thing up,

来把这东西挂起来，

even if, you know, they might live in a round hut

而他们很可能住在一个圆形的小屋

in which it's difficult to string up a square net.

很难挂起一个方形的蚊帐……

Now that's no big deal if you're fighting a killer disease.

但所有这些麻烦，对于要与一种致命疾病抗争来说

I mean, these are minor inconveniences.

我觉得都微不足道。

But that's not how people with malaria think of malaria.

而患上疟疾的人们也许不这样认为

So for them, the calculus must be quite different.

他们有着完全不同的逻辑。

Imagine, for example, if a bunch of well-meaning Kenyans

想象一下，如果有一群好心的肯尼亚人

came up to those of us in the temperate world and said,

来到我们这些在温带世界生活的人面前，告诉我们说

"You know, you people have a lot of cold and flu.

"你知道，你们有很多的感冒和流感。

We've designed this great, easy-to-use, cheap tool,

我们设计出了这个伟大的、便利的、廉价的工具，

we're going to give it to you for free.

并愿意无偿送给你们。

It's called a face mask,

它叫口罩，

and all you need to do is

你们只需要

wear it every day during cold and flu season

在感冒和流感季节来临时，

when you go to school and when you go to work."

上班上学都戴着它。"

Would we do that?

我们会这样做吗？

And I wonder if that's how people

我猜想那些生活在疟疾泛滥地区的人们

in the malarious world thought of those nets

第一次收到蚊帐的时候，

when they first received them?

就是这么看待那些蚊帐的吧？

Indeed, we know from studies

事实上，根据我们的调查

that only 20 percent of the bed nets

我们第一次派发的蚊帐中只有20%

that were first distributed were actually used.

被实际使用了，

And even that's probably an overestimate,

甚至连这个数字也是高估的，

because the same people who distributed the nets

因为分发蚊帐的那人回访时

went back and asked the recipients,

问那些受助人

"Oh, did you use that net I gave you?"

"哦，你使用我给你的蚊帐了吗?"

Which is like your Aunt Jane asking you,

这就像你的姑妈Jane在问你，

"Oh, did you use that vase I gave you for Christmas?"

"嘿，我圣诞节送你的礼物用了没有？"

So it's probably an overestimate.

所以它很可能是被高估了。

But that's not an insurmountable problem.

但这不是一个不能克服的问题。

We can do more education,

我们可以多做教育工作，

we can try to convince these people to use the nets.

试着说服这些人使用蚊帐，

And that's what happening now.

而我们现在就正在这么做。

We're throwing a lot more time and money

我们花费了更多的时间和金钱

into workshops and trainings and musicals and plays

进行讲习和培训，还通过音乐剧和戏剧，

and school meetings,

通过学校会议，

all these things to convince people

所有这些努力都是为了说服人们

to use the nets we gave you.

去使用我们送的蚊帐，

And that might work.

这也许可能奏效。

But it takes time. It takes money.

只是需要时间和花钱，

It takes resources. It takes infrastructure.

需要资源和基础设施。

It takes all the things that that cheap,

为了这便宜又简便的蚊帐

easy-to-use bed net was not supposed to be.

我们必须大费周折。

So it's difficult to attack malaria from inside malarious societies,

所以，在疟疾流行的社会，与疟疾的斗争很困难。

but it's equally tricky when we try to attack it

但其实当我们试图从这些社会外部去攻击疟疾时，

from outside of those societies.

也会遇到相同的阻碍。

We end up imposing our own priorities

最终，我们把关注的焦点

on the people of the malarious world.

放在了世界上疟疾流行地区的人们身上。

That's exactly what we did in the 1950s,

这正是我们在1950年代所做的，

and that effort backfired.

而结果却是事与愿违。

I would argue today,

今天，我想说的是，

when we are distributing tools that we've designed

我们分发我们设计的那些

and that don't necessarily make sense in people's lives,

不一定会有意义的工具时，

we run the risk of making the same mistake again.

我们其实在再次冒风险犯同样的错误。

That's not to say that malaria is unconquerable,

这并不是说疟疾是不可战胜的，

because I think it is,

我觉得它可以攻克，

but what if we attacked this disease

只是在疾病攻关时

according to the priorities of the people who lived with it?

我们是不是应该优先考虑那些受疟疾困扰的人们？

Take the example of England and the United States.

举个英国和美国的例子。

We had malaria in those countries for hundreds of years,

数百年来，在这些国家中都有疟疾，

and we got rid of it completely,

我们已经完全摆脱了它，

not because we attacked malaria. We didn't.

但不是因为我们攻克了疟疾，我们没有。

We attacked bad roads and bad houses

我们攻克的其实是破旧的道路和鄙陋的住房

and bad drainage and lack of electricity and rural poverty.

不良的排水系统，不足的电力供应和贫困的农村经济，

We attacked the malarious way of life,

易感染疟疾的生活方式是我们攻击的目标。

and by doing that, we slowly built malaria out.

通过这样做，我们慢慢地将疟疾驱赶出去。

Now attacking the malarious way of life,

攻击与疟疾为伴的生活方式

this is something -- these are things people care about today.

才是今天人们所关心的。

And attacking the malarious way of life,

攻击与疟疾为伴的生活方式

it's not fast, it's not cheap, it's not easy,

不是一种可以迅速见效、廉价或者容易的办法，

but I think it's the only lasting way forward.

但却是可持续走下去的唯一选择。

Thank you so much.

非常感谢。

(Applause)

（掌声）