Why your doctor should care about social justice | Mary Bassett

譯者: Melody Tang 審譯者: May Cheung

When I moved to Harare in 1985,

我於1985年搬到哈拉雷，

社會公義是津巴布韋的醫療核心政策。

social justice was at the core of Zimbabwe's national health policy.

The new government emerged from a long war of independence

長期爭取獨立戰爭而湧現的新政府

and immediately proclaimed a socialist agenda:

立即宣布社會主義議程：

health care services, primary education

醫療保健服務，小學敎育，

became essentially free.

大體上都成為免費的。

A massive expansion of rural health centers

農村醫療中心大規模的擴充。

placed roughly 80 percent of the population

地方約人口80%

less than a two-hour walk from these facilities,

能在兩小時內走到一個醫療中心。

a truly remarkable accomplishment.

那是一個真正了不起的成就。

In 1980, the year of independence,

在1980年獨立的那一年，

25 percent of Zimbabwean children were fully immunized.

津巴布韋只有25%兒童有接種全套兒童疫苗。

By 1990, a mere decade later,

到了1990年，僅僅10年後，

this proportion stood at 80 percent.

兒童接種比率達到80%。

I felt tremendously privileged to be part of this transformation,

我感到十分榮幸參與了這個大轉變，

a revolution.

一個革命。

The excitement, the camaraderie, was palpable.

這種興奮，那種同志友情，無可言喻。

Working side by side with brilliant Zimbabweans --

能與優秀的津巴布韋市民並肩作戰 --

scientists, doctors, activists --

當中包括科學家，醫生，運動家等等--

I felt connected not only to an African independence movement,

我覺得不單只是與非洲獨立運動連結，

but to a global progressive public health movement.

也與全球公共醫療運動的進步連繫。

But there were daunting challenges.

但我們曾有嚴峻的挑戰。

Zimbabwe reported its first AIDS case in 1985, the year I arrived.

1985年，我初到津巴布韋的那年， 那裡出現首宗愛滋病病例。

I had taken care of a few patients with AIDS in the early 1980s,

80年代初我就照顧過一些患有愛滋病的病人。

when I did my medical training at Harlem Hospital, but --

當時我到哈萊姆醫院接受醫療訓練， 但是 －－

we had no idea what lay in store for Africa.

那時我們無法想像非洲今日會有這樣的情況。

Infection rate stood at about two percent in my early days there.

早期我在這裡時，感染率只有2%。

These would soar

這個數字不斷飊升，

to one out of every four adults

直到每4個成年人當中有一個愛滋病患者。

by the time I left Harare 17 years later.

那是我17年後離開哈拉雷時的感染率，

By the mid-1990s,

在1990年代中期，

I'd told hundreds of people in the prime of life

我告訴過數百位在他們生命最高峰的人，

that they were HIV-positive.

他們患上愛滋病。

I saw colleagues and friends die,

我看著同事及朋友死去，

my students, hospital patients, die.

看著我的學生，醫院內的病人離世。

In response, my colleagues and I set up a clinic.

因此，我與我的一些同事成立一了間診所。

We did condom demonstrations.

我們示範避孕套用法。

We launched school education and workplace interventions.

我們在學校和工作場所 提供預防的資訊。

We did research. We counseled the partners of infected men

我們做研究。 我們為被感染的男性夥伴做諮詢。

about how to protect themselves.

告訴他們如何保護自己。

We worked hard, and at the time, I believed that I was doing my best.

我們非常努力工作。 在那時，我相信我已竭盡所能。

I was providing excellent treatment,

我提供了，就當時而言，最好的治療。

such as it was.

我提供最好的治療。

But I was not talking about structural change.

但我沒有談到有關架構的改變，

Former UN Secretary Kofi Annan has spoken candidly

前聯合國秘書長-科菲·安南

他坦誠因自己個人的失誤，

about his personal failure

leading to the Rwandan genocide.

而導致盧旺達種族滅絕。

In 1994, he was head of the UN peacekeeping department.

在1994年， 他是聯合國維和部的負責人。

At a 10-year memorial for the genocide,

在這個種族滅絕的10週年，

he reflected, "I believed at the time I was doing my best,

他說， "當時我以為已經竭盡所能了，

but I realized after the genocide

但在種族滅絕之後，我才瞭解到

that there was more I could and should have done

原來我是可以，也應該可以做更多。

to sound the alarm and rally support."

就是發出警報並爭取支援。“

The AIDS epidemic caught the health community unprepared,

愛滋病的流行讓衛生界猝不及防。

and today, when the World Health Organization estimates

今天，世界衛生組織估算

that 39 million people have lost their lives to this disease,

約有3900萬人，因為愛滋病喪失生命。

I'm not alone in feeling remorse and regret

不只是我一個人感到自責和後悔

沒有在早期採取更多行動。

at not having done more earlier.

But while living in Zimbabwe,

但是，當我住在津巴布韋時，

I didn't see my role as an advocacy or a political one.

我不覺得我的角色是提倡鼓吹， 或是政治性的角色。

I was there for my technical skills,

我是以我的專業技能在參與，

both my clinical and my research epidemiology skills.

我的臨床及研究流行病學兩方面的技能。

And in my mind, my job was to take care of patients

我那時認為我的工作就是照顧病人，

and to do research to better understand the population patterns of transmission,

以及從研究中去了解 傳染病在人口中的分佈模式。

and I hoped that we'd slow the spread of the virus.

我希望我們會減慢病毒傳播。

I was aware that socially marginalized populations were at disproportionate risk

我知道社會邊緣化人群 對患愛滋病風險或

of getting and dying of AIDS.

死於此病的比率特別高。

And on the sugar plantations,

在甘蔗種植園區，

which really more closely resembled feudal fiefdoms

那裡其實比想像更是封建領地，

than any modern enterprise,

比起現代任何企業，

60 percent of pregnant women

百分之60的懷孕婦女

tested HIV-positive.

在愛滋病測試中呈陽性反應。

I worked to show how getting infected was not a moral failure

我致力於宣導愛滋病 並不是表示道德敗壞。

but instead related to a culture of male superiority,

而是與男尊女卑的文化有關，

to forced migrant labor and to colonialism.

與被迫害的農民工，和與殖民主義有關。

Whites were largely unscathed.

白種人幾乎沒受到影響。

As health professionals,

身為醫療專業人員，

our tools were pitifully weak:

我們的工具非常薄弱：

imploring people to change their individual behaviors,

我們懇請人們改變他們的個人行為，

use condoms, reduce number of partners.

使用安全套，和減少性伴侶。

Infection rates climbed,

可惜感染率仍不斷上升。

and when treatment became available in the West,

當西方國家有愛滋病的治療方法時，

treatment that remains our most potent weapon

那治療是我們對抗這種病毒 最有力的武器。

against this virus,

對抗這種病毒

it was unaffordable to the public sector across Africa.

在整個非洲的一般大眾無法負擔得起。

I didn't speak out

我對於

about the unequal access to these life-saving drugs

無法公平取得這些救命藥品，

or about the underlying economic and political systems

或引起高傳染率的基本經濟和政治體制

that were driving infection rates

沒有大聲疾呼。

in such huge swaths of the population.

在如此龐大人口的區域，

I rationalized my silence

我對我的沈默自我合理化。

by reminding myself that I was a guest in the country,

我提醒自己我只是這國土的一位客人，

that sounding the alarm could even get me kicked out,

我若發出警報，可能會被驅逐出境，

keep me from doing good work,

讓我無法做好我的工作，

taking care of my patients,

不能照顧好我的病人，

doing much-needed research.

以及做急需的研究工作。

So I didn't speak out

所以我沒說出

about the government's early stance on AIDS.

有關政府早期對愛滋病的態度。

I didn't voice my concerns loudly enough.

我沒大聲提出我的擔憂。

Many doctors, health professionals,

許多醫生，專業醫療人員，

may think I did nothing wrong.

可能覺得我沒有做錯。

Our pact with our patients,

我們和病人的協議，

the Hippocratic Oath and its variants,

我們虛偽（成為醫師時）的宣誓，

is about the sanctity of the patient-doctor relationship.

是關於醫患之間神聖關係。

And I did everything I could

對於我的每位病人，

for each and every patient of mine.

我都做了我所能做到的。

But I knew

但我那時就知道

that epidemics emerge along the fissures of our society,

該疫情沿著我們的社會裂隙出現，

reflecting not only biology,

不只反映在生理上，

but more importantly patterns of marginalization, exclusion,

更重要的是，他們被邊緣化，排斥，

discrimination related to race, gender, sexuality, class and more.

以及由於種族，性別，性取向，階級和 更多方面被歧視的模式。

It was true of AIDS.

對愛滋病而言是如此。

It was true just recently of Ebola.

對最近發生的埃博拉病毒亦然。

Medical anthropologists such as Paul Farmer,

醫療人類學者如保羅·法瑪爾博士

who worked on AIDS in Haiti,

他在海地致力於愛滋病工作，

call this structural violence:

稱之為架構性的暴力：

structural because inequities are embedded

它是架構性的，因為深植於不平等

in the political and economic organization of our social world,

我們社會的政治和經濟組織內。

often in ways that are invisible to those with privilege and power;

那些有特權和權力的人通常是看不到的；

and violence because its impact --

它是暴力的，因為它所造成的影響 --

premature deaths, suffering, illness -- is violent.

過早死亡，痛苦，疾病 -- 這就是暴力。

We do little for our patients

我們為病人做得很少，

if we fail to recognize

如果我們沒有意識到

these social injustices.

這些社會的不公平。

Sounding the alarm is the first step towards doing public health right,

發警報是走向正確的公共醫療的第一步，

and it's how we may rally support

我們也才得到支援，

to break through and create real change together.

去突破及共同創造真正的改變。

So these days, I'm not staying quiet.

因此現在，我不會再保持沉默。

I'm speaking up about a lot of things,

我會講出很多事情，

even when it makes listeners uncomfortable,

即使聽眾聽起來不舒服，

even when it makes me uncomfortable.

即使連自己也不舒服。

And a lot of this is about racial disparities

許多是有關種族差異對待，

and institutionalized racism,

及制度化的種族主義。

things that we're not supposed to have in this country anymore,

這些其實不應該還存在於我們的國家，

certainly not in the practice of medicine

特別不應該在醫療，

or public health.

或公共衛生。

But we have them,

但我們都還有這些問題，

and we pay for them in lives cut short.

我們以許多的早夭的生命付出代價。

That's why sounding the alarm

這就是為什麼要响起警報

about the impact of racism on health in the United States,

在美國種族主義對醫療的影響，

the ongoing institutional and interpersonal violence

繼續在發生的對有色人種的 機構性和人際的暴力，

that people of color face,

發出警報。

compounded by our tragic legacy

這些加上我們的悲劇性的遺產更為嚴重：

of 250 years of slavery,

250年的奴隸制度，

90 years of Jim Crow

90多年的種族隔離，

and 60 years of imperfect equality,

以及60多年來的不平等。

sounding the alarm about this

對這些問題拉警報，

is central to doing my job right

是我做為紐約市衛生專員

as New York City's Health Commissioner.

的工作核心。

In New York City, premature mortality -- that's death before the age of 65 --

在紐約市，市民過早死亡 - 即65歲之前去逝 -

is 50 percent higher for black men than white ones.

黑人男性比白人高出50%。

A black woman in 2012

在 2012 年的黑人女性，

faced more than 10 times the risk of dying related to childbirth

在分娩時死亡的機率

as a white woman.

是白人婦女的十倍。

And though we've made enormous strides

儘管我們在

降低嬰兒死亡率已有長足的進步，

in reducing infant mortality rates,

a black baby still faces

黑人嬰兒

在出生後第一年內死亡風險是

nearly three times the risk of death in its first year of life

白人嬰兒的三倍左右。

as compared to a white baby.

New York City's not exceptional.

紐約市也不例外。

These statistics are paralleled

這些統計數字

和整個美國地區的統計數據相似。

by statistics found across the United States.

A recent New York Times analysis

最近紐約時報的一個分析，

reported that there are 1.5 million missing black men across the country.

報導說全國各地有150萬黑人男性失蹤。

They noted that more than one

他們指出在

每六名黑人男性中至少有一位，

out of every six black men

who today should be between the ages of 25 and 54 years

他們現在的年齡應該是在25至54歲之間，

have disappeared from daily life,

從日常生活中消失。

lost either to prison or premature death.

他們正被監禁或過早死亡。

There is great injustice

對於

面對日常和過份暴力的年輕黑人男性很不公平。

in the daily and disproportionate violence faced by young black men,

the focus of recent protests under the banner #BlackLivesMatter.

聚焦於最近舉著”黑人生命可貴“標語抗議活動。

But we have to remember

但是我們必須記著

that enduring and disparate rates

那忍耐能力和截然不同進度

and the occurrence and outcome of common medical conditions --

常見疾病的發生率和結果 －－

heart disease, cancer, diabetes, HIV --

心臟病，癌症，糖尿病，愛滋病等 －－

diseases that may kill slowly and quietly

那些慢慢地安靜地殺死我們的疾病，

and take even more black lives prematurely.

讓更多黑人更早逝。

As the #BlackLivesMatter movement unfolded,

由於”黑人生命可貴“運動展開，

I felt frustrated and angry

我感到沮喪和憤怒，

that the medical community

因為醫學界，

has been reluctant to even use the word "racism"

在我們的研究和工作中發現，

甚至不願意用“種族主義”這字眼。

in our research and our work.

You've probably felt something every time I've said it.

每次我講到這裡可能你們已經感受到

Our medical students held die-ins in their white coats,

我們的醫學學生穿著白色外套舉行裝死示威，

but the medical community has largely stood by passively

但是醫學界基本上是袖手旁觀著

as ongoing discrimination continues to affect

持續的歧視繼續影響著

the disease profile and mortality.

疾病的資料和死亡率.

And I worry

我擔心

that the trend towards personalized and precision medicine,

這個朝向個人化及精密醫療的趨勢,

looking for biological or genetic targets to better tailor treatment,

為創造出更好治療， 尋找生物學的或遺傳學的目標，

may inadvertently cause us to lose sight of the big picture,

可能反而讓我們失焦於大局，

that it is the daily context,

這是每日的景況，

where a person lives, grows,

一個人活著，成長，

works, loves,

工作及愛，

that most importantly determines population health,

重度影響人群的健康，

and for too many of us, poor health.

對我們多數而言，是不健康。

As health professionals in our daily work,

身為醫療專業人員的日常工作，

whether in the clinic or doing research,

無論是在門診或做研究，

we are witness to great injustice:

我們見證了極不正義：

the homeless person who is unable to follow medical advice

無家可歸的人實在無法遵從醫囑，

because he has more pressing priorities;

因為他有更急迫的困境；

the transgender youth who is contemplating suicide

一位變性青年正在考慮自殺，

because our society is just so harsh;

因為我們的社會對他們如此苛刻；

the single mother who has been made to feel that she is responsible

社會讓單身媽媽感覺她們不負責任，

for the poor health of her child.

因為她們的孩子健康很差。

Our role as health professionals

我們作為醫療專業人員的角色，

is not just to treat our patients

不只是治療我們的病人，

but to sound the alarm

還要發出警報，

and advocate for change.

並倡導改革。

Rightfully or not,

理所當然與否，

our societal position gives our voices great credibility,

我們的社會地位 使我們的聲音的可信程度變得很大，

and we shouldn't waste that.

我們不應該浪費這個優勢。

I regret not speaking up in Zimbabwe,

我很後悔沒有在津巴布韋大聲疾呼，

and I've promised myself

我對自己發誓，

that as New York City's Health Commissioner,

做為紐約市衛生專員，

I will use every opportunity I have

我將利用每一個機會，

to sound the alarm

去發警報，

and rally support for health equity.

以及爭取對醫療平等的支持。

I will speak out against racism,

我會站出來反對種族主義，

and I hope you will join me,

我希望你們會和我一起。

and I will join you when you speak out against sexism

當你站出來反對性別歧視時， 我會支持你，

or any other form of inequality.

包括任何其他形式的不平等。

It's time for us to rise up

現在是我們奮起的時候，

and collectively speak up

我們要集體聲討

about structural inequality.

有關架構性的不平等。

We don't have to have all the answers

我們不必知道所有的答案，

to call for change.

才呼籲改革。

We just need courage.

我們只需要勇氣。

The health of our patients,

為了我們病人的健康，

the health of us all, depends on it.

我們所有人的健康，全有賴於它。

(Applause)

（掌聲）