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  • In the mid-'90s,

    90 年代中期,

  • the CDC and Kaiser Permanente

    疾病防治中心和凱薩醫療機構

  • discovered an exposure that dramatically increased the risk

    發現暴露於某種物質, 會使死亡風險劇增。

  • for seven out of 10 of the leading causes of death in the United States.

    在美國,它占主要死亡原因的 70%。

  • In high doses, it affects brain development,

    暴露於高劑量時,會影響大腦發育、

  • the immune system, hormonal systems,

    免疫系統、激素系統、

  • and even the way our DNA is read and transcribed.

    甚至影響 DNA 讀取和轉錄方式。

  • Folks who are exposed in very high doses

    暴露在高劑量下的人們,

  • have triple the lifetime risk of heart disease and lung cancer

    有 3 倍風險患上心臟病和肺癌。

  • and a 20-year difference in life expectancy.

    預期壽命減少 20 年。

  • And yet, doctors today are not trained in routine screening or treatment.

    但現時醫生未接受相關培訓, 對其進行常規檢查或治療。

  • Now, the exposure I'm talking about is not a pesticide or a packaging chemical.

    這種病因指的不是農藥 或包裝上的化學物質,

  • It's childhood trauma.

    而是童年創傷。

  • Okay. What kind of trauma am I talking about here?

    到底是哪種創傷呢?

  • I'm not talking about failing a test or losing a basketball game.

    不是考試不合格或輸掉籃球賽。

  • I am talking about threats that are so severe or pervasive

    那種危害極其嚴重、無孔不入,

  • that they literally get under our skin and change our physiology:

    以致深入骨髓,改變了我們的生理:

  • things like abuse or neglect,

    例如虐待、忽視,

  • or growing up with a parent who struggles with mental illness

    或童年受到患有精神病的父母影響,

  • or substance dependence.

    或父母患物質依賴症。

  • Now, for a long time,

    很長一段時間裡,

  • I viewed these things in the way I was trained to view them,

    我看待這些事的方式受教育影響,

  • either as a social problem -- refer to social services --

    將其視為社會問題, 交由社會服務解決,

  • or as a mental health problem -- refer to mental health services.

    或視為心理健康問題, 運用心理健康服務。

  • And then something happened to make me rethink my entire approach.

    但有一件事, 重塑了我整個思維方式。

  • When I finished my residency,

    醫院實習結束後,

  • I wanted to go someplace where I felt really needed,

    我想去一個真正需要我的地方,

  • someplace where I could make a difference.

    一個我能有所作為的地方。

  • So I came to work for California Pacific Medical Center,

    所以我去了 加利福尼亞太平洋醫療中心,

  • one of the best private hospitals in Northern California,

    北加最好的私立醫院之一,

  • and together, we opened a clinic in Bayview-Hunters Point,

    我們合作 在舊金山灣景區開了家診所,

  • one of the poorest, most underserved neighborhoods in San Francisco.

    那是舊金山最窮、 社區服務最差的區。

  • Now, prior to that point,

    在這之前,

  • there had been only one pediatrician in all of Bayview

    整個灣景區只有一位兒科醫生,

  • to serve more than 10,000 children,

    負責一萬多名兒童的醫療,

  • so we hung a shingle, and we were able to provide top-quality care

    於是我們開始掛牌營業, 提供最優質的服務,

  • regardless of ability to pay.

    不論病人能否支付費用。

  • It was so cool. We targeted the typical health disparities:

    這很有意義, 我們旨在減少常見醫療服務的差距:

  • access to care, immunization rates, asthma hospitalization rates,

    如:看護服務、 疫苗接種率、哮喘住院率,

  • and we hit all of our numbers.

    每項我們都達標了,

  • We felt very proud of ourselves.

    我們感到很自豪。

  • But then I started noticing a disturbing trend.

    但我注意到一個讓人憂心的趨勢。

  • A lot of kids were being referred to me for ADHD,

    很多孩子被診斷患有 「過動症」交給我,

  • or Attention Deficit Hyperactivity Disorder,

    或稱:「注意力不足過動症」。

  • but when I actually did a thorough history and physical,

    但我給他們做 全面病史和身體檢查後,

  • what I found was that for most of my patients,

    發現大部分病人,

  • I couldn't make a diagnosis of ADHD.

    我難以斷定是過動症。

  • Most of the kids I was seeing had experienced such severe trauma

    這些孩子多數受過嚴重的創傷,

  • that it felt like something else was going on.

    讓我覺得另有起因。

  • Somehow I was missing something important.

    我莫名地感覺遺漏了一個重要因素。

  • Now, before I did my residency, I did a master's degree in public health,

    實習之前, 我取得過公共衛生碩士學位,

  • and one of the things that they teach you in public health school

    在學校裡,我學到的一點是:

  • is that if you're a doctor

    如果你是個醫生

  • and you see 100 kids that all drink from the same well,

    看到 100 個孩子喝了同一口井的水,

  • and 98 of them develop diarrhea,

    其中 98 個得了腹瀉,

  • you can go ahead and write that prescription

    你可以直接開張處方,

  • for dose after dose after dose of antibiotics,

    一劑又一劑的抗生素,

  • or you can walk over and say, "What the hell is in this well?"

    或問:「這井裡到底有什麼鬼東西?」

  • So I began reading everything that I could get my hands on

    於是,我開始查閱 手上所有相關文獻,

  • about how exposure to adversity

    研究長期暴露在逆境下

  • affects the developing brains and bodies of children.

    對成長期間的小孩 有何身心健康影響。

  • And then one day, my colleague walked into my office,

    有一天,我同事走進辦公室,說:

  • and he said, "Dr. Burke, have you seen this?"

    「柏醫生,妳看過這個嗎?」

  • In his hand was a copy of a research study

    他手裡是一份研究報告,

  • called the Adverse Childhood Experiences Study.

    名字是《童年不良經驗研究》。

  • That day changed my clinical practice and ultimately my career.

    那一天,改變了我的醫療方法, 最終改變了我的職業生涯。

  • The Adverse Childhood Experiences Study

    童年不良經歷研究

  • is something that everybody needs to know about.

    是大家都需要了解的東西。

  • It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC,

    它由凱薩醫療機構的文醫生 (Vince Felitti) 和 疾控中心的安達醫生 (Bob Anda) 聯手完成。

  • and together, they asked 17,500 adults about their history of exposure

    他們詢問了 17500 名成年人,

  • to what they called "adverse childhood experiences," or ACEs.

    了解他們的「童年不良經驗」, 簡稱 ACE。

  • Those include physical, emotional, or sexual abuse;

    包括身心上的不良經歷及性虐待;

  • physical or emotional neglect;

    生理或情感忽略;

  • parental mental illness, substance dependence, incarceration;

    父母患精神疾病、物質依賴或入獄;

  • parental separation or divorce;

    父母分居或離婚;

  • or domestic violence.

    或家庭暴力。

  • For every yes, you would get a point on your ACE score.

    每經歷一種,ACE 指數就加 1。

  • And then what they did

    接著,

  • was they correlated these ACE scores against health outcomes.

    他們把 ACE 指數 與健康現狀聯系起來。

  • What they found was striking.

    他們得出驚人的結果。

  • Two things:

    其中有兩點:

  • Number one, ACEs are incredibly common.

    一是 ACE 非常普遍。

  • Sixty-seven percent of the population had at least one ACE,

    67% 的人有至少一個 ACE,

  • and 12.6 percent, one in eight, had four or more ACEs.

    12.6%,即八分之一的人 有 4 個以上的 ACE。

  • The second thing that they found

    二是:

  • was that there was a dose-response relationship

    ACE 經歷的多少與 健康狀況有關係:

  • between ACEs and health outcomes:

    ACE 指數越高, 健康現狀越差。

  • the higher your ACE score, the worse your health outcomes.

    ACE 指數為 4 或更高的人,

  • For a person with an ACE score of four or more,

    患慢性阻塞性肺疾病的相對機率,

  • their relative risk of chronic obstructive pulmonary disease

    是指數爲 0 的人的 2.5 倍。

  • was two and a half times that of someone with an ACE score of zero.

    患肝炎的機率也是 2.5 倍。

  • For hepatitis, it was also two and a half times.

    患憂鬱症的機率是 4.5 倍。

  • For depression, it was four and a half times.

    自殺傾向則是 12 倍。

  • For suicidality, it was 12 times.

    ACE 指數為 7 或以上的人

  • A person with an ACE score of seven or more

    患肺癌的終身風險為 3 倍,

  • had triple the lifetime risk of lung cancer

    患冠心病的終身風險為 3.5 倍,

  • and three and a half times the risk of ischemic heart disease,

    這疾病是美國頭號殺手。

  • the number one killer in the United States of America.

    這當然說得通,

  • Well, of course this makes sense.

    有些人看了這些數據會說:

  • Some people looked at this data and they said, "Come on.

    「如果你有個痛苦的童年, 你抽煙喝酒的機率更高,

  • You have a rough childhood, you're more likely to drink and smoke

    會做些毀掉健康的行為。

  • and do all these things that are going to ruin your health.

    這不是科學,只是不健康行爲。」

  • This isn't science. This is just bad behavior."

    但這正是其科學性的所在。

  • It turns out this is exactly where the science comes in.

    現在我們比以前更清楚地知道,

  • We now understand better than we ever have before

    童年遭遇不良經歷,

  • how exposure to early adversity

    會影響兒童的身體及大腦發育,

  • affects the developing brains and bodies of children.

    它對腦部伏核産生影響,

  • It affects areas like the nucleus accumbens,

    這是大腦對快樂和獎勵的處理中心,

  • the pleasure and reward center of the brain

    它與物質依賴有關。

  • that is implicated in substance dependence.

    不良經歷會抑制前額皮質,

  • It inhibits the prefrontal cortex,

    這個部位對衝動控制 和行動力有影響,

  • which is necessary for impulse control and executive function,

    對學習能力有決定性影響。

  • a critical area for learning.

    在核磁共振掃描上,

  • And on MRI scans,

    會發現杏仁核有明顯的差異,

  • we see measurable differences in the amygdala,

    它是大腦的恐懼反應中心。

  • the brain's fear response center.

    因此,從神經學而言

  • So there are real neurologic reasons

    遭遇較多不良經歷的人,

  • why folks exposed to high doses of adversity

    做出高風險行為的機率更大,

  • are more likely to engage in high-risk behavior,

    了解這一點很重要。

  • and that's important to know.

    但事實上,即使你不做高風險行爲,

  • But it turns out that even if you don't engage in any high-risk behavior,

    你依然容易患上心臟病或者癌症。

  • you're still more likely to develop heart disease or cancer.

    這點跟 下丘腦—垂體—腎上腺軸有關,

  • The reason for this has to do with the hypothalamicpituitaryadrenal axis,

    它是大腦和身體的應激反應系統。

  • the brain's and body's stress response system

    影響著我們「戰還是逃」的決定。

  • that governs our fight-or-flight response.

    這是怎麼運作的呢?

  • How does it work?

    想像一下, 你在森林中看見一隻熊。

  • Well, imagine you're walking in the forest and you see a bear.

    你的下丘腦會瞬間發送信號到腦垂體,

  • Immediately, your hypothalamus sends a signal to your pituitary,

    腦垂體向腎上腺發信號,

  • which sends a signal to your adrenal gland that says,

    「釋放應激激素!腎上腺素!皮質醇!」

  • "Release stress hormones! Adrenaline! Cortisol!"

    然後你開始心跳加快,

  • And so your heart starts to pound,

    瞳孔放大,呼吸道大開,

  • Your pupils dilate, your airways open up,

    你已經做好準備, 跟這只熊抗擊或逃跑。

  • and you are ready to either fight that bear or run from the bear.

    這非常重要,

  • And that is wonderful

    如果你在森林中,而那裡有隻熊。

  • if you're in a forest and there's a bear.

    (笑)

  • (Laughter)

    但問題是, 如果這只熊每天都來騷擾你,

  • But the problem is what happens when the bear comes home every night,

    這個應激系統 一而再再而三地啓動,

  • and this system is activated over and over and over again,

    它從一種適應性或救命的系統,,

  • and it goes from being adaptive, or life-saving,

    變成適應不良或有損健康的系統。

  • to maladaptive, or health-damaging.

    兒童對這種反復的應激激活很敏感,

  • Children are especially sensitive to this repeated stress activation,

    因爲他們的大腦和身體 都還在發育階段,

  • because their brains and bodies are just developing.

    大量的逆境 不單損傷他們的大腦結構和功能,

  • High doses of adversity not only affect brain structure and function,

    還會影響發育中的免疫系統、

  • they affect the developing immune system,

    激素系統,

  • developing hormonal systems,

    甚至影響 DNA 的讀取和轉錄方式。

  • and even the way our DNA is read and transcribed.

    對我而言, 這個發現顛覆了我以前的認知,

  • So for me, this information threw my old training out the window,

    因爲當我們明白了一種疾病的機制,

  • because when we understand the mechanism of a disease,

    知道了被干擾的路徑及方式,

  • when we know not only which pathways are disrupted, but how,

    作爲醫生,我們理應運用科學

  • then as doctors, it is our job to use this science

    去預防和治療這種疾病。

  • for prevention and treatment.

    是職責所在。

  • That's what we do.

    於是,我們在舊金山 創立了青少年健康中心,

  • So in San Francisco, we created the Center for Youth Wellness

    用以預防、檢查並治癒 因 ACE 及有害壓力所造成的影響。

  • to prevent, screen and heal the impacts of ACEs and toxic stress.

    我們開始對每個孩子做檢查, 作為常規體檢的一部分,

  • We started simply with routine screening of every one of our kids

    因爲我知道 如果病人有 4 分的 ACE 值,

  • at their regular physical,

    她患肝炎或慢性阻塞性肺病 機率是 2.5 倍,

  • because I know that if my patient has an ACE score of 4,

    4.5 倍的機率患憂鬱,

  • she's two and a half times as likely to develop hepatitis or COPD,

    12 倍的機率選擇自殺,

  • she's four and half times as likely to become depressed,

    比那些 ACE 為 0 的人而言。

  • and she's 12 times as likely to attempt to take her own life

    當她在檢查室裡,我就知道了。

  • as my patient with zero ACEs.

    檢查結果呈陽性的患者,

  • I know that when she's in my exam room.

    我們有支多學科的團隊, 致力於降低逆境的影響。

  • For our patients who do screen positive,

    運用最好的療法, 包括家訪、協調護理、

  • we have a multidisciplinary treatment team that works to reduce the dose of adversity

    心理保健及營養均衡、

  • and treat symptoms using best practices, including home visits, care coordination,

    全面干預措施, 以及藥物治療,有必要的話。

  • mental health care, nutrition,

    同時我們也向家長普及 ACE 和有害壓力的危害。

  • holistic interventions, and yes, medication when necessary.

    這危害可與觸電或鉛中毒相提並論。

  • But we also educate parents about the impacts of ACEs and toxic stress

    同時我們調整對哮喘患者 和糖尿病患者的護理,

  • the same way you would for covering electrical outlets, or lead poisoning,

    意識到他們可能需要更積極的治療,

  • and we tailor the care of our asthmatics and our diabetics

    因為他們的荷爾蒙 和免疫系統受到了影響。

  • in a way that recognizes that they may need more aggressive treatment,

    知道這個科學道理後,

  • given the changes to their hormonal and immune systems.

    你會想要廣而告之,

  • So the other thing that happens when you understand this science

    因爲這不僅是灣景區孩子們的問題。

  • is that you want to shout it from the rooftops,

    我以為每個人明白這道理後,

  • because this isn't just an issue for kids in Bayview.

    相關檢查會變為常規, 多學科團隊會組成,

  • I figured the minute that everybody else heard about this,

    大家爭先尋找有效治療方案。

  • it would be routine screening, multi-disciplinary treatment teams,

    但這些都沒有發生。

  • and it would be a race to the most effective clinical treatment protocols.

    對我而言,這是個大教訓。

  • Yeah. That did not happen.

    我簡單地認為 找到最好的治療方法就能解決。

  • And that was a huge learning for me.

    現在我明白了,這是一場運動。

  • What I had thought of as simply best clinical practice

    如美國兒科學會的前會長 羅伯特博士所說:

  • I now understand to be a movement.

    「不良的童年經歷

  • In the words of Dr. Robert Block,

    是現時我國唯一一個最大的 未解決的公共健康威脅。」

  • the former President of the American Academy of Pediatrics,

    對於大多數人而言, 這個前景並不樂觀。

  • "Adverse childhood experiences

    這個問題的範圍和規模似乎太大了,

  • are the single greatest unaddressed public health threat

    以至讓人感覺這難以解決。

  • facing our nation today."

    但於我而言,那正是希望之所在,

  • And for a lot of people, that's a terrifying prospect.

    因爲當我們有正確的框架,

  • The scope and scale of the problem seems so large that it feels overwhelming

    並意識到這是個公眾健康危機,

  • to think about how we might approach it.

    我們就可以開始運用合適的工具 去找出解決辦法。

  • But for me, that's actually where the hopes lies,

    例如煙草、鉛中毒、愛滋病,

  • because when we have the right framework,

    美國在解決公共健康問題方面,

  • when we recognize this to be a public health crisis,

    實際上保持了良好的記錄,

  • then we can begin to use the right tool kit to come up with solutions.

    若要在 ACE 和有害壓力方面也成功,

  • From tobacco to lead poisoning to HIV/AIDS,

    將需要決心和承諾,

  • the United States actually has quite a strong track record

    基於現時我看到民眾對此的反響,

  • with addressing public health problems,

    我想知道,

  • but replicating those successes with ACEs and toxic stress

    爲什麽我們沒有 更嚴肅地看待這個問題?

  • is going to take determination and commitment,

    起初我以為我們忽略了這個問題,

  • and when I look at what our nation's response has been so far,

    以為它和我們無關,

  • I wonder,

    那只是鄰居家孩子的問題。

  • why haven't we taken this more seriously?

    這很奇怪, 因爲數據不支持這個說法。

  • You know, at first I thought that we marginalized the issue

    在最早的 ACE 研究中,

  • because it doesn't apply to us.

    白種人占 70%,

  • That's an issue for those kids in those neighborhoods.

    受過大學教育的占 70%。

  • Which is weird, because the data doesn't bear that out.

    但我愈向人們談論此問題,

  • The original ACEs study was done in a population

    我愈認為我可能本末倒置了。

  • that was 70 percent Caucasian,

    若我問在座各位有多少人

  • 70 percent college-educated.

    與患有心理疾病的家人一起長大,

  • But then, the more I talked to folks,

    我打賭有幾個人會舉起手。

  • I'm beginning to think that maybe I had it completely backwards.

    若我問有多少人的父母經常喝醉酒,

  • If I were to ask how many people in this room

    或認為你不打孩子就是溺愛他們,

  • grew up with a family member who suffered from mental illness,

    我打賭會有更多人舉起手。

  • I bet a few hands would go up.

    即使是在這個會場, 這個問題也影響了很多人,

  • And then if I were to ask how many folks had a parent who maybe drank too much,

    我開始認為,我們忽視這個問題

  • or who really believed that if you spare the rod, you spoil the child,

    正因爲它影響著我們。

  • I bet a few more hands would go up.

    或許作為旁觀者更易看清,

  • Even in this room, this is an issue that touches many of us,

    因爲我們寧願生病, 也不想面對這個問題。

  • and I am beginning to believe that we marginalize the issue

    幸運的是,科學的進步以及 坦率地說,經濟現實

  • because it does apply to us.

    逐漸使我們變得難以忽視它。

  • Maybe it's easier to see in other zip codes

    科學道理很明確:

  • because we don't want to look at it.

    童年逆境對健康 有著終身性的巨大影響。

  • We'd rather be sick.

    現在我們開始了解如何阻止其發展,

  • Fortunately, scientific advances and, frankly, economic realities

    從童年逆境發展到疾病和過早死亡,

  • make that option less viable every day.

    現在開始未來 30 年裡,

  • The science is clear:

    ACE 指數過高的小孩,

  • Early adversity dramatically affects health across a lifetime.

    若其行為症狀無法確認,

  • Today, we are beginning to understand how to interrupt the progression

    哮喘治療未與 ACE 關聯,

  • from early adversity to disease and early death,

    逐漸發展成爲高血壓,

  • and 30 years from now,

    或是早期心臟病或癌症,

  • the child who has a high ACE score

    這將和患愛滋病六個月 就死亡一樣異常。

  • and whose behavioral symptoms go unrecognized,

    對此,人們會問: 「到底發生了什麼?」

  • whose asthma management is not connected,

    這是可以治癒的。

  • and who goes on to develop high blood pressure

    可以戰勝的。

  • and early heart disease or cancer

    現在我們需要做最重要的一件事是

  • will be just as anomalous as a six-month mortality from HIV/AIDS.

    勇於直接面對這個問題,

  • People will look at that situation and say, "What the heck happened there?"

    接受這就是現實, 它和我們息息相關。

  • This is treatable.

    我認為我們就是這項運動的關鍵。

  • This is beatable.

    謝謝。

  • The single most important thing that we need today

    (掌聲)

  • is the courage to look this problem in the face

  • and say, this is real and this is all of us.

  • I believe that we are the movement.

  • Thank you.

  • (Applause)

In the mid-'90s,

90 年代中期,