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

and improve health where it begins.

從源頭查看及改善健康狀況。

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,

吃、喝、睡覺、 學習及享樂的地方開始，

where we eat, sleep, learn and play,

從我們花大把時間的地方開始。

where we spend the majority of our lives.

所以這個不同的醫療方法 是什麼樣子？

So what does this different approach to healthcare look like,

這個能從源頭改善健康的方法？

an approach that can improve health where it begins?

為了解釋清楚， 我跟大家說說小維的故事。

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

小維是我第 17 號病人，

Veronica was the 17th patient

我每天要看 26 名病人，

out of my 26-patient day

診所位於洛杉磯南區。

at that clinic in South Central Los Angeles.

她來我的診所看慢性頭痛。

She came into our clinic with a chronic headache.

這個頭痛已經持續好多年，

This headache had been going on

而這段經歷讓她非常非常困擾。

for a number of years, and this particular episode

其實在她來看我們的三個星期前，

was very, very troubling.

她才去過洛杉磯的某急診室。

In fact, three weeks before she came to visit us

這個急診室的醫師說，

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

「小維，我們做了幾項檢查，

The emergency room doctors said,

結果都很正常， 所以我現在給你開一些止痛藥，

"We've run some tests, Veronica.

妳要回去看妳的家庭醫師，

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

但是如果還繼續痛，或是更痛，

and follow up with a primary care doctor,

妳再回來找我們。」

but if the pain persists or if it worsens,

小維謹遵這些制式的醫囑，

then come on back."

最後還是回去急診室了。

Veronica followed those standard instructions

她回去不只一次，她去了三次。

and she went back.

在小維來找我們前的那三個星期，

She went back not just once, but twice more.

她回去急診室三次。

In the three weeks before Veronica met us,

她來來回回，

she went to the emergency room three times.

進進出出各個醫院及診所，

She went back and forth,

就像之前一年一樣，

in and out of hospitals and clinics,

想要找解方卻徒勞無功。

just like she had done in years past,

小維來我們的診所，

trying to seek relief but still coming up short.

無論她看了多少醫療專家，

Veronica came to our clinic,

小維還是病著。

and despite all these encounters with healthcare professionals,

她到我們的診所時， 我們試了一種不同的療法。

Veronica was still sick.

我們的療法從我們的醫務助理開始，

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

這位助理有同等學歷的訓練，

Our approach started with our medical assistant,

也很瞭解這個社區。

someone who had a GED-level training

我們的醫務助理問了幾個例行問題。

but knew the community.

她問，「妳主訴的症狀是什麼？」

Our medical assistant asked some routine questions.

「頭痛。」

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

「那我們量一下生命徵象」，

"Headache."

量一下妳的血壓心跳。

"Let's get your vital signs" —

但我們還要多問幾個問題，

measure your blood pressure and your heart rate,

對小維及許多類似的 洛杉磯南區病人，

but let's also ask something equally as vital

就跟生命徵象一樣重要的問題。

to Veronica and a lot of patients like her

「小維，可不可以告訴我 妳住的地方的情況？

in South Los Angeles.

特別是妳住處的狀況？

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

有發霉嗎？有漏水嗎？

Specifically, about your housing conditions?

家裡有蟑螂嗎？」

Do you have mold? Do you have water leaks?

結果是，小維家三「有」：

Do you have roaches in your home?"

蟑螂、漏水、發霉。

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

我拿到那張病歷，看了一下，

roaches, water leaks, mold.

然後我轉轉門把

I received that chart in hand, reviewed it,

進入診間。

and I turned the handle on the door

你得了解，小維

and I entered the room.

就像我有幸照護的 大部分病人一樣，

You should understand that Veronica,

是個有尊嚴、不可輕忽，

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

有著鮮明個性的人，

is a dignified person, a formidable presence,

但在這裡，她坐在

a personality that's larger than life,

我的診療檯上痛苦地蜷縮著。

but here she was

她的頭很明顯搏痛著， 擱在她的手上。

doubled over in pain sitting on my exam table.

她抬起頭，

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

我看著她的臉，說了妳好，

She lifted her head up,

然後我立刻注意到

and I saw her face, said hello,

在她的鼻樑上，

and then I immediately noticed something

皮膚有一道皺摺。

across the bridge of her nose,

在醫學上，我們稱這道皺摺為 「過敏性敬禮徵」。

a crease in her skin.

這通常發生在 有慢性過敏的兒童上。

In medicine, we call that crease the allergic salute.

起因是長期上下磨擦鼻子，

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

想要擺脫那些過敏症狀。

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

但是，在這的小維， 已經是成年婦女，

trying to get rid of those allergy symptoms,

卻還是有過敏的示警徵兆。

and yet, here was Veronica, a grown woman,

幾分鐘後，我一邊問小維問題，

with the same telltale sign of allergies.

一邊檢查及聽她說，

A few minutes later, in asking Veronica some questions,

我說：「小維， 我想我知道妳得了什麼。

and examining her and listening to her,

我認為妳是慢性過敏，

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

而且我認為妳還有偏頭痛及鼻塞，

I think you have chronic allergies,

我想這些都跟妳住的地方有關。」

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

她看起來有點鬆了口氣，

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

因為這是她第一次得到真的診斷，

She looked a little bit relieved,

但我說：「小維， 現在我們來談一下治療方法。

because for the first time, she had a diagnosis,

我們會針對妳的症狀開幾款藥，

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

但我也想把妳轉診給一位專科， 如果妳同意。」

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

不過，專科

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

在洛杉磯南區有點難找，

Now, specialists are a little hard to find

所以她看了我一眼，好像在說， 「真的？」

in South Central Los Angeles,

我說，「小維，其實我說的這位專科

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

是我所謂的社區保健員，

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

如果妳同意，這個人

is someone I call a community health worker,

會到妳家試著了解情況，

someone who, if it's okay with you,

看看為什麼漏水及發霉，

can come to your home

試著幫妳解決房子的狀況， 我認為是這些造成妳的症狀，

and try to understand what's going on

如果有必要，這位專科還會幫妳轉診

with those water leaks and that mold,

去另一位專科，我們叫他公益律師，

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

因為妳的房東很可能

and if required, that specialist might refer you

沒有按照法律規定替妳修房子。」

to another specialist that we call a public interest lawyer,

小維幾個月後跑回來。

because it might be that your landlord

她同意所有上述的治療計畫。

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

她告訴我們她的症狀 改善了 90%，

Veronica came back in a few months later.

她可以花更多時間在工作

She agreed to all of those treatment plans.

及跟家人相處上，不用常常

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

在洛杉磯的急診室來回奔波。

She was spending more time at work

小維有很明顯的進步。

and with her family and less time

她的幾個兒子，其中一個有氣喘，

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

不再像以前一樣病著。

Veronica had improved remarkably.

她好多了，而且一點也不意外，

Her sons, one of whom had asthma,

小維的房屋狀況也改善了。

were no longer as sick as they used to be.

我們採用的這種迥異的方法

She had gotten better, and not coincidentally,

為什麼能提供更好的照護？

Veronica's home was better too.

讓病人少跑急診室，更健康？

What was it about this different approach we tried

很簡單，就從那個問題開始：

that led to better care,

「小維，妳住在哪？」

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

但更重要的是，我們推出

Well, quite simply, it started with that question:

一種系統，讓我們能問小維

"Veronica, where do you live?"

及數百計像小維那樣的人 幾個簡單問題，

But more importantly, it was that we put in place

對她的社區很重要的環境問題，

a system that allowed us to routinely ask questions

健康的源頭問題，

to Veronica and hundreds more like her

因為不幸的是，有時候疾病的確

about the conditions that mattered

從像南洛杉磯一樣的地方開始。

in her community, about where health,

在那個社區，不合格的房屋

and unfortunately sometimes illness, do begin

及食物供給不穩定是最主要的問題，

in places like South L.A.

是我們身為診所必須注意到的事，

In that community, substandard housing

但在其他的社區問題可能是

and food insecurity are the major conditions

交通運輸的天然障礙、肥胖、

that we as a clinic had to be aware of,

家附近有沒有公園、槍枝暴力。

but in other communities it could be

重要的是，我們推出的這種系統

transportation barriers, obesity,

有成效，

access to parks, gun violence.

而這種方法我稱為上游管理。

The important thing is, we put in place a system

在座很多人都很熟悉的名詞。

that worked,

這來自一個很常聽到的

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

公共衛生界寓言。

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

這是三個朋友的寓言。

It comes from a parable that's very common

想像一下你是這三個朋友之一，

in the public health community.

你們走到一條河。

This is a parable of three friends.

風景很美， 但有個小孩的哭聲劃破了寧靜，

Imagine that you're one of these three friends

而且其實有好幾個孩子 在水裡需要救援。

who come to a river.

所以你會去做 但願每個人都會做的事。

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

你與你的朋友趕快跳進去。

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

第一個朋友說，

So you do hopefully what everybody would do.

我要去救那些快沉下去的，

You jump right in along with your friends.

那些快要掉到瀑布下面的幾個。

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

第二個朋友說，我來造個木筏。

who are about to drown,

我要確保

those at most risk of falling over the waterfall.

流到瀑布邊的人能少幾個。

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

透過造木筏， 讓我們多領幾個人到安全區，

I'm going to make sure that fewer people

把幾根樹枝綁在一起。

need to end up at the waterfall's edge.

一段時間後，他們成功了， 但也不盡然，

Let's usher more people to safety

因為成效不如預期。

by building this raft,

更多人成為漏網之魚， 所以他們終於往上游看，

coordinating those branches together.

發現他們第三個朋友

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

不在視線範圍內。

as much as they want to be.

最後他們終於看到她。

More people slip through, and they finally look up

她在水裡。她愈游愈遠，

and they see that their third friend

朝上游去，邊游邊救兒童，

is nowhere to be seen.

他們對著她喊：「妳要去哪裡？

They finally spot her.

這裡還有兒童要救。」

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

她回答說：

upstream, rescuing children as she goes,

「我要去找

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

是誰或是什麼東西 丟這些兒童進水裡。」

There are children here to save."

在醫療界，我們有第一個朋友：

And she says back,

我們有專科醫師，

"I'm going to find out

我們有外傷外科醫師、 加護病房護士、

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

急診室醫師。

In healthcare, we have that first friend —

我們有搶救生命的人，

we have the specialist,

你在急難中最需要的人。

we have the trauma surgeon, the ICU nurse,

我們也知道我們有第二個朋友：

the E.R. doctors.

我們有造筏的人。

We have those people that are vital rescuers,

那就是第一線的臨床醫師。

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

那些人在醫療團隊裡

We also know that we have the second friend —

照護你的慢性疾病、

we have that raft-builder.

你的糖尿病、你的高血壓、

That's the primary care clinician,

幫你做年度健檢、

people on the care team who are there

盯著你按時打疫苗。

to manage your chronic conditions,

同時也確保你有木筏可乘，

your diabetes, your hypertension,

把你帶到安全的地方。

there to give you your annual checkups,

雖然這些都很重要也很必要，

there to make sure your vaccines are up to date,

但我們最缺的卻是第三個朋友。

but also there to make sure that you have

我們沒有足夠向上游的人。

a raft to sit on and usher yourself to safety.

向上游的人是醫療照護專家，

But while that's also vital and very necessary,

但瞭解健康起始於

what we're missing is that third friend.

我們居住工作及玩樂的地方，

We don't have enough of that upstreamist.

但除了那樣的體認，

The upstreamists are the health care professionals

還能動員各種資源以創建系統，

who know that health does begin

使他們的診所及醫院

where we live and work and play,

能真正開始著手處理這個問題，

but beyond that awareness, is able to mobilize

能將眾人與他們

the resources to create the system

在診所的四面牆外 所需的資源連結在一起。

in their clinics and in their hospitals

現在你可能會問個很明顯的問題，

that really does start to approach that,

有很多醫界同僚都這麼問：

to connect people to the resources they need

「醫師與護士還要去考慮 交通及住房的問題？

outside the four walls of the clinic.

我們不是只要提供藥丸及醫療處置，

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

並確定我們會專心 做手上的工作就好？」

that a lot of colleagues in medicine ask:

的確，將人從水邊救起

"Doctors and nurses thinking about transportation and housing?

已經是夠重要的工作。

Shouldn't we just provide pills and procedures

誰有那麼多時間？

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

我卻認為，假如我們以科學為指引，

Certainly, rescuing people at the water's edge

就知道找到上游管理方法 是絕對必要的。

is important enough work.

科學家現在知道

Who has the time?

生活及工作條件，

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

我們都是其中的部分，

that we would find an upstream approach is absolutely necessary.

對我們健康的影響

Scientists now know that

比遺傳還超過兩倍之多，

the living and working conditions that we all

而且生活及工作條件，

are part of

我們環境的結構，

have more than twice the impact on our health

我們的社交圈交織在一起的方式，

than does our genetic code,

及其對我們行為的影響，

and living and working conditions,

通通加在一起， 對我們的健康影響

the structures of our environments,

比醫師及醫院開出的 藥丸及醫療處置總合

the ways in which our social fabric is woven together,

超過五倍之多。

and the impact those have on our behaviors,

生活及工作條件加在一起，

all together, those have more than five times

佔了可預防性死亡的 60%。

the impact on our health

讓我舉個例子來看看這是什麼感覺。

than do all the pills and procedures

就說有家公司，一家科技新創公司

administered by doctors and hospitals combined.

來你這裡說：「我們有個很棒的產品。

All together, living and working conditions

會降低你死於心臟病的風險。」

account for 60 percent of preventable death.

那麼，你很可能會願意投資，

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

如果那個產品是種藥或儀器的話，

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

但是如果那個產品是座公園？

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

在英國有項研究，

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

一項具里程碑意義的研究，檢閱了

Now, you might be likely to invest

英國超過四千萬居民的紀錄，

if that product was a drug or a device,

他們看了幾項變數，

but what if that product was a park?

即幾項管制因子，發現

A study in the U.K.,

當試著校正心臟病的風險，

a landmark study that reviewed the records

一個人能否接觸綠地 有很大的影響。

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

你越接近綠地、

looked at several variables,

公園及樹木，

controlled for a lot of factors, and found that

你得心臟病的機會就愈低，

when trying to adjust the risk of heart disease,