Mental Health for All by Involving All | Vikram Patel | TED Talks

Translator: Joseph Geni Reviewer: Morton Bast

翻译人员: Ma Yao 校对人员: Yuguo Zhang

I want you to imagine this for a moment.

让我们一起来想象一下，

Two men, Rahul and Rajiv,

有两个人，拉胡和拉吉，

living in the same neighborhood,

住在一个小区，

from the same educational background, similar occupation,

教育程度相同，工作也差不多。

and they both turn up at their local accident emergency

他俩都去当地的急诊室，

complaining of acute chest pain.

说他们有严重的胸部疼痛

Rahul is offered a cardiac procedure,

急诊室给拉胡做了心脏检查，

but Rajiv is sent home.

却让拉吉回家。

What might explain the difference in the experience

是什么原因让这两个几乎一样的人

of these two nearly identical men?

有着不同的遭遇？

Rajiv suffers from a mental illness.

因为拉吉患有精神疾病。

The difference in the quality of medical care

得不到同等质量的医疗服务，

received by people with mental illness is one of the reasons

是导致精神疾病患者寿命

why they live shorter lives

短于不罹患精神疾病的人

than people without mental illness.

的原因之一。

Even in the best-resourced countries in the world,

即使是在世界上资源最为丰富的国家，

this life expectancy gap is as much as 20 years.

这一寿命差距也有20年之多。

In the developing countries of the world, this gap

而在发展中国家，

is even larger.

两者的寿命差距更大。

But of course, mental illnesses can kill in more direct ways

然而，精神疾病当然也可以更直接地导致死亡。

as well. The most obvious example is suicide.

最常见的例子就是自杀。

It might surprise some of you here, as it did me,

也许在座的一些朋友会感到吃惊，我那时也是，

when I discovered that suicide is at the top of the list

因为我发现，自杀在引起青年死亡的主要原因中

of the leading causes of death in young people

排在第一位。

in all countries in the world,

在每一个国家都是如此，

including the poorest countries of the world.

包括世界上最贫穷的国家。

But beyond the impact of a health condition

不过，除去健康状况对寿命的影响，

on life expectancy, we're also concerned

我们还关心

about the quality of life lived.

生活质量。

Now, in order for us to examine the overall impact

现在，为了让我们准确的知道

of a health condition both on life expectancy

健康对寿命和生活质量的全面影响

as well as on the quality of life lived, we need to use

我们需要用到

a metric called the DALY,

一个叫做DALY的度量单位，

which stands for a Disability-Adjusted Life Year.

DALY是伤残调整生命年的缩写(Disability-Adjusted Life Year)。

Now when we do that, we discover some startling things

当我们这么做时，我们发现了精神疾病的一些令人震惊的事实，

about mental illness from a global perspective.

而这些事实是世界各国普遍存在的。

We discover that, for example, mental illnesses are

例如，我们发现了精神疾病是

amongst the leading causes of disability around the world.

引起生活不能自理的主要原因。

Depression, for example, is the third-leading cause

比如，抑郁正是第三大原因，

of disability, alongside conditions such as

除此之外，还有

diarrhea and pneumonia in children.

腹泻和儿童肺炎。

When you put all the mental illnesses together,

当把所有精神疾病看成一个整体，

they account for roughly 15 percent

全球15%的疾病负担

of the total global burden of disease.

是由他们造成的。

Indeed, mental illnesses are also very damaging

事实上，精神疾病对人们的身体将抗具有很大的破坏性，

to people's lives, but beyond just the burden of disease,

除了疾病负担，

let us consider the absolute numbers.

让我们全面的了解一下精神疾病的破坏性。

The World Health Organization estimates

世界卫生组织统计到

that there are nearly four to five hundred million people

全世界有

living on our tiny planet

接近四亿到五亿的人

who are affected by a mental illness.

受到精神疾病的影响。

Now some of you here

你们中有一些人

look a bit astonished by that number,

对这个数字赶到震惊，

but consider for a moment the incredible diversity

但是，仔细想一下，精神疾病有数以万计的种类，

of mental illnesses, from autism and intellectual disability

从儿童时的自闭症、智障

in childhood, through to depression and anxiety,

到成年的抑郁、焦虑、

substance misuse and psychosis in adulthood,

滥用药物和精神病，

all the way through to dementia in old age,

再到老年的痴呆，

and I'm pretty sure that each and every one us

我敢肯定的说，今天在座的每一个人

present here today can think of at least one person,

都能想到至少一个人，

at least one person, who's affected by mental illness

在我们最熟悉的人中，至少有一个人

in our most intimate social networks.

受到精神疾病的影响。

I see some nodding heads there.

我看到一些人在点头。

But beyond the staggering numbers,

除了这些令人震惊的数字，

what's truly important from a global health point of view,

从全球健康的角度来看，

what's truly worrying from a global health point of view,

真正重要和真正令人担忧的是，

is that the vast majority of these affected individuals

在受影响的这些人中有很大一部分

do not receive the care

没有接受治疗

that we know can transform their lives, and remember,

然而，这些治疗确实可以改变他们的生活，请注意，

we do have robust evidence that a range of interventions,

我们有充分的证据表明，

medicines, psychological interventions,

一些干预、药物治疗、心理辅导和社会干预

and social interventions, can make a vast difference.

确实对精神疾病的治疗有很大的作用。

And yet, even in the best-resourced countries,

但是，即使在资源丰富的国家

for example here in Europe, roughly 50 percent

例如欧洲也有大约50%的人

of affected people don't receive these interventions.

不能接受治疗。

In the sorts of countries I work in,

在我工作的一些国家，

that so-called treatment gap

甚至有90%的人

approaches an astonishing 90 percent.

不能接受治疗。

It isn't surprising, then, that if you should speak

因此，当你与

to anyone affected by a mental illness,

患有精神疾病的人交谈时，

the chances are that you will hear stories

你一般总是能听到他们说起

of hidden suffering, shame and discrimination

几乎在他们所有的生活领域，

in nearly every sector of their lives.

他们都会有隐藏的痛苦、羞耻和被歧视的感觉。

But perhaps most heartbreaking of all

但是，或许在他们的描述中，

are the stories of the abuse

最令人痛心的就是

of even the most basic human rights,

对最基本的人权的践踏，

such as the young woman shown in this image here

就像这张照片中的女子

that are played out every day,

这样的事情每天都会发生，

sadly, even in the very institutions that were built to care

悲哀的是，即使是在本应该治疗人们精神疾病的

for people with mental illnesses, the mental hospitals.

医院中也存在这种现象。

It's this injustice that has really driven my mission

这是这一点让我感觉到我应该

to try to do a little bit to transform the lives

试着做一点努力来改变

of people affected by mental illness, and a particularly

遭受精神疾病折磨的人们的生活，

critical action that I focused on is to bridge the gulf

我做的一个主要的工作就是在

between the knowledge we have that can transform lives,

我们所拥有的改变生活、有效治疗的知识与

the knowledge of effective treatments, and how we actually

把知识运用到日常生活中之间

use that knowledge in the everyday world.

搭建一所桥梁。

And an especially important challenge that I've had to face

我所要面对的一个重要挑战就是

is the great shortage of mental health professionals,

极度缺乏像精神病专家和心理学专家这类的

such as psychiatrists and psychologists,

精神健康专家，

particularly in the developing world.

而这一现在在发展中国家尤为严重。

Now I trained in medicine in India, and after that

现在，我在印度学习了医学，

I chose psychiatry as my specialty, much to the dismay

我选择了精神病治疗作为的专业，

of my mother and all my family members who

这让我妈妈和我的亲戚觉得很失望，

kind of thought neurosurgery would be

因为在她们严重神经外科医生才

a more respectable option for their brilliant son.

配得上他们聪明的儿子。

Any case, I went on, I soldiered on with psychiatry,

我始终坚持着做精神病治疗不论遇到什么病例，

and found myself training in Britain in some of

并且我让自己在英国一些最好的医院得到了锻炼。

the best hospitals in this country. I was very privileged.

我十分的幸运。

I worked in a team of incredibly talented, compassionate,

我与一些十分有天赋、有工作热情的人一起工作，

but most importantly, highly trained, specialized

但是最重要的是，他们也是接受了严格训练的、

mental health professionals.

专业的精神疾病专家。

Soon after my training, I found myself working

在我学习完不久，我首先在津巴布韦工作，

first in Zimbabwe and then in India, and I was confronted

之后到了印度，

by an altogether new reality.

我又需要面对一个新的事实。

This was a reality of a world in which there were almost no

我需要面对的是，有一些地方

mental health professionals at all.

根本就没有精神病专家。

In Zimbabwe, for example, there were just about

例如，在津巴布韦，只有大约十来个精神病医生，

a dozen psychiatrists, most of whom lived and worked

并且他们中的大部分居住在哈拉雷（津巴布韦首都），

in Harare city, leaving only a couple

使得只有几个精神病医生

to address the mental health care needs

负责生活在乡下的9百万人的

of nine million people living in the countryside.

精神健康。

In India, I found the situation was not a lot better.

印度的情况不比津巴布韦好到哪里去。

To give you a perspective, if I had to translate

具体地说，如果我把

the proportion of psychiatrists in the population

英国精神病医生的人口比例

that one might see in Britain to India,

应用到印度

one might expect roughly 150,000 psychiatrists in India.

印度大约需要15万精神病医生。

In reality, take a guess.

然而事实又是怎样呢？

The actual number is about 3,000,

实际上，印度只有3千精神病医生，

about two percent of that number.

只是15万的百分之2。

It became quickly apparent to me that I couldn't follow

我很快的意识到，在像印度或津巴布韦这些国家，我不能

the sorts of mental health care models that I had been trained in,

我不能再遵循我所学的那种精神病治疗模式了，

one that relied heavily on specialized, expensive

因为那种模式的精神病治疗，

mental health professionals to provide mental health care

只能在一个人有能力获得专业的、昂贵的精神病专家的治疗

in countries like India and Zimbabwe.

的情况下才能成功。

I had to think out of the box about some other model

我必须打破思维定势，

of care.

寻找其他方式。

It was then that I came across these books,

那时，我接触了这些书，

and in these books I discovered the idea of task shifting

在这些书中我发现了

in global health.

全球健康任务转变这一观点。

The idea is actually quite simple. The idea is,

这一想法十分的简单。就是，

when you're short of specialized health care professionals,

当你缺少专业的健康专家时，

use whoever is available in the community,

可以找社区中有空闲时间的人

train them to provide a range of health care interventions,

教给他们一些保健干预的知识，

and in these books I read inspiring examples,

这些书中就有一些鼓舞我的例子。

for example of how ordinary people had been trained

例如，书中有写到怎样使普通人学会

to deliver babies,

接生、诊断并治疗早期肺炎，

diagnose and treat early pneumonia, to great effect.

这些都十分的有效。

And it struck me that if you could train ordinary people

于是，我想到，如果我们可以训练普通人去

to deliver such complex health care interventions,

完成这些复杂的保健干预，

then perhaps they could also do the same

或许他们也能进行

with mental health care.

精神疾病治疗。

Well today, I'm very pleased to report to you

今天，我十分高兴的告诉你们

that there have been many experiments in task shifting

在过去十年，发展中国家有许多

in mental health care across the developing world

精神疾病治疗任务转移的实验，

over the past decade, and I want to share with you

我想和你们分享3个特殊的实验

the findings of three particular such experiments,

的成果，

all three of which focused on depression,

这三个实验都是关于最普遍

the most common of all mental illnesses.

的精神疾病——抑郁症。

In rural Uganda, Paul Bolton and his colleagues,

在乌干达的郊区，Paul Bolton 和他的同事

using villagers, demonstrated that they could deliver

对该村村民进行实验，发现他们可以

interpersonal psychotherapy for depression

进行抑郁症的人际关系精神疗法，

and, using a randomized control design,

Paul 和他的同事进行了一些随机控制实验，

showed that 90 percent of the people receiving

他们发现接受这种干预的90%的人恢复健康，

this intervention recovered as compared

而与之相比在对照组，只有

to roughly 40 percent in the comparison villages.

大约40%的人恢复了健康。

Similarly, using a randomized control trial in rural Pakistan,

类似的，Atif Rahman和他的同时在

Atif Rahman and his colleagues showed

巴基斯坦的郊区也进行了随机控制实验，

that lady health visitors, who are community maternal

该实验表明在巴基斯坦保健系统

health workers in Pakistan's health care system,

的社区女工作者

could deliver cognitive behavior therapy for mothers

在对患有抑郁的母亲进行认知行为治疗时

who were depressed, again showing dramatic differences

也同样在康复比例上取得了显著的提高。

in the recovery rates. Roughly 75 percent of mothers

大约75%的母亲获得了康复，而

recovered as compared to about 45 percent

对照组中只有45%

in the comparison villages.

恢复了健康。

And in my own trial in Goa, in India, we again showed

我在印度果阿的实验再一次证明

that lay counselors drawn from local communities

从当地社区中寻找的普通人

could be trained to deliver psychosocial interventions

在经过培训后可以对抑郁、焦虑进行心理干涉，

for depression, anxiety, leading to 70 percent

这些健康顾问可以让70%的人恢复健康，

recovery rates as compared to 50 percent

而即使在主要的健康中心，

in the comparison primary health centers.

这一数据也只能达到50%。

Now, if I had to draw together all these different

现在，总观这些关于任务转换的不同实验，

experiments in task shifting, and there have of course

当然还有其他的实验，

been many other examples, and try and identify

当我试着寻找

what are the key lessons we can learn that makes

成功的任务转换的

for a successful task shifting operation,

关键所在时，

I have coined this particular acronym, SUNDAR.

我将其总结为这样一个缩略语：SUNDAR。

What SUNDAR stands for, in Hindi, is "attractive."

SUNDAR是什么意思呢？在印度语中是“诱人的意思”。

It seems to me that there are five key lessons

在我看来，对于一个有效的任务转换，

that I've shown on this slide that are critically important

有五个关键之处，

for effective task shifting.

请看幻灯片。

The first is that we need to simplify the message

第一，我们需要简化信息，

that we're using, stripping away all the jargon

将医学中的专业术语

that medicine has invented around itself.

剔除。

We need to unpack complex health care interventions

我们需要将复杂的，未经加工的保健干预

into smaller components that can be more easily

变成短小的内容，只有这样我们才能简单的将其

transferred to less-trained individuals.

教授给缺乏专业训练的人员。

We need to deliver health care, not in large institutions,

我们提供的健康治疗，并不是在一些大型的机构中提供，

but close to people's homes, and we need to deliver

而是在人们家附近提供，并且

health care using whoever is available and affordable

我们用的是当地社区有空闲时间且有能力

in our local communities.

的人。

And importantly, we need to reallocate the few specialists

重要的是，我们要将有时间的仅有的几个专家

who are available to perform roles

也重新划定角色，

such as capacity-building and supervision.

例如，让他们做一些能力培养和监督的工作。

Now for me, task shifting is an idea

对我来说，任务转换是一个

with truly global significance,

在全球都有重要性的想法，

because even though it has arisen out of the

即使，这一想法是在发展中国家

situation of the lack of resources that you find

这些缺乏资源的条件下产生的，

in developing countries, I think it has a lot of significance

它对资源充足的国家同样有

for better-resourced countries as well. Why is that?

许多重要意义。为什么是这样呢？

Well, in part, because health care in the developed world,

一部分的原因是发达国家和发展中国家

the health care costs in the [developed] world,

疾病治疗的费用差距

are rapidly spiraling out of control, and a huge chunk

正在呈现螺旋式的发展，而这一趋势已经控制不了了，

of those costs are human resource costs.

其中，人力资源的耗费占很大一部分。

But equally important is because health care has become

还有一个同样重要的原因就是，随着健康治疗

so incredibly professionalized that it's become very remote

变得越来越专业，

and removed from local communities.

它与当地社区的距离也就越来越远。

For me, what's truly sundar about the idea of task shifting,

对我来说，任务转变这一思想真正吸引人的地方

though, isn't that it simply makes health care

不是它可以使更多的人接受

more accessible and affordable but that

健康治疗，而是

it is also fundamentally empowering.

它的最基本的激励作用。

It empowers ordinary people to be more effective

它激励普通人在治疗

in caring for the health of others in their community,

本社区患者时变得更加有效，

and in doing so, to become better guardians

同时，他们也成了患者们更好的

of their own health. Indeed, for me, task shifting

健康卫士。事实上，对我来说，任务转变是

is the ultimate example of the democratization

医疗知识民主化的最终范例，

of medical knowledge, and therefore, medical power.

因此他也是医学力量民主化的最终范例。

Just over 30 years ago, the nations of the world assembled

仅在30年前，世界各国聚集在

at Alma-Ata and made this iconic declaration.

阿拉木图发表了如图这个图标式宣言。

Well, I think all of you can guess

我认为，你们都能想到

that 12 years on, we're still nowhere near that goal.

12年后，我们离那个目标还是很遥远。

Still, today, armed with that knowledge

然而，今天，我们有条件

that ordinary people in the community

在充足的监督和支持下，

can be trained and, with sufficient supervision and support,

使得社区中的普通人通过接受训练

can deliver a range of health care interventions effectively,

可以进行一系列有效的健康干预，

perhaps that promise is within reach now.

或许那个承诺已在我们的能力范围之内。

Indeed, to implement the slogan of Health for All,

事实上，为了贯彻实现所有人健康这一口号，

we will need to involve all

我们需要所有人

in that particular journey,

对此的参与，

and in the case of mental health, in particular we would

在精神健康方面，我们格外

need to involve people who are affected by mental illness

需要患有精神疾病的患者和

and their caregivers.

他们的护理者的参与。

It is for this reason that, some years ago,

几年前，正是因为这个原因，

the Movement for Global Mental Health was founded

全球精神卫生运动成立了，

as a sort of a virtual platform upon which professionals

作为一个虚拟平台，

like myself and people affected by mental illness

许多像我一样的专家和被精神疾病困扰着的人们

could stand together, shoulder-to-shoulder,

团结起来，肩并着肩，

and advocate for the rights of people with mental illness

倡导精神疾病患者获得

to receive the care that we know can transform their lives,

可以改变他们生活的治疗的权利，

and to live a life with dignity.

让他们活的有尊严。

And in closing, when you have a moment of peace or quiet

最后，我希望当你们空闲时或

in these very busy few days or perhaps afterwards,

在这不忙的几天或者以后的任何时候，

spare a thought for that person you thought about

你们可以替你们认识的

who has a mental illness, or persons that you thought about

患有精神疾病的

who have mental illness,

人或人们想想，

and dare to care for them. Thank you. (Applause)

并尽可能的照顾他们。谢谢。（鼓掌）

(Applause)

（鼓掌）