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？

They sit, they watch the goldfish in the fish tank,

他們坐著，看水族箱裡的金魚