Elizabeth Pisani: Sex, drugs and HIV -- let's get rational

譯者: Jing Yao 審譯者: Adrienne Lin

"People do stupid things.

「人們會做蠢事，

That's what spreads HIV."

愛滋病就這樣傳播開來。」

This was a headline in a U.K. newspaper,

這是不久前英國報紙

The Guardian, not that long ago.

《衛報》的頭條標題。

I'm curious, show of hands, who agrees with it?

我很好奇，有誰同意這句話? 舉個手吧!

Well, one or two brave souls.

嗯，有一兩位，真是勇敢。

This is actually a direct quote from an epidemiologist

這句話出自一位流行病學家，

who's been in field of HIV for 15 years,

她研究HIV已有15年，

worked on four continents,

足跡遍及四大洲，

and you're looking at her.

這個人就是我

And I am now going to argue

我想說的是，

that this is only half true.

這句話只有一半是真的。

People do get HIV because they do stupid things,

有些人的確是因為做了蠢事而感染HIV，

but most of them are doing stupid things

但其中大部分的人做出這些蠢事

for perfectly rational reasons.

是有完全合乎理性的原因

Now, "rational" is the dominant paradigm

現在，理性在公共衛生上

in public health,

是首要的準則。

and if you put your public health nerd glasses on,

如果你戴上了愚蠢的公共衛生檢視鏡，

you'll see that if we give people the information that they need

你將會看到若我們提供人們所需的資訊，

about what's good for them and what's bad for them,

告訴他們什麼對他們是好的，什麼是不好的，

if you give them the services

或是我們提供服務，

that they can use to act on that information,

讓他們可以根據所得的資訊來行動

and a little bit of motivation,

加上一點點動機，

people will make rational decisions

人們將可以做出理性的決定，

and live long and healthy lives.

並過著健康長壽的生活

Wonderful.

棒極了!

That's slightly problematic for me because I work in HIV,

這對我來講是有點問題的，因為我在愛滋病領域工作，

and although I'm sure you all know

雖然我很確定你們都知道

that HIV is about poverty and gender inequality,

HIV關乎著貧窮還有性別不平等，

and if you were at TED '07

如果你有參加2007年的TED，

it's about coffee prices ...

就會知道愛滋病也和咖啡的價格息息相關。

Actually, HIV's about sex and drugs,

事實上，HIV和性交、毒品脫不了關係。€

and if there are two things that make

若有兩樣東西

human beings a little bit irrational,

能讓人類喪失理智，

they are erections and addiction.

那就是勃起跟上癮。

(Laughter)

(笑聲)

So, let's start with what's rational for an addict.

我們先看看對於一個癮君子來說，什麼是不合理的。

Now, I remember speaking to an Indonesian friend of mine, Frankie.

我記得我跟一個印尼籍的朋友聊天，他叫做法蘭克。

We were having lunch and he was telling me

我們當時正在吃午餐，他正在跟我分享

about when he was in jail in Bali for a drug injection.

在巴里島獄中注射毒品的經驗。

It was someone's birthday, and they had very kindly

那一天是某個人的生日，他們很體貼地

smuggled some heroin into jail,

走私了一些海洛因到獄中。

and he was very generously sharing it out

他非常大方地跟獄中好友

with all of his colleagues.

分享這些海洛因。

And so everyone lined up,

於是每個人排成一排，

all the smackheads in a row,

所有的癮君子排成一排。

and the guy whose birthday it was

而過生日的壽星

filled up the fit,

把注射器裝滿海洛因，

and he went down and started injecting people.

然後他走過來開始為大家注射。

So he injects the first guy,

他替第一個傢伙注射，

and then he's wiping the needle on his shirt,

接著他將針頭往襯衫上擦一擦，

and he injects the next guy.

繼續幫下一個傢伙注射。

And Frankie says, "I'm number 22 in line,

法蘭克說「我排在第22個，

and I can see the needle coming down towards me,

我可以看到朝著我前進的針頭，

and there is blood all over the place.

到處都有血跡，

It's getting blunter and blunter.

針頭變得越來越鈍，

And a small part of my brain is thinking,

然後我大腦的一部分開始思考，

'That is so gross

「這真的很令人作嘔，

and really dangerous,'

真的很危險。」

but most of my brain is thinking,

但我大部份的腦子想的卻是

'Please let there be some smack left

「輪到我的時候

by the time it gets to me.

請留一點點給我。

Please let there be some left.'"

拜託留下一些海洛因給我。」

And then, telling me this story,

接著，故事說完後，

Frankie said,

法蘭克說，

"You know ... God,

「天啊!你知道嗎?

drugs really make you stupid."

毒品真的會讓你變得很蠢。」

And, you know, you can't fault him for accuracy.

你也知道，你無法反駁他說的，

But, actually, Frankie, at that time,

但事實上，那時的法蘭克

was a heroin addict and he was in jail.

是個海洛因成癮者，而且他被關在監獄裡。

So his choice was either

所以他只能選擇

to accept that dirty needle or not to get high.

接受骯髒的針頭或是不要吸毒

And if there's one place you really want to get high,

如果真有個地方會讓你想吸毒，

it's when you're in jail.

那一定是在監獄了

But I'm a scientist

我是個科學家，

and I don't like to make data out of anecdotes,

我不根據八卦軼聞做數據，

so let's look at some data.

所以讓我們來看看以下的數據吧。

We talked to 600 drug addicts

我們訪談了在印尼三大城市的

in three cities in Indonesia,

600個毒癮者，

and we said, "Well, do you know how you get HIV?"

我們問：「你知道你是如何感染愛滋的嗎?」

"Oh yeah, by sharing needles."

「噢!那當然! 透過共用的針頭。」

I mean, nearly 100 percent. Yeah, by sharing needles.

幾乎全部的人都知道，是透過共用針頭感染的。

And, "Do you know where you can get a clean needle

「你知道你可以在哪裡取得乾淨

at a price you can afford to avoid that?"

而且你也負擔得起的針頭來避免感染愛滋病呢?」

"Oh yeah." Hundred percent.

「知道啊!」全部的人都知道。

"We're smackheads; we know where to get clean needles."

「我們是吸毒的人，我們當然知道去哪弄到乾淨的針頭。」

"So are you carrying a needle?"

「那你會隨身攜帶針頭嗎?」

We're actually interviewing people on the street,

我們真的就在馬路上採訪這些人，

in the places where they're hanging out and taking drugs.

他們就在這些地方出沒和買賣毒品。

"Are you carrying clean needles?"

「你隨身會帶著乾淨的針頭嗎?」

One in four, maximum.

最多，四個中會有一個帶著。

So no surprises then that

這也就難怪

the proportion that actually used clean needles

上週注射毒品時，

every time they injected in the last week

使用乾淨針頭的

is just about one in 10,

比例只有十分之一，

and the other nine in 10 are sharing.

其他的十分之九都是共用針頭。

So you've got this massive mismatch;

你看這是多麼地矛盾，

everyone knows that

大家都知道

if they share they're going to get HIV,

如果他們共用針頭就會感染HIV，

but they're all sharing anyway.

但他們會共用針頭

So what's that about? Is it like you get a better high if you share or something?

那到底是為什麼呢? 是不是共用東西會讓你比較過癮嗎?

We asked that to a junkie and they're like, "Are you nuts?"

我們問這些吸毒者，他們會說「你瘋了不成?」

You don't want to share a needle anymore than you want

你當然不會想跟別人共用一個針頭

to share a toothbrush even with someone you're sleeping with.

就像是你也不想跟別人共用牙刷，就算是枕邊人也一樣

There's just kind of an ick factor there.

會共用針頭只有一個令人討厭的原因。

"No, no. We share needles because we don't want to go to jail."

不，不。我們共用針頭是因為我們不想進監獄。

So, in Indonesia at this time,

所以，現在的印尼，

if you were carrying a needle and the cops rounded you up,

如果你隨身帶著針頭，那警察就會把你圍起來，

they could put you into jail.

然後把你丟到牢裡。

And that changes the equation slightly, doesn't it?

這有點改變了整件事，對吧?

Because your choice now is either

因為當下你的選擇

I use my own needle now,

我可以用自己的針頭

or I could share a needle now

不然就是共用針頭，

and get a disease that's going to

然後染上愛滋病，

possibly kill me 10 years from now,

很可能在十年後就因此死掉，

or I could use my own needle now

或是用我自己的針頭，

and go to jail tomorrow.

然後明天就進監牢。

And while junkies think that

雖然毒蟲們覺得

it's a really bad idea to expose themselves to HIV,

把自己暴露在愛滋病病毒下是個極糟的主意，

they think it's a much worse idea

但他們深信在牢裡度過一年

to spend the next year in jail

會是個更糟的決定，

where they'll probably end up in Frankie's situation

他們很可能在牢裡會面對到法蘭克遇到的狀況，

and expose themselves to HIV anyway.

然後不管怎樣，還是暴露在HIV的威脅下。

So, suddenly it becomes perfectly rational

突然間，共用針頭似乎

to share needles.

是個相當理性的決定。

Now, let's look at it from a policy maker's point of view.

現在，讓我們從決策者的角度來看這個問題。

This is a really easy problem.

這真的是個很簡單的問題。

For once, your incentives are aligned.

有那麼一度，你有很足夠的動機做對的決定。

We've got what's rational for public health.

我們已經知道就公共衛生而言何謂理性。

You want people to use clean needles --

政府想要人們使用乾淨的針頭，

and junkies want to use clean needles.

這些毒癮者也想要使用乾淨的針頭。

So we could make this problem go away

所以我們很簡單地就可以解決這個問題，

simply by making clean needles universally available

就是讓大家廣泛地拿到乾淨的針頭，

and taking away the fear of arrest.

他們也不用擔心被捕的問題。

Now, the first person to figure that out

第一個想出這一個方法的

and do something about it on a national scale

並把它全國性推廣的

was that well-known, bleeding heart liberal

就是眾所皆知、心腸善良的民主主義者，

Margaret Thatcher.

瑪格麗特·柴契爾夫人。

And she put in the world's first

她實施的世界上第一個

national needle exchange program,

全國性的針頭交換計畫，

and other countries followed suit: Australia, The Netherlands and few others.

其他的國家也跟進，包含澳洲、紐西蘭還有一些其他國家，

And in all of those countries, you can see,

在這些國家中，你可以看到的，

not more than four percent of injectors

注射者之中

ever became infected with HIV.

感染上HIV的不超過4%

Now, places that didn't do this -- New York City for example,

目前，沒有實施這項政策的地方，像是紐約，

Moscow, Jakarta --

莫斯科，雅加達，

we're talking, at its peak,

我們講的是高峰期，

one in two injectors

每兩個注射者

infected with this fatal disease.

就有一個會感染上這個致命的疾病。

Now, Margaret Thatcher didn't do this

瑪格麗特·柴契爾夫人並不是

because she has any great love for junkies.

出自於對毒癮者的愛而實施這個政策。

She did it because she ran a country

她這麼做是因為她治理著一個

that had a national health service.

實施全國性健康福利的國家。

So, if she didn't invest in effective prevention,

所以，如果她不先投資來做有效的預防，

she was going to have pick up the costs

她就得為後來的治療

of treatment later on,

付出昂貴的代價，

and obviously those are much higher.

很明顯的，後者的代價也高多了。

So she was making a politically rational decision.

所以她做了一個很理性的政治決定。

Now, if I take out my

現在，如果我戴上了

public health nerd glasses here

公共衛生怪胎眼鏡，

and look at these data,

再看看這些數據，

it seems like a no-brainer, doesn't it?

這一切看起來很簡單，不是嗎?

But in this country,

但在這個國家，

where the government apparently does not feel compelled

政府很明顯地覺得並沒有這樣的迫切性

to provide health care for citizens, (Laughter)

去為大眾提供健康醫療，

we've taken a very different approach.

於是我們採取了一個很不一樣的解決方法。

So what we've been doing in the United States

我們在美國一直做的事就是

is reviewing the data -- endlessly reviewing the data.

驗證這些數據，不停地驗證。

So, these are reviews of hundreds of studies

你看到的就是數百篇研究的驗證，

by all the big muckety-mucks

都是由美國頂尖科學界中的

of the scientific pantheon in the United States,

菁英科學家們所整理出來的，

and these are the studies that show

這裡則是一些研究指出

needle programs are effective -- quite a lot of them.

針頭交換計畫是有用的，絕大部分都有。

Now, the ones that show that needle programs aren't effective --

現在，這些秀出了針頭交換計畫沒有成效的研究，

you think that's one of these annoying dynamic slides

你們可能會認為這只是一張煩人的幻燈片，

and I'm going to press my dongle and the rest of it's going to come up,

而我接著會按下控制，然後其他的幻燈片會接著播放，

but no -- that's the whole slide.

不過並沒有，這就是全部了

(Laughter)

(笑聲)

There is nothing on the other side.

另外一面沒有東西了

So, completely irrational,

所以，這是非常不理性的，

you would think.

你會想，

Except that, wait a minute, politicians are rational, too,

甚至期待，政客也是有理性的，

and they're responding to what they think the voters want.

而且他們會回應選民所想要的。

So what we see is that voters respond

所以我們看到選民會

very well to things like this

很樂於回應像這樣的情況，

and not quite so well to things like this.

而不願意看到這樣的狀況。

(Laughter)

(為孩童創造美好世界) (為毒蟲創造美好世界)

So it becomes quite rational

所以拒絕提供針頭給成癮者

to deny services to injectors.

變得相當有道理。

Now let's talk about sex.

現在讓我們來談談性。

Are we any more rational about sex?

我們面對性會更有理性?

Well, I'm not even going to address

我甚至不會去講到

the clearly irrational positions

那些天主教教會

of people like the Catholic Church,

完全不合邏輯的論點。

who think somehow that if you give out condoms,

他們認為如果你發送保險套，

everyone's going to run out and have sex.

那麼人們就會跑出去性交。

I don't know if Pope Benedict

我不知道教皇班尼迪克

watches TEDTalks online,

會不會在線上看TEDTalks

but if you do, I've got news for you Benedict --

但如果你有在看，那我有話想跟你說。

I carry condoms all the time

我隨身都帶著保險套，

and I never get laid.

我卻從沒有機會使用過。

(Laughter) (Applause)

(笑聲)

It's not that easy!

這沒那麼簡單。

Here, maybe you'll have better luck.

也許你運氣會好些。

(Applause)

(掌聲)

Okay, seriously,

好的，嚴格來說，

HIV is actually not that easy

HIV不是這麼簡單

to transmit sexually.

就透過性交傳染的。

So, it depends on how much virus there is

是否會傳染是要看你的血液和體液裡

in your blood and in your body fluids.

含著多少愛滋病的病毒。

And what we've got is a very, very high level of virus

當感染上的最初期，就在一開始，

right at the beginning when you're first infected,

我們身體內會有非常非常高量的病毒數，

then you start making antibodies,

然後你會開始製造抗體，

and then it bumps along at quite low levels

之後很長的時間內，10年或12年，

for a long time -- 10 or 12 years --

病毒的數量都會維持在相當低的數目，

you have spikes if you get another sexually transmitted infection.

如果你又因性交感染到，那病毒數量會再向上衝。

But basically, nothing much is going on

但基本上來說，身體並不會產生變化

until you start to get symptomatic AIDS,

直到你開始有愛滋病的症狀。

and by that stage,

但到了這個階段，就在這，

you're not looking great, you're not feeling great,

你看起來狀況不會太好，你也會覺得不舒服，

you're not having that much sex.

你也不會像以往性交地那樣頻繁。

So the sexual transmission of HIV

所以人們是否因性交而感染HIV

is essentially determined by how many partners you have

基本上是取決於這些為期相當短的階段中

in these very short spaces of time

你有多少個性伴侶，

when you have peak viremia.

而這時你體內的病毒數量正值高峰期

Now, this makes people crazy

現在，這就會讓大家抓狂了，

because it means that you have to talk about

因為這意味著你必須討論

some groups having more sexual partners

有些人會在較短的時間內

in shorter spaces of time than other groups,

比其他人擁有更多性伴侶，

and that's considered stigmatizing.

而這是很侮辱人的。

I've always been a bit curious about that

我一直很好奇，

because I think stigma is a bad thing,

因為我覺得恥辱是一件不好的事，

whereas lots of sex is quite a good thing,

而頻繁的性交是相當好的一件事，

but we'll leave that be.

不過我們姑且先不討論這個吧。

The truth is that 20 years

事實是，耗時20年的

of very good research

詳盡研究

have shown us that

告訴我們

there are groups that are more likely to turnover

有一群人會更傾向於在短時間內

large numbers of partners in a short space of time.

換大量的性伴侶，

And those groups are, globally,

而這些人，基本上來說

people who sell sex and their more regular partners.

是賣春者，他們的性伴侶

They are gay men on the party scene

多半是舞會上的同性戀者，

who have, on average, three times more partners

而這些人，平均而言都有著比異性戀

than straight people on the party scene.

多上三倍的性伴侶，

And they are heterosexuals

這其中有異性戀，

who come from countries that have

他們的國家有著

traditions of polygamy

一妻多夫制的傳統，

and relatively high levels of female autonomy,

而女性相對地有較高的女性自主權，

and almost all of those countries are in east or southern Africa.

這些國家大部分都是在南非的東岸。

And that is reflected in the epidemic that we have today.

這都反映在我們今天面對的傳染病上。

You can see these horrifying figures from Africa.

你可以看到這些從非洲得到的可怕數據。

These are all countries in southern Africa

這些都是在南非的國家，

where between one in seven,

在這裡的成年人

and one in three

3分之一

of all adults,

到7分之一

are infected with HIV.

比例感染HIV

Now, in the rest of the world,

現在，在世界上其他的國家，

we've got basically nothing going on in the general population --

基本上人口沒有太大的變化，

very, very low levels --

變動的比例相當相當低，

but we have extraordinarily high levels of HIV

但是在高危險群中

in these other populations who are at highest risk:

卻有相當大比例的人感染到HIV

drug injectors, sex workers

更不用說毒品注射者、性工作者、

and gay men.

還有同性戀者。

And you'll note, that's the local data from Los Angeles:

你會看到洛杉磯的數據中，

25 percent prevalence among gay men.

同性戀者中有25%的人感染上愛滋。

Of course, you can't get HIV just by having unprotected sex.

當然，你不會光是因為不安全的性交而感染HIV

You can only HIV by having unprotected sex

你只會因為跟一個呈陽性反應的HIV患者

with a positive person.

有不安全的性交而染上HIV

In most of the world,

在世界上大部分的地方，

these few prevention failures

極少數的預防措施失效了，

notwithstanding,

沒有抵抗愛滋成功，

we are actually doing quite well these days

但實際上針對性交易中的預防措施，

in commercial sex:

我們這些日子以來其實做得還不錯。

condom use rates are between 80 and 100 percent

在大部分國家性交易中

in commercial sex in most countries.

保險套的使用率介於80%~100%

And, again, it's because of an alignment of the incentives.

再一次地說，這都是因為這一連串的鼓勵措施。

What's rational for public health

對公共衛生而言這是理智的，

is also rational for individual sex workers

對個人的性工作者也是理性的選擇。

because it's really bad for business to have another STI.

因為染上性病對生意是很不好的

No one wants it.

沒有人想要這樣。

And, actually, clients don't want to go home with a drip either.

而且，事實上，顧客也不想染病回家。

So essentially, you're able to achieve

所以本質上來說，在性交易這行業中

quite high rates of condom use in commercial sex.

是可以達到相當高的保險套使用率。

But in "intimate" relations

但是在"親密"關係中，

it's much more difficult because,

這就困難多了，

with your wife or your boyfriend

因為你的太太或你的男友，

or someone that you hope might turn into one of those things,

或那些你希望成為伴侶的人，

we have this illusion of romance

我們都有著對羅曼史的幻想，

and trust and intimacy,

信任還有親密度，

and nothing is quite so unromantic

而再也沒有什麼話會比

as the, "My condom or yours, darling?" question.

「親愛的，要用誰的保險套呢?」這類的問題更掃興了。

So in the face of that,

所以，面對到這樣的問題，

you really need quite a strong incentive

你真的需要相當大的鼓勵

to use condoms.

來讓你使用保險套。

This, for example, this gentleman is called Joseph.

讓我們來舉個例子。這位男士名叫約瑟。

He's from Haiti and he has AIDS.

他來自海地，患有愛滋，

And he's probably not having a lot of sex right now,

而他現在大概也沒有活躍的性生活，

but he is a reminder in the population,

但他卻提醒了大眾

of why you might want to be

需要使用保險套

using condoms.

的原因

This is also in Haiti and is a reminder

這也是在海地，同樣提醒著

of why you might want to be having sex, perhaps.

大家為何你會想要性交，也許會吧。

Now, funnily enough, this is also Joseph

現在，還蠻好笑的是，這也是約瑟，

after six months on antiretroviral treatment.

是在六個月的抗逆轉錄病毒藥物治療後。

Not for nothing do we call it the Lazarus Effect.

這就是我們所說的拉薩路效應。

But it is changing the equation

但這改變了等式，

of what's rational

在面對性交時，

in sexual decision-making.

作出怎樣的決定才算理智。

So, what we've got --

所以，我們得到這樣的回應。

some people say, "Oh, it doesn't matter very much

有些人會說，「噢，這不太重要，

because, actually, treatment is effective prevention

因為事實上，治療也是很有效的預防措施，

because it lowers your viral load and therefore

因為治療會降低你體內的病毒量，

makes it more difficult to transmit HIV."

因此也比較不容易感染到愛滋。」

So, if you look at the viremia thing again,

如果大家再看看這些病毒報告，

if you do start treatment when you're sick,

如果在染病時，你真的有接受治療，

well, what happens? Your viral load comes down.

那麼，接著你的病毒攜帶量會下降。

But compared to what? What happens if you're not on treatment?

但這是跟什麼數據相比?如果你沒有接受治療呢?

Well, you die,

那，你會死亡，

so your viral load goes to zero.

所以你的病毒量會降到零。

And all of this green stuff here, including the spikes --

還有這些綠色部分，包含這些數量衝高的部分，

which are because you couldn't get to the pharmacy,

這些都是因為你無法就診，

or you ran out of drugs, or you went on a three day party binge

或你藥吃完了，或是你去派對狂歡了三天，

and forgot to take your drugs,

根本就忘了吃藥，

or because you've started to get resistance, or whatever --

又或因為你開始有抗藥性，不管怎樣，

all of that is virus

事實是，愛滋病病毒

that wouldn't be out there, except for treatment.

是不會消失不見的，除非你接受治療。

Now, am I saying, "Oh, well, great prevention strategy.

現在，難道我是在說「噢，好吧，這是很棒的預防策略!

Let's just stop treating people."

我們乾脆停止治療吧?」

Of course not, of course not.

當然不是。當然不是這樣。

We need to expand antiretroviral treatment as much as we can.

我們當然需要盡所可能地擴展這抑制病毒的治療。

But what I am doing is calling into question

但現在我要做的是

those people who say that more treatment

問問那些

is all the prevention we need.

說治療勝過預防的人

That's simply not necessarily true,

這根本就不是真相，

and I think we can learn a lot from the experience of gay men

我認為我們可以從這些同性戀的經驗中學到更多，

in rich countries where treatment has been widely available

他們身處的國家都有著更普及的治療，

for going on 15 years now.

也已施行15年了，

And what we've seen is

我們看到的是，

that, actually, condom use rates,

事實上，保險套的使用率

which were very, very high --

相當地高，

the gay community responded very rapidly to HIV,

同性戀群對HIV的反應也很快，

with extremely little help

幾乎不太需要

from public health nerds, I would say --

來自公共衛生人員的協助，我會說

that condom use rate has come down dramatically since treatment

自接受治療後，保險套的使用率明顯驟降，

for two reasons really:

主要是有兩個原因。

One is the assumption of, "Oh well,

其中一個假設是，「噢，

if he's infected, he's probably on meds,

如果他有感染愛滋，他可能在服藥了，

and his viral load's going to be low, so I'm pretty safe."

那他所攜帶的病毒量一定較低，所以我還蠻安全的。」

And the other thing is that people are simply

另一種就是

not as scared of HIV

人們就根本不怕HIV

as they were of AIDS, and rightly so.

就像他們也不怕愛滋病，的確如此。

AIDS was a disfiguring disease that killed you,

愛滋病是會致死的疾病

and HIV is an invisible virus

而HIV是種看不見的病毒，

that makes you take a pill every day.

就只是讓你每天吃顆藥。

And that's boring,

這是蠻無趣的，

but is it as boring as

但這有比

having to use a condom every time you have sex,

每次性交都使用保險套來得無聊嗎?

no matter how drunk you are,

不管你喝得多醉，

no matter how many poppers you've taken, whatever?

不管你喝了多少杯。

If we look at the data, we can see that

如果我們看看數據，我們可以發現

the answer to that question

問題的答案就是

is, mmm.

呃....

So these are data from Scotland.

這些是蘇格蘭的數據。

You see the peak in drug injectors

你可以看到毒品注射者染病的高峰期

before they started the national needle exchange program.

是在他們開始推行全國性的針頭交換計畫之前。

Then it came way down.

然後數據一路下滑，

And both in heterosexuals -- mostly in commercial sex --

不管是異性戀，其中大多數是性工作者

and in drug users,

或毒品施打者，

you've really got nothing much going on after treatment begins,

在治療開始後，其實不會有太多狀況發生，

and that's because of that alignment of incentives

這是因為我先前提到的

that I talked about earlier.

一連串的鼓勵措施。

But in gay men,

但在同性戀中，

you've got quite a dramatic rise

數值急遽上升

starting three or four years

就在治療開始變得普及

after treatment became widely available.

的三四年間。

This is of new infections.

這是新的感染案例。

What does that mean?

這意味著什麼?

It means that the combined effect of being less worried

這意味著人們一方面較不擔心愛滋，

and having more virus out there in the population --

另一方面在人群中也有著更多的愛滋病毒，

more people living longer, healthier lives,

越來越多人活得更久，更健康，

more likely to be getting laid

也更可能帶著HIV

with HIV --

與別人性交

is outweighing the effects of lower viral load,

這兩種影響遠大於較低病毒攜帶量所帶來的影響，

and that's a very worrisome thing.

而這是件很值得我們擔心的問題。

What does it mean?

這到底指的是什麼?

It means we need to be doing more prevention the more treatment we have.

這說明了當我們有著更好的治療，我們卻也需要做更多的預防措施。

Is that what's happening?

實際狀況是這樣嗎?

No, and I call it the "compassion conundrum."

不，而且我稱這現象叫同情謎團。

We've talked a lot about compassion the last couple of days,

我們過去這幾天談了很多關於同情的話題。

and what's happening really is that people are

而實際的狀況是

unable quite to bring themselves to put in

人們無法真的提供

good sexual and reproductive health services for sex workers,

良好的性交及生育健康服務給性工作者，

unable quite to be giving out needles to junkies.

也無法發放針頭給毒癮者，

But once they've gone from being

但一旦他們不再是

transgressive people whose behaviors we don't want to condone

不可饒恕的毒蟲或賣春者

to being AIDS victims,

而是愛滋病受害者時

we come over all compassionate

我們就能有同情心

and buy them incredibly expensive drugs for the rest of their lives.

來為他們一輩子購買這些極為昂貴的藥物，

It doesn't make any sense

從公共衛生的角度看，

from a public health point of view.

這一點都沒道理。

I want to give what's very nearly the last word to Ines.

我想要跟伊恩絲說些話，這幾乎是最後所說的話了。

Ines is a a transgender hooker on the streets of Jakarta;

伊恩絲是個變性人，在雅加達的路上當妓女。

she's a chick with a dick.

她是個有小雞雞的女生。

Why does she do that job?

為什麼她要作妓女呢?

Well, of course, because she's forced into it

當然，這是因為她迫於無奈。

because she doesn't have any better option, etc., etc.

因為她沒有比較好的選擇，等等等。

And if we could just teach her to sew

如果我們可以教她縫紉，

and get her a nice job in a factory, all would be well.

幫她在工廠找到工作，這一切都會好轉。

This is what factory workers earn in an hour in Indonesia:

這是印尼的工廠員工一天的所得，

on average, 20 cents.

平均20分。

It varies a bit province to province.

會因省份有所不同。

I do speak to sex workers, 15,000 of them

我跟性工作者訪談，在15,000個訪談後，

for this particular slide,

我得到這張幻燈片。

and this is what sex workers

這是她們說賣春者在

say they earn in an hour.

一個小時中所賺到的。

So it's not a great job, but for a lot of people

所以，這不是件好差事，但對很多人來說，

it really is quite a rational choice.

這真的是相當理性的選擇。

Okay, Ines.

好的，伊恩絲。

We've got the tools, the knowledge and the cash,

我們有工具，知識，也有現金，

and commitment to preventing HIV too.

也有著要預防愛滋病病毒的決心。

Ines: So why is prevalence still rising?

伊恩絲：那為何愛滋病患者的數目還在上升?

It's all politics.

這都是政治問題。

When you get to politics, nothing makes sense.

當牽扯到政治，一切都毫無道理了。

Elizabeth Pisani: "When you get to politics, nothing makes sense."

伊麗莎白 ˙皮薩尼:「當牽扯到政治，一切都毫無道理了。」

So, from the point of view of a sex worker,

所以，從性工作者的角度來看，

politicians are making no sense.

政客讓這一切變得很沒有道理。

From the point of view of a public health nerd,

從公共衛生學者的角度看，

junkies are doing dumb things.

毒癮者只是在做蠢事。

The truth is that everyone has a different rationale.

我的意思是，事實是每個人都有不同的合理解釋。

There are as many different ways of being rational

這個星球有多少人

as there are human beings on the planet,

就會有同樣多的各種理性決定，

and that's one of the glories of human existence.

這也是人類存在的光輝之一。

But those ways of being rational

但這些不同的理性決定

are not independent of one another,

並不是完全和彼此不相干。

so it's rational for

對一個毒品注射者來說，

a drug injector to share needles

分享針頭是理智的，

because of a stupid decision that's made by a politician,

而這全是因為政治家所做出的一個蠢決定。

and it's rational for a politician

對一個政治家而言，

to make that stupid decision

做出這個蠢決定也是理智的，

because they're responding to

因為他們必須對選民的需求

what they think the voters want.

做出回應。

But here's the thing:

但重點是:

we are the voters.

我們就是選民。

We're not all of them, of course, but TED is a community of opinion leaders.

我們當然不是全部的選民，但是TED是一個有著思想領導者的群體，

And everyone who's in this room,

在這房間的每一個人，

and everyone who's watching this out there on the web,

還有在線上收看的每一個人，

I think, has a duty to demand of their politicians

我想我們都有責任要求這些政治家

that we make policy based on scientific evidence

根據科學證據和常識

and on common sense.

來做出決策。

It's going to be really hard for us

對我們來說，

to individually affect what's rational

單獨影響在世界各地，像法蘭克、伊恩絲

for every Frankie and every Ines out there,

這些人，是真的很困難的

but you can at least use your vote

但你可以，至少用你的選票

to stop politicians doing stupid things

來阻止政治家做出傳播HIV

that spread HIV.

這樣的蠢事

Thank you.

謝謝!

(Applause)

(掌聲)