Sonia Shah: 3 reasons we still haven't gotten rid of malaria

譯者: Yi-Hua Yang 審譯者: Bert Chen

So over the long course of human history,

在人類悠久的歷史文化中

the infectious disease that's killed more humans

致死率最高的傳染病

than any other is malaria.

是瘧疾

It's carried in the bites of infected mosquitos,

它是藉由病媒蚊叮咬來傳染

and it's probably our oldest scourge.

瘧疾可以算是人類史上最早發生的大浩劫

We may have had malaria since we evolved from the apes.

從人類還在人猿的發展階段就已經有瘧疾

And to this day, malaria takes a huge toll on our species.

至今有非常多人因罹患瘧疾而死亡

We've got 300 million cases a year

平均每年都有3億人罹患瘧疾

and over half a million deaths.

超過50萬人死亡

Now this really makes no sense.

這真的令人匪夷所思

We've known how to cure malaria

我們已經知道要如何治療瘧疾

since the 1600s.

早在16世紀的時候就知道

That's when Jesuit missionaries in Peru

當時基督教傳道士在秘魯

discovered the bark of the cinchona tree,

發現金雞納樹的樹皮

and inside that bark was quinine,

含有奎寧的成份

still an effective cure for malaria to this day.

它至今仍是一種能有效治療瘧疾的藥物

So we've known how to cure malaria for centuries.

所以好幾世紀前 我們就已經知道要如何治癒瘧疾

We've known how to prevent malaria since 1897.

自1897年我們就知道 要如何預防瘧疾的發生

That's when the British army surgeon Ronald Ross

當時英國陸軍外科醫生Ronald Ross

discovered that it was mosquitos that carried malaria,

發現瘧疾的傳播媒介就是蚊子

not bad air or miasmas, as was previously thought.

而不是我們以前一直認為的髒空氣或瘴氣

So malaria should be a relatively simple disease to solve,

所以瘧疾應該是一個很容易解決的疾病才對

and yet to this day, hundreds of thousands of people

然而至今仍有數十萬人

are going to die from the bite of a mosquito.

仍因被帶有瘧疾的病媒蚊叮咬而感染瘧疾死亡

Why is that?

為什麼會這樣呢?

This is a question that's

這個問題

personally intrigued me for a long time.

讓我想了很久

I grew up as the daughter of Indian immigrants

我是印度裔移民家庭出身

visiting my cousins in India every summer,

每到印度進入夏季時 我都會回去拜訪我的堂兄弟姊妹

and because I had no immunity to the local malarias,

因為我對當地瘧疾沒有免疫力

I was made to sleep under this hot, sweaty mosquito net every night

所以每晚我都必須在熱悶的蚊帳中睡覺

while my cousins, they were allowed to sleep

而我的堂兄弟姊妹們則能直接睡

out on the terrace and have

在大陽台上

this nice, cool night breeze wafting over them.

吹著清爽舒服的晚風

And I really hated the mosquitos for that.

就因為這樣 我真的很討厭蚊子

But at the same time, I come from a Jain family,

同時我是來自於一個耆那教家庭

and Jainism is a religion that espouses

耆那教極力主張

a very extreme form of nonviolence.

無暴力主義

So Jains are not supposed to eat meat.

所以耆那教徒不能吃肉

We're not supposed to walk on grass,

我們也不能走在草地上

because you could, you know,

因為你可能會

inadvertently kill some insects when you walk on grass.

在你走路的時候 不小心踩死一些昆蟲

We're certainly not supposed to swat mosquitos.

當然我們也不能打蚊子

So the fearsome power of this little insect

所以我很怕蚊子這種小蟲

was apparent to me from a very young age,

從我很小的時候開始

and it's one reason why I spent five years as a journalist

而這也是為什麼我花了五年當記者

trying to understand, why has malaria

想試著了解為什麼瘧疾

been such a horrible scourge for all of us for so very long?

對我們所有人造成一個非常長期的恐怖浩劫

And I think there's three main reasons why.

我認為其中有三種主因

Those three reasons add up to the fourth reason,

這三個原因湊在一起可以變成第四個原因

which is probably the biggest reason of all.

那可能是所有中最大也最重要的原因

The first reason is certainly scientific.

第一個是純科學化的理由

This little parasite that causes malaria,

這種引起瘧疾的寄生蟲

it's probably one of the most complex

可能是已知最複雜

and wily pathogens known to humankind.

最難搞的病原體

It lives half its life inside the cold-blooded mosquito

瘧原蟲的生命中 有一半活在冷血動物-蚊子體內

and half its life inside the warm-blooded human.

另一半則活在溫血動物-人類體內

These two environments are totally different,

這是兩種完全不同的生存環境

but not only that, they're both utterly hostile.

不只如此 病原蟲對兩者環境都有害

So the insect is continually trying to fight off the parasite,

所以當蚊子會不斷抵抗寄生蟲

and so is the human body continually trying to fight it off.

而人類身體也會不斷抵抗

This little creature survives under siege like that,

這種小生物在這種困境下生存下來了

but not only does it survive, it has thrived.

它不只是生存下來 還蓬勃發展

It has spread. It has more ways to evade attack than we know.

它會散播開來 它有許多方式躲避攻擊 比我們知道的還多

It's a shape-shifter, for one thing.

另一方面這是一種變態

Just as a caterpillar turns into a butterfly,

就像毛毛蟲變成蝴蝶一樣

the malaria parasite transforms itself like that

瘧原蟲會像那樣

seven times in its life cycle.

在牠們一生中 經歷七次變態的過程

And each of those life stages not only looks totally different from each other,

而每個生長階段都完全不同

they have totally different physiology.

有完全不同的生理結構

So say you came up with some great drug

你說你有想到某種不錯的藥

that worked against one stage of the parasite's life cycle.

可以用來消滅處於某生長階段的病原蟲

It might do nothing at all to any of the other stages.

那這藥可能就對處於其他階段的病原蟲無效

It can hide in our bodies, undetected,

它能夠躲在我們的身體裡 無法檢查到

unbeknownst to us, for days, for weeks,

並潛伏數天 數周

for months, for years, in some cases even decades.

數月數年也曾有潛伏數十年的案例

So the parasite is a very big scientific challenge to tackle,

所以要處理瘧原蟲是一項非常艱鉅的科學挑戰

but so is the mosquito that carries the parasite.

攜帶瘧原蟲的病媒蚊也很難處理

Only about 12 species of mosquitos

大約只有12種蚊子

carry most of the world's malaria,

帶有全世界絕大部分的瘧原蟲

and we know quite a bit about the kinds of

我們相當多種蚊子

watery habitats that they specialize in.

是屬於水棲性

So you might think, then, well, why don't we just

所以你可能會想說 為什麼我們不

avoid the places where the killer mosquitos live? Right?

避開那些可怕的病媒蚊棲息的地方 對吧?

We could avoid the places where the killer grizzly bears live

我們可以避開恐怖的棕熊棲息地

and we avoid the places where the killer crocodiles live.

我們可以遠離嚇人的鱷魚棲息地

But say you live in the tropics

但當你居住在屬於熱帶氣候的地區時

and you walk outside your hut one day

有一天你走出棚屋

and you leave some footprints in the soft dirt

踩在軟泥土中留下你的腳印

around your home.

在你家附近

Or say your cow does, or say your pig does,

或是你的牛或豬走動留下的腳印

and then, say, it rains,

然後 下雨了

and that footprint fills up with a little bit of water.

而這些由生物走動而形成的小水坑中積滿雨水

That's it. You've created the perfect

就這樣! 你創造出完美的

malarial mosquito habitat that's right outside your door.

瘧蚊孳生地 就在你家門口

So it's not easy for us to extricate ourselves from these insects.

所以要擺脫這些蚊子還沒那麼容易

We kind of create places that they love to live

我們可能創造出瘧蚊喜歡棲息的地方

just by living our own lives.

藉由我們日常的生活方式與習慣

So there's a huge scientific challenge,

所以這是一項艱鉅的科學挑戰

but there's a huge economic challenge too.

同時 也是一像龐大的經濟挑戰

Malaria occurs in some of the poorest

瘧疾通常發生在一些極度貧窮的地方

and most remote places on Earth,

與地球最偏遠的地方

and there's a reason for that.

這是有原因的

If you're poor, you're more likely to get malaria.

如果你很窮 你得瘧疾的機率較高

If you're poor, you're more likely to live

如果你很窮 你很可能住在

in rudimentary housing on marginal land that's poorly drained.

邊際土地上方的簡陋房屋 邊際土地又排水不良

These are places where mosquitos breed.

蚊子就是在那種環境孳生

You're less likely to have door screens or window screens.

你不太可能會有門窗來遮蔽

You're less likely to have electricity

也不太可能會有電

and all the indoor activities that electricity makes possible,

而所有室內活動都需要電

so you're outside more.

所以你通常都待在室外

You're getting bitten by mosquitos more.

所以你也較常遭到蚊子叮咬

So poverty causes malaria,

所以貧窮導致瘧疾的發生

but what we also know now is that malaria itself

不過現在我們知道瘧疾本身

causes poverty.

也會帶來貧窮

For one thing, it strikes hardest during harvest season,

另一方面 在豐收季節裡影響最嚴重

so exactly when farmers need to be out in the fields

當農夫都需要去田裡

collecting their crops, they're home sick with a fever.

採收他們的作物時 卻因發燒 只能再家休養

But it also predisposes people to death

瘧疾也會容易置人於死

from all other causes.

因為其他各種原因

So this has happened historically.

所以瘧疾已經成為歷史

We've been able to take malaria out of a society.

現今我們已經有能力將瘧疾趕出文明社會

Everything else stays the same,

其他還是一樣

so we still have bad food, bad water, bad sanitation,

我們的食物不好 水源不乾淨 衛生環境髒亂

all the things that make people sick.

這些都會讓人生病

But just if you take malaria out,

但如果單單只將瘧疾根除

deaths from everything else go down.

各種原因所造成的死亡率都會下降

And the economist Jeff Sachs has actually quantified

實際上 經濟學家傑夫薩克斯已經量化

what this means for a society.

這事對社會的影響

What it means is, if you have malaria in your society,

他的意思是 如果你的國家有瘧疾發生

your economic growth is depressed

你的經濟成長率將會

by 1.3 percent every year,

每年下降1.3%

year after year after year, just this one disease alone.

年復一年 就只是因為瘧疾的關係

So this poses a huge economic challenge,

因此 這造成了巨大的經濟挑戰

because say you do come up with your great drug

因為 就算你有想到很有療效的藥物

or your great vaccine -- how do you deliver it

或不錯的疫苗 你要怎麼運送?

in a place where there's no roads,

在一個沒有道路

there's no infrastructure,

沒有基礎建設

there's no electricity for refrigeration to keep things cold,

沒有電供應冰箱保冷

there's no clinics, there's no clinicians

也沒有診所 沒有醫生

to deliver these things where they're needed?

又要如何運送這些必要物資呢?

So there's a huge economic challenge in taming malaria.

所以抑制瘧疾是一個艱鉅的經濟挑戰

But along with the scientific challenge and the economic challenge,

除了是科技上的難題與經濟上的挑戰

there's also a cultural challenge,

瘧疾也是一種文化的困境

and this is probably the part about malaria

這也可能是部分原因

that people don't like to talk about.

所以大家不想討論它

And it's the paradox that the people

這是一種非常矛盾的情況

who have the most malaria in the world

那些住在全世界罹患瘧疾率最高地區的人們

tend to care about it the least.

卻往往最不關心這件事情

This has been the finding of medical anthropologists again and again.

醫療人類學家一再發現這種情況

They ask people in malarious parts of the world,

他們訪問居住在瘧疾疫區的人民

"What do you think about malaria?"

關於瘧疾 你們有什麼想法?

And they don't say, "It's a killer disease. We're scared of it."

他們不會說 它是一個致命的疾病 我們很害怕

They say, "Malaria is a normal problem of life."

他們反而會說 瘧疾只是一個生活上常見的問題

And that was certainly my personal experience.

這也是我的個人經驗

When I told my relatives in India

當我告訴我在印度的親戚

that I was writing a book about malaria,

我正撰寫一本有關瘧疾的書

they kind of looked at me like

他們看著我的眼神就好像

I told them I was writing a book about warts or something.

我只是告訴他們我在寫一本關於疣或甚麼的書

Like, why would you write about something so boring,

就好像 你為什麼要寫這麼無聊的書?

so ordinary? You know?

這麼普通的書?

And it's simple risk perception, really.

這其實是個顯而易見的危機預兆

A child in Malawi, for example,

例如 有一位在馬拉維的小孩

she might have 12 episodes of malaria before the age of two,

在2歲之前 她可能得過12次瘧疾

but if she survives,

但如果她活下來

she'll continue to get malaria throughout her life,

她將終其一生繼續與瘧疾對抗

but she's much less likely to die of it.

不過她再次罹患瘧疾致死的機率將會大幅減少

And so in her lived experience,

所以在她生活的經驗中

malaria is something that comes and goes.

瘧疾只不過是會發病 再過一段時間又好了

And that's actually true for most of the world's malaria.

事實上大部分的瘧疾也確實如此

Most of the world's malaria comes and goes on its own.

世界上多數的瘧疾都是會發病 再過一段時間又好了

It's just, there's so much malaria

就是這樣而已 有許多種瘧疾

that this tiny fraction of cases that end in death

只有發生極少數的死亡案例

add up to this big, huge number.

但這些案例加起來也是一個龐大的數字

So I think people in malarious parts of the world

所以我認為生活在瘧疾地區的人們

must think of malaria the way

必須改變看待瘧疾的方式

those of us who live in the temperate world

就像我們生活在溫帶地區

think of cold and flu. Right?

看待感冒和流行感冒一樣 對吧?

Cold and flu have a huge burden on our societies

感冒與流感是一大重擔 在我們的社會

and on our own lives,

和生活中

but we don't really even take

但是我們不需要真的去做

the most rudimentary precautions against it because

基礎的預防措施來防範

we consider it normal to get cold and flu

因為我們覺得感冒和得到流行性感冒 是件很正常的事

during cold and flu season.

在流行性感冒的高峰期

And so this poses a huge cultural challenge in taming malaria,

所以 抑制瘧疾造成一種巨大的文化挑戰

because if people think it's normal to have malaria,

因為如果人們認為感染瘧疾是件正常的事

then how do you get them to run to the doctor

那麼你要如何叫他們去看醫生

to get diagnosed, to pick up their prescription,

去接受診斷 拿處方籤

to get it filled, to take the drugs,

把處方籤拿去藥局 拿藥吃

to put on the repellents, to tuck in the bed nets?

用驅蚊用品 躺到蚊帳裡去呢?

This is a huge cultural challenge in taming this disease.

抑制這種疾病是一個巨大的文化挑戰

So take all that together.

所以把這些因素都湊在一起

We've got a disease. It's scientifically complicated,

我們可以說 瘧疾在科學上很複雜

it's economically challenging to deal with,

對經濟方面有挑戰性 不好處理

and it's one for which the people who stand

因此就有人站出來

to benefit the most care about it the least.

盡力幫助這些最弱勢卻又莫不關心的人

And that adds up to the biggest problem of all,

所有一切加起來 就形成最大的問題

which, of course, is the political problem.

當然就是政治問題

How do you get a political leader to do anything

你要叫政治領袖要怎樣去處理

about a problem like this?

這種問題?

And the answer is, historically, you don't.

從過去的經驗來看 答案是沒辦法

Most malarious societies throughout history

歷史上 大部分瘧疾猖獗的國家

have simply lived with the disease.

就是放任這種疾病發生在人民的生活中

So the main attacks on malaria have come

所以主要會去處理瘧疾問題的力量是

from outside of malarious societies,

來自於瘧疾疫區之外

from people who aren't constrained

來自於那些

by these rather paralyzing politics.

不會受到那些欲癱瘓政治之人影響的人

But this, I think, introduces a whole host of other kinds of difficulties.

但是 我認為這會延伸出各種問題

The first concerted attack against malaria

第一次針對瘧疾的協同防治行動

started in the 1950s.

是從1950年代開始

It was the brainchild of the U.S. State Department.

是由美國國務院所提出的

And this effort well understood the economic challenge.

此行動也恰好應映經濟的困境

They knew they had to focus on cheap, easy-to-use tools,

他們知道他們必須使用便宜 容易使用的工具

and they focused on DDT.

著重使用DDT（一種殺蟲劑）

They understood the cultural challenge.

他們知道文化所面臨的挑戰

In fact, their rather patronizing view was that

事實上當時的觀點非常主觀 認為

people at risk of malaria shouldn't be asked to do anything at all.

易感染瘧疾的人們 什麼事都不能做

Everything should be done to them and for them.

一切只要做給他們使用 幫他們做就好

But they greatly underestimated the scientific challenge.

但他們太低估科學所面臨的挑戰

They had so much faith in their tools

他們對他們使用的工具太過自信

that they stopped doing malaria research.

導致他們不再研究瘧疾

And so when those tools started to fail,

所以當這些工具開始失效了

and public opinion started to turn against those tools,

公眾輿論開始批評那些工具

they had no scientific expertise to figure out what to do.

他們就無法以專業知識判定下一步該怎麼走

The whole campaign crashed, malaria resurged back,

整個行動失敗 瘧疾又再次爆發

but now it was even worse than before

甚至比以前的情況更糟

because it was corralled into the hardest-to-reach places

它已經變得更加嚴重

in the most difficult-to-control forms.

原先就是非常難控制的狀況

One WHO official at the time actually called that whole campaign

當時有一位世界衛生組織的官員將那整個行動稱作

"one of the greatest mistakes ever made in public health."

公共衛生領域所犯的最大錯誤之一

The latest effort to tame malaria started in the late 1990s.

最近抑制瘧疾的行動是從1990 年代後期開始

It's similarly directed and financed primarily

同樣主要指揮行動與金援資助的國家

from outside of malarious societies.

都是來自於非疫區國家

Now this effort well understands the scientific challenge.

這行動也恰好因應科學挑戰

They are doing tons of malaria research.

他們做了非常多有關瘧疾研究

And they understand the economic challenge too.

她們懂得經濟面臨的挑戰

They're focusing on very cheap, very easy-to-use tools.

所以主要著重在獲取非常便宜 容易使用的工具

But now, I think, the dilemma is the cultural challenge.

但現在 我認為文化挑戰是主要的困境

The centerpiece of the current effort is the bed net.

目前著重在盡量獲取蚊帳

It's treated with insecticides.

這種蚊帳是用殺蟲劑處理過

This thing has been distributed across the malarious world

這種蚊帳已經在世界各地的瘧疾疫區發放

by the millions.

目前已經發給數百萬人

And when you think about the bed net,

當你想到蚊帳的時候

it's sort of a surgical intervention.

就像某種手術干預

You know, it doesn't really have any value

你知道 這沒有任何用處

to a family with malaria except that it helps prevent malaria.

若全家都罹患瘧疾 除非蚊帳真的對防範瘧疾有幫助

And yet we're asking people to use these nets every night.

我們要求人們睡覺都要掛蚊帳

They have to sleep under them every night.

必須都睡在蚊帳當中

That's the only way they are effective.

這是唯一有效的方法

And they have to do that

他們必須這樣做

even if the net blocks the breeze,

即使蚊帳擋住窗外吹來的微風

even if they might have to get up in the middle of the night

即使他們有可能在半夜起床

and relieve themselves,

上廁所

even if they might have to move all their furnishings

即使他們可能需要更動他們所有傢俱的位置

to put this thing up,

來把蚊帳掛起來，

even if, you know, they might live in a round hut

即使 他們可能住在一個圓形的棚屋

in which it's difficult to string up a square net.

那種房子很難掛起一個方形的蚊帳

Now that's no big deal if you're fighting a killer disease.

你要對抗一種致命疾病 這沒什麼大不了的

I mean, these are minor inconveniences.

這些麻煩的瑣事真是微不足道

But that's not how people with malaria think of malaria.

但是 罹患瘧疾的人可不這樣認為

So for them, the calculus must be quite different.

對他們來說 有著完全不同的觀念與想法

Imagine, for example, if a bunch of well-meaning Kenyans

想像一下 例如 如果有一群好心的肯尼亞人

came up to those of us in the temperate world and said,

對這些在溫帶地區生活的人們說

"You know, you people have a lot of cold and flu.

你們這裏有很多感冒和染上流感的人

We've designed this great, easy-to-use, cheap tool,

我們設計出這個又好用 又便利 又廉價的工具

we're going to give it to you for free.

我們免費送給你們

It's called a face mask,

這東西叫口罩

and all you need to do is

你們要做的就是

wear it every day during cold and flu season

在感冒和流感盛行的季節 天天帶著它

when you go to school and when you go to work."

去學校也帶 去上班也帶

Would we do that?

我們會這樣做嗎？

And I wonder if that's how people

我在想 瘧疾興盛地區的人們

in the malarious world thought of those nets

對這些蚊帳的想法會是什麼

when they first received them?

當他們第一次收到這些東西的時候?

Indeed, we know from studies

確實，從研究中我們可得知

that only 20 percent of the bed nets

第一次分配出去的蚊帳只有20%

that were first distributed were actually used.

有實際使用過

And even that's probably an overestimate,

那數字甚至都可能被高估了

because the same people who distributed the nets

因為發放蚊帳的那批人

went back and asked the recipients,

回去訪問那些受助人

"Oh, did you use that net I gave you?"

你有使用我給你的蚊帳了嗎?

Which is like your Aunt Jane asking you,

這就像Aunt Jane 問你

"Oh, did you use that vase I gave you for Christmas?"

你用我聖誕節送你的花瓶了嗎?

So it's probably an overestimate.

所以這數字可能是被高估了

But that's not an insurmountable problem.

但這不是一個無法克服的問題。

We can do more education,

我們可以辦更多教育活動

we can try to convince these people to use the nets.

我們可以試著說服他們使用蚊帳

And that's what happening now.

我們現在就是這麼做的

We're throwing a lot more time and money

我們花更多時間和金錢

into workshops and trainings and musicals and plays

投注在工作坊 訓練計畫 歌舞劇 演戲

and school meetings,

和學校會議上

all these things to convince people

這些東西都是為了要說服人們

to use the nets we gave you.

使用我們送的蚊帳

And that might work.

這可能有用

But it takes time. It takes money.

但需要時間 需要資金

It takes resources. It takes infrastructure.

需要資源 也需要基礎設施

It takes all the things that that cheap,

這需要很多因素的配合才能做到

easy-to-use bed net was not supposed to be.

但目的只是為了這些便宜好用的蚊帳

So it's difficult to attack malaria from inside malarious societies,

所以要從瘧疾疫區內部去改善瘧疾是一件很難的事

but it's equally tricky when we try to attack it

這也是一很難處理的事 當我們試著改善瘧疾

from outside of those societies.

從瘧疾疫區外部

We end up imposing our own priorities

我們終究還是將我們的優先權

on the people of the malarious world.

強加於居住在瘧疾疫區的人們身上

That's exactly what we did in the 1950s,

這正是我們在1950年代所做的

and that effort backfired.

然而卻得到反效果

I would argue today,

我認為今天

when we are distributing tools that we've designed

我們將我們設計的工具分送給他們

and that don't necessarily make sense in people's lives,

而那樣工具不一定對他們的生活有幫助的時候

we run the risk of making the same mistake again.

我們冒著風險 再次犯下相同的錯誤

That's not to say that malaria is unconquerable,

這並不表示無法將瘧疾根除

because I think it is,

因為我覺得我們可以根除瘧疾

but what if we attacked this disease

但要是我們針對這項疾病做處理

according to the priorities of the people who lived with it?

並優先考慮那些罹患瘧疾的人們又會怎樣？

Take the example of England and the United States.

舉英國和美國為例

We had malaria in those countries for hundreds of years,

在這兩個國家中 瘧疾存在有數百年之久

and we got rid of it completely,

但我們已經完全擺脫它了

not because we attacked malaria. We didn't.

不是因為我們針對瘧疾去 我們沒有

We attacked bad roads and bad houses

我們修繕破舊的道路 鄙陋的住房

and bad drainage and lack of electricity and rural poverty.

改善不良的排水系統 電力不足與農村貧窮等問題

We attacked the malarious way of life,

我們改變在生活中可能會引起瘧疾的因素

and by doing that, we slowly built malaria out.

透過這種方式 我們逐漸將瘧疾趕出去

Now attacking the malarious way of life,

改變在生活中可能會引起瘧疾的因素

this is something -- these are things people care about today.

這才是今天人們關心的

And attacking the malarious way of life,

改變在生活中可能會引起瘧疾的因素

it's not fast, it's not cheap, it's not easy,

無法很快看見成效 價格不便宜​​ 也不是容易的事

but I think it's the only lasting way forward.

但我認為這是唯一能夠持續下去的辦法

Thank you so much.

謝謝大家

(Applause)

（掌聲）