Mental Health for All by Involving All | Vikram Patel | TED Talks

Translator: Joseph Geni Reviewer: Morton Bast

譯者: Yu-Sheng Lin 審譯者: Anna Dung

I want you to imagine this for a moment.

請大家想像一下這樣的情境

Two men, Rahul and Rajiv,

有兩個人, 名叫 拉胡跟拉吉

living in the same neighborhood,

住在同一個區域

from the same educational background, similar occupation,

有相同的教育背景, 從事相似的職業

and they both turn up at their local accident emergency

兩個人同樣的都出現在同一個區域急救中心

complaining of acute chest pain.

主訴症狀都是劇烈的胸痛

Rahul is offered a cardiac procedure,

拉胡被施以心血管的療程

but Rajiv is sent home.

而拉吉被告知直接回家

What might explain the difference in the experience

這兩個幾乎相同的人,

of these two nearly identical men?

為什麼會有截然不同的醫療待遇呢?

Rajiv suffers from a mental illness.

拉吉的症狀是心理疾病所造成的

The difference in the quality of medical care

在醫療照護方面的品質落差

received by people with mental illness is one of the reasons

是造成心理疾病患者的壽命比較短,

why they live shorter lives

的眾多原因之一

than people without mental illness.

相較於沒有心理疾病的人

Even in the best-resourced countries in the world,

就算是在世界上資源充分的國家裡

this life expectancy gap is as much as 20 years.

這樣的壽命差異仍可以高達20年

In the developing countries of the world, this gap

若是在開發中的國家, 這項差異

is even larger.

還會更大

But of course, mental illnesses can kill in more direct ways

當然了, 心理疾病也可能更直接致命

as well. The most obvious example is suicide.

最常見的例子就是自殺

It might surprise some of you here, as it did me,

你可能會大吃一驚, 就如同我當時

when I discovered that suicide is at the top of the list

發現自殺是造成年輕人死亡清單中

of the leading causes of death in young people

榜上有名的

in all countries in the world,

在全世界的每個國家都是如此

including the poorest countries of the world.

包括世界上最貧窮的那些國家

But beyond the impact of a health condition

心理疾病除了影響人的健康

on life expectancy, we're also concerned

影響人的壽命, 我們更關切的是

about the quality of life lived.

對生活品質的影響

Now, in order for us to examine the overall impact

我們為了要調查心理疾病對健康的整體影響

of a health condition both on life expectancy

包括壽命(餘命), 還有

as well as on the quality of life lived, we need to use

生活的品質, 我們採用了

a metric called the DALY,

一個量表, 縮寫字首是DALY

which stands for a Disability-Adjusted Life Year.

全名是失能修正餘命年數

Now when we do that, we discover some startling things

透過這樣的研究, 我們發現一些驚人的事實

about mental illness from a global perspective.

是關於心理疾病, 從全球的觀點來看

We discover that, for example, mental illnesses are

我們發現到, 比方說, 心理疾病

amongst the leading causes of disability around the world.

是造成失能的主要原因之一

Depression, for example, is the third-leading cause

以精神抑鬱來說, 是失能的第三主因

of disability, alongside conditions such as

前兩名分別是

diarrhea and pneumonia in children.

兒童的痢疾(腹瀉)與肺炎

When you put all the mental illnesses together,

綜觀所有心理疾病

they account for roughly 15 percent

約佔全球疾病負擔

of the total global burden of disease.

15%之多

Indeed, mental illnesses are also very damaging

很明顯, 心理疾病對於人的生活構成很大的傷害

to people's lives, but beyond just the burden of disease,

除了造成疾病負擔外

let us consider the absolute numbers.

我們也來看看一些實際的數據

The World Health Organization estimates

世界衛生組織(WHO)估計

that there are nearly four to five hundred million people

大約有四到五億人

living on our tiny planet

在這個地球上

who are affected by a mental illness.

正受到心理疾病的影響

Now some of you here

在座各位

look a bit astonished by that number,

看起來對這樣的數字有些吃驚

but consider for a moment the incredible diversity

但若試想一下, 心理疾病有如此多的種類

of mental illnesses, from autism and intellectual disability

從童年期的自閉症及智能障礙

in childhood, through to depression and anxiety,

到成年期的抑鬱與焦慮

substance misuse and psychosis in adulthood,

藥物濫用與精神失調

all the way through to dementia in old age,

一直到老年期的失智症

and I'm pretty sure that each and every one us

我非常肯定, 今天在這裡的每一個人

present here today can think of at least one person,

至少都能夠想出一個人,

at least one person, who's affected by mental illness

至少有一個人, 曾受到心理疾病的影響

in our most intimate social networks.

就在我們最親近的社交圈裡

I see some nodding heads there.

我看到有些人在點頭

But beyond the staggering numbers,

除了這些令人驚愕的統計數字之上

what's truly important from a global health point of view,

從全球健康的觀點來看, 更關鍵的是什麼?

what's truly worrying from a global health point of view,

更值得擔憂的是什麼?

is that the vast majority of these affected individuals

就是這些受到心理疾病影響的個人, 絕大部分

do not receive the care

都沒有接受治療照護

that we know can transform their lives, and remember,

我們明明知道治療照護可以改變這些人的人生

we do have robust evidence that a range of interventions,

也清楚一些醫療措施明確證實

medicines, psychological interventions,

像是藥物, 心理方面的措施

and social interventions, can make a vast difference.

社會方面的措施, 可以產生重大的改善

And yet, even in the best-resourced countries,

但是, 就算是在資源最豐富的國家裡

for example here in Europe, roughly 50 percent

例如在歐洲這裡, 仍然有將近一半的

of affected people don't receive these interventions.

受心理疾病影響的人, 沒有受到任何措施的協助

In the sorts of countries I work in,

在我工作的那些國家裡

that so-called treatment gap

這種所謂的醫療缺口

approaches an astonishing 90 percent.

逼近到驚人的90%

It isn't surprising, then, that if you should speak

如果你跟一個受到心理疾病所苦的人談談

to anyone affected by a mental illness,

不出人意表地，你往往會聽到

the chances are that you will hear stories

他們的故事裡充滿了

of hidden suffering, shame and discrimination

壓抑的苦痛, 恥辱, 還有歧視

in nearly every sector of their lives.

發生在他們生活的每環節

But perhaps most heartbreaking of all

但或許最讓人心碎的

are the stories of the abuse

是那些關於被虐待的故事

of even the most basic human rights,

連最基本的人權都被剝奪

such as the young woman shown in this image here

如同這張照片裡的年輕女子的遭遇

that are played out every day,

令人遺憾的, 每天

sadly, even in the very institutions that were built to care

都在發生, 就在這些專門為照護

for people with mental illnesses, the mental hospitals.

心理疾病患者的機構,精神專科醫院裡面

It's this injustice that has really driven my mission

就是這種不公義, 驅使我投入了一個願景

to try to do a little bit to transform the lives

試著改變這些人的生活

of people affected by mental illness, and a particularly

幫助這些受到心理疾病影響的人, 特別著重在

critical action that I focused on is to bridge the gulf

一個關鍵環節, 就是彌補其間的鴻溝

between the knowledge we have that can transform lives,

一方面是改變他們生活所需的知識,

the knowledge of effective treatments, and how we actually

有效療法的知識, 另一方面在於如何實際地

use that knowledge in the everyday world.

在日常生活裡運用這些知識

And an especially important challenge that I've had to face

而我們所要面對的一個特別重要的挑戰

is the great shortage of mental health professionals,

就是心理衛生專業人員的嚴重不足

such as psychiatrists and psychologists,

例如精神病學家與心理學家

particularly in the developing world.

特別是在開發中世界

Now I trained in medicine in India, and after that

我在印度接受醫學教育的, 後來

I chose psychiatry as my specialty, much to the dismay

我選擇了精神病學作為專科, 違背了

of my mother and all my family members who

我母親和家庭成員的期待,

kind of thought neurosurgery would be

他們多少會覺得這麼聰明的孩子,

a more respectable option for their brilliant son.

應該選擇神經外科才比較有出息

Any case, I went on, I soldiered on with psychiatry,

不管怎麼說, 我還是堅持, 投入了精神病學

and found myself training in Britain in some of

並且有幸到英國

the best hospitals in this country. I was very privileged.

最頂尖的醫院裡接受訓練

I worked in a team of incredibly talented, compassionate,

與一群非常具有天份, 非常熱情的成員共事

but most importantly, highly trained, specialized

更重要的, 是受過高度的專業訓練的

mental health professionals.

心理健康方面的專業人士

Soon after my training, I found myself working

受完訓練之後, 我開始的第一項工作

first in Zimbabwe and then in India, and I was confronted

是在辛巴威, 然後回到印度. 那時我面對的

by an altogether new reality.

是一個全然陌生的現實狀況

This was a reality of a world in which there were almost no

在這個現實狀況中，幾乎找不到任何的

mental health professionals at all.

精神衛生專業人員。

In Zimbabwe, for example, there were just about

例如: 在辛巴威，大約只有

a dozen psychiatrists, most of whom lived and worked

十幾個精神病醫生，其中大多在哈拉雷市(Harare)居住

in Harare city, leaving only a couple

和執業(行醫), 只剩下一兩個

to address the mental health care needs

去服務住在農村的900 萬人

of nine million people living in the countryside.

的精神衛生保健需要

In India, I found the situation was not a lot better.

在印度，我發現情況也好不到哪裡去

To give you a perspective, if I had to translate

打個比方比較好理解，如果我用

the proportion of psychiatrists in the population

精神科醫生在人口中所占的比例來說明

that one might see in Britain to India,

如果以英國的比例來套用到印度

one might expect roughly 150,000 psychiatrists in India.

那麼印度應該大約有150,000 個精神病醫生。

In reality, take a guess.

在現實中，大家猜一猜。

The actual number is about 3,000,

實際的精神病醫生的數目約3000個，

about two percent of that number.

只有英國的2%

It became quickly apparent to me that I couldn't follow

很快地我就認清了沒有辦法按照

the sorts of mental health care models that I had been trained in,

先前我所學的那些精神健康護理模式

one that relied heavily on specialized, expensive

其中高度依賴專業且所費不貲的

mental health professionals to provide mental health care

精神衛生專業人員來提供心理衛生保健

in countries like India and Zimbabwe.

在印度和辛巴威這樣的國家。

I had to think out of the box about some other model

我必須跳脫既有的框架, 想出其他模式的

of care.

護理服務。

It was then that I came across these books,

就在那時候, 我偶然看到這些書，

and in these books I discovered the idea of task shifting

在這些書中發現了所謂 "任務轉移" 的想法

in global health.

可用在全球保健上。

The idea is actually quite simple. The idea is,

這種想法實際上很簡單。就是

when you're short of specialized health care professionals,

當你缺乏專門的醫護專業人員的時候

use whoever is available in the community,

就直接從社區裡找可用的人選

train them to provide a range of health care interventions,

培訓他們來提供一個特定範圍的各種保健措施

and in these books I read inspiring examples,

其中有些很具啟發性的例子

for example of how ordinary people had been trained

例如, 如何培訓一般人

to deliver babies,

去接生嬰兒

diagnose and treat early pneumonia, to great effect.

學會診斷和治療早期肺炎，以發揮大效用。

And it struck me that if you could train ordinary people

這讓我目瞪口呆，如果你可以訓練普通百姓

to deliver such complex health care interventions,

來提供如此複雜的衛生保健措施，

then perhaps they could also do the same

那麼, 也許一般人也可以做到相同的地步

with mental health care.

在精神衛生保健這方面。

Well today, I'm very pleased to report to you

今天，我很高興向各位報告

that there have been many experiments in task shifting

有許多關於"任務轉移" 的實驗被執行

in mental health care across the developing world

在精神衛生保健這方面, 在開發中世界的許多地方

over the past decade, and I want to share with you

在過去十年裡，我想在這裡與你們分享

the findings of three particular such experiments,

這三個特別的實驗

all three of which focused on depression,

這三個都是以抑鬱症為主題

the most common of all mental illnesses.

這是所有的精神疾病中, 最常見的。

In rural Uganda, Paul Bolton and his colleagues,

在烏干達的鄉下、 保羅·博爾頓(Paul Bolton)和他的同事們，

using villagers, demonstrated that they could deliver

與一些村民合作，證明了他們可以提供

interpersonal psychotherapy for depression

抑鬱症的人際心理治療方式

and, using a randomized control design,

而且, 透過隨機對照組的實驗設計

showed that 90 percent of the people receiving

觀察到了接受這種治療的人, 有90%

this intervention recovered as compared

的治癒率, 相較之下

to roughly 40 percent in the comparison villages.

那些對照組的村莊, 大約是40%。

Similarly, using a randomized control trial in rural Pakistan,

在巴基斯坦鄉下，也進行了類似的隨機對照試驗

Atif Rahman and his colleagues showed

據阿替夫·拉赫曼(Atif Rahman)和他的同事們發現到

that lady health visitors, who are community maternal

女性健康訪視員, 就是社區內孕產婦的保健員

health workers in Pakistan's health care system,

是屬於巴基斯坦的衛生保健系統的一部份，

could deliver cognitive behavior therapy for mothers

可以為有抑鬱症狀的母親, 提供認知行為療法

who were depressed, again showing dramatic differences

結果也再次展示了很大的差異

in the recovery rates. Roughly 75 percent of mothers

以治癒率來看。採用村莊大約是75%的治癒率

recovered as compared to about 45 percent

相較於只有45%的治癒率

in the comparison villages.

在對照組的村莊。

And in my own trial in Goa, in India, we again showed

而我自己的試驗，在印度的果阿(Goa)，我們再一次顯示

that lay counselors drawn from local communities

培訓來自當地社區的輔導員

could be trained to deliver psychosocial interventions

來提供心理社會干預措施

for depression, anxiety, leading to 70 percent

針對抑鬱，焦慮，可得70%

recovery rates as compared to 50 percent

的治癒率, 相較

in the comparison primary health centers.

在那些對照組的初級保健中心的50%。

Now, if I had to draw together all these different

現在，如果我必須總結這些各式各樣的

experiments in task shifting, and there have of course

任務轉移的實驗，當然在此之外

been many other examples, and try and identify

還有許多其他的例子，嘗試著歸納出

what are the key lessons we can learn that makes

一些關鍵要素, 讓我們可以學習並促成

for a successful task shifting operation,

任務轉換的成功運作

I have coined this particular acronym, SUNDAR.

我創造了這個特別的首字母縮寫詞，SUNDAR

What SUNDAR stands for, in Hindi, is "attractive."

這個字在印度語的意思是 "吸引力"。

It seems to me that there are five key lessons

我用這個字來代表五個主要關鍵要素

that I've shown on this slide that are critically important

列在這張投影片上，對於有效進行任務轉移

for effective task shifting.

是非常重要的

The first is that we need to simplify the message

第一個是, 我們需要簡化用詞

that we're using, stripping away all the jargon

拿掉那些學界裡慣用的術語

that medicine has invented around itself.

只有醫學院的人才聽得懂的

We need to unpack complex health care interventions

我們還需要解構整個複雜的保健干預措施

into smaller components that can be more easily

分成較小的元件，可以更容易地

transferred to less-trained individuals.

轉移給受過簡易訓練的個人。

We need to deliver health care, not in large institutions,

我們所要提供的衛生保健, 並不是在大型機構，

but close to people's homes, and we need to deliver

而是要貼近人們的家園，我們提供衛生保健的方式

health care using whoever is available and affordable

是運用所有可得的與可負擔的,

in our local communities.

在地的資源

And importantly, we need to reallocate the few specialists

也很重要的是，要重新配置這些數量有限的專家

who are available to perform roles

讓他們扮演的角色

such as capacity-building and supervision.

負責建立生產力還有監導

Now for me, task shifting is an idea

現在對我來說，轉移任務是一個

with truly global significance,

具有真正影響全球的想法

because even though it has arisen out of the

因為即使它源自於

situation of the lack of resources that you find

開發中國家資源缺乏的情境下

in developing countries, I think it has a lot of significance

但我認為它對於資源較充足的國家來說

for better-resourced countries as well. Why is that?

也是非常重要的。為什麼呢？

Well, in part, because health care in the developed world,

嗯，有部份原因, 是因為在已開發世界

the health care costs in the [developed] world,

的衛生保健費用

are rapidly spiraling out of control, and a huge chunk

快速攀升直超出控制, 其中的一大部分

of those costs are human resource costs.

是人力資源成本。

But equally important is because health care has become

但同樣重要的是，因為衛生保健已發展成

so incredibly professionalized that it's become very remote

如此令人難以置信地專業化, 以至於變成和

and removed from local communities.

當地社區越離越遠, 甚至完全脫節.

For me, what's truly sundar about the idea of task shifting,

對我來說，任務轉移這想法真正順達(有吸引力)的

though, isn't that it simply makes health care

並不僅僅是讓衛生保健

more accessible and affordable but that

更容易取得且更能夠負擔

it is also fundamentally empowering.

而是能夠從根本上授權

It empowers ordinary people to be more effective

它使普羅大眾能夠更有效的

in caring for the health of others in their community,

在他們的社區照顧大眾的健康，

and in doing so, to become better guardians

也因為如此做, 能成為在地人的健康導師

of their own health. Indeed, for me, task shifting

所以, 對於我來說，任務轉移

is the ultimate example of the democratization

是民主化的最典型的例子

of medical knowledge, and therefore, medical power.

把醫學知識, 連帶著醫療能量, 都民主化了

Just over 30 years ago, the nations of the world assembled

30 多年前(1978年)，世界各國聚集在

at Alma-Ata and made this iconic declaration.

在阿拉木圖(哈薩克共和國城市)開會, 作出這樣的宣言

Well, I think all of you can guess

嗯，我想大家都猜得到

that 12 years on, we're still nowhere near that goal.

已經超過了宣言期限12年了, 我們還離這目標很遙遠

Still, today, armed with that knowledge

不過如今呢, 透過基本知識的裝備訓練

that ordinary people in the community

讓在社區的一般人

can be trained and, with sufficient supervision and support,

在充分的監督和支援下

can deliver a range of health care interventions effectively,

可以有效地提供一系列保健干預措施

perhaps that promise is within reach now.

或許當初的宣言有達成的可能了

Indeed, to implement the slogan of Health for All,

事實上，為了落實"全民健康" 這個口號

we will need to involve all

我們必須讓全民都能

in that particular journey,

參與這個特別的過程

and in the case of mental health, in particular we would

而在心理保健方面，我們特別需要讓

need to involve people who are affected by mental illness

受精神疾病影響的人, 還有他們的照護者

and their caregivers.

都參與進來

It is for this reason that, some years ago,

這也是為什麼在幾年前

the Movement for Global Mental Health was founded

全球精神衛生運動開始推動

as a sort of a virtual platform upon which professionals

扮演一種虛擬平臺的角色,

like myself and people affected by mental illness

讓像我這樣的專業人員, 和受精神疾病影響的人

could stand together, shoulder-to-shoulder,

能並肩而站

and advocate for the rights of people with mental illness

宣揚心理疾病患者的權利

to receive the care that we know can transform their lives,

一個得到改善生活照護的權力

and to live a life with dignity.

並且有尊嚴地活下去

And in closing, when you have a moment of peace or quiet

最後，當你有片刻的寧靜時

in these very busy few days or perhaps afterwards,

在這幾個忙碌的日子, 或是在往後

spare a thought for that person you thought about

花些心思在那個你想到的, 受心理疾病影響的人

who has a mental illness, or persons that you thought about

或是那群你想到的

who have mental illness,

受心理疾病影響的人們

and dare to care for them. Thank you. (Applause)

勇於關心他們吧.謝謝（掌聲）

(Applause)

（掌聲）