What makes us get sick? Look upstream | Rishi Manchanda

翻译人员: Twisted Meadows 校对人员: Min WANG

For over a decade as a doctor,

做医生的十年以来,

I've cared for homeless veterans,

我治疗过流浪的老兵，

for working-class families.

也治疗过工薪阶层的家庭。

I've cared for people who live and work in conditions

我治疗过那些生活或工作在

艰苦条件中的人们，

that can be hard, if not harsh,

and that work has led me to believe

这些工作经历让我坚信，

that we need a fundamentally different way

我们需要一种新的视角

of looking at healthcare.

来看待医疗。

We simply need a healthcare system

我们真正需要的医疗卫生系统，

that moves beyond just looking at the symptoms

是一个不只把患者接到诊所里，

that bring people into clinics,

诊断他们的症状，

but instead actually is able to look

而是能够从源头上，

and improve health where it begins.

关注和改善人们的健康。

And where health begins

is not in the four walls of a doctor's office,

健康问题不是

从医生的办公室里开始的，

but where we live

而是源自我们生活和

and where we work,

工作的地方，

where we eat, sleep, learn and play,

源自于跟我们的衣食住行 息息相关的地方，

where we spend the majority of our lives.

那些我们花费大半生所生活的地方。

So what does this different approach to healthcare look like,

那么，这个全新的医疗卫生系统 是怎样的呢？

an approach that can improve health where it begins?

什么样的方式可以从源头上 改善我们的健康？

To illustrate this, I'll tell you about Veronica.

为了阐明这个问题，让我来和你们 说说Veronica的故事。

Veronica was the 17th patient

Veronica是我某天在

out of my 26-patient day

洛杉矶南中心诊所接待的

at that clinic in South Central Los Angeles.

26位患者中的第17位。

She came into our clinic with a chronic headache.

她来我们诊所是因为患有慢性头痛。

This headache had been going on

这头痛已持续好几年了，

for a number of years, and this particular episode

她这个特殊的病例

was very, very troubling.

非常棘手。

In fact, three weeks before she came to visit us

事实上，在她第一次来 拜访我们的三周前，

for the first time, she went to an emergency room in Los Angeles.

她去过了洛杉矶的一处急诊室。

The emergency room doctors said,

急诊室的医生说，

"We've run some tests, Veronica.

“我们对你做了些测试，Veronica.

The results are normal, so here's some pain medication,

结果很正常， 你可以先吃些头疼药，

and follow up with a primary care doctor,

服用后跟基础护理医师进行反馈，

but if the pain persists or if it worsens,

但如果疼痛持续或变严重，

then come on back."

那就再回来找我们。”

Veronica followed those standard instructions

Veronica遵循了这些常规的医疗指示，

之后她又回急诊室来了。

and she went back.

She went back not just once, but twice more.

她回来不止一次，而是两次。

In the three weeks before Veronica met us,

在Veronica与我们见面前的三周里，

she went to the emergency room three times.

她已经去过三次急诊室。

She went back and forth,

她来来回回地跑，

in and out of hospitals and clinics,

反复进出医院和诊所，

just like she had done in years past,

就像她在过去几年间所做的一样，

trying to seek relief but still coming up short.

她试着寻找解决头疼的方法， 但仍以失败告终。

Veronica came to our clinic,

最后，Veronica来到我们的诊所，

and despite all these encounters with healthcare professionals,

尽管之前尝试了各种专业医疗手段，

Veronica was still sick.

她的病却扔没有好转。

When she came to our clinic, though, we tried a different approach.

但当她来我们诊所的时候， 我们尝试了一种不同的方法。

Our approach started with our medical assistant,

我们首先得到了医疗助理的帮助，

someone who had a GED-level training

她受过GED专业训练 （持有普通教育发展证书），

but knew the community.

而且熟悉我们所在的社区。

Our medical assistant asked some routine questions.

我们的医疗助理问了一些常规问题。

She asked, "What's your chief complaint?"

她问：“你的主要症状是什么？”

"Headache."

——“头疼。”

"Let's get your vital signs" —

“让我们来测一些重要指标”——

measure your blood pressure and your heart rate,

也就是量一量血压，测一测心律，

but let's also ask something equally as vital

但也让我们问些同样重要的问题吧，

to Veronica and a lot of patients like her

许多像Veronica一样， 居住在洛杉矶南部的病人

in South Los Angeles.

都会面临的问题。

"Veronica, can you tell me about where you live?

“Veronica,你能告诉我们你住在哪吗？

Specifically, about your housing conditions?

特别说明下你的居住条件，好吗？

Do you have mold? Do you have water leaks?

家里有发霉吗，有漏水吗？

Do you have roaches in your home?"

有蟑螂吗？”

Turns out, Veronica said yes to three of those things:

结果，Veronica对其中三个问题的回答 是肯定的：

roaches, water leaks, mold.

有蟑螂，房屋漏水，已经发霉。

我拿到了那份记录， 从头至尾又看了一遍，

I received that chart in hand, reviewed it,

and I turned the handle on the door

我推开了门，

and I entered the room.

然后进了房间。

You should understand that Veronica,

你们要知道，Veronica，

like a lot of patients that I have the privilege of caring for,

像我有幸接诊过的大多数病人一样，

is a dignified person, a formidable presence,

是一位端庄的女性，一个强大的存在，

a personality that's larger than life,

她的人格比生命更宏大。

but here she was

但此时此刻她在我的

doubled over in pain sitting on my exam table.

体检台上， 却经历着超出常人的痛苦。

Her head, clearly throbbing, was resting in her hands.

她抱着头，正忍受着阵阵抽痛。

She lifted her head up,

然后，她抬起了头。

and I saw her face, said hello,

我看到了她的脸，说了声你好，

接着我马上意识到

and then I immediately noticed something

across the bridge of her nose,

她的鼻梁有些不对劲，

a crease in her skin.

那里的皮肤有褶皱。

在医学上，我们称之为“变应性鼻炎”。

In medicine, we call that crease the allergic salute.

It's usually seen among children who have chronic allergies.

它通常见于有慢性过敏的孩子身上。

It comes from chronically rubbing one's nose up and down,

孩子为了摆脱过敏症状，

trying to get rid of those allergy symptoms,

长期地上下摩擦鼻子从而致病。

and yet, here was Veronica, a grown woman,

但现在，这发生在Veronica—— 一位成年女性身上，

with the same telltale sign of allergies.

她的身上出现了同样的过敏现象。

A few minutes later, in asking Veronica some questions,

在之后的几分钟里， 我问了Veronica一些问题，

and examining her and listening to her,

为她做体检，听她讲述病情，

I said, "Veronica, I think I know what you have.

我说：“Veronica， 我想我知道是怎么回事了。

I think you have chronic allergies,

我觉得是慢性过敏，

and I think you have migraine headaches and some sinus congestion,

我猜你还伴有偏头痛和鼻窦充血，

and I think all of those are related to where you live."

而这些，在我看来 都和你住的地方有关。”

She looked a little bit relieved,

她看上去稍稍宽慰了些，

because for the first time, she had a diagnosis,

因为这是她第一次得到了确诊，

but I said, "Veronica, now let's talk about your treatment.

但我说：“好，Veronica， 现在让我们来谈谈你的治疗方案。

We're going to order some medications for your symptoms,

我们将会为你的症状开些药，

but I also want to refer you to a specialist, if that's okay."

但如果可以的话， 我想为你介绍一位专家。”

Now, specialists are a little hard to find

时至今日，在洛杉矶中南部

in South Central Los Angeles,

已经很难找到专家了，

so she gave me this look, like, "Really?"

于是，她看着我， 就像在说：“真的吗？”

And I said, "Veronica, actually, the specialist I'm talking about

而我回答道：“事实上，Veronica， 我说的专家

is someone I call a community health worker,

是一位社区卫生工作者，

someone who, if it's okay with you,

如果方便的话，

can come to your home

他可以到你家里来，

and try to understand what's going on

试着找出房子漏水、发霉的原因，

with those water leaks and that mold,

试着帮你解决这些房屋问题，

trying to help you manage those conditions in your housing that I think are causing your symptoms,

我觉得正是这些导致了你的症状，

and if required, that specialist might refer you

如果你觉得有必要，那位专家也许

to another specialist that we call a public interest lawyer,

会为你引荐另一位专家， 我们称之为公益律师，

because it might be that your landlord

因为，也许你的健康问题要归咎于

isn't making the fixes he's required to make."

你的房东不愿意掏钱修缮房屋。”

Veronica came back in a few months later.

Veronica在几个月后回来了。

She agreed to all of those treatment plans.

她对整个治疗计划感到满意。

She told us that her symptoms had improved by 90 percent.

她告诉我们， 她的症状已经改善了90%。

She was spending more time at work

她可以花更多的时间

and with her family and less time

在工作和家庭上了，

shuttling back and forth between the emergency rooms of Los Angeles.

也省下了在洛杉矶的 急诊室来回奔波的时间。

Veronica的生活得到了显著改善。

Veronica had improved remarkably.

Her sons, one of whom had asthma,

她还有一个患哮喘的儿子，

were no longer as sick as they used to be.

他们病情都得到了缓解。

She had gotten better, and not coincidentally,

她的病好多了，同时，理所当然的，

Veronica's home was better too.

她的居住环境也变好了。

What was it about this different approach we tried

我们所尝试的这种

that led to better care,

改善医疗的方式，

更少去急诊室，却可以更健康， 这说明了什么呢？

fewer visits to the E.R., better health?

Well, quite simply, it started with that question:

其实很简单，这始于最初那个问题：

"Veronica, where do you live?"

“Veronica，你住在哪儿？”

But more importantly, it was that we put in place

但更重要的是，我们建立了一个机制，

a system that allowed us to routinely ask questions

通过一些例行的提问，

to Veronica and hundreds more like her

对Veronica，和几百名像她一样

about the conditions that mattered

生活在那个社区的人的

居住环境加以关注，

in her community, about where health,

and unfortunately sometimes illness, do begin

而那里才是南洛杉矶这样的 地区健康问题

in places like South L.A.

甚至是疾病的根源所在。

In that community, substandard housing

在这样的社区，劣质的房屋，

and food insecurity are the major conditions

食品安全问题可能是我们诊所

that we as a clinic had to be aware of,

应该关注的主要问题。

but in other communities it could be

但在其他社区，问题可能是

transportation barriers, obesity,

交通拥堵、肥胖、

access to parks, gun violence.

没有公园、枪支暴力。

The important thing is, we put in place a system

重要的是，我们建立的机制

that worked,

奏效了，

and it's an approach that I call an upstream approach.

——我把它称为“逆流机制“ （upstream approach）。

It's a term many of you are familiar with.

你们中许多人可能都熟悉。

It comes from a parable that's very common

它来自一个在公共卫生领域里

in the public health community.

非常著名的寓言故事。

This is a parable of three friends.

这是一则有关”三个朋友“的寓言。

Imagine that you're one of these three friends

假设有3个朋友来到河边，

who come to a river.

你是其中之一。

河边景色优美， 但却被一个孩子的哭声打破了，

It's a beautiful scene, but it's shattered by the cries of a child,

and actually several children, in need of rescue in the water.

实际是上好几个孩子 都掉进了河里，亟待营救。

So you do hopefully what everybody would do.

所以你们本能的做了此刻该做的事。

You jump right in along with your friends.

你和朋友们径直跳入河中。

The first friend says, I'm going to rescue those

第一个朋友说，我去救那些

who are about to drown,

快要淹死的孩子、

those at most risk of falling over the waterfall.

那些濒临落下瀑布的孩子。

The second friends says, I'm going to build a raft.

第二个朋友说， 那我去造只筏子。

I'm going to make sure that fewer people

来确保更少的孩子

need to end up at the waterfall's edge.

会漂到瀑布边缘。

Let's usher more people to safety

我们用它来把更多的孩子

by building this raft,

送到安全地带，

coordinating those branches together.

把树枝绑起来（造只筏子）就好。

Over time, they're successful, but not really,

时间一分一秒过去， 他们成功救起一些人，

as much as they want to be.

但还没达到预期的数量。

More people slip through, and they finally look up

激流把更多人冲走了， 当他们终于抬起头时，

and they see that their third friend

却发现第三个朋友

is nowhere to be seen.

不见了踪影。

They finally spot her.

他们最终发现了她。

She's in the water. She's swimming away from them

她在水里，她游得越来越远，

upstream, rescuing children as she goes,

逆流而上，沿途救起孩子们，

and they shout to her, "Where are you going?

然后他们朝她喊：“你要去哪？

There are children here to save."

这儿有这么多孩子等待救援。”

And she says back,

她回答道：

“我要去找出

"I'm going to find out

who or what is throwing these children in the water."

是谁或什么原因， 让这些孩子掉进了水里。”

In healthcare, we have that first friend —

在医疗卫生中心， 我们有第一个朋友——

we have the specialist,

我们有专家，

we have the trauma surgeon, the ICU nurse,

有创伤外科医师， 有负责重症监护的护士，

the E.R. doctors.

We have those people that are vital rescuers,

还有急诊医生。

我们有这些必要的救援者，

people you want to be there when you're in dire straits.

他们是你处于水深火热中时， 最需要的人。

We also know that we have the second friend —

我们也知道，我们有第二个朋友——

we have that raft-builder.

我们有木筏建造者。

That's the primary care clinician,

基础护理临床医生，

people on the care team who are there

医疗团队中治疗你的

to manage your chronic conditions,

慢性疾病症状的人，

your diabetes, your hypertension,

监护你的糖尿病、高血压，

there to give you your annual checkups,

他们每年为你进行体检，

there to make sure your vaccines are up to date,

确保你接种了最新的疫苗，

but also there to make sure that you have

他们同时也确保你有一只木筏，

a raft to sit on and usher yourself to safety.

可以随时送你去安全地带的人。

But while that's also vital and very necessary,

但与此同时， 很重要也十分必要的是，

what we're missing is that third friend.

被我们忽视了的，那第三个朋友。

We don't have enough of that upstreamist.

我们并没有足够的那种”逆流而上者“。

The upstreamists are the health care professionals

逆流而上者是健康护理专家，

who know that health does begin

他们知道健康来自于我们

where we live and work and play,

工作、生活、娱乐的地方。

but beyond that awareness, is able to mobilize

但他们不仅要能意识到这一点，

the resources to create the system

还得有能力调集资源， 在他们的诊所里、医院里

in their clinics and in their hospitals

建立起一套系统，

that really does start to approach that,

这样才能真正地接近源头，

to connect people to the resources they need

把病人和他们需要的资源联系起来

outside the four walls of the clinic.

——那些资源可能并不在诊所里。

Now you might ask, and it's a very obvious question

现在你也许会问，

that a lot of colleagues in medicine ask:

也是许多从医的同事显然会问的问题：

"Doctors and nurses thinking about transportation and housing?

“医生和护士还要考虑 交通和住房的问题？

Shouldn't we just provide pills and procedures

难道我们不应该只是提供药片和处方

and just make sure we focus on the task at hand?"

并且确保自己专注于手头的工作吗？”

Certainly, rescuing people at the water's edge

诚然，拯救处于瀑布边缘的人

is important enough work.

是足够重要的工作了。

谁还有时间干别的？

Who has the time?

I would argue, though, that if we were to use science as our guide,

但我会说，即使这样， 如果我们有科学的方法做指导，

that we would find an upstream approach is absolutely necessary.

就会发现逆流而上寻找根源 是绝对必要的。

Scientists now know that

科学家现在已经了解，

the living and working conditions that we all

我们每个人都置身其中的 这个工作和

are part of

生活环境，

have more than twice the impact on our health

对我们健康的影响，是我们自身

than does our genetic code,

基因编码的两倍还要多，

and living and working conditions,

而我们的工作生活处境，

the structures of our environments,

环境结构组成，

the ways in which our social fabric is woven together,

我们的社会网络联结的方式，

and the impact those have on our behaviors,

以及它们对我们行为的影响，

all together, those have more than five times

这些全部加起来，比医院

the impact on our health

和医生开出的

than do all the pills and procedures

所有处方和药物

administered by doctors and hospitals combined.

对我们健康的影响的五倍还多。

All together, living and working conditions

这些所有的，生活和工作条件，

account for 60 percent of preventable death.

在可预防的死亡中占了60%。

Let me give you an example of what this feels like.

我给你们举个例子吧。

我们假设有一个公司，科技创业公司，

Let's say there was a company, a tech startup

that came to you and said, "We have a great product.

对你说：“我们有了个伟大的产品，

It's going to lower your risk of death from heart disease."

可以降低你因心脏病死亡的风险。”

Now, you might be likely to invest

那么，你可能会愿意为他们公司投资，

if that product was a drug or a device,

开发这么一种新药物或者医疗设备。

but what if that product was a park?

但如果他们的产品是一座公园呢？

A study in the U.K.,

在英国有一项研究，

a landmark study that reviewed the records

——一项里程碑式的研究，

of over 40 million residents in the U.K.,

调查了4000万英国居民，

通过控制诸多因素，

looked at several variables,

关注了若干变量，最后得出结论：

controlled for a lot of factors, and found that

when trying to adjust the risk of heart disease,

当我们试图控制、调节心脏病的风险时，

one's exposure to green space was a powerful influence.

患者在绿色空间中生活 对其有极大的影响。

The closer you were to green space,

你越靠近绿色空间

to parks and trees,

——像公园和树木，

the lower your chance of heart disease,

你犯心脏病的概率就越小。

and that stayed true for rich and for poor.

而这一点，对穷人和富人都一样适用。

That study illustrates what my friends in public health

这一研究，证实了我在 公共健康领域的朋友

often say these days:

近来常说的话：

一个人的邮政编码，

that one's zip code matters more

比他的基因编码更重要。

than your genetic code.

We're also learning that zip code

我们也知道，邮政编码（地理位置）

is actually shaping our genetic code.

实际上也在塑造我们的基因编码。

The science of epigenetics looks at those molecular mechanisms,

表观遗传学家观察了分子机制，

those intricate ways in which our DNA is literally shaped,

——我们的DNA逐一组合起来的 复杂的方式，

genes turned on and off

基因的激活和休眠，

based on the exposures to the environment,

是基于所暴露的环境，

to where we live and to where we work.

基于我们生活和工作的地方。

So it's clear that these factors,

所以显而易见的是，这些因素

these upstream issues, do matter.

这些逆流而上的问题，确实重要。

They matter to our health,

它们关乎我们的健康，

因此我们的医疗卫生人员 应该在这方面有所作为。

and therefore our healthcare professionals should do something about it.

And yet, Veronica asked me

然而，Veronica也问了我一个

也许是最值得注意的问题，

perhaps the most compelling question

I've been asked in a long time.

这问题被问过很多次了。

In that follow-up visit, she said,

在那次随访中，她说：

"Why did none of my doctors

“为什么之前那些医生

ask about my home before?

从未问过我的住房情况？

In those visits to the emergency room,

我去急诊室的时候，

I had two CAT scans,

做过2次CAT扫描，

I had a needle placed in the lower part of my back

他们还在我背部下方插了根针

to collect spinal fluid,

收集脊髓液，

I had nearly a dozen blood tests.

还做了一大堆血液测试。

I went back and forth, I saw all sorts of people in healthcare,

我来来回回地跑， 找过医疗卫生中心所有类别的医师，

and no one asked about my home."

却没有任何人询问过我的住宅情况。“

The honest answer is that in healthcare,

坦率地说，这是因为在医疗卫生中心，

we often treat symptoms without addressing

在治疗病症时，我们通常不将

the conditions that make you sick in the first place.

导致你生病的环境因素放在首位考虑。

And there are many reasons for that, but the big three

有很多因素导致了这一现象， 说三个主要的，

are first, we don't pay for that.

排在第一的是，这么做不赚钱。

In healthcare, we often pay for volume and not value.

在医疗卫生中心，我们通常 根据”数量“而非”质量“来支付报酬。

We pay doctors and hospitals usually

我们根据医院和医生

for the number of services they provide,

提供服务的次数来付钱，

but not necessarily on how healthy they make you.

而不是取决于他们使你变得多健康。

That leads to a second phenomenon that I call

这导致了第二个现象，我叫它

the "don't ask, don't tell" approach

在医疗卫生系统里，关于逆流问题的

to upstream issues in healthcare.

”别问，别说“倾向。

We don't ask about where you live and where you work,

我们不问你住在哪儿，在哪儿工作，

because if there's a problem there,

因为如果那儿有问题，

we don't know what to tell you.

我们都不知道该如何解释。

It's not that doctors don't know these are important issues.

医生不是不知道这些问题有多重要。

In a recent survey done in the U.S. among physicians,

在最近一次对美国医生进行的调查中，

over 1,000 physicians,

超过1000位受访医生中

80 percent of them actually said that

80%的人确实表示，

they know that their patients' upstream problems

他们知道患者的”上游问题“

are as important as their health issues,

和他们的健康问题一样重要，

as their medical problems,

和医疗问题一样重要。

and yet despite that widespread awareness

然而，尽管对上游问题的

of the importance of upstream issues,

重要性有着普遍共识，

only one in five doctors said they had

只有五分之一的医生说

any sense of confidence to address those issues,

他们有自信能解决这些问题，

to improve health where it begins.

从源头上改善患者健康。

There's this gap between knowing

在了解患者的生活，

that patients' lives, the context of where they live and work,

他们居住、工作的环境， 遇到的问题，

matters, and the ability to do something about it

以及我们现有的医疗系统 做提供的帮助，

in the systems in which we work.

这二者之间的供求严重不匹配。

This is a huge problem right now,

现在，这已经成为一个大问题了，

因为这将人们引向了 下一个问题，那就是：

because it leads them to this next question, which is,

whose responsibility is it?

”谁应该对此负责？“

And that brings me to that third point,

而这就将我带到了第三点，

that third answer to Veronica's compelling question.

Veronica那个引人注目的问题的 第三个答案。

Part of the reason that we have this conundrum

导致我们困境的一部分原因，

is because there are not nearly enough upstreamists

是因为在医疗系统中没有足够的

in the healthcare system.

逆流而上者。

我们没有足够多的那种”第三位朋友“，

There are not nearly enough of that third friend,

that person who is going to find out

那位要去找出

who or what is throwing those kids in the water.

是谁或什么原因， 让这些孩子掉进了水里的人。

Now, there are many upstreamists,

现在，出现了许多逆流而上者，

and I've had the privilege of meeting many of them,

我有幸可以在洛杉矶

in Los Angeles and in other parts of the country

或国内其他地区，

and around the world,

以及世界各地见到他们，

and it's important to note that upstreamists

值得指出的是，逆流而上者，

sometimes are doctors, but they need not be.

可能是医生，但并不一定是。

They can be nurses, other clinicians,

他们也可以是护士、 别的卫生工作者、

care managers, social workers.

护理管理者、社会工作者。

It's not so important what specific degree

逆流而上者不需要

upstreamists have at the end of their name.

有什么特定的头衔。

What's more important is that they all seem

更重要的是他们都具备

to share the same ability to implement a process

相同的能力，可以去推动

that transforms their assistance,

医疗系统改革的过程，

transforms the way they practice medicine.

改变他们医学实践的方式。

That process is a quite simple process.

这一过程十分简单，

It's one, two and three.

它就是：一，二，三。

第一步，他们坐下来，说

First, they sit down and they say,

let's identify the clinical problem

“让我们从一群特定患者中找出

among a certain set of patients.

共同存在的临床问题。”

Let's say, for instance,

比如说，

“让我们试着去帮助那些

let's try to help children

who are bouncing in and out of the hospital

反复进出医院的

with asthma.

哮喘儿童。

一旦抓住了问题的实质， 他们就进入“第二步”，

After identifying the problem, they then move on to that second step,

and they say, let's identify the root cause.

然后他们说， “让我们找到问题的根源。”

好，问题根源分析，在医疗卫生领域，

Now, a root cause analysis, in healthcare,

usually says, well, let's look at your genes,

他们经常会说， “好吧，让我们看看你的基因，

let's look at how you're behaving.

再让我们看看你的生活方式如何。

Maybe you're not eating healthy enough.

也许你吃得不够健康。

赶紧改善饮食吧！”

Eat healthier.

It's a pretty simplistic

这是一种过于简化的

approach to root cause analyses.

分析根源的方法。

It turns out, it doesn't really work

事实上，如果我们只把自己的视野

when we just limit ourselves that worldview.

限制于此， 这种治疗就起不到什么作用。

The root cause analysis that an upstreamist brings

逆流而上者做的 问题根源分析是这样的：

to the table is to say, let's look at the living

“让我们看看你生活和

and the working conditions in your life.

工作的环境怎么样。”

Perhaps, for children with asthma,

也许，对患有哮喘的孩子们来说，

it's what's happening in their home,

可能是他们家里有什么问题，

or perhaps they live close to a freeway with major air pollution

或他们住的离高速公路比较近， 那里空气污染严重，

that triggers their asthma.

会引发他们的哮喘。

And perhaps that's what we should mobilize our resources to address,

也许这正是我们应该 调集资源去解决的，

because that third element, that third part of the process,

因为那第三个元素， 这个过程中的“第三步”，

is that next critical part of what upstreamists do.

也就是逆流而上者将要采取的 关键步骤。

They mobilize the resources to create a solution,

他们调集资源来设计一个解决方案，

both within the clinical system,

不仅仅是在临床医学系统，

and then by bringing in people from public health,

还要从公共卫生系统，

from other sectors, lawyers,

从其他领域，找律师等等，

whoever is willing to play ball,

任何一个愿意出一份力的人，

let's bring in to create a solution that makes sense,

把他们都集中到一起， 设计一个有效的解决方案，

to take those patients who actually have clinical problems

去找出病人的问题根源，

and address their root causes together

将他们与需要的资源连接起来，

by linking them to the resources you need.

从而合力解决医疗中的根源问题。

It's clear to me that there are so many stories

对我来说，很显然， 逆流而上者做出的

of upstreamists who are doing remarkable things.

引人注目的成就数不胜数。

The problem is that there's just not nearly enough of them out there.

问题是， 这样的逆流而上者还是不够多。

By some estimates, we need one upstreamist

经过估算，我们认为医疗卫生系统中

for every 20 to 30 clinicians in the healthcare system.

每20到30位患者就需要一位逆流而上者。

In the U.S., for instance, that would mean

例如，在美国，这意味着

that we need 25,000 upstreamists

到2020年时我们将需要25000个

by the year 2020.

逆流而上者。

但我们现在只有几千个逆流而上者， 数来数去只有这么多，

But we only have a few thousand upstreamists out there right now, by all accounts,

and that's why, a few years ago, my colleagues and I

这就是为何， 几年前我和我的同事会说：

said, you know what, we need to train

你们知道吗，我们需要训练和培养

and make more upstreamists.

更多的逆流而上者。

So we decided to start an organization

所以我们决定发起一个叫

called Health Begins,

”健康起航”（Health Begins）的组织，

and Health Begins simply does that:

任务很简单：

我们训练逆流而上者。

We train upstreamists.

And there are a lot of measures that we use for our success,

我们有很多种衡量自己成就的方式，

but the main thing that we're interested in

但我们最关注的是

is making sure that we're changing

确保我们在改变

the sense of confidence,

医疗领域的信心，

也就是改变临床医师中的 “别问，别说”现象。

that "don't ask, don't tell" metric among clinicians.

We're trying to make sure that clinicians,

我们正在试着让医师

and therefore their systems that they work in

及他们所在的医疗卫生系统，

have the ability, the confidence

有能力和自信，

to address the problems in the living

去找出那些来自我们的

and working conditions in our lives.

生活、工作环境里的问题。

We're seeing nearly a tripling

我们正在我们的工作中，

of that confidence in our work.

见证着三倍于那样的自信。

It's remarkable,

这是个非凡的成就，

but I'll tell you the most compelling part

但我要说，与逆流而上者共事，

of what it means to be working

将他们的力量聚集起来

with upstreamists to gather them together.

所蕴含的意义是最鼓舞人心的部分。

What is most compelling is that every day,

最令人兴奋的是，每天、每周，

every week, I hear stories just like Veronica's.

我都会听到像Veronica一样的故事。

There are stories out there of Veronica

有很多和Veronica相似的故事，

and many more like her,

甚至越来越多，

people who are coming to the healthcare system

那些前来医疗卫生中心的人们

and getting a glimpse of what it feels like

正实际地体验着

to be part of something that works,

我们的工作成果，

a health care system that stops bouncing you back and forth

这个医疗卫生系统 不再来来回回地折腾你，

but actually improves your health,

而是能够实际改善你的健康，

listens to you who you are,

倾听你的故事，

addresses the context of your life,

了解你的生活经历，

无论你是富人，还是穷人，或者中产阶级。

whether you're rich or poor or middle class.

These stories are compelling because

这些故事令人印象深刻，是因为

not only do they tell us that we're this close

它们不仅让我们知道了我们的工作

to getting the healthcare system that we want,

已经如此接近理想的医疗系统，

but that there's something that we can all do to get there.

还让我们知道了要如何实现这个目标。

Doctors and nurses can get better at asking

医护人员通过询问患者的生活情况，

about the context of patients' lives,

可以更好地为他们服务，

not simply because it's better bedside manner,

不仅仅因为更好的问诊态度，

but frankly, because it's a better standard of care.

坦率地说， 还因为这代表着更高水准的医疗方式。

Healthcare systems and payers

医疗卫生系统和纳税人可以共同

can start to bring in public health agencies

建立相关的公共卫生机构和部门，

and departments and say,

然后说：

让我们共享数据。

let's look at our data together.

Let's see if we can discover some patterns in our data about our patients' lives

看看能否从患者的生活数据上 找出一些端倪，

and see if we can identify an upstream cause,

从而诊断出上游的诱因，

and then, as importantly, can we align the resources

然后，同样重要的，能否调整社会资源

to be able to address them?

来解决这些问题？

Medical schools, nursing schools,

医学院校，护理学校，

all sorts of health professional education programs

所有医疗卫生专业教育项目

can help by training the next generation of upstreamists.

都能够通过训练新一代的 逆流而上者来帮助我们。

我们也很确定，这些学校

We can also make sure that these schools

certify a backbone of the upstream approach,

将成为“逆流机制”的中坚力量，

and that's the community health worker.

那将是一个先进卫生工作者的群体。

We need many more of them in the healthcare system

我们的医疗卫生系统里 需要很多这样的人，

if we're truly going to have it be effective,

——如果我们确实想让它变得更高效，

to move from a sickcare system

让它从一个“只关心病痛”的系统，

to a healthcare system.

转变成一个“关注健康”的系统。

But finally, and perhaps most importantly,

但最终，也许是最重要的是：

what do we do? What do we do as patients?

我们能做些什么？ 作为患者该应该怎么做？

We can start by simply going to our doctors

很简单，当我们到诊所时，

and our nurses, to our clinics,

面对我们的医生、护士，

and asking, "Is there something in where I live

我们可以问：“我居住和工作的地方

and where I work that I should be aware of?"

有没有什么值得注意的？”

Are there barriers to health that I'm just not aware of,

是否存在一些被我忽视的 影响我健康的细节？

and more importantly, if there are barriers

而更重要的是， 如果真的存在一些问题，

that I'm surfacing, if I'm coming to you

我已经察觉到了，然后找到医生说：

and I'm saying I think have a problem with

我觉得我的公寓或者办公环境

my apartment or at my workplace

可能有些问题，

or I don't have access to transportation,

或者我家附近交通不便，

or there's a park that's way too far,

或是，那个公园离我家太远，

so sorry doctor, I can't take your advice

抱歉，医生， 我无法听从你的建议，

to go and jog,

每天去公园慢跑。

if those problems exist,

如果这些问题真的存在，

then doctor, are you willing to listen?

那么，医生，你愿意去倾听吗？

And what can we do together

我们能彼此配合

to improve my health where it begins?

从根源上改善我的健康吗？

If we're all able to do this work,

如果我们都能做到这些，

doctors and healthcare systems,

从医生，到医疗系统，

payers, and all of us together,

到纳税人，我们所有人一起，

we'll realize something about health.

就能实现一种不同以往的健康状况。

Health is not just a personal responsibility or phenomenon.

健康不仅是患者个人的责任或现象。

健康是共同利益。

Health is a common good.

It comes from our personal investment in knowing

它来自我们的个人生活投资，

that our lives matter,

要认识到：生活是不能将就的，

the context of where we live and where we work,

我们居住与工作的环境、

eat, and sleep, matter,

饮食、睡眠…它们都很重要，

and that what we do for ourselves,

而这些我们为自己做的事，

we also should do for those

同样也应该为那些

whose living and working conditions

生活和工作环境

相对比较艰苦的人去做。

again, can be hard, if not harsh.

We can all invest in making sure that we improve

当然，我们都可以寄希望于

the allocation of resources upstream,

能提升”上游“资源的分配。

but at the same time work together

但同时，我们可以协同合作，

and show that we can move healthcare

来证明，我们能让医疗卫生系统 ”逆流而上“地

upstream.

解决问题。

We can improve health where it begins.

我们可以从根源上改善健康。

Thank you.

谢谢。

（掌声）

(Applause)