Gary Slutkin: Let's treat violence like a contagious disease

譯者: lin piao 審譯者: Willy Feng

I'm a physician trained in infectious diseases,

我是一名治療傳染性疾病的醫生

and following my training,

學業結束以後

I moved to Somalia

我從舊金山

from San Francisco.

搬到索馬利亞

And my goodbye greeting

當時舊金山綜合醫院的

from the chief of infectious diseases

傳染科主任

at San Francisco General was,

送給我的離別致辭是

"Gary, this is the biggest mistake you'll ever make."

”蓋瑞，這是你一生中最錯的決定。“

But I landed in a refugee situation

當我在難民營落腳時

that had a million refugees in 40 camps,

那裏有40個難民營收容了100萬難民

and there were six of us doctors.

卻只有我們6個醫生

There were many epidemics there.

流行病隨處可見

My responsibilities were largely related to

我的職責主要是

tuberculosis,

肺結核

and then we got struck by an epidemic of cholera.

但我們隨即遇上了流行性霍亂。

So it was the spread of tuberculosis

我負責阻止肺結核

and the spread of cholera

和霍亂的

that I was responsible for inhibiting.

大幅擴散。

And in order to do this work, we, of course,

為了讓工作得以順利進行，

because of the limitation in health workers,

我們數量有限的醫護人員

had to recruit refugees to be a specialized

不得不從難民中招人

new category of health worker.

特訓成醫護人員。

Following three years of work in Somalia,

在索馬利亞工作了三年以後，

I got picked up by the World Health Organization,

我被世界衛生組織選中

and got assigned to the epidemics of AIDS.

從事防治愛滋病流行的工作。

My primary responsibility was Uganda,

我的主要工作是在烏干達。

but also I worked in Rwanda and Burundi

我也在盧安達、蒲隆地、

and Zaire, now Congo,

薩伊、現在的剛果、

Tanzania, Malawi, and several other countries.

坦尚尼亞、馬拉威和其他幾個國家。

And my last assignment there was to run a unit

我最後一個任務是負責一個

called intervention development,

叫介入性發展的機構。

which was responsible for designing interventions.

這個機構主要負責設計介入性治療。

After 10 years of working overseas,

10年的海外工作

I was exhausted.

令我身心俱疲

I really had very little left.

我幾乎身無分文

I had been traveling to one country after another.

常年的四處奔波，

I was emotionally feeling very isolated.

令我倍感孤獨無助。

I wanted to come home.

我想回家歇歇。

I'd seen a lot of death,

我看過太多的死亡，

in particular epidemic death,

尤其是流行病造成的死亡，

and epidemic death has a different feel to it.

它與一般死亡有些不同。

It's full of panic and fear,

它充滿痛苦和恐懼

and I'd heard the women wailing and crying

我在沙漠中聽過女人的

in the desert.

慟哭和哀號。

And I wanted to come home and take a break

我很想回家歇歇

and maybe start over.

也許重新開始。

I was not aware of any epidemic problems

在美國，我沒發現任何

in America.

流行病的問題。

In fact, I wasn't aware of any problems in America.

實際上，我沒覺得美國有任何問題。

In fact -- seriously.

我是說真的。

And in fact I would visit friends of mine,

我去拜訪我的朋友時

and I noticed that they had water

我看到他們家裏有水

that came right into their homes.

直接地流到家裏來

How many of you have such a situation?

你們當中有多少人有這種設備？

(Laughter)

(笑聲)

And some of them, many of them actually,

有些朋友，其實是很多朋友，

had water that came into more than one room.

可以在家裏的不同房間取用水。

And I noticed that they would move

我還發現他們在家裏安裝了

this little thermoregulatory device

小巧的溫度調節器，

to change the temperature in their home

可以一度一度地或者兩度兩度地調節

by one degree or two degrees.

家裏的室內溫度。

And now I do that.

我家現在也是這樣。

And I really didn't know what I would do,

所以我不知道我該做什麽好。

but friends of mine began telling me

但我的一個朋友告訴我

about children shooting other children with guns.

關於青少年之間的槍擊事件。

And I asked the question,

我就想

what are you doing about it?

對這樣的事件你該做些什麽？

What are you in America doing about it?

在美國你該些做什麼？

And there were two essential explanations

大家都知道主要有兩種方案

or ideas that were prevalent.

或者說方法。

And one was punishment.

一個是懲罰。

And this I had heard about before.

我以前就聽說過的方法。

We who had worked in behavior

我們以前研究行為學

knew that punishment was something that was discussed

知道懲罰是經常被探討的方法。

but also that it was highly overvalued.

但它也是個被高估的方法。

It was not a main driver of behavior,

它不是行為的主要動力，

nor was it a main driver of behavior change.

也不是改變行為的主要動力。

And besides that, it reminded me

而且，它讓我意識到

of ancient epidemics

過去歷史上的流行病

that were previously completely misunderstood

就曾經被完全曲解。

because the science hadn't been there before,

因為當時的科學尚未發展足夠

epidemics of plague

瘟疫、

or typhus or leprosy,

斑疹傷寒和麻瘋病的疫區中

where the prevalent ideas were that there were

大家都普遍認為

bad people or bad humors or bad air,

疫區裡有不好的人、不好的環境、或不好的空氣

and widows were dragged around the moat,

解決方式之一是

and dungeons were part of the solution.

把寡婦被拖到護城河或地牢中

The other explanation or, in a way,

另一種方案，或者說，

the solution suggested,

解決方法是

is please fix all of these things:

改善所有的設施：

the schools, the community, the homes, the families,

學校、公共場所、私人住處、各個家庭，以及

everything.

所有的東西。

And I'd heard this before as well.

我也同樣知道這個方法

I'd called this the "everything" theory,

我把這叫做“凡事”理論

or EOE: Everything On Earth.

又稱世上萬物

But we'd also realized

但是我們也認識到

in treating other processes and problems

在治療的過程中

that sometimes you don't need to treat everything.

有時候你並不需要改變所有的東西。

And so the sense that I had

所以我感覺

was there was a giant gap here.

人們的認知上有一個鴻溝。

The problem of violence was stuck,

暴力問題陷入僵局

and this has historically been the case

這歷來都是

in many other issues.

其他重大問題的特點。

Diarrheal diseases had been stuck.

腹瀉病曾陷入僵局

Malaria had been stuck.

瘧疾也曾陷入僵局

Frequently, a strategy has to be rethought.

通常情況下，一個治療方案必需進行反思。

It's not as if I had any idea what it would look like,

不是說我知道應該怎麽做，

but there was a sense that we would have to do

我是覺得我們需要

something with new categories of workers

和新類型的工作者一起來解決這個問題，

and something having to do with behavior change

改變人們的行事態度，

and something having to do with public education.

與公家教育體制一起合作。

But I began to ask questions

我開始提出問題，

and search out the usual things

和搜尋以前研究過的

that I had been exploring before,

一些常見指標

like, what do the maps look like?

比如說，分布圖是什麽樣的？

What do the graphs look like?

圖表是什麽樣的？

What does the data look like?

數據又是什麽樣的？

And the maps of violence

在美國大部分的城市，

in most U.S. cities

暴力事件的分布圖

looked like this.

就像這個。

There was clustering.

是叢集分布的

This reminded me of clustering that we'd seen also

這讓我意識到我們以前見過的流行傳染病

in infectious epidemics,

就是叢集分布的。

for example cholera.

比如說霍亂

And then we looked at the maps,

我們觀察曲線圖發現

and the maps showed this typical wave

曲線圖裏有這樣的典型曲線。

upon wave upon wave,

一個波形疊著一個波形的分布。

because all epidemics

因為所有的流行病

are combinations of many epidemics.

都跟著其他流行病發生。

And it also looked like infectious epidemics.

而暴力事件的曲線圖和流行病的曲線圖也很相似。

And then we asked the question,

然後我們問，

well what really predicts a case of violence?

怎樣預警暴力案件呢？

And it turns out that the greatest predictor

結果我們發現 對一個暴力事件的最好預警

of a case of violence is a preceding case of violence.

就是上一次的暴力事件

Which also sounds like, if there is a case of flu,

這就跟流感疫情相似，

someone gave someone a case of flu, or a cold,

就像某人把流感，或者感冒傳給別人

or the greatest risk factor of tuberculosis

結核病最大的罹患因素就是

is having been exposed to tuberculosis.

結核病的接觸史。

And so we see that violence is, in a way,

我們發現暴力事件，在某種程度上，

behaving like a contagious disease.

很像傳染病的爆發。

We're aware of this anyway

其實，我們可以了解到

even in our common experiences

在日常生活中

or our newspaper stories

或者媒體的報導中

of the spread of violence from fights

爭吵中的暴力會蔓延成

or in gang wars or in civil wars

幫派鬥爭，內戰，

or even in genocides.

甚至種族屠殺。

And so there's good news about this, though,

但有個好消息，就是

because there's a way to reverse epidemics,

我們有治療傳染病的方式。

and there's really only three things that are done

只要做好三件事就可以

to reverse epidemics,

阻止傳染病的發生。

and the first of it is interrupting transmission.

第一點就是切斷傳播途徑。

In order to interrupt transmission,

為了切斷傳播途徑，

you need to detect and find first cases.

我們需要找到第一個案例。

In other words, for T.B. you have to find somebody

就是說，如果是結核病，你必須要找到

who has active T.B. who is infecting other people.

誰有活動性結核病菌，誰會把結核病傳染給別人。

Make sense?

合理吧？

And there's special workers for doing that.

我們有專業人員來做這個工作。

For this particular problem,

對這樣特定的問題，

we designed a new category of worker

我們設計出新類型的工作者

who, like a SARS worker

就像 SARS (非典) 的工作者，

or someone looking for bird flu,

或禽流感的工作者，

might find first cases.

他們可能找到首例患病者

In this case, it's someone who's very angry

在暴力事件裏，起因是有人

because someone looked at his girlfriend

因為別人看了他的女朋友一眼

or owes him money,

或者欠了他的錢而動怒

and you can find workers and train them

你可以找到一些人，訓練他們成為

into these specialized categories.

特殊類型的工作者。

And the second thing to do, of course,

第二點呢，當然就是

is to prevent further spread,

防止擴散。

that means to find who else has been exposed,

就是說，要找到誰有可能被牽涉進去。

but may not be spreading so much right now

雖然他可能不會很快被牽涉

like someone with a smaller case of T.B.,

就像在結核病傳染的小型案例裏一樣。

or someone who is just hanging out in the neighborhoods,

有人可能只是的街頭鄰居

but in the same group,

但是在同個活動範圍裏

and then they need to be, in a way,

那麽這些人就需要以某種方式，

managed as well,

被好好管理

particular to the specific disease process.

就象處理某些特殊疾病的過程一樣

And then the third part, the shifting the norms,

第三點就是，恢復到正常。

and that means a whole bunch of community activities,

就是整個社區活動的

remodeling, public education,

重新建構和公共教育

and then you've got what you might call

然後你可以做到所謂的

group immunity.

“群體免疫”。

And that combination of factors

這幾個因素的結合

is how the AIDS epidemic in Uganda

當年使我們成功地阻止了

was very successfully reversed.

愛滋病在烏干達的擴散

And so what we decided to do in the year 2000

在2000年我們決定嘗試

is kind of put this together in a way

把這些因素結合起來。

by hiring in new categories of workers,

首先我們雇用了一些新類型的工作者，

the first being violence interruptors.

也就是首起暴力事件的阻止人。

And then we would put all of this into place

然後我們把三個因素全部運用到

in one neighborhood

某個社區，

in what was the worst police district

也就是美國國內

in the United States at the time.

某個治安最差的地區。

So violence interruptors hired from the same group,

暴力阻止者是從同一社區子裡選出來

credibility, trust, access,

有信譽、值得信任、能接近他人，

just like the health workers in Somalia,

就像在索馬利亞的那些醫護工作者一樣

but designed for a different category,

只不過他們為不同的目的而工作

and trained in persuasion,

他們受訓學習如何勸說別人，

cooling people down, buying time, reframing.

讓人息怒，拖延時間，轉變他的態度。

And then another category of worker,

還有其他類別的員工，

the outreach workers, to keep people

外展服務人員

in a way on therapy for six to 24 months.

讓人接受6到24個月的“治療”。

Just like T.B., but the object is behavior change.

就像結核病的治療，但目標是行為上的改變。

And then a bunch of community activities

然後一些社區活動就會

for changing norms.

恢復正常

Now our first experiment of this

我們首次實驗結果

resulted in a 67-percent drop

顯示在芝加哥的西加菲爾德地區

in shootings and killings

槍擊和殺人案件

in the West Garfield neighborhood of Chicago.

減少了67％

(Applause)

(掌聲)

And this was a beautiful thing

這對一個社區來說

for the neighborhood itself,

是一件非常好的事

first 50 or 60 days, then 90 days,

剛開始堅持了50或60天，然後是90天，

and then there was unfortunately another shooting

在接下來的90天中

in another 90 days,

僅發生了一件不幸的槍擊事件。

and the moms were hanging out in the afternoon.

那些社區裏的媽媽們開始在下午一起出來散步

They were using parks they weren't using before.

他們開始利用他們以前不曾利用的公園

The sun was out. Everybody was happy.

太陽出來了。每個人都很開心。

But of course, the funders said, "Wait a second,

當然，有些捐款人會說

do it again."

“等等，再試一次。”

And so we had to then, fortunately,

所以呢，我們幸運地

get the funds to repeat this experience,

拿到了資金來重複這個實驗。

and this is one of the next four neighborhoods

在實驗中的四個社區之一

that had a 45-percent drop in shootings and killings.

槍擊和殺人案件減少了45%

And since that time, this has been replicated

從那時開始，這個實驗已經被重複了

20 times.

20次

There have been independent evaluations

我們的實驗被獨立評估過

supported by the Justice Department

評估是由司法部門和

and by the CDC and performed by Johns Hopkins

疾病預防控制中心和約翰霍普金斯大學來進行

that have shown 30-to-50-percent and 40-to-70-percent

評估結果顯示，使用我們的新方法

reductions in shootings and killings

槍擊和殺人案件

using this new method.

減少到了 30~50% 和 40~60%

In fact, there have been three independent

實際上，我們的工作到目前為止已經通過了

evaluations of this now.

三次的獨立評估。

Now we've gotten a lot of attention as a result of this,

我們的工作也因此受到了很多人的矚目

including being featured on

其中包括

The New York Times' Sunday magazine cover story.

《紐約時報》周日雜誌的封面故事

The Economist in 2009

2009年的《經濟學家》雜誌曾說

said this is "the approach that will come to prominence."

"這種方法將被廣泛使用“

And even a movie was made around our work.

甚至有一部電影是講述關於我們的工作

[The Interrupters]

[中斷]

However, not so fast,

但是，先不要急，

because a lot of people did not agree

因為很多人還不同意

with this way of going about it.

我們的做法。

We got a lot of criticism,

我們受到了很多的批評，

a lot of opposition,

很多的反對意見，

and a lot of opponents.

很多的敵對態度。

In other words, what do you mean, health problem?

像是，為什麼你說這是健康問題？

What do you mean, epidemic?

為什麼你稱它為流行病？

What do you mean, no bad guys?

為什麼你說沒有壞人？

And there's whole industries designed

整個業界早已經有

for managing bad people.

管理壞人的方法

What do you mean, hiring people

你說雇用有(不良)背景的人

who have backgrounds?

是什麽意思？

My business friends said,

我商界的朋友說，

"Gary, you're being criticized tremendously.

”蓋瑞，你竟然受到這麼多批評

You must be doing something right."

你一定是做了一些好事！“

(Laughter)

(笑聲)

My musician friends added the word "dude."

我的音樂家朋友還外加了 ”兄弟“ 一詞

So anyway, additionally,

總之

there was still this problem,

這仍然是個問題

and we were getting highly criticized as well

還有另外一種批評是

for not dealing with all of these other problems.

我們的工作無法處理所有的問題。

Yet we were able to manage malaria

目前為止，我們能控制瘧疾，

and reduce HIV and reduce diarrheal diseases

減少愛滋病和腹瀉的發病，

in places with awful economies

在那些貧困的

without healing the economy.

經濟沒有復甦的地區。

So what's actually happened is,

所以實際上，

although there is still some opposition,

儘管有一些反對意見，

the movement is clearly growing.

很明顯大家都行動起來了。

Many of the major cities in the U.S.,

美國的很多大城市，

including New York City and Baltimore

包括紐約市、巴爾的摩

and Kansas City,

和堪薩斯城

their health departments are running this now.

他們的衛生部門在開展著類似的工作

Chicago and New Orleans, the health departments

芝加哥和紐奧良的衛生部門

are having a very large role in this.

扮演著重大的角色

This is being embraced more by law enforcement

執法單位也比過去

than it had been years ago.

更能接受這些做法

Trauma centers and hospitals

創傷中心和醫院

are doing their part in stepping up.

也在不斷跟進

And the U.S. Conference of Mayors

美國市長聯會

has endorsed not only the approach

已經核准不僅要開展類似的工作

but the specific model.

而且要作為特別模式來做

Where there's really been uptake even faster

在國際上

is in the international environment,

有著更迅速的行動

where there's a 55-percent drop

在波多黎各的第一個施行社區

in the first neighborhood in Puerto Rico,

案件減少了55%

where interruptions are just beginning in Honduras,

在宏都拉斯的工作正在著手進行

where the strategy has been applied in Kenya

在肯亞最近的選舉活動中

for the recent elections,

我們的方式也被列入政策中

and where there have been 500 interruptions in Iraq.

伊拉克已經完成了500次阻斷犯罪的工作

So violence is responding as a disease

所以，暴力事件可以當作疾病來對待，

even as it behaves as a disease.

它的表現形式就像是疾病一樣

So the theory, in a way,

這個理論在某方面來說

is kind of being validated by the treatment.

在處理的過程中得到了驗證

And recently, the Institute of Medicine

最近，美國醫學研究所 (IOM)

came out with a workshop report

提出一個研究報告

which went through some of the data,

根據一些數據

including the neuroscience,

其中包括神經科學

on how this problem is really transmitted.

來解釋暴力是如何傳播的

So I think this is good news,

我認為這是一個好消息

because it allows us an opportunity

因為這些研究讓我們有機會

to come out of the Middle Ages,

走出以往的

which is where I feel this field has been.

中世紀般的陳舊思維。

It gives us an opportunity to consider the possibility

這些研究給我們重新考慮

of replacing some of these prisons

把一些監獄變成

with playgrounds or parks,

休閒場所和公園的可能性。

and to consider the possibility

重新考慮

of converting our neighborhoods into neighborhoods,

重建我們的社區的可能性

and to allow there to be a new strategy,

採用新的策略

a new set of methods, a new set of workers:

新的方法，新類型的工作者

science, in a way, replacing morality.

某方面用科學的方法來替代道德

And moving away from emotions

平息情緒

is the most important part of the solution

是解決問題中最重要的一部分

to science as a more important part of the solution.

用科學的方法是更加重要的。

So I didn't mean to come up with this at all.

我不是說全部都能用我們的方法來解決

It was a matter of,

重要的是，

I wanted actually a break,

我想要突破，

and we looked at maps, we looked at graphs,

讓我們能夠看著分布圖，看著圖表，

we asked some questions

提出一些問題，

and tried some tools

然後使用一些

that actually have been used many times before

以前在其他方面運用過很多次的

for other things.

方法。

For myself, I tried to get away from

對我自己來說，我曾試圖從

infectious diseases,

感染性疾病中脫身

and I didn't.

可是我沒有。

Thank you.

謝謝大家！

(Applause)

(掌聲)