What makes us get sick? Look upstream | Rishi Manchanda

譯者: Regina Chu 審譯者: Adrienne Lin

For over a decade as a doctor,

當了十幾年的醫師，

I've cared for homeless veterans,

我照護過無家可歸的退伍軍人，

for working-class families.

也照護過勞動階級的家庭。

I've cared for people who live and work in conditions

我照護的人都住在或工作在

that can be hard, if not harsh,

即使不惡劣也很糟的環境下。

and that work has led me to believe

這樣的工作讓我相信

that we need a fundamentally different way

我們需要以完全不同的方式

of looking at healthcare.

來看醫療的問題。

We simply need a healthcare system

我們需要的醫療系統

that moves beyond just looking at the symptoms

不能只是單診療

that bring people into clinics,

病人來診所時的症狀，

but instead actually is able to look

而是要實際

從源頭查看及改善健康狀況。

and improve health where it begins.

And where health begins

健康不是從

is not in the four walls of a doctor's office,

診療室的四面牆開始，

but where we live

而是從我們居住及工作、

and where we work,

where we eat, sleep, learn and play,

吃、喝、睡覺、 學習及享樂的地方開始，

where we spend the majority of our lives.

從我們花大把時間的地方開始。

So what does this different approach to healthcare look like,

所以這個不同的醫療方法 是什麼樣子？

an approach that can improve health where it begins?

這個能從源頭改善健康的方法？

To illustrate this, I'll tell you about Veronica.

為了解釋清楚， 我跟大家說說小維的故事。

Veronica was the 17th patient

小維是我第 17 號病人，

out of my 26-patient day

我每天要看 26 名病人，

at that clinic in South Central Los Angeles.

診所位於洛杉磯南區。

She came into our clinic with a chronic headache.

她來我的診所看慢性頭痛。

This headache had been going on

這個頭痛已經持續好多年，

for a number of years, and this particular episode

而這段經歷讓她非常非常困擾。

was very, very troubling.

In fact, three weeks before she came to visit us

其實在她來看我們的三個星期前，

for the first time, she went to an emergency room in Los Angeles.

她才去過洛杉磯的某急診室。

The emergency room doctors said,

這個急診室的醫師說，

"We've run some tests, Veronica.

「小維，我們做了幾項檢查，

The results are normal, so here's some pain medication,

結果都很正常， 所以我現在給你開一些止痛藥，

and follow up with a primary care doctor,

妳要回去看妳的家庭醫師，

but if the pain persists or if it worsens,

但是如果還繼續痛，或是更痛，

then come on back."

妳再回來找我們。」

Veronica followed those standard instructions

小維謹遵這些制式的醫囑，

and she went back.

最後還是回去急診室了。

She went back not just once, but twice more.

她回去不只一次，她去了三次。

In the three weeks before Veronica met us,

在小維來找我們前的那三個星期，

she went to the emergency room three times.

她回去急診室三次。

She went back and forth,

她來來回回，

in and out of hospitals and clinics,

進進出出各個醫院及診所，

just like she had done in years past,

就像之前一年一樣，

trying to seek relief but still coming up short.

想要找解方卻徒勞無功。

Veronica came to our clinic,

小維來我們的診所，

and despite all these encounters with healthcare professionals,

無論她看了多少醫療專家，

Veronica was still sick.

小維還是病著。

When she came to our clinic, though, we tried a different approach.

她到我們的診所時， 我們試了一種不同的療法。

Our approach started with our medical assistant,

我們的療法從我們的醫務助理開始，

someone who had a GED-level training

這位助理有同等學歷的訓練，

but knew the community.

也很瞭解這個社區。

Our medical assistant asked some routine questions.

我們的醫務助理問了幾個例行問題。

She asked, "What's your chief complaint?"

她問，「妳主訴的症狀是什麼？」

"Headache."

「頭痛。」

"Let's get your vital signs" —

「那我們量一下生命徵象」，

measure your blood pressure and your heart rate,

量一下妳的血壓心跳。

but let's also ask something equally as vital

但我們還要多問幾個問題，

to Veronica and a lot of patients like her

對小維及許多類似的 洛杉磯南區病人，

in South Los Angeles.

就跟生命徵象一樣重要的問題。

"Veronica, can you tell me about where you live?

「小維，可不可以告訴我 妳住的地方的情況？

Specifically, about your housing conditions?

特別是妳住處的狀況？

Do you have mold? Do you have water leaks?

有發霉嗎？有漏水嗎？

Do you have roaches in your home?"

家裡有蟑螂嗎？」

Turns out, Veronica said yes to three of those things:

結果是，小維家三「有」：

roaches, water leaks, mold.

蟑螂、漏水、發霉。

I received that chart in hand, reviewed it,

我拿到那張病歷，看了一下，

and I turned the handle on the door

然後我轉轉門把

and I entered the room.

進入診間。

You should understand that Veronica,

你得了解，小維

like a lot of patients that I have the privilege of caring for,

就像我有幸照護的 大部分病人一樣，

is a dignified person, a formidable presence,

是個有尊嚴、不可輕忽，

a personality that's larger than life,

有著鮮明個性的人，

but here she was

但在這裡，她坐在

doubled over in pain sitting on my exam table.

我的診療檯上痛苦地蜷縮著。

Her head, clearly throbbing, was resting in her hands.

她的頭很明顯搏痛著， 擱在她的手上。

She lifted her head up,

她抬起頭，

and I saw her face, said hello,

我看著她的臉，說了妳好，

and then I immediately noticed something

然後我立刻注意到

across the bridge of her nose,

在她的鼻樑上，

a crease in her skin.

皮膚有一道皺摺。

In medicine, we call that crease the allergic salute.

在醫學上，我們稱這道皺摺為 「過敏性敬禮徵」。

It's usually seen among children who have chronic allergies.

這通常發生在 有慢性過敏的兒童上。

It comes from chronically rubbing one's nose up and down,

起因是長期上下磨擦鼻子，

trying to get rid of those allergy symptoms,

想要擺脫那些過敏症狀。

and yet, here was Veronica, a grown woman,

但是，在這的小維， 已經是成年婦女，

with the same telltale sign of allergies.

卻還是有過敏的示警徵兆。

A few minutes later, in asking Veronica some questions,

幾分鐘後，我一邊問小維問題，

and examining her and listening to her,

一邊檢查及聽她說，

I said, "Veronica, I think I know what you have.

我說：「小維， 我想我知道妳得了什麼。

I think you have chronic allergies,

我認為妳是慢性過敏，

and I think you have migraine headaches and some sinus congestion,

而且我認為妳還有偏頭痛及鼻塞，

and I think all of those are related to where you live."

我想這些都跟妳住的地方有關。」

She looked a little bit relieved,

她看起來有點鬆了口氣，

because for the first time, she had a diagnosis,

因為這是她第一次得到真的診斷，

but I said, "Veronica, now let's talk about your treatment.

但我說：「小維， 現在我們來談一下治療方法。

We're going to order some medications for your symptoms,

我們會針對妳的症狀開幾款藥，

but I also want to refer you to a specialist, if that's okay."

但我也想把妳轉診給一位專科， 如果妳同意。」

Now, specialists are a little hard to find

不過，專科

在洛杉磯南區有點難找，

in South Central Los Angeles,

so she gave me this look, like, "Really?"

所以她看了我一眼，好像在說， 「真的？」

And I said, "Veronica, actually, the specialist I'm talking about

我說，「小維，其實我說的這位專科

is someone I call a community health worker,

是我所謂的社區保健員，

someone who, if it's okay with you,

如果妳同意，這個人

can come to your home

會到妳家試著了解情況，

and try to understand what's going on

with those water leaks and that mold,

看看為什麼漏水及發霉，

trying to help you manage those conditions in your housing that I think are causing your symptoms,

試著幫妳解決房子的狀況， 我認為是這些造成妳的症狀，

and if required, that specialist might refer you

如果有必要，這位專科還會幫妳轉診

to another specialist that we call a public interest lawyer,

去另一位專科，我們叫他公益律師，

because it might be that your landlord

因為妳的房東很可能

isn't making the fixes he's required to make."

沒有按照法律規定替妳修房子。」

Veronica came back in a few months later.

小維幾個月後跑回來。

She agreed to all of those treatment plans.

她同意所有上述的治療計畫。

She told us that her symptoms had improved by 90 percent.

她告訴我們她的症狀 改善了 90%，

She was spending more time at work

她可以花更多時間在工作

and with her family and less time

及跟家人相處上，不用常常

shuttling back and forth between the emergency rooms of Los Angeles.

在洛杉磯的急診室來回奔波。

Veronica had improved remarkably.

小維有很明顯的進步。

Her sons, one of whom had asthma,

她的幾個兒子，其中一個有氣喘，

were no longer as sick as they used to be.

不再像以前一樣病著。

She had gotten better, and not coincidentally,

她好多了，而且一點也不意外，

Veronica's home was better too.

小維的房屋狀況也改善了。

What was it about this different approach we tried

我們採用的這種迥異的方法

that led to better care,

為什麼能提供更好的照護？

fewer visits to the E.R., better health?

讓病人少跑急診室，更健康？

Well, quite simply, it started with that question:

很簡單，就從那個問題開始：

"Veronica, where do you live?"

「小維，妳住在哪？」

But more importantly, it was that we put in place

但更重要的是，我們推出

a system that allowed us to routinely ask questions

一種系統，讓我們能問小維

to Veronica and hundreds more like her

及數百計像小維那樣的人 幾個簡單問題，

about the conditions that mattered

對她的社區很重要的環境問題，

in her community, about where health,

健康的源頭問題，

and unfortunately sometimes illness, do begin

因為不幸的是，有時候疾病的確

in places like South L.A.

從像南洛杉磯一樣的地方開始。

In that community, substandard housing

在那個社區，不合格的房屋

and food insecurity are the major conditions

及食物供給不穩定是最主要的問題，

that we as a clinic had to be aware of,

是我們身為診所必須注意到的事，

but in other communities it could be

但在其他的社區問題可能是

transportation barriers, obesity,

交通運輸的天然障礙、肥胖、

access to parks, gun violence.

家附近有沒有公園、槍枝暴力。

The important thing is, we put in place a system

重要的是，我們推出的這種系統

that worked,

有成效，

and it's an approach that I call an upstream approach.

而這種方法我稱為上游管理。

It's a term many of you are familiar with.

在座很多人都很熟悉的名詞。

It comes from a parable that's very common

這來自一個很常聽到的

in the public health community.

公共衛生界寓言。

This is a parable of three friends.

這是三個朋友的寓言。

Imagine that you're one of these three friends

想像一下你是這三個朋友之一，

who come to a river.

你們走到一條河。

It's a beautiful scene, but it's shattered by the cries of a child,

風景很美， 但有個小孩的哭聲劃破了寧靜，

and actually several children, in need of rescue in the water.

而且其實有好幾個孩子 在水裡需要救援。

So you do hopefully what everybody would do.

所以你會去做 但願每個人都會做的事。

You jump right in along with your friends.

你與你的朋友趕快跳進去。

The first friend says, I'm going to rescue those

第一個朋友說，

who are about to drown,

我要去救那些快沉下去的，

those at most risk of falling over the waterfall.

那些快要掉到瀑布下面的幾個。

The second friends says, I'm going to build a raft.

第二個朋友說，我來造個木筏。

I'm going to make sure that fewer people

我要確保

need to end up at the waterfall's edge.

流到瀑布邊的人能少幾個。

Let's usher more people to safety

透過造木筏， 讓我們多領幾個人到安全區，

by building this raft,

coordinating those branches together.

把幾根樹枝綁在一起。

Over time, they're successful, but not really,

一段時間後，他們成功了， 但也不盡然，

as much as they want to be.

因為成效不如預期。

More people slip through, and they finally look up

更多人成為漏網之魚， 所以他們終於往上游看，

and they see that their third friend

發現他們第三個朋友

is nowhere to be seen.

不在視線範圍內。

They finally spot her.

最後他們終於看到她。

She's in the water. She's swimming away from them

她在水裡。她愈游愈遠，

upstream, rescuing children as she goes,

朝上游去，邊游邊救兒童，

and they shout to her, "Where are you going?

他們對著她喊：「妳要去哪裡？

There are children here to save."

這裡還有兒童要救。」

And she says back,

她回答說：

"I'm going to find out

「我要去找

who or what is throwing these children in the water."

是誰或是什麼東西 丟這些兒童進水裡。」

In healthcare, we have that first friend —

在醫療界，我們有第一個朋友：

we have the specialist,

我們有專科醫師，

we have the trauma surgeon, the ICU nurse,

我們有外傷外科醫師、 加護病房護士、

the E.R. doctors.

急診室醫師。

We have those people that are vital rescuers,

我們有搶救生命的人，

people you want to be there when you're in dire straits.

你在急難中最需要的人。

We also know that we have the second friend —

我們也知道我們有第二個朋友：

we have that raft-builder.

我們有造筏的人。

That's the primary care clinician,

那就是第一線的臨床醫師。

people on the care team who are there

那些人在醫療團隊裡

to manage your chronic conditions,

照護你的慢性疾病、

your diabetes, your hypertension,

你的糖尿病、你的高血壓、

there to give you your annual checkups,

幫你做年度健檢、

there to make sure your vaccines are up to date,

盯著你按時打疫苗。

but also there to make sure that you have

同時也確保你有木筏可乘，

a raft to sit on and usher yourself to safety.

把你帶到安全的地方。

But while that's also vital and very necessary,

雖然這些都很重要也很必要，

what we're missing is that third friend.

但我們最缺的卻是第三個朋友。

We don't have enough of that upstreamist.

我們沒有足夠向上游的人。

The upstreamists are the health care professionals

向上游的人是醫療照護專家，

who know that health does begin

但瞭解健康起始於

where we live and work and play,

我們居住工作及玩樂的地方，

but beyond that awareness, is able to mobilize

但除了那樣的體認，

the resources to create the system

還能動員各種資源以創建系統，

in their clinics and in their hospitals

使他們的診所及醫院

that really does start to approach that,

能真正開始著手處理這個問題，

to connect people to the resources they need

能將眾人與他們

outside the four walls of the clinic.

在診所的四面牆外 所需的資源連結在一起。

Now you might ask, and it's a very obvious question

現在你可能會問個很明顯的問題，

that a lot of colleagues in medicine ask:

有很多醫界同僚都這麼問：

"Doctors and nurses thinking about transportation and housing?

「醫師與護士還要去考慮 交通及住房的問題？

Shouldn't we just provide pills and procedures

我們不是只要提供藥丸及醫療處置，

and just make sure we focus on the task at hand?"

並確定我們會專心 做手上的工作就好？」

Certainly, rescuing people at the water's edge

的確，將人從水邊救起

is important enough work.

已經是夠重要的工作。

Who has the time?

誰有那麼多時間？

I would argue, though, that if we were to use science as our guide,

我卻認為，假如我們以科學為指引，

that we would find an upstream approach is absolutely necessary.

就知道找到上游管理方法 是絕對必要的。

Scientists now know that

科學家現在知道

the living and working conditions that we all

生活及工作條件，

are part of

我們都是其中的部分，

have more than twice the impact on our health

對我們健康的影響

than does our genetic code,

比遺傳還超過兩倍之多，

and living and working conditions,

而且生活及工作條件，

the structures of our environments,

我們環境的結構，

the ways in which our social fabric is woven together,

我們的社交圈交織在一起的方式，

and the impact those have on our behaviors,

及其對我們行為的影響，

all together, those have more than five times

通通加在一起， 對我們的健康影響

the impact on our health

than do all the pills and procedures

比醫師及醫院開出的 藥丸及醫療處置總合

administered by doctors and hospitals combined.

超過五倍之多。

All together, living and working conditions

生活及工作條件加在一起，

account for 60 percent of preventable death.

佔了可預防性死亡的 60%。

Let me give you an example of what this feels like.

讓我舉個例子來看看這是什麼感覺。

Let's say there was a company, a tech startup

就說有家公司，一家科技新創公司

that came to you and said, "We have a great product.

來你這裡說：「我們有個很棒的產品。

It's going to lower your risk of death from heart disease."

會降低你死於心臟病的風險。」

Now, you might be likely to invest

那麼，你很可能會願意投資，

if that product was a drug or a device,

如果那個產品是種藥或儀器的話，

but what if that product was a park?

但是如果那個產品是座公園？

A study in the U.K.,

在英國有項研究，

a landmark study that reviewed the records

一項具里程碑意義的研究，檢閱了

of over 40 million residents in the U.K.,

英國超過四千萬居民的紀錄，

looked at several variables,

他們看了幾項變數，

controlled for a lot of factors, and found that

即幾項管制因子，發現

when trying to adjust the risk of heart disease,

當試著校正心臟病的風險，

one's exposure to green space was a powerful influence.

一個人能否接觸綠地 有很大的影響。

The closer you were to green space,

你越接近綠地、

to parks and trees,

公園及樹木，

the lower your chance of heart disease,

你得心臟病的機會就愈低，

and that stayed true for rich and for poor.

無論貧富皆準。

That study illustrates what my friends in public health

那項研究闡明了我在公衛界的朋友

often say these days:

這些日子常常說的：

that one's zip code matters more

就是一個人的郵遞區號

than your genetic code.

比你的遺傳密碼還重要。

We're also learning that zip code

我們也了解到郵遞區號

is actually shaping our genetic code.

其實會改變我們的遺傳密碼。

The science of epigenetics looks at those molecular mechanisms,

表觀遺傳學就是要看這些分子機制，

those intricate ways in which our DNA is literally shaped,

那些真的會改變 我們 DNA 的複雜機制，

genes turned on and off

基因開、關，

based on the exposures to the environment,

基於其所暴露的環境，

to where we live and to where we work.

及我們在哪裡生活在哪裡工作。

So it's clear that these factors,

所以很清楚這些因素，

these upstream issues, do matter.

這些上游的問題，的確至關重要。

They matter to our health,

它們對我們的健康至關重要，

and therefore our healthcare professionals should do something about it.

因此我們的醫療專家 應該為此出力。

And yet, Veronica asked me

但是，小維問了我

perhaps the most compelling question

一個可說是長久以來 我一直難以回答的問題，

I've been asked in a long time.

In that follow-up visit, she said,

在回診那天，她問：

"Why did none of my doctors

「為什麼我的醫師

ask about my home before?

以前都不問我住家的狀況？

In those visits to the emergency room,

去急診室的那幾次，

I had two CAT scans,

我做了兩次斷層掃瞄，

I had a needle placed in the lower part of my back

有針穿刺進我的下背部

to collect spinal fluid,

抽取脊髓液，

I had nearly a dozen blood tests.

我大概抽了將近一打的血。

I went back and forth, I saw all sorts of people in healthcare,

我進進出出， 我看過各種醫療照護人員，

and no one asked about my home."

從來沒有人問過我的家。」

The honest answer is that in healthcare,

最誠實的答案是在醫療界，

we often treat symptoms without addressing

我們常常只是頭痛醫頭、腳痛醫腳，

the conditions that make you sick in the first place.

And there are many reasons for that, but the big three

有很多因素造成這樣，但三大點

are first, we don't pay for that.

是第一，我們拿不到錢。

In healthcare, we often pay for volume and not value.

在醫療界，我們計量不計質。

We pay doctors and hospitals usually

我們通常付醫師及醫院的錢

for the number of services they provide,

是以診療過多少人來算，

but not necessarily on how healthy they make you.

不見得是看他們有沒有醫好你。

That leads to a second phenomenon that I call

這就導致第二個現象我叫它

the "don't ask, don't tell" approach

「你不說我不問」，

to upstream issues in healthcare.

普遍存在醫療界的上游問題。

We don't ask about where you live and where you work,

我們不問你住哪、在哪工作，

because if there's a problem there,

因為如果那裡有問題，

we don't know what to tell you.

我們也不知道要給你什麼建議。

It's not that doctors don't know these are important issues.

醫師不是不了解 這些是很重要的問題。

In a recent survey done in the U.S. among physicians,

最近有項針對美國醫師的調查，

over 1,000 physicians,

問了超過一千名醫師，

80 percent of them actually said that

其中有 80% 真的說

they know that their patients' upstream problems

他們知道他們病人的上游問題

are as important as their health issues,

與他們的健康問題一樣重要，

as their medical problems,

也與醫療問題一樣重要。

and yet despite that widespread awareness

但儘管對上游問題的重要性

of the importance of upstream issues,

有如此廣泛的意識，

only one in five doctors said they had

只有五分之一的醫師說他們有

any sense of confidence to address those issues,

相當程度的信心應付這個問題，

to improve health where it begins.

找出改善健康的源頭。

There's this gap between knowing

瞭解病人的生活，

that patients' lives, the context of where they live and work,

即他們生活及工作的背景

matters, and the ability to do something about it

很重要是一回事， 但有能力在我們工作的系統中

in the systems in which we work.

為之出力又是另一回事。

This is a huge problem right now,

這是現在很大的問題，

because it leads them to this next question, which is,

因為這導引出下一個問題，就是

whose responsibility is it?

這是誰的責任？

And that brings me to that third point,

這也帶出我的第三點，

that third answer to Veronica's compelling question.

小維難題的第三個答案。

Part of the reason that we have this conundrum

造成我們這個難題的部分原因

is because there are not nearly enough upstreamists

在於在醫療系統內，

in the healthcare system.

根本就沒有足夠的上游管理人。

There are not nearly enough of that third friend,

根本就沒有足夠的第三個朋友，

that person who is going to find out

就是那個要去找出

who or what is throwing those kids in the water.

誰或什麼東西把孩子進水裡的人。

Now, there are many upstreamists,

現在，的確有很多上游管理人，

and I've had the privilege of meeting many of them,

我有幸遇過許多位，

in Los Angeles and in other parts of the country

在洛杉磯及這個國家的其它地方

and around the world,

及全世界都遇到過，

and it's important to note that upstreamists

值得注意的是很多上游管理人

sometimes are doctors, but they need not be.

有時候的確是醫師， 但不一定得是醫師。

They can be nurses, other clinicians,

他們也可以是護士、其他臨床師、

care managers, social workers.

照護策劃管理人、社工。

It's not so important what specific degree

上游管理人在名字後面

upstreamists have at the end of their name.

掛什麼學位頭銜並不重要。

What's more important is that they all seem

重要的是他們幾乎

to share the same ability to implement a process

都有能力落實執行某種步驟

that transforms their assistance,

以改造他們援助的手法，

transforms the way they practice medicine.

改造他們行醫的方法。

That process is a quite simple process.

那種步驟是還滿簡單的步驟。

It's one, two and three.

就是一二三。

First, they sit down and they say,

第一，他們坐下來說，

let's identify the clinical problem

我們來鑑別一下到底

為什麼某些病人會有這種臨床問題。

among a certain set of patients.

Let's say, for instance,

舉個例，

let's try to help children

讓我們試試幫助

who are bouncing in and out of the hospital

因為氣喘而在醫院

with asthma.

進進出出的兒童。

After identifying the problem, they then move on to that second step,

診斷出問題後， 他們就進到下一步，

and they say, let's identify the root cause.

他們說，讓我們來找根源。

Now, a root cause analysis, in healthcare,

現在，根本原因分析，

在醫療界通常這麼說， 讓我們看一下你的基因，

usually says, well, let's look at your genes,

let's look at how you're behaving.

看一下你的行為。

Maybe you're not eating healthy enough.

可能你吃得不夠健康。

Eat healthier.

那就吃健康點。

It's a pretty simplistic

這是過度簡單化的

approach to root cause analyses.

根本原因分析方法。

It turns out, it doesn't really work

結果是，這個方法根本沒有用

when we just limit ourselves that worldview.

因為我們限制了自己的視界。

The root cause analysis that an upstreamist brings

上游管理人提出的根本原因分析

to the table is to say, let's look at the living

會這麼說，讓我們看一下

and the working conditions in your life.

你的生活及工作條件。

Perhaps, for children with asthma,

也許，對有氣喘的孩童，

it's what's happening in their home,

家裡的狀況是原因，

or perhaps they live close to a freeway with major air pollution

或是因為他們住在 空氣很糟的高速公路旁，

that triggers their asthma.

引發了他們的氣喘。

And perhaps that's what we should mobilize our resources to address,

這大概是我們應該動員 所有資源來對付的事，

because that third element, that third part of the process,

因為第三個因素， 步驟的第三部分，

is that next critical part of what upstreamists do.

是上游管理人會做的 下一步關鍵部分。

They mobilize the resources to create a solution,

他們會動員所有的資源 以找出解決的方法，

both within the clinical system,

無論在臨床系統內，

and then by bringing in people from public health,

或是之後在公衛界找人、

from other sectors, lawyers,

其他部門、律師

whoever is willing to play ball,

任何願意參與的人皆可，

let's bring in to create a solution that makes sense,

讓我們把這些人引進， 找出合理的解決方法，

to take those patients who actually have clinical problems

把這些有實際臨床問題的病人

and address their root causes together

幫助他們治本，

by linking them to the resources you need.

把他們與你所需的資源連在一起。

It's clear to me that there are so many stories

對我而言這很清楚，有很多故事在說

of upstreamists who are doing remarkable things.

上游管理人所做卓越非凡的事。

The problem is that there's just not nearly enough of them out there.

問題是這樣的人不夠多。

By some estimates, we need one upstreamist

粗估我們在醫療系統內 每 20 至 30 位臨床醫師

for every 20 to 30 clinicians in the healthcare system.

就需要一位上游管理人。

In the U.S., for instance, that would mean

在美國，舉個例，這意味著

that we need 25,000 upstreamists

我們在 2020 年前， 需要二萬五千名上游管理人。

by the year 2020.

But we only have a few thousand upstreamists out there right now, by all accounts,

但是現在據說我們只有少少的 幾千名上游管理人，

and that's why, a few years ago, my colleagues and I

而這就是為什麼在幾年前， 我與幾位同僚說，

said, you know what, we need to train

你知道嗎，我們需要訓練出

and make more upstreamists.

更多上游管理人。

So we decided to start an organization

所以我們決定創辦一個組織，

called Health Begins,

稱為「健康源」，

and Health Begins simply does that:

「健康源」只作這件事：

We train upstreamists.

我們訓練上游管理人。

And there are a lot of measures that we use for our success,

我們使用許多方法 評量我們是否成功，

but the main thing that we're interested in

但我們最主要的目標

is making sure that we're changing

是確定我們要改變信心，

the sense of confidence,

that "don't ask, don't tell" metric among clinicians.

改變在臨床醫師間 「你不問我不說」的制式心態。

We're trying to make sure that clinicians,

我們試著要確定臨床醫師，

and therefore their systems that they work in

及他們工作的系統

have the ability, the confidence

因而有能力、有信心

to address the problems in the living

能解決我們生活

and working conditions in our lives.

及工作條件的問題。

We're seeing nearly a tripling

我們看見在我們的努力下 信心增加了二倍。

of that confidence in our work.

It's remarkable,

成效顯著，

but I'll tell you the most compelling part

但我要告訴你們最有趣的部分

of what it means to be working

就是與上游管理人合作

with upstreamists to gather them together.

把他們集合在一起是什麼意思。

What is most compelling is that every day,

最有趣的是每一天，

every week, I hear stories just like Veronica's.

每一週我都聽到像小維的故事。

There are stories out there of Veronica

多的是像小維

and many more like her,

一般的故事，

people who are coming to the healthcare system

人們進入一個醫療系統

and getting a glimpse of what it feels like

窺視能參與

to be part of something that works,

有成效系統的感覺，

a health care system that stops bouncing you back and forth

一種醫療系統不再把你當足球踢，

but actually improves your health,

卻能實際改善你的健康，

listens to you who you are,

傾聽你的人生，

addresses the context of your life,

處理你的生活背景，

whether you're rich or poor or middle class.

無論你是貧富還是中產階級。

These stories are compelling because

這些故事引人注意，因為

not only do they tell us that we're this close

它們不但告訴我們，我們有多接近

to getting the healthcare system that we want,

我們想要的醫療保健系統，

but that there's something that we can all do to get there.

也告訴我們， 我們能合作達成這件事。

Doctors and nurses can get better at asking

醫師及護士能做得更好， 只要他們問問病人的生活背景，

about the context of patients' lives,

not simply because it's better bedside manner,

因為這不僅是更好的醫療服務態度，

but frankly, because it's a better standard of care.

但坦白說，這也是更好的照護標準。

Healthcare systems and payers

醫療系統及醫療給付單位

can start to bring in public health agencies

可以開始把公衛局

and departments and say,

及衛生署帶進來並說，

let's look at our data together.

讓我們一起來看看數據。

Let's see if we can discover some patterns in our data about our patients' lives

看一看我們能否在數據中 發現病人的生活型態，

and see if we can identify an upstream cause,

看看我們能否找出發病的源頭。

and then, as importantly, can we align the resources

然後，同樣重要的是， 我們能不能運用資源

to be able to address them?

去解決這個問題？

Medical schools, nursing schools,

醫學院、護理學院、

all sorts of health professional education programs

各種專業醫療教育課程

can help by training the next generation of upstreamists.

都可以訓練下一代的 上游管理人來達成目標。

We can also make sure that these schools

我們也要確定這些學校

certify a backbone of the upstream approach,

要認證上游管理的基礎，

and that's the community health worker.

即社區保健員。

We need many more of them in the healthcare system

在醫療系統內我們需要更多這種人，

if we're truly going to have it be effective,

如果我們真的想要有成效的話，

to move from a sickcare system

要從「疾病」照護系統

to a healthcare system.

變成「健康」照護系統。

But finally, and perhaps most importantly,

但最後一點， 或許也是最重要的一點，

what do we do? What do we do as patients?

我們要怎麼做？ 身為病人我們要怎麼做？

We can start by simply going to our doctors

我們可以這樣開始：去看醫生、

and our nurses, to our clinics,

看護理師、去診所時，

and asking, "Is there something in where I live

問他們，「在我居住

and where I work that I should be aware of?"

及工作的地方， 有什麼是我該注意的嗎？」

Are there barriers to health that I'm just not aware of,

有什麼讓我不健康的事物 是我從沒注意到的嗎？

and more importantly, if there are barriers

更重要的是，如果真有這種障礙

that I'm surfacing, if I'm coming to you

我意識到了，如果我來你這裡，

and I'm saying I think have a problem with

而且告訴你，我認為在我的公寓

my apartment or at my workplace

或我的工作場所的確有問題，

or I don't have access to transportation,

或是我無法搭公共交通工具，

or there's a park that's way too far,

或公園離我太遠，

so sorry doctor, I can't take your advice

所以真抱歉醫師， 我無法採納你的建議

to go and jog,

去慢跑，

if those problems exist,

如果這些問題的確存在，

then doctor, are you willing to listen?

那醫師，你願意聽嗎？

And what can we do together

我們能一同做什麼

to improve my health where it begins?

從源頭改善我的健康？

If we're all able to do this work,

如果我們能一同做這件事，

doctors and healthcare systems,

醫師及醫療系統，

payers, and all of us together,

醫療給付單位，及所有的人都一起，

we'll realize something about health.

我們就能瞭解健康的真義。

Health is not just a personal responsibility or phenomenon.

健康不僅是個人的責任或現象。

Health is a common good.

健康是共有財。

It comes from our personal investment in knowing

它始於我們個人付出心力瞭解

that our lives matter,

我們的生活非常重要，

the context of where we live and where we work,

我們生活及工作的地方的背景、

eat, and sleep, matter,

我們吃、睡也非常重要，

and that what we do for ourselves,

我們不但要為自己做，

we also should do for those

我們同時也應該要為那些

whose living and working conditions

生活及工作條件，

again, can be hard, if not harsh.

再說一次， 即使不惡劣也很糟的人做這件事。

We can all invest in making sure that we improve

我們要付出心力確保我們改善

the allocation of resources upstream,

上游資源的分配，

but at the same time work together

但同時也要一同合作

and show that we can move healthcare

證明我們能將醫療系統

upstream.

帶往上游。

We can improve health where it begins.

我們能從源頭改善健康。

Thank you.

謝謝。

(Applause)

（掌聲）