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  • Translator: Timothy Covell Reviewer: Morton Bast

    譯者: Gina Wang 審譯者: Anny Chung

  • So my freshman year of college

    我大一的時候

  • I signed up for an internship in the housing unit

    申請成為大波士頓法律援助處的實習生

  • at Greater Boston Legal Services.

    在住宅部門

  • Showed up the first day

    第一天上工時

  • ready to make coffee and photocopies,

    我準備好要幫大家煮咖啡、影印

  • but was paired with this righteous, deeply inspired attorney

    卻被分配與一位充滿正義感與啟發性的律師共事

  • named Jeff Purcell,

    他是Jeff Purcell

  • who thrust me onto the front lines

    他在我實習的第一天

  • from the very first day.

    便將我丟到工作前線

  • And over the course of nine months

    而在之後的九個月中

  • I had the chance

    我有機會

  • to have dozens of conversations

    跟許多波士頓低收入的家庭

  • with low-income families in Boston

    有許多會談

  • who would come in presenting with housing issues,

    他們來我們這裡,通常是因為許多關於居住的問題

  • but always had an underlying health issue.

    但潛藏其中,總有與健康相關的問題

  • So I had a client who came in,

    我有一個客戶

  • about to be evicted because he hasn't paid his rent.

    他因長期沒付房租,即將被逐出房屋

  • But he hasn't paid his rent, of course,

    但他一直沒付房租

  • because he's paying for his HIV medication

    是因為他必須支付愛滋病的醫藥費

  • and just can't afford both.

    所以無法負荷兩者加起來的支出

  • We had moms who would come in,

    也有許多母親來我們這裡

  • daughter has asthma,

    女兒有氣喘病

  • wakes up covered in cockroaches every morning.

    卻每天早晨在蟑螂堆中起床

  • And one of our litigation strategies

    我們訴訟的策略之一

  • was actually to send me into the home of these clients

    是派我去這些客戶的家裡

  • with these large glass bottles.

    用大玻璃瓶

  • And I would collect the cockroaches,

    蒐集這些蟑螂

  • hot glue-gun them to this poster board

    用熱熔膠把蟑螂黏在海報板上

  • that we'd bring to court for our cases.

    再帶到法庭打官司

  • And we always won

    而我們總能贏得這些案件

  • because the judges were just so grossed out.

    因為法官看了這些都覺得很噁心

  • Far more effective, I have to say,

    這方法,我必須承認

  • than anything I later learned in law school.

    比我日後在法學院所學的都還要有效

  • But over the course of these nine months,

    但是在這九個月中

  • I grew frustrated with feeling

    我越來越感到挫敗

  • like we were intervening too far downstream

    因為在客戶的生活中

  • in the lives of our clients --

    我們出手相助的時機總是太晚

  • that by the time they came to us,

    當他們來尋求幫助時

  • they were already in crisis.

    他們的生活早已陷入危機

  • And at the end of my freshman year of college,

    當我大一那年即將結束時

  • I read an article about the work

    我讀到一篇文章

  • that Dr. Barry Zuckerman was doing

    是有關Barry Zuckerman博士的工作

  • as Chair of Pediatrics

    他是小兒科主任

  • at Boston Medical Center.

    在波士頓醫療中心工作

  • And his first hire was a legal services attorney

    而他的第一份工作是當律師

  • to represent the patients.

    為病患辯護

  • So I called Barry,

    我打電話給Barry

  • and with his blessing, in October 1995

    並在他的幫助之下,於1995年10月

  • walked into the waiting room

    走進波士頓醫療中心

  • of the pediatrics clinic at Boston Medical Center.

    小兒科的候診室

  • I'll never forget,

    我永遠不會忘記

  • the TVs played this endless reel of cartoons.

    他們的電視上不斷播放卡通

  • And the exhaustion of mothers

    而那些筋疲力竭的母親們

  • who had taken two, three, sometimes four buses

    有些已經轉了2、3次,甚至是4次的公車

  • to bring their child to the doctor

    才能帶她的小孩來看醫生

  • was just palpable.

    她們的疲憊真實的如可觸見

  • The doctors, it seemed,

    那些醫生

  • never really had enough time for all the patients,

    看似永遠沒有足夠時間來看所有的病患

  • try as they might.

    儘管他們很努力

  • And over the course of six months,

    而接下來的六個月

  • I would corner them in the hallway

    我常在走廊上攔下這些醫生

  • and ask them a sort of naive but fundamental question:

    問他們一個看似天真但卻很基本的問題:

  • "If you had unlimited resources,

    「如果你有無限的資源

  • what's the one thing you would give your patients?"

    你會給你的病患什麼?」

  • And I heard the same story again and again,

    同樣的回答一次又一次的出現

  • a story we've heard hundreds of times since then.

    我們大概聽了一百遍這樣的故事

  • They said, "Every day we have patients that come into the clinic --

    他們說:"我們每天有許多病患來求診

  • child has an ear infection,

    像耳朵感染的小孩

  • I prescribe antibiotics.

    我會開抗生素

  • But the real issue is there's no food at home.

    但是最大的問題是他們家中沒有食物

  • The real issue

    真正的問題

  • is that child is living with 12 other people

    是這小孩與其他12個人一起

  • in a two-bedroom apartment.

    住在一間只有兩個臥房的公寓

  • And I don't even ask about those issues

    而我對於這樣的事卻不願多問

  • because there's nothing I can do.

    因為我也束手無策

  • I have 13 minutes with each patient.

    我與每位病患有13分鐘的診療時間

  • Patients are piling up in the clinic waiting room.

    候診室塞滿病人

  • I have no idea where the nearest food pantry is.

    我不曉得最近的救濟中心在哪

  • And I don't even have any help."

    也沒有人能幫我。"

  • In that clinic, even today,

    即便今日,在那間醫療中心

  • there are two social workers

    只有2位社工

  • for 24,000 pediatric patients,

    卻要處理2萬4千位小兒科病人

  • which is better than a lot of the clinics out there.

    但這狀況已經比其他的醫療中心好了

  • So Health Leads was born of these conversations --

    「導向健康組織(Heath Leads)」從這些會談中誕生

  • a simple model

    運用簡單的模式

  • where doctors and nurses

    讓醫生和護士

  • can prescribe nutritious food,

    能開營養的食物

  • heat in the winter

    冬天的暖氣

  • and other basic resources for their patients

    和其他基本的生活資源給病患

  • the same way they prescribe medication.

    就像他們開其他藥方一樣

  • Patients then take their prescriptions

    病患拿著這些處方籤

  • to our desk in the clinic waiting room

    來我們位於候診室的櫃台

  • where we have a core of well-trained college student advocates

    在這我們有一群訓練優良的大學生

  • who work side by side with these families

    可以從旁協助這些家庭

  • to connect them out

    幫他們向外聯繫

  • to the existing landscape of community resources.

    取得社區現有的資源

  • So we began with a card table in the clinic waiting room --

    一開始我們在診療室設立了一個簡單的櫃台

  • totally lemonade stand style.

    就像賣檸檬汁的攤販那樣

  • But today we have a thousand college student advocates

    但如今我們已有1千名支持這項行動的大學生

  • who are working to connect nearly 9,000 patients and their families

    他們幫忙9千個病患和其家庭

  • with the resources that they need to be healthy.

    幫忙取得他們維持健康所需的資源

  • So 18 months ago

    18個月前

  • I got this email that changed my life.

    我收到一封改變我人生的電郵

  • And the email was from Dr. Jack Geiger,

    是Jack Geiger博士寄給我的

  • who had written to congratulate me on Health Leads

    他寫來恭賀我和導向健康組織

  • and to share, as he said,

    並且分享,如同他說的

  • a bit of historical context.

    一些歷史脈絡

  • In 1965 Dr. Geiger founded

    1965年,Geiger博士創立

  • one of the first two community health centers in this country,

    那時全國唯二社區健康中心的其中一個

  • in a brutally poor area in the Mississippi Delta.

    位於密西西比三角洲,是極為貧窮的地區

  • And so many of his patients came in

    博士有許多前來求診的病患

  • presenting with malnutrition

    呈現營養不良的問題

  • that be began prescribing food for them.

    於是他開始開食物給病患當藥方

  • And they would take these prescriptions to the local supermarket,

    病人將這些處方籤拿去當地超市

  • which would fill them

    取得他們所需的食物

  • and then charge the pharmacy budget of the clinic.

    超市則向診所支取這些費用

  • And when the Office of Economic Opportunity in Washington, D.C. --

    當華府的職業訓練部

  • which was funding Geiger's clinic --

    --他們當時資助Geiger的診所--

  • found out about this,

    發現這件事後

  • they were furious.

    他們十分不高興

  • And they sent this bureaucrat down

    派官員告訴Geiger

  • to tell Geiger that he was expected to use their dollars

    他們期待將這些資助的費用

  • for medical care --

    花在醫療保健上

  • to which Geiger famously and logically responded,

    Geiger的回應出名且有邏輯:

  • "The last time I checked my textbooks,

    "上回我查課本的時候

  • the specific therapy for malnutrition was food."

    針對改善營養不良,最好的解藥就是食物。"

  • (Laughter)

    (笑聲)

  • So when I got this email from Dr. Geiger,

    因此當我收到Geiger博士的這封電郵

  • I knew I was supposed to be proud

    我知道我身為這段歷史的一份子

  • to be part of this history.

    應該感到驕傲

  • But the truth is

    但事實上

  • I was devastated.

    我卻感到挫敗

  • Here we are,

    我們現在

  • 45 years after Geiger has prescribed food for his patients,

    離Geiger開食物給他的病人當藥方已經45年

  • and I have doctors telling me,

    卻仍有醫生告訴我

  • "On those issues, we practice a 'don't ask, don't tell' policy."

    "面對這些問題 我們奉行「不問、不說」的原則"

  • Forty-five years after Geiger,

    在Geiger開始這項行動的45年後

  • Health Leads has to reinvent

    導向健康組織必須重新創造

  • the prescription for basic resources.

    給予病人基本生活資源的的藥方

  • So I have spent hours upon hours

    我花了好多時間

  • trying to make sense of this weird Groundhog Day.

    試圖了解這個怪異的迴圈

  • How is it that if for decades

    為什麼這幾十年來

  • we had a pretty straightforward tool for keeping patients,

    我們一直有非常直接的方法讓病患健康

  • and especially low-income patients, healthy,

    特別是低收入戶的患者

  • that we didn't use it?

    我們卻從不使用?

  • If we know what it takes to have a healthcare system

    如果我們知道要如何成立「健保」系統

  • rather than a sick-care system,

    而不是「病保」系統

  • why don't we just do it?

    為什麼我們不做呢?

  • These questions, in my mind,

    在我心中,這些問題

  • are not hard because the answers are complicated,

    並不因為答案很複雜而困難

  • they are hard because they require that we be honest with ourselves.

    它們是如此困難, 是因為它需要我們誠實的面對自己

  • My belief is that it's almost too painful

    我認為這是一件極為痛苦的事

  • to articulate our aspirations for our healthcare system,

    以致我們無法表達對健保制度的期望

  • or even admit that we have any at all.

    或甚至承認有任何期待

  • Because if we did,

    因為如果我們這麼做

  • they would be so removed

    它們將看似遙不可及

  • from our current reality.

    不可能存在現實生活中

  • But that doesn't change my belief

    但這並不能改變我的信念

  • that all of us, deep inside,

    我認為每個人在心深處

  • here in this room and across this country,

    在這間大廳和整個國家

  • share a similar set of desires.

    都有相同的渴望

  • That if we are honest with ourselves

    如果我們能誠實的面對自己

  • and listen quietly,

    並安靜的傾聽

  • that we all harbor

    我們便能懷抱

  • one fiercely held aspiration for our healthcare:

    對健保制度的熱切期望:

  • that it keep us healthy.

    它幫我們保持健康

  • This aspiration that our healthcare keep us healthy

    認為健保制度能讓人們健康的期待

  • is an enormously powerful one.

    是非常強大有影響力的

  • And the way I think about this

    我是這麼認為:

  • is that healthcare is like any other system.

    健保制度跟其它制度一樣

  • It's just a set of choices that people make.

    它只是一系列人們的選擇

  • What if we decided

    如果我們決定

  • to make a different set of choices?

    做出不同的選擇,將會如何?

  • What if we decided to take all the parts of healthcare

    如果我們決定不讓健保制度

  • that have drifted away from us

    拿走對我們有助益的部分

  • and stand firm and say, "No.

    並且堅決的說:"不

  • These things are ours.

    這些都是屬於我們的

  • They will be used for our purposes.

    它們會幫助我們達成目標

  • They will be used to realize

    它們會被使用並實現

  • our aspiration"?

    我們的期望"

  • What if everything we needed

    所有能讓我們實現

  • to realize our aspiration for healthcare

    對健保制度期望的要件

  • was right there in front of us

    會不會就在我們面前

  • just waiting to be claimed?

    等待被使用?

  • So that's where Health Leads began.

    這就是導向健康組織的開端

  • We started with the prescription pad --

    我們從處方籤著手

  • a very ordinary piece of paper --

    一張非常平凡的紙

  • and we asked, not what do patients need to get healthy --

    我們不問病患要怎麼做才能健康

  • antibiotics, an inhaler, medication --

    不是抗生素、吸入劑、藥物治療

  • but what do patients need to be healthy,

    而是問病患需要什麼才能保持健康

  • to not get sick in the first place?

    讓他們一開始就不會生病

  • And we chose to use the prescription

    而我們選擇使用的藥方

  • for that purpose.

    專為這個目的

  • So just a few miles from here

    離這裡幾哩遠的地方

  • at Children's National Medical Center,

    在國家兒童醫療中心

  • when patients come into the doctor's office,

    當病人來到醫生辦公室

  • they're asked a few questions.

    他們會被問幾個問題

  • They're asked, "Are you running out of food at the end of the month?

    "你的食物夠不夠每月所需?

  • Do you have safe housing?"

    你有安全的住處嗎?"

  • And when the doctor begins the visit,

    因此當醫生診療時

  • she knows height, weight, is there food at home,

    他知道病人的身高、體重、家裡存糧的狀況

  • is the family living in a shelter.

    他的家庭是否住在安全的地方

  • And that not only leads to a better set of clinical choices,

    這些問題不只讓診療結果更好

  • but the doctor can also prescribe those resources for the patient,

    醫生也能開給病患他們所需的資源

  • using Health Leads like any other sub-specialty referral.

    藉由導向健康或其他組織的幫助

  • The problem is,

    問題是

  • once you get a taste of what it's like

    當你嚐到

  • to realize your aspiration for healthcare,

    實現對健保制度的期望的滋味

  • you want more.

    你會想要更多

  • So we thought,

    因此我們想:

  • if we can get individual doctors

    如果我們可以讓每位醫生

  • to prescribe these basic resources for their patients,

    開基本的生活資源給患者

  • could we get an entire healthcare system

    我們是否能讓整個健保制度

  • to shift its presumption?

    改變它先入為主的態度?

  • And we gave it a shot.

    所以我們決定一試

  • So now at Harlem Hospital Center

    現在,哈林醫學中心

  • when patients come in with an elevated body mass index,

    當前來的病患測出有過高身體質量指數(BMI)時

  • the electronic medical record

    電子醫療記錄

  • automatically generates a prescription for Health Leads.

    自動產生處方給導向健康組織

  • And our volunteers can then work with them

    而我們的志工即可協助

  • to connect patients to healthy food and excercise programs

    讓病患取得他們的社區中

  • in their communities.

    健康飲食與運動計畫

  • We've created a presumption

    我們創造出這個假設:

  • that if you're a patient at that hospital

    如果你去醫院

  • with an elevated BMI,

    身體質量指數很高

  • the four walls of the doctor's office

    在醫院裡

  • probably aren't going to give you everything

    你可能無法得到你需要的

  • you need to be healthy.

    你需要健康

  • You need more.

    你需要更多

  • So on the one hand,

    所以一方面

  • this is just a basic recoding

    這只是基本重新設計

  • of the electronic medical record.

    電子醫療的記錄程式

  • And on the other hand,

    另一方面

  • it's a radical transformation

    這是大規模的改變

  • of the electronic medical record

    對電子醫療記錄而言

  • from a static repository of diagnostic information

    從靜態儲存診斷記錄

  • to a health promotion tool.

    變成推廣健康的工具

  • In the private sector,

    在私營部門

  • when you squeeze that kind of additional value

    當你從固定成本的投資中

  • out of a fixed-cost investment,

    找出這樣的附加價值

  • it's called a billion-dollar company.

    這被稱做高盈利公司

  • But in my world,

    但在我的世界裡

  • it's called reduced obesity and diabetes.

    這被稱做減少肥胖和糖尿病

  • It's called healthcare --

    這就是健保

  • a system where doctors can prescribe solutions

    讓醫生能開好處方的系統

  • to improve health,

    讓病人改善健康

  • not just manage disease.

    不只是控制病情

  • Same thing in the clinic waiting room.

    在醫院的候診室也是如此

  • So every day in this country

    在這個國家裡,每一天

  • three million patients

    3百萬名病人

  • pass through about 150,000 clinic waiting rooms in this country.

    會先待在15萬的候診室

  • And what do they do when they're there?

    他們在那裡要做什麼呢?