What Americans agree on when it comes to health | Rebecca Onie

譯者: Lilian Chiu 審譯者: Helen Chang

Today, we are a country divided,

現今，我們是個分裂的國家，

or at least that's what we're told.

或者，至少我們聽到的是這樣。

We are torn apart by immigration, education, guns

我們被移民、教育、槍枝，

以及健康照護拆得四分五裂。

and health care.

Health care is ugly and it is loud,

健康照護很醜惡， 且它的聲音很大，

so loud that it threatens to drown out everything else.

大到幾乎可以蓋過 所有其他的聲音。

(Voice-over) Protesters: Health care is a human right! Fight, fight, fight!

（旁白）抗議者：健康照護 是人權！拼啊，拼啊，拼啊！

Protesters: Hey hey! Ho ho! Obamacare has got to go!

抗議者：嘿嘿！喔喔！ 歐巴馬照護不能留！

Rebecca Onie: But what if underneath all the noise,

雷貝嘉奧尼：但，如果 在所有這些噪音的背後，

we're not divided?

我們其實並沒有分裂呢？

What if the things that we don't ask about

如果我們不過問的事物

are the things that we most agree upon?

就是我們最一致同意的事物呢？

It turns out that when we ask the right questions,

結果發現，當我們問對問題，

the answers are startling,

答案是很驚人的，

because we agree, not on health care, but on something more important:

因為在健康照護上 我們並沒有一致看法，

但在更重要的地方卻有：

we agree on health.

我們對健康的看法一致。

For 20 years, I've been obsessed with one question:

二十年來，我一直 對一個問題很著迷：

What do we, what do all of us need in order to be healthy?

我們所有人需要什麼， 才能夠保持健康？

As a college student in 1995,

1995 年，我讀大學時， 花了數個月時間，

I spent months talking to physicians at a chaotic hospital in Boston,

在波士頓一間混亂的醫院， 和該院的醫生談，

asking them, "What's the one thing your patients most need to be healthy?"

我問他們：「你的病人 最需要什麼，才能夠保持健康？」

They shared the same story again and again,

他們一次又一次跟我說相同的故事，

one that I've heard hundreds of variations of since.

從那之後，我聽過 這故事的數百種版本。

They say, "Every day I see a patient with an asthma exacerbation,

他們說：「每天，當我看了 一名哮喘急性發作的病人，

and I prescribe a controller medication.

我就會控制性藥物的處方給他。

But I know she is living in a mold-infested apartment.

但我知道她住在 有大量黴菌的公寓裡。

Or I see a kid with an ear infection, and I prescribe antibiotics,

或者，我看了一個耳朵感染的 孩子，開了抗生素給他，

but I know there is no food at home.

但我知道他家中沒有食物。

And I don't ask about those issues, because there's nothing I can do."

我不會去問那些議題， 因為我幫不上忙。」

Now, it seemed that it shouldn't be so complicated

要根據人們真正的健康需求

to design a doctor's visit around what people actually need to be healthy.

來設計一種醫生拜訪， 似乎不是太難的事。

So I created Health Leads,

所以我創立了 「Health Leads」這個組織，

an organization enabling thousands of physicians and other caregivers

它讓數千名醫生與其他照護者

to ask their patients,

能夠問他們的的病人：

"What do you need to be healthy?"

「你需要什麼才能保持健康？」

and then prescribe those things --

接著針對他們的答案來開處方——

fruits and vegetables, heat in the winter,

水果、蔬菜、冬天的暖氣、

electricity to refrigerate their medication --

冰箱需要的電力， 這些是他們的藥——

and we then navigated patients to those resources

接著我們指引病人 在他們的的社區中

in their communities.

取得那些資源。

The model works.

這個模型行得通。

A Mass General Hospital study found that navigating patients to essential resources

麻省總醫院有一項研究發現， 指引病人取得必要資源，

is associated with improvements in blood pressure and cholesterol levels

會改善他們的血壓及膽固醇，

similar to introducing a new drug,

就類似使用新藥，

but without all the side effects.

只差沒有那些副作用。

So two decades later, what's changed?

二十年後，什麼改變了？

It's now widely recognized that just 20 percent of health outcomes

現在已經廣為認定，

只有 20% 的健康結果 和醫療照護有關，

are tied to medical care,

whereas up to 70 percent are tied to healthy behaviors

而高達 70% 來自健康的行為

and what's called the social determinants of health --

和所謂的「健康的社會決定因素」，

basically, everything that happens to us for that vast majority of time

基本上就是絕大部分

when we're not in the doctor's office

不在醫生辦公室或醫院裡。

or the hospital.

Health care executives now routinely remind us

健康照護執行者經常提醒我們

that our zip code matters more than our genetic code.

郵遞區號比基因編碼更重要。

And one health care publication even recently had the audacity

近期甚至有一本 健康照護刊物大膽地

to describe the social determinants of health

將健康的社會決定因素描述為 「年度感覺良好的行話」。

as "the feel-good buzzword of the year."

Now, there's been some action, too.

一直也有些行動。

Over the past decade, six major health care providers and insurers

在過去十年間，六間大型 健康照護提供者和保險業者

have committed over 600 million dollars

提撥了超過六億美金

to affordable housing,

用來協助提供可負擔住房，

recognizing that it reduces infant mortality

因為知道可負擔住房 能減低嬰兒的死亡率，

and increases life expectancy.

並延長壽命。

But let's be honest.

但，老實說，

Is our 3.5 trillion dollar health care system

我們的 3.5 兆美金健康照護體制

fundamentally designed to create health?

基本上不就是設計來 創造健康的嗎？

Absolutely not.

絕對不是。

Take access to healthy food.

以健康食物的取得管道為例。

Not long ago, a teenage boy shows up at a hospital in Baltimore,

不久前，一位青少年去 巴爾的摩的一間醫院看病，

losing weight.

他體重減輕很多。

Just as his doctors are huddled up figuring out which metabolic panels

當他的醫生們在討論要採用

哪些新陳代謝檢驗套組 以及血液檢測時，

and blood tests to run,

one of my colleagues asks out loud,

我有一位同事大聲問：

"Do you think he might be hungry?"

「你們覺得他會不會是餓了？」

It turned out that this kid had been kicked out of his housing

結果發現這個孩子被趕出住房，

and literally hadn't had a meal in weeks.

數個星期沒有吃正餐。

He said he was "... so relieved that somebody finally asked me."

他說他「鬆了一口氣， 因為終於有人問我了。」

Somehow, we've created a health care system

不知怎麼的，在我們 創造的健康照護體制中，

where asking a patient "Are you hungry?"

問病人「你餓不餓？」

is so far outside the bounds of what counts as health care

竟然遠超出健康照護的範圍，

that we mostly fail or forget to ask altogether;

我們幾乎沒有或是忘了問這個問題；

where doctors lament a hospital's "no third sandwich policy,"

讓醫生們很感慨的就是醫院的 「不給第三個三明治政策」，

meaning that if you're a hungry patient in the ER,

意思就是，如果你是 急診室的病人且你餓了，

you can have only two free sandwiches,

你只能拿到兩個免費的三明治，

but as many MRIs as the doctor orders;

但只要醫生囑付， 做多少次核磁共振都行；

where, in 2016 in the state of Texas,

2016 年，在德州，

they spent 1.2 billion dollars on the medical costs of malnutrition

有十二億美金被花在

營養失調的醫療成本上，

instead of on access to healthy food;

而不是花在取得 健康食物的管道上；

where a Centers for Medicare and Medicaid Services program

聯邦醫療保險和聯邦醫療 輔助計劃服務中心有一個方案

stratifies hungry patients,

會將飢餓的病人分階級，

so that some get access to food and some get information about food,

有些人得到食物，

有些人得到食物的相關資訊，

with the justification that doing nothing for hungry patients

對飢餓患者無所作為

is standard and usual care in this country.

是我國合理、標準與常規的護理。

And that's just food.

那只是食物方面。

The same is true for housing, electricity ...

住房、電力等等也一樣……

The bottom line is, health care may be changing,

說到底，健康照護也許在改變，

but not by enough and certainly not fast enough.

但程度不夠大，速度也不夠快。

We ask the wrong questions of our doctors, of our patients,

我們不只問錯了醫生及病人的問題，

but also of our citizens.

公民的也錯了。

We ask about and argue about health care,

我們詢問、爭論「健康照護」，

but how do voters think about health?

但選民對「健康」的看法呢？

No one could tell us the answer to that question,

沒有人能告訴我們 那個問題的答案，

so we launched a new initiative

所以我們推出了一項新計畫，

and hired a polling firm to ask voters across the country:

僱用民調公司來問我國的選民：

What do you need to be healthy?

你需要什麼才健康？

What was so striking about this was that no one has any clue

很令人驚訝的是，

對於我們在健康照護中所談的東西，

what we are talking about in health care.

沒有人有任何頭緒。

Voters do not think the social determinants of health

選民不認為 「健康的社會決定因素」是個好詞，

is a feel-good phrase.

They actually hate it.

反而很討厭它。

"What uneducated person came up with that language?"

「是哪個沒受過教育的人 想出那個用語的？」

one of the voters said.

這是其中一名選民說的。

Or my favorite was the guy who said,

我最愛的則是這個傢伙的說法：

"You're killing me."

「敗給你了。」

But when you strip away all the ridiculousness

但，當你把荒謬的健康照護用語

of our language in health care,

先擱在一旁，

we know exactly what creates health.

就清楚知道什麼創造健康。

So take Charlotte, North Carolina.

以北卡羅萊納州的夏洛特為例。

We had two focus groups,

我們有兩個焦點小組，

one of African American Democratic women and one of white Republican women.

一組是民主黨的非裔美國女性， 另一組是共和黨的白人女性。

And we asked them, "If you had a hundred dollars,

我們問他們：「如果你有一百元，

how would you spend it to buy health in your community?

在你的社區中，你會 怎麼用它來買到健康？」

Turns out, they agree nearly to the last percentage point.

結果發現他們看法幾乎完全一致。

First, they agree that health care only sort of impacts health.

首先，他們都認為健康照護 只對健康有部分影響。

So they choose to spend the majority of their dollars

所以他們選擇將大部分的錢花在

outside of hospitals and clinics.

醫院和診所以外的地方。

And second, they agree on what creates health,

第二，對於什麼能創造健康， 他們的意見也一致，

spending 19 percent on affordable housing

19% 的錢花在可負擔的住房上，

and about 25 percent on access to healthy food.

約 25% 的錢花在 取得健康食物的管道上。

So I am sure you are thinking, "This has got to be a fluke."

我相信你們現在在想 「這一定是僥倖碰對的」。

But it's not.

但並不是。

White and Latino male swing voters in Seattle,

西雅圖的白種 和拉丁裔男性中間選民、

white and African American Democratic voters in Cleveland,

克里夫蘭的民主黨 白種和非裔選民、

white male Republicans in Dallas,

達拉斯的共和黨白種男性、

low-income white Democrats in Hendersonville, North Carolina:

北卡羅萊納州亨德森維爾的 民主黨低收入白種人：

their answers are strikingly similar,

他們的答案都非常相似，

with all of them choosing to spend more money

他們全都選擇把比較多的錢

on healthy food and safe housing

花在健康食物和安全住房上，

than they would on hospitals and health centers.

高於花在醫院和健康中心的錢。

When you ask the right questions,

當你問對了問題，

it becomes pretty clear:

就能很清楚地知道：

we may be fractured on health care in this country,

在美國，我們或許 對健康照護的意見分歧，

but we are unified on health.

但我們對健康的意見是一致的。

The thing that I've been struggling with is why.

我一直在絞盡腦汁思考為什麼。

Why do we agree on health?

為什麼我們對健康的意見一致？

We agree on health because it is common sense.

我們對健康的意見一致， 是因為它是常識。

We all know that the things we need to get healthy --

我們都知道我們要 「變健康」所需要的東西——

medicine and medical care --

藥物和醫療照護——

are not the things we need to be healthy,

並不等於我們要 「保持健康」所需要的東西，

to not get sick in the first place.

也就是根本就不要生病。

But we also agree because of common experience.

我們對健康的意見一致， 也是因為共同經驗。

In a study of 5,000 patients,

有一項針對五千名病人 做的研究指出，

24 percent of the patients with commercial health insurance --

24% 有商業健康保險的病人——

meaning, they had a job --

也就是有工作的病人——

still ran out of food or struggled to find housing or transportation

仍然會沒有食物

或很難取得住房、交通工具，

or other essential resources.

或其他必要資源。

Twenty-four percent.

24%。

And we saw the same thing in our focus groups.

在我們的焦點小組中 也有相同的發現。

Nearly every voter knew what it meant to struggle,

幾乎每位選民都知道 艱困是怎樣的感覺，

either themselves or their families

也許是發生在自己身上、 家人身上，或鄰居身上。

or their neighbors.

One of those white Republican women in Charlotte was a waitress

夏洛特的一位共和黨白種女服務生

struggling to stay awake with an enormous Big Gulp soda.

幾乎無法保持清醒， 要靠巨量杯的汽水幫忙。

She just looked exhausted.

她看起來累壞了。

And she was.

她的確累壞了。

She told us that she worked two jobs

她告訴我們，她有兩份工作，

but still could not afford a membership to the Y,

但仍然無法負擔 YMCA 的會籍，

but it was OK that she couldn't go to the gym, she said,

但她說，她不能上健身房沒關係，

because she also could not afford gas

因為她也負擔不起油錢，

and walked 10 miles to and from work

所以上班來回各要走十英哩路，

every single day.

天天用走的。

Listening to her, I felt this familiar panic rise in me,

聽她說時，我感到我內在 出現了一種熟悉的恐慌，

the residue of my own childhood.

是我童年的殘留下來的。

When I was 10 years old,

當我十歲時，

my father lay on the living room floor

我爸爸躺在客廳地板上，

in the grips of one of his many depressions.

他常常憂鬱症發作， 這是其中一次。

As I crouched next to him, he told me that he wanted to kill himself.

我蹲在他身邊時， 他告訴我他想要自殺。

My father lived,

我爸爸活下來了，

but he struggled to work.

但他很難找到工作。

And my family survived,

我的家庭存活下來了， 但我們過得很辛苦，

but we teetered,

down one paycheck,

只靠我媽媽當老師的一份薪水養家。

relying on my mom's schoolteacher salary.

Even as a little kid, I knew we lived in the shadow

即使我當時很小，我也知道

我們住在財務和情緒崩潰的陰影下。

of financial and emotional collapse.

This is really hard to say,

這真的很難說出來，

because it's taken me 25 years to be honest with myself

因為我花了二十五年的時間， 才誠實面對自己，

that this is why I do this work:

承認這是我從事這項工作的原因。

knowing that my father needed health care to recover,

我知道爸爸需要健康照護才能復元，

but to be healthy, my family needed something else,

但我的家庭還需要別的才健康。

we needed a decent income;

我知道我們需要夠用的收入；

and knowing, as so many do more than I,

還知道，很多人比我更熟悉的，

that panic when the basics threaten to slip away.

那可能失去基本飽暖的恐慌感。

To the voters in our focus groups, the solutions were straightforward.

對我們焦點小組中的選民來說， 解決方案是很直觀的。

As one of those white Republican women in Charlotte said,

有一位夏洛特的 共和黨白種女性說：

"Instead of putting all this money into health care,

「別把所有的錢用在健康照護上，

put it into affordable housing.

把錢改用在可負擔住房上。

You know, like, take it and distribute it differently."

你知道的，用不同的方式 來分配錢的使用。」

It turns out that when you have the right language

結果發現，只要你用對了用語

and you ask the right questions,

並問對了問題，

the answers become remarkably clear

答案就非常清楚且全體一致。

and unanimous.

What we know is that, despite all the noise,

我們知道的是，

儘管有許多噪音，

the plan for health care in this country

這個國家中的健康照護計畫

is that there is no plan.

就是沒有計畫。

But we have something more powerful than any politician's bill,

但我們有更強大的東西， 勝過任何政客的法案、

any candidate's platform,

任何候選人的平台、

any think tank's policy statement.

任何智囊團的政策聲明。

We have our common sense and our common experience.

我們有我們的常識以及共同經驗。

So I ask, if you are a health care executive:

所以，如果你是健康照護 執行者，我想問：

Do you know how many of your patients run out of food

你是否知道你的病人中 有多少人沒有食物？

or struggle to pay the rent at the end of the month?

或為了月底付不出房租而苦？

Is that data on your scorecard,

你的事業和你的獎金所參考的

shaping your business and your bonuses?

計分卡上有那些資料嗎？

If you are a politician:

如果你是政治人物：

Will you continue to fight on the scorched earth of health care,

你會在健康照護的 焦土上努力奮鬥嗎？

or will you act on what your voters,

或者你會依選民 來決定採取什麼行動？

what Democratic and Republican voters alike,

民主黨和共和黨的選民同樣，

already know,

他們已經知道

which is that good wages, healthy food and safe housing

好的薪水、健康的食物，

和安全的住房就是健康。

are health?

And for the rest of us, for the citizens of this country:

至於其餘的人，我國的公民們：

Will we demand accountability to what we know to be true,

我們能否要求對已知的事實究責？

which is that our common sense,

也就是我們的常識

our common experience,

以及我們的共同經驗

makes us the experts in what it takes to be healthy?

讓我們成為專家， 知道健康需要什麼。

This moment, as it turns out,

事實證明，此時，

is not about changing minds.

重點不在於改變想法。

It is about something more powerful.

重點在於更強大的東西。

It is about changing the questions we ask

重點在於改變我們所問的問題

and quieting the noise to hear each other's answers.

以及讓噪音安靜下來， 才能聽見彼此的答案。

It is about the radical possibility that we the patients,

重點在於，很有可能我們病人、

we the physicians, we the caregivers,

我們醫生、我們照護者、

we the health care executives

我們健康照謢執行者， 還有我們人民，

and yes, even we the people,

that we agree.

其實意見一致。

And it is now time --

現在是時候了——

in fact, long overdue --

事實上，早就該做了——

for us to marshal the courage

我們應該要引領有勇氣的人，

to hear those answers and to act upon them.

去聽見那些答案， 並採取相應的行動。

Thank you.

謝謝。

(Applause)

（掌聲）