I want you to imagine this for a moment.

有兩個人, 名叫 拉胡跟拉吉

Two men, Rahul and Rajiv,

住在同一個區域

living in the same neighborhood,

有相同的教育背景, 從事相似的職業

from the same educational background, similar occupation,

兩個人同樣的都出現在同一個區域急救中心

and they both turn up at their local accident emergency

主訴症狀都是劇烈的胸痛

complaining of acute chest pain.

拉胡被施以心血管的療程

Rahul is offered a cardiac procedure,

而拉吉被告知直接回家

but Rajiv is sent home.

這兩個幾乎相同的人,

What might explain the difference in the experience

為什麼會有截然不同的醫療待遇呢?

of these two nearly identical men?

拉吉的症狀是心理疾病所造成的

Rajiv suffers from a mental illness.

在醫療照護方面的品質落差

The difference in the quality of medical care

是造成心理疾病患者的壽命比較短,

received by people with mental illness is one of the reasons

的眾多原因之一

why they live shorter lives

相較於沒有心理疾病的人

than people without mental illness.

就算是在世界上資源充分的國家裡

Even in the best-resourced countries in the world,

這樣的壽命差異仍可以高達20年

this life expectancy gap is as much as 20 years.

若是在開發中的國家, 這項差異

In the developing countries of the world, this gap

還會更大

is even larger.

當然了, 心理疾病也可能更直接致命

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

最常見的例子就是自殺

as well. The most obvious example is suicide.

你可能會大吃一驚, 就如同我當時

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

發現自殺是造成年輕人死亡清單中

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

榜上有名的

of the leading causes of death in young people

在全世界的每個國家都是如此

in all countries in the world,

包括世界上最貧窮的那些國家

including the poorest countries of the world.

心理疾病除了影響人的健康

But beyond the impact of a health condition

影響人的壽命, 我們更關切的是

on life expectancy, we're also concerned

對生活品質的影響

about the quality of life lived.

我們為了要調查心理疾病對健康的整體影響

Now, in order for us to examine the overall impact

包括壽命(餘命), 還有

of a health condition both on life expectancy

生活的品質, 我們採用了

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

一個量表, 縮寫字首是DALY

a metric called the DALY,

全名是失能修正餘命年數

which stands for a Disability-Adjusted Life Year.

透過這樣的研究, 我們發現一些驚人的事實

Now when we do that, we discover some startling things

是關於心理疾病, 從全球的觀點來看

about mental illness from a global perspective.

我們發現到, 比方說, 心理疾病

We discover that, for example, mental illnesses are

是造成失能的主要原因之一

amongst the leading causes of disability around the world.

以精神抑鬱來說, 是失能的第三主因

Depression, for example, is the third-leading cause

前兩名分別是

of disability, alongside conditions such as

兒童的痢疾(腹瀉)與肺炎

diarrhea and pneumonia in children.

綜觀所有心理疾病

When you put all the mental illnesses together,

約佔全球疾病負擔

they account for roughly 15 percent

15%之多

of the total global burden of disease.

很明顯, 心理疾病對於人的生活構成很大的傷害

Indeed, mental illnesses are also very damaging

除了造成疾病負擔外

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

我們也來看看一些實際的數據

let us consider the absolute numbers.

世界衛生組織(WHO)估計

The World Health Organization estimates

大約有四到五億人

that there are nearly four to five hundred million people

在這個地球上

living on our tiny planet

正受到心理疾病的影響

who are affected by a mental illness.

在座各位

Now some of you here

看起來對這樣的數字有些吃驚

look a bit astonished by that number,

但若試想一下, 心理疾病有如此多的種類

but consider for a moment the incredible diversity

從童年期的自閉症及智能障礙

of mental illnesses, from autism and intellectual disability

到成年期的抑鬱與焦慮

in childhood, through to depression and anxiety,

藥物濫用與精神失調

substance misuse and psychosis in adulthood,

一直到老年期的失智症

all the way through to dementia in old age,

我非常肯定, 今天在這裡的每一個人

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

至少都能夠想出一個人,

present here today can think of at least one person,

至少有一個人, 曾受到心理疾病的影響

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

就在我們最親近的社交圈裡

in our most intimate social networks.

我看到有些人在點頭

I see some nodding heads there.

除了這些令人驚愕的統計數字之上

But beyond the staggering numbers,

從全球健康的觀點來看, 更關鍵的是什麼?

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

更值得擔憂的是什麼?

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

就是這些受到心理疾病影響的個人, 絕大部分

is that the vast majority of these affected individuals

都沒有接受治療照護

do not receive the care

我們明明知道治療照護可以改變這些人的人生

that we know can transform their lives, and remember,

也清楚一些醫療措施明確證實

we do have robust evidence that a range of interventions,

像是藥物, 心理方面的措施

medicines, psychological interventions,

社會方面的措施, 可以產生重大的改善

and social interventions, can make a vast difference.

但是, 就算是在資源最豐富的國家裡

And yet, even in the best-resourced countries,

例如在歐洲這裡, 仍然有將近一半的

for example here in Europe, roughly 50 percent

受心理疾病影響的人, 沒有受到任何措施的協助

of affected people don't receive these interventions.

在我工作的那些國家裡

In the sorts of countries I work in,

這種所謂的醫療缺口

that so-called treatment gap

逼近到驚人的90%

approaches an astonishing 90 percent.

如果你跟一個受到心理疾病所苦的人談談

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

不出人意表地，你往往會聽到

to anyone affected by a mental illness,

他們的故事裡充滿了

the chances are that you will hear stories

壓抑的苦痛, 恥辱, 還有歧視

of hidden suffering, shame and discrimination

發生在他們生活的每環節

in nearly every sector of their lives.

但或許最讓人心碎的

But perhaps most heartbreaking of all

是那些關於被虐待的故事

are the stories of the abuse

連最基本的人權都被剝奪

of even the most basic human rights,

如同這張照片裡的年輕女子的遭遇

such as the young woman shown in this image here

令人遺憾的, 每天

that are played out every day,

都在發生, 就在這些專門為照護

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

心理疾病患者的機構,精神專科醫院裡面

for people with mental illnesses, the mental hospitals.

就是這種不公義, 驅使我投入了一個願景

It's this injustice that has really driven my mission

試著改變這些人的生活

to try to do a little bit to transform the lives

幫助這些受到心理疾病影響的人, 特別著重在

of people affected by mental illness, and a particularly

一個關鍵環節, 就是彌補其間的鴻溝

critical action that I focused on is to bridge the gulf

一方面是改變他們生活所需的知識,

between the knowledge we have that can transform lives,

有效療法的知識, 另一方面在於如何實際地

the knowledge of effective treatments, and how we actually

在日常生活裡運用這些知識

use that knowledge in the everyday world.

而我們所要面對的一個特別重要的挑戰

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

就是心理衛生專業人員的嚴重不足

is the great shortage of mental health professionals,

例如精神病學家與心理學家

such as psychiatrists and psychologists,

特別是在開發中世界

particularly in the developing world.

我在印度接受醫學教育的, 後來

Now I trained in medicine in India, and after that

我選擇了精神病學作為專科, 違背了

I chose psychiatry as my specialty, much to the dismay

我母親和家庭成員的期待,

of my mother and all my family members who

他們多少會覺得這麼聰明的孩子,

kind of thought neurosurgery would be

應該選擇神經外科才比較有出息

a more respectable option for their brilliant son.

不管怎麼說, 我還是堅持, 投入了精神病學

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

並且有幸到英國

and found myself training in Britain in some of

最頂尖的醫院裡接受訓練

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

與一群非常具有天份, 非常熱情的成員共事

I worked in a team of incredibly talented, compassionate,

更重要的, 是受過高度的專業訓練的

but most importantly, highly trained, specialized

心理健康方面的專業人士

mental health professionals.

受完訓練之後, 我開始的第一項工作

Soon after my training, I found myself working

是在辛巴威, 然後回到印度. 那時我面對的

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

是一個全然陌生的現實狀況

by an altogether new reality.

在這個現實狀況中，幾乎找不到任何的

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

精神衛生專業人員。

mental health professionals at all.

例如: 在辛巴威，大約只有

In Zimbabwe, for example, there were just about

十幾個精神病醫生，其中大多在哈拉雷市(Harare)居住

a dozen psychiatrists, most of whom lived and worked

和執業(行醫), 只剩下一兩個

in Harare city, leaving only a couple

去服務住在農村的900 萬人

to address the mental health care needs

的精神衛生保健需要

of nine million people living in the countryside.

在印度，我發現情況也好不到哪裡去

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

打個比方比較好理解，如果我用

To give you a perspective, if I had to translate

精神科醫生在人口中所占的比例來說明

the proportion of psychiatrists in the population

如果以英國的比例來套用到印度

that one might see in Britain to India,

那麼印度應該大約有150,000 個精神病醫生。

one might expect roughly 150,000 psychiatrists in India.

在現實中，大家猜一猜。

In reality, take a guess.

實際的精神病醫生的數目約3000個，

The actual number is about 3,000,

只有英國的2%

about two percent of that number.

很快地我就認清了沒有辦法按照

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

先前我所學的那些精神健康護理模式

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

其中高度依賴專業且所費不貲的

one that relied heavily on specialized, expensive

精神衛生專業人員來提供心理衛生保健

mental health professionals to provide mental health care

在印度和辛巴威這樣的國家。

in countries like India and Zimbabwe.

我必須跳脫既有的框架, 想出其他模式的

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

護理服務。

of care.

就在那時候, 我偶然看到這些書，

It was then that I came across these books,

在這些書中發現了所謂 "任務轉移" 的想法

and in these books I discovered the idea of task shifting

可用在全球保健上。

in global health.

這種想法實際上很簡單。就是

The idea is actually quite simple. The idea is,

當你缺乏專門的醫護專業人員的時候

when you're short of specialized health care professionals,

就直接從社區裡找可用的人選

use whoever is available in the community,

培訓他們來提供一個特定範圍的各種保健措施

train them to provide a range of health care interventions,

其中有些很具啟發性的例子

and in these books I read inspiring examples,

例如, 如何培訓一般人

for example of how ordinary people had been trained

去接生嬰兒

to deliver babies,

學會診斷和治療早期肺炎，以發揮大效用。

diagnose and treat early pneumonia, to great effect.

這讓我目瞪口呆，如果你可以訓練普通百姓

And it struck me that if you could train ordinary people

來提供如此複雜的衛生保健措施，

to deliver such complex health care interventions,

那麼, 也許一般人也可以做到相同的地步

then perhaps they could also do the same

在精神衛生保健這方面。

with mental health care.

今天，我很高興向各位報告

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

有許多關於"任務轉移" 的實驗被執行

that there have been many experiments in task shifting

在精神衛生保健這方面, 在開發中世界的許多地方

in mental health care across the developing world

在過去十年裡，我想在這裡與你們分享

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

這三個特別的實驗

the findings of three particular such experiments,

這三個都是以抑鬱症為主題

all three of which focused on depression,

這是所有的精神疾病中, 最常見的。

the most common of all mental illnesses.

在烏干達的鄉下、 保羅·博爾頓(Paul Bolton)和他的同事們，

In rural Uganda, Paul Bolton and his colleagues,

與一些村民合作，證明了他們可以提供

using villagers, demonstrated that they could deliver

抑鬱症的人際心理治療方式

interpersonal psychotherapy for depression

而且, 透過隨機對照組的實驗設計

and, using a randomized control design,

觀察到了接受這種治療的人, 有90%

showed that 90 percent of the people receiving

的治癒率, 相較之下

this intervention recovered as compared

那些對照組的村莊, 大約是40%。

to roughly 40 percent in the comparison villages.

在巴基斯坦鄉下，也進行了類似的隨機對照試驗

Similarly, using a randomized control trial in rural Pakistan,

據阿替夫·拉赫曼(Atif Rahman)和他的同事們發現到

Atif Rahman and his colleagues showed

女性健康訪視員, 就是社區內孕產婦的保健員

that lady health visitors, who are community maternal

是屬於巴基斯坦的衛生保健系統的一部份，

health workers in Pakistan's health care system,

可以為有抑鬱症狀的母親, 提供認知行為療法

could deliver cognitive behavior therapy for mothers

結果也再次展示了很大的差異

who were depressed, again showing dramatic differences

以治癒率來看。採用村莊大約是75%的治癒率

in the recovery rates. Roughly 75 percent of mothers

相較於只有45%的治癒率

recovered as compared to about 45 percent

在對照組的村莊。

in the comparison villages.

而我自己的試驗，在印度的果阿(Goa)，我們再一次顯示

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

培訓來自當地社區的輔導員

that lay counselors drawn from local communities

來提供心理社會干預措施

could be trained to deliver psychosocial interventions

針對抑鬱，焦慮，可得70%

for depression, anxiety, leading to 70 percent

的治癒率, 相較

recovery rates as compared to 50 percent

在那些對照組的初級保健中心的50%。

in the comparison primary health centers.

現在，如果我必須總結這些各式各樣的

Now, if I had to draw together all these different

任務轉移的實驗，當然在此之外

experiments in task shifting, and there have of course

還有許多其他的例子，嘗試著歸納出

been many other examples, and try and identify

一些關鍵要素, 讓我們可以學習並促成

what are the key lessons we can learn that makes

任務轉換的成功運作

for a successful task shifting operation,

我創造了這個特別的首字母縮寫詞，SUNDAR

I have coined this particular acronym, SUNDAR.

這個字在印度語的意思是 "吸引力"。

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

我用這個字來代表五個主要關鍵要素

It seems to me that there are five key lessons

列在這張投影片上，對於有效進行任務轉移

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

是非常重要的

for effective task shifting.

第一個是, 我們需要簡化用詞

The first is that we need to simplify the message

拿掉那些學界裡慣用的術語

that we're using, stripping away all the jargon

只有醫學院的人才聽得懂的

that medicine has invented around itself.

我們還需要解構整個複雜的保健干預措施

We need to unpack complex health care interventions

分成較小的元件，可以更容易地

into smaller components that can be more easily

轉移給受過簡易訓練的個人。

transferred to less-trained individuals.

我們所要提供的衛生保健, 並不是在大型機構，

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

而是要貼近人們的家園，我們提供衛生保健的方式

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

是運用所有可得的與可負擔的,

health care using whoever is available and affordable

在地的資源

in our local communities.

也很重要的是，要重新配置這些數量有限的專家

And importantly, we need to reallocate the few specialists