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 hypothalamic–pituitary–adrenal 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.