How does one supply health care in a world in which cost is everything?

我想跟各位討論的問題

How do you do that?

其實真正的問題

And the basic paradigm we want to suggest to you,

是如何提供健康照護

I want to suggest to you,

一方面又要顧及成本

is one in which you say that in order to treat disease,

要如何處理這問題呢？

you have to first know what you're treating, that's diagnostics,

在此我們要推薦一種基本模式

and then you have to do something.

我要推薦的是

The program we're involved in is something we call "Diagnostics for All,"

如果你需要醫治某種疾病

or "zero-cost diagnostics."

首先，你得知道，治療對象是什麼

How do you provide medically relevant information

這就是診斷，之後才能有對策

at as close as possible to zero cost?

因此，我們將這個計畫

How do you do it?

稱為全民診斷，或是免費診斷

Let me just give you two examples.

如何用幾近於零的費用

The rigors of military medicine are not so dissimilar from the third world:

又能提供醫療相關資料，如何能做到這點呢?

poor resources, a rigorous environment -- a series of problems --

讓我為你們舉兩個例子

light weight and things of this kind.

例如軍隊醫療，往往稍嫌粗糙

And also they're not so different from the home health care

就和第三世界的醫療沒什麼不同

and diagnostic system world.

資源貧乏，環境惡劣

So, the technology I want to talk about is for the third world,

還有體重過輕，或是種種類似的問題

for the developing world,

也和有家庭照護與診斷系統的世界

but it has, I think, much broader application,

沒什麼差異

because information is so important in the health care system.

因此，我在此要提及的科技

So you see two examples here.

是為了第三世界國家，開發中國家

One is a lab that is actually a fairly high-end laboratory in Africa.

但我想，它還有更廣的運用

The second is basically an entrepreneur who is set up and doing who-knows-what

因為資訊對健康醫療非常重要

at a table in a market.

所以，你們來看這兩個例子

I don't know what kind of health care is delivered there.

首先這是一個實驗室，在非洲這是個相當高級的實驗室

But it's not really what is probably most efficient.

再來，這是個創業家

What is our approach?

他正在桌邊不知道做什麼

The way in which one typically approaches a problem of lowering cost,

我不知道這對健康醫療有何貢獻

starting from the perspective of the United States,

但這實在不是最有效率的

is to take our solution,

我們的對策是什麼呢?

and then try to cut cost out of it.

一個人採取的典型策略

No matter how you do that,

要解決成本問題時

you're not going to start with a $100,000 instrument

都是先從聯合國的角度出發

and bring it down to no cost.

採用我們的解決方案

It isn't going to work.

之後再設法降低成本

So the approach we took was the other way around, to ask:

不論你如何著手

What is the cheapest possible stuff

你不會是一開始就使用十萬元的儀器

that you could make a diagnostic system out of,

再把成本降至極低，這樣是行不通的

and get useful information and add function?

因此，我們的策略是從另一方向來的

And what we've chosen is paper.

是要問：「什麼會是最便宜的材料

What you see here is a prototypic device.

可以用來製作診斷系統

It's about a centimeter on the side.

並得到有用的資訊

It's about the size of a fingernail.

還有附加功能呢？」 為此我們選用紙張

The lines around the edges are a polymer.

你現在看到的就是這器材原型

It's made of paper.

它一邊約一公分

And paper, of course, wicks fluid, as you know, paper, cloth --

大小約如指甲一般

drop wine on the tablecloth,

這邊緣上的線

and the wine wicks all over everything.

是一種高分子物質

Put it on your shirt, it ruins the shirt.

它的材質是紙，紙當然會吸水

That's what a hydrophilic surface does.

大家都知道，紙料 布料...若桌巾上有酒滴

So in this device, the idea is that you drip the bottom end of it

會滲得到處都是

in a drop of, in this case, urine.

若滴到襯衫，襯衫就報銷了

The fluid wicks its way into those chambers at the top.

這就是親水性表面的特色

The brown color indicates the amount of glucose in the urine,

因此，這器材的構想是讓你

the blue color indicates the amount of protein in the urine.

在它的底端滴上一滴

And the combination of those two is a first-order shot

這裡使用的是尿液

at a number of useful things that you want.

當這液體滲佈到上端的這些小格子

So, this is an example of a device made from a simple piece of paper.

若呈褐色表示這尿液含有葡萄糖

Now, how simple can you make the production?

若呈藍色表示這尿液含有蛋白質

Why do we choose paper?

若是兩種都有

There's an example of the same thing on a finger,

那麼你可是得到了炙手可熱

showing you basically what it looks like.

的第一手資料呢

One reason for using paper is that it's everywhere.

在此，提到的是一則僅由紙片作成的器材

We have made these kinds of devices using napkins and toilet paper

那麼，又是如何才能簡單容易的製作呢？

and wraps, and all kinds of stuff.

為什麼我們選擇紙張呢？

So the production capability is there.

這裡有個樣本，就在這指頭上

The second is, you can put lots and lots of tests in a very small place.

成品就像你們這兒看到的

I'll show you in a moment that the stack of paper there

採用紙張，原因之一是它到處都有

would probably hold something like 100,000 tests,

紙張已經用在各處

something of that kind.

就像是紙巾 衛廁用紙

And then finally, a point you don't think of so much

包裝紙 及各種用品.

in developed world medicine:

所以，製作上是沒問題的

it eliminates sharps.

第二個原因是，是這小小的面積中

And what sharps means is needles, things that stick.

可以置入許多的測試

If you've taken a sample of someone's blood

待會兒，我會讓大家看到，這疊紙片

and the someone might have hepatitis C,

大約包含了

you don't want to make a mistake and stick it in you.

十萬個測試呢

You don't want to do that.

最後呢，有一點之前並沒有料到的是

So how do you dispose of that?

在已開發國家的醫藥中

It's a problem everywhere, and here, you simply burn it.

它使尖銳物消失了

So it's a sort of a practical approach to starting on things.

這裡說的尖銳物，是指針筒

Now, you say, "If paper is a good idea,

如果你要取樣某人的血液

other people have surely thought of it."

而這人也許有C型肝炎

And the answer is, of course, yes.

而你可不希望不小心感染到

Those half of you, roughly, who are women,

事實上，你是完全不希望有那種可能

at some point may have had a pregnancy test.

所以，要如何防止呢？各地都有這種問題

And the most common of these is in a device

很簡單，把它燒掉就解決了

that looks like the thing on the left.

因此這算是以非常務實的觀點

It's something called a lateral-flow immunoassay.

來設計器具

In that particular test,

現在你會問，若紙材是個好主意

urine, either containing a hormone called hCG,

別人應該早就想到了

does or does not flow across a piece of paper.

答案是，是的

And there are two bars; one bar indicates that the test is working,

在座的大約有一半

and if the second bar shows up, you're pregnant.

是女性

This is a terrific kind of test in a binary world,

某個時候，也許會驗孕

and the nice thing about pregnancy is either you are pregnant

最普遍的

or you're not pregnant;

就是像左方的這種器材

you're not partially pregnant or thinking about being pregnant

這是所謂的側向流動疫試檢驗

or something of that sort.

在這特定的檢驗

So it works very well there, but it doesn't work very well

使用的尿液，會是含有 或是沒有

when you need more quantitative information.

一種稱作HCG的賀爾蒙

There are also dipsticks,

當流過這紙片

but if you look at the dipsticks,

在這兩條顯示線，第一條顯示這測試是否有效

they're for another kind of urine analysis.

若第二條線也出現，表示你懷孕了

There are an awful lot of colors and things like that.

在非黑即白的情況中，這是個很棒的測試方法

What do you actually do about that in a difficult circumstance?

而在是否懷孕上

So the approach we started with is to ask:

答案只有懷孕了或是沒懷孕

Is it really practical to make things of this sort?

不可能是部份懷孕或是也許有懷孕之類

And that problem is now, in a purely engineering way, solved.

模擬兩可的

And the procedure that we have is simply to start with paper.

所以，應用在這裡很適合

You run it through a new kind of printer called a wax printer.

但是若應用在比較量化的資訊上就不合適

The wax printer does what looks like printing.

另有一種是探棒型

It is printing.

若使用探棒，那是

You put that on, you warm it a little bit,

另一種尿液分析

the wax prints through, so it absorbs into the paper,

那會呈現許許多多的顏色之類的

and you end up with the device you want.

碰到這種糟糕的情形，你該做些什麼呢？

The printers cost 800 bucks now.

為此，我們又要提出問題

We estimate that if you were to run them 24 hours a day,

製作這樣的東西真的實用嗎？

they'd make about 10 million tests a year.

現在這個問題，在工程面上算是解決了

So it's a solved problem. That particular problem is solved.

製作程續就由紙張開始

And there is an example of the kind of thing that you see.

當你將它放入一種印表機，叫蠟質印表機

That's on a piece of 8 by 12 paper.

它看來就像一般印表機

That takes about two seconds to make.

它執行列印，你將紙張放入加熱

And so I regard that as done.

這蠟質經由列印，被紙張吸入

There's a very important issue here,

你要的器材就完成了

which is that because it's a printer, a color printer, it prints colors.

這台印表機價位是八百美元

That's what color printers do.

若是它一天24小時不停地運作，我們估計

I'll show you in a moment, that's actually quite useful.

一年下來總共可以作一千萬個測試

Now, the next question that you would like to ask is:

因此，這問題解決了

What would you like to measure? What would you like to analyze?

這還有一個例子要讓你們參考

And the thing you'd most like to analyze, we're a fair distance from.

這張8x12的紙上

It's what's called "fever of undiagnosed origin."

只需花兩秒鐘就成了

Someone comes into the clinic, they have a fever, they feel bad.

這部分，算是大功告成

What do they have?

還有一個重要議題

Do they have TB? Do they have AIDS? Do they have a common cold?

就是因為它是一臺印表機

The triage problem.

彩色印表機，可以印出不同顏色。這是它的功能

That's a hard problem for reasons I won't go through.

我等一下會讓各位看到，這一點非常實用

There are an awful lot of things that you'd like to distinguish among.

接下來，你可能會問

But then there are a series of things --

你到底想要測量什麼？分析什麼？

AIDS, hepatitis, malaria, TB, others --

你最想要分析的東西

and simpler ones, such as guidance of treatment.

我們快要成功了

Now, even that's more complicated than you think.

就是所謂的「不明原因發燒」

A friend of mine works in transcultural psychiatry,

當某人走進診所

and he is interested in the question

說他發燒，不舒服。會是得了什麼病？

of why people do and don't take their meds.

會是肺結核？或是愛滋病嗎？

So Dapsone, or something like that, you have to take for a while.

或只是普通感冒呢？

He has a wonderful story of talking to a villager in India

這是個難解的三角習題

and saying,

有些太複雜的我就不多說

"Have you taken your Dapsone?" "Yes."

因為太多的細節需要釐清

"Have you taken it every day?" "Yes."

另外有些疾病

"Have you taken if for a month?" "Yes."

例如愛滋病 肝炎 虐疾

What the guy actually meant

肺結核之類的

was that he'd fed a 30-day dose of Dapsone to his dog that morning.

或是像一些治療指導

(Laughter)

這些都比你想像中複雜多了

And he was telling the truth, because in a different culture,

我的一位朋友從事跨文化精神諮詢

the dog is a surrogate for you;

他感興趣的問題是

"today," "this month," "since the rainy season" --

為什麼人們想吃藥或不想吃藥

there are lots of opportunities for misunderstanding.

例如戴普松之類的藥物

(Laughter)

你得連續服用一段時間的藥物

And so an issue here is to, in some cases, figure out

有個關於印度村民的故事

how to deal with matters that seem uninteresting, like compliance.

你問村民：「你有服用戴普松嗎？」 「有」

Now, take a look at what a typical test looks like.

「是否有每天服用？」 「是的」

Prick a finger, you get some blood -- about 50 microliters.

「有連續服用一個月嗎？」 「有的」

That's about all you're going to get,

事實上，這村民的意思是

because you can't use the usual sort of systems.

將他那三十天份量的戴普松

You can't manipulate it very well;

在當天早上都餵給他的狗吃了

I'll show something about that in a moment.

(笑聲)

So you take the drop of blood, no further manipulations,

他講的是實話

you put it on a little device,

因為在不同的文化中

the device filters out the blood cells, lets the serum go through,

家犬就是你的替身

and you get a series of colors down in the bottom there.

你也知道，像「今天」 「 這個月」 「這個雨季以來」

And the colors indicate "disease" or "normal."

這些都是可能造成誤解的

But even that's complicated,

所以接下來這議題是

because to me, colors might indicate "normal,"

讓我們解決一些

but after all, we're all suffering from probably an excess of education.

不是那麼有趣的一些事

What do you do about something which requires quantitative analysis?

就像是一些標準程序

And so the solution that we and many other people

例如，讓我們看一些典型的試驗

are thinking about there,

刺一下手指頭，擠些血

and at this point, there is a dramatic flourish,

約50毫升

and out comes the universal solution to everything these days,

大約只有這麼多

which is a cell phone --

因為你不能用一般的方法

in this particular case, a camera phone.

你並不能操作得很準確

They're everywhere -- six billion a month in India.

待會兒我再讓各位看個東西

And the idea is that what one does is to take the device,

好，你擠出了一些血，沒有進一步操作

you dip it, you develop the color,

你將這血放入這小器材

you take a picture, the picture goes to a central laboratory.

這小器材會過濾掉血球細胞，讓血清流過

You don't have to send out a doctor,

之後，你會看到一系列顏色

you send out somebody who can just take the sample,

陳列在底部那裡

and in the clinic either a doctor, or ideally, a computer in this case,

這顏色會是代表有疾病或是正常

does the analysis.

這樣仍是有些複雜

Turns out to work actually quite well,

因為對你我來說，有顏色也可能表示是正常

particularly when your color printer has printed the color bars

畢竟我們共同的問題

that indicate how things work.

就是可能都受了太多教育

So my view of the health care worker of the future

當你需要量化分析結果的時候

is not a doctor, but an 18-year-old,

你會怎麼作呢？

otherwise unemployed, who has two things:

這個答案 就在我們和一些其他人

a backpack full of these tests and a lancet

不斷思考的情形下

to occasionally take a blood sample,

有了一個戲劇性的好結果

and an AK-47.

也造就了今天這個讓大家看到的結果

And these are the things that get him through his day.

就是手機，應該說是有照相功能的手機

(Laughter)

現在人手一機。在印度，一個月可以賣出六百萬支

There's another very interesting connection here,

這構想是讓一個人

and that is, that what one wants to do is pass through useful information

拿這器材

over what is generally a pretty awful telephone system.

浸入試液後，就會看到顏色

It turns out there's an enormous amount of information

你把結果照下來，照片會送入中央實驗室

already available on that subject, which is the Mars Rover problem.

你不需要把它送到醫生那裡

How do you get back an accurate view of the color on Mars

而是送給專收樣本的某個人

if you have a really terrible bandwidth to do it with?

然後在某間診所的一位醫師，更好一點是一台電腦

And the answer is not complicated,

就會像這樣，進行分析

but it's one which I don't want to go through here,

這種流程很順利，特別是

other than to say that the communication systems for doing this

當你的彩色印表機能印出有顏色的條碼

are really pretty well understood.

代表運作的狀況

Also, a fact which you may not know

所以，我對未來健康醫療工作人員的看法

is that the compute capability of this thing is not so different

不再是醫生了

from the compute capability of your desktop computer.

而是一個十八歲的年輕人，不再失業

This is a fantastic device which is only beginning to be tapped.

身上有兩件東西。一樣是一個背包，裝滿了這種測試品

I don't know whether the idea of one computer, one child

及一根刺絡針，偶爾可以抽取血液樣本

makes any sense.

另一樣是俄製突擊步槍

Here's the computer of the future,

這些夠他們忙一整天呢

because this screen is already there and they're ubiquitous.

這裡還有另一個十分有趣的關聯

All right, let me show you just a little bit about advanced devices.

當一個人想要

And we'll start by posing a little problem.

把這些重要的資訊