to live in a place with no rules?

請問你有曾想過，

That sounds pretty cool.

生活在一個不受管制的地方 是怎樣感覺嗎？

(Laughter)

聽來是蠻酷的。

You wake up one morning, however,

（笑聲）

and you discover that the reason there are no rules

可是，大早醒來後，

is because there's no government, and there are no laws.

你發現沒有管制的原因

In fact, all social institutions have disappeared.

卻是因為已沒有政府了， 而且也沒有任何法律了，

So there's no schools,

甚至一切社會體制都不存在了：

there's no hospitals,

沒有學校，

there's no police,

沒有醫院，

there's no banks,

沒有警察，

there's no athletic clubs,

沒有銀行，

there's no utilities.

沒有健身會所，

Well, I know a little bit about what this is like,

沒有水電等供應。

because when I was a medical student in 1999,

我倒是知道這是什麼的感覺。

I worked in a refugee camp in the Balkans during the Kosovo War.

因為在 1999 年， 我為醫學院學生時，

When the war was over,

在科索沃戰爭中，曾在巴爾幹的 一個難民收留中心工作。

I got permission -- unbelievably -- from my medical school

當戰爭結束後，

to take some time off

難以置信， 我居然獲得醫學院的允許，

and follow some of the families that I had befriended in the camp

拿到假期，

back to their village in Kosovo,

跟著我在營地結識的一些家庭，

and understand how they navigated life in this postwar setting.

回到他們在科索沃的家鄉。

Postwar Kosovo was a very interesting place

去觀察他們在戰火後， 是如何作生活的安排。

because NATO troops were there,

戰後的科索沃 是一個非常有趣的地方，

mostly to make sure the war didn't break out again.

因為有北約部隊在那裡，

But other than that, it was actually a lawless place,

目的是為了確保戰爭 不會再度爆發。

and almost every social institution, both public and private,

但除此之外，科索沃實際上已是 一個無法無天的地方，

had been destroyed.

而且幾乎所有的社會體制， 不論是公營或私營，

So I can tell you

都已被毀掉了。

that when you go into one of these situations and settings,

所以我可以告訴你，

it is absolutely thrilling ...

當你置身在這種情況和環境中，

for about 30 minutes,

它是會令你絕對毛骨悚然......

because that's about how long it takes before you run into a situation

長達 30 分鐘左右，

where you realize how incredibly vulnerable you are.

因為這就是發現自己 是何等的脆弱，所需要的時間。

For me, that moment came when I had to cross the first checkpoint,

個人來說，那一刻發生在當我要 通過第一個檢查站時，

and I realized as I drove up

當車子開近時，我就意識到

that I would be negotiating passage through this checkpoint

我必須跟一名全副武裝的人討價還價

with a heavily armed individual

才能通過這個檢查點；

who, if he decided to shoot me right then and there,

如他想在此時此地把我射殺的話，

actually wouldn't be doing anything illegal.

也是完全合法之事。

But the sense of vulnerability that I had was absolutely nothing

但當時我體會到的脆弱感， 是絲毫比不上

in comparison to the vulnerability of the families that I got to know

我將在未來一年認識的家庭

over that year.

所體會的脆弱感。

You see, life in a society where there are no social institutions

你要明白，生活在一個沒有 任何社會體制的社會裡，

is riddled with danger and uncertainty,

是充滿危險和不確定性的。

and simple questions like, "What are we going to eat tonight?"

甚至一個簡單的問題， 像「今晚我們要吃什麼呢？」

are very complicated to answer.

要回答也很複雜了。

Questions about security, when you don't have any security systems,

至於安全問題， 當你沒有任何保安系統時，

are terrifying.

是非常可怕的。

Is that altercation I had with the neighbor down the block

我與街頭那邊的鄰居吵得面紅耳赤，

going to turn into a violent episode that will end my life

會不會演變成暴力事件， 終結我的生命

or my family's life?

或我家人的生命呢？

Health concerns when there is no health system

沒有衛生系統時，健康問題

are also terrifying.

也是非常可怕的。

I listened as many families had to sort through questions like,

我聽到很多家庭必須解決這類問題：

"My infant has a fever. What am I going to do?"

「我的嬰兒在發燒。我該怎麼辦？」

"My sister, who is pregnant, is bleeding. What should I do?

「我懷孕的姐姐正在出血， 我該怎麼辦？

Who should I turn to?"

我該去找誰呢？」

"Where are the doctors, where are the nurses?

「醫生在哪裡？護士在哪裡？」

If I could find one, are they trustworthy?

如果我能找到一位，會可靠嗎？

How will I pay them? In what currency will I pay them?"

我該怎麼付錢？ 我要用哪國貨幣支付？」

"If I need medications, where will I find them?

「如果我需要藥物， 我在哪裡可以找到？

If I take those medications, are they actually counterfeits?"

如果我服用了這些藥物， 它會是假冒的嗎？」

And on and on.

連綿不斷的問題。

So for life in these settings,

所以在這環境之下生活，

the dominant theme, the dominant feature of life,

生活的主要特徵，

is the incredible vulnerability that people have to manage

就是人民日以繼夜要懂得掌控

day in and day out,

這難以置信的脆弱感，

because of the lack of social systems.

起因就是缺乏社會制度。

And it actually turns out

原來，

that this feature of life is incredibly difficult to explain

這生活特徵是很難解釋的，

and be understood by people who are living outside of it.

難以得到身置其外的人理解的。

I discovered this when I left Kosovo.

當我離開科索沃時， 我才發現這一點。

I came back to Boston, I became a physician,

我回到了波士頓，我成了一名醫生，

I became a global public health policy researcher.

我成了一名 環球公共衞生政策研究員。

I joined the Harvard Medical School

我加入了哈佛醫學院

and Brigham and Women's Hospital Division of Global Health.

和布萊根婦女醫院的全球衞生部門。

And I, as a researcher,

我作為研究員，

really wanted to get started on this problem right away.

真的很想立即就研究這問題。

I was like, "How do we reduce the crushing vulnerability

我在想： 「對生活在這種匱乏環境的人，

of people living in these types of fragile settings?

我們如何能減少 這令人窒息的脆弱感？

Is there any way we can start to think about

我們可以開始思考用什麼方法

how to protect and quickly recover

去保護和迅速恢復

the institutions that are critical to survival,

這些對生存至關重要的體制，

like the health system?"

像醫療衞生系統？」

And I have to say, I had amazing colleagues.

我不得不說，我有了不起的同事，

But one interesting thing about it was,

但有一件有趣的事情是：

this was sort of an unusual question for them.

對他們來說， 這是一種不尋常的問題。

They were kind of like, "Oh, if you work in war,

他們的反應是： 「哦，你在戰場中工作，

doesn't that mean you work on refugee camps,

那是不是你是在難民營工作？

and you work on documenting mass atrocities?" --

在記錄戰爭暴行？」

which is, by the way, very, very, very important.

順帶一提，這些工作都是非常重要。

So it took me a while to explain why I was so passionate about this issue,

所以我必得花上一段時間來解釋 我為什麼對這個問題那麼熱衷，

until about six years ago.

直至大約六年前。

That's when this landmark study

當時這份重點研究被發表，

that looked at and described the public health consequences of war

內容是探討和描述戰爭對公共衞生

was published.

所帶來的後果。

They came to an incredible, provocative conclusion.

研究人員作出一個 意想不到的驚世結論：

These researchers concluded

這些研究人員的結論

that the vast majority of death and disability from war

就是絕大多數因戰爭 死亡和殘疾的事情

happens after the cessation of conflict.

是發生在衝突停止之後。

So the most dangerous time to be a person living in a conflict-affected state

所以活在受衝突影響的國家中 最危險的時候，

is after the cessation of hostilities;

是在敵對行動停止之後；

it's after the peace deal has been signed.

是在和平協議簽署之後；

It's when that political solution has been achieved.

是在政治解決方案已經實現之後。

That seems so puzzling, but of course it's not,

這表面看來令人費解，但當然不是，

because war kills people by robbing them of their clinics,

因為戰爭之所以殺人， 是因為它摧毀了診所，

of their hospitals,

摧毀了醫院，

of their supply chains.

摧毀了供應鏈。

Their doctors are targeted, are killed; they're on the run.

醫生們被狙擊、殺害，以至逃命。

And more invisible and yet more deadly is the destruction

而且雖無形但更致命的，

of the health governance institutions and their finances.

就是衞生管治體制及其財政崩潰。

So this is really not surprising at all to me.

我對這些並不驚訝，

But what is surprising and somewhat dismaying,

但令我驚訝和有一點沮喪的是：

is how little impact this insight has had,

從這份研究得出的見解，

in terms of how we think about human suffering and war.

只能稍微改變 我們對人類苦難和戰爭的看法。

Let me give you a couple examples.

讓我給你幾個例子。

Last year, you may remember,

你可能會記得去年

Ebola hit the West African country of Liberia.

伊波拉病毒侵襲西非國家賴比瑞亞。

There was a lot of reporting about this group, Doctors Without Borders,

當時有很多關於 無國界醫生這個組織的報導，

sounding the alarm and calling for aid and assistance.

叫人提高警覺並呼籲作出援助。

But not a lot of that reporting answered the question:

但沒有很多報導解答到這個問題：

Why is Doctors Without Borders even in Liberia?

為什麼無國界醫生會在賴比瑞亞呢？

Doctors Without Borders is an amazing organization,

無國界醫生是一個令人敬佩的組織，

dedicated and designed to provide emergency care in war zones.

盡心盡力在戰區提供緊急護理。

Liberia's civil war had ended in 2003 --

賴比瑞亞的內戰在 2003 年已結束，

that was 11 years before Ebola even struck.

亦是伊波拉病毒爆發的 11 年前。

When Ebola struck Liberia,

當伊波拉病毒衝擊賴比瑞亞時，

there were less than 50 doctors in the entire country

在全國 450 萬人口之中， 醫生不到 50 名。

of 4.5 million people.

無國界醫生駐守在賴比瑞亞，

Doctors Without Borders is in Liberia

是因為賴比瑞亞依然沒有 一個能運作的醫療系統，

because Liberia still doesn't really have a functioning health system,

在 11 年後仍沒有。

11 years later.

在 2010 年，地震衝擊海地後，

When the earthquake hit Haiti in 2010,

來自國際社會的援助排山倒海。

the outpouring of international aid was phenomenal.

但你知不知道國際社會 捐款中只有 2%

But did you know that only two percent of that funding

用去重建海地的公共體制，

went to rebuild Haitian public institutions,

包括衞生部門？

including its health sector?

從這個角度看，

From that perspective,

海地人民可謂到了今天 還因地震而繼續死亡。

Haitians continue to die from the earthquake even today.

我最近認識了這位先生，

I recently met this gentleman.

他是尼薩‧伊斯密特醫生。

This is Dr. Nezar Ismet.

他是伊拉克北部自治區庫爾德斯坦的

He's the Minister of Health in the northern autonomous region of Iraq,

衞生部長。

in Kurdistan.

他正在宣佈在過去九個月中，

Here he is announcing that in the last nine months,

他所屬地區的人口從 400 萬

his country, his region, has increased from four million people

增加到 500 萬。

to five million people.

這是增加 25％ 之多。

That's a 25 percent increase.

這些數以千計的新移民 經歷了難言的創傷。

Thousands of these new arrivals have experienced incredible trauma.

他轄下的醫生們 每天無薪的工作 16 小時。

His doctors are working 16-hour days without pay.

可是他的財政預算 並沒有增加 25 ％，

His budget has not increased by 25 percent;

而是減少了 20％。

it has decreased by 20 percent,

因為撥款已調去應付保安問題 和短期救援工作。

as funding has flowed to security concerns and to short-term relief efforts.

所以當他的衞生部門崩潰時—

When his health sector fails --

如果歷史有任何預告能力， 它是一定會的——

and if history is any guide, it will --

你覺得這會怎樣影響

how do you think that's going to influence

當地 500 萬居民的決定呢？

the decision making of the five million people in his region

他們正在考量是否應該逃跑，

as they think about whether they should flee

離開這危機重重的生活環境。

that type of vulnerable living situation?

所以你可以看到， 這是個令我沮喪的議題。

So as you can see, this is a frustrating topic for me,

我很用心去嘗試理解：

and I really try to understand:

大家為什麼不願意維護和支持

Why the reluctance to protect and support

本土的衞生和保安系統呢？

indigenous health systems and security systems?

我常聽到兩個關注點或論點。

I usually tier two concerns, two arguments.

第一個關注點是貪污：

The first concern is about corruption,

在這些系統工作的人都是腐敗的，

and the concern that people in these settings are corrupt

都是不可信的。

and they are untrustworthy.

我承認我是有見過品德不良的人物，

And I will admit that I have met unsavory characters

在這種情況下之衞生部門工作。

working in health sectors in these situations.

但我也可告訴你， 相反的也是絕對有的，

But I will tell you that the opposite is absolutely true

在我有參與的每一個案件中都有——

in every case I have worked on,

從阿富汗到利比亞、到科索沃、 到海地、到賴比瑞亞——

from Afghanistan to Libya, to Kosovo, to Haiti, to Liberia --

我都遇到鼓舞人心的人，

I have met inspiring people,

他們都在國家存亡的一刻，

who, when the chips were down for their country,

冒著一切風險來 挽救他們的衞生體制。

they risked everything to save their health institutions.

所以，對真心想幫忙的局外人來說，

The trick for the outsider who wants to help

難題是如何識別這些人，

is identifying who those individuals are,

並建立渠道讓他們走上領導位置。

and building a pathway for them to lead.

這也正是在阿富汗能做到的。

That is exactly what happened in Afghanistan.

我們在阿富汗國家建設上付出的努力

One of the unsung and untold success stories

其中一個無聲無聞的成功故事，

of our nation-building effort in Afghanistan

就是世界銀行在 2002 年 投放大量資金

involved the World Bank in 2002 investing heavily

去發掘、培訓和提拔 阿富汗的衞生部門領袖。

in identifying, training and promoting Afghani health sector leaders.

這些衞生部門領袖在阿富汗

These health sector leaders have pulled off an incredible feat

排除萬難完成壯舉。

in Afghanistan.

他們積極增加醫療服務

They have aggressively increased access to health care

讓大部分人口可以使用。

for the majority of the population.

他們正在迅速改善

They are rapidly improving the health status

阿富汗人口的健康狀況，

of the Afghan population,

而它曾經是世界上最糟糕的。

which used to be the worst in the world.

事實上，阿富汗衞生部所做的事

In fact, the Afghan Ministry of Health does things

是我希望我們也能在美國做到的。

that I wish we would do in America.

他們用數據資料來製定政策。

They use things like data to make policy.

簡直不可思議。

It's incredible.

（笑聲）

(Laughter)

我經常聽到的另外一個關注點是：

The other concern I hear a lot about is:

「我們負擔不起，我們真的沒錢。

"We just can't afford it, we just don't have the money.

這是不可能持續的。」

It's just unsustainable."

但讓我告訴你：我們現有的情況

I would submit to you that the current situation

和我們現有的制度

and the current system we have

是我們可以想像 最昂貴、效率最低的制度。

is the most expensive, inefficient system we could possibly conceive of.

目前的情況是美國等多國政府——

The current situation is that when governments like the US --

或者說組成歐盟委員會的

or, let's say, the collection of governments

一眾成員國政府——

that make up the European Commission --

每年就要花費 150 億美元

every year, they spend 15 billion dollars

在全球的人道、緊急和災難救援上。

on just humanitarian and emergency and disaster relief worldwide.

這數字不包括外援，只是賑災而已。

That's nothing about foreign aid, that's just disaster relief.

這費用 95% 給了國際救援機構，

Ninety-five percent of it goes to international relief agencies,

然後他們必須把資源引進這些地區，

that then have to import resources into these areas,

並且拼湊一個臨時衞生系統，

and knit together some type of temporary health system, let's say,

錢用光後就要把它瓦解， 把人員遣散。

which they then dismantle and send away when they run out of money.

所以我們的工作原來是非常清楚的。

So our job, it turns out, is very clear.

我們作為全球衞生政策專家，

We, as the global health community policy experts,

首要工作就是要專注監控

our first job is to become experts in how to monitor

在政局不定環境下，衞生部門的

the strengths and vulnerabilities of health systems

各個強項和弱項。

in threatened situations.

當我們看到醫生逃跑時，

And that's when we see doctors fleeing,

當我們看到衞生資源枯竭時，

when we see health resources drying up,

當我們看到體制崩潰時，

when we see institutions crumbling --

這就是緊急情況。

that's the emergency.

這就是我們需要發出警報 並揮手求救之時。

That's when we need to sound the alarm and wave our arms.

行嗎？

OK?

還等什麼？

Not now.

大家都可以看到這是緊急情況， 他們不需要我們告訴他們吧。

Everyone can see that's an emergency, they don't need us to tell them that.

第二點：

Number two:

我在哈佛任職的機構和類似機構

places like where I work at Harvard need to take their cue

需要從世界銀行 在阿富汗的經驗中學習，

from the World Bank experience in Afghanistan,

我們需要並將會

and we need to -- and we will --

建立一個強大的平台來支援 這些衞生部門領袖。

build robust platforms to support health sector leaders like these.

這些人都是冒著生命危險，

These people risk their lives.

我們應該以行動來支持他們的勇氣。

I think we can match their courage with some support.

第三點：

Number three:

我們需要積極溝通， 並建立新的伙伴關係。

we need to reach out and make new partnerships.

在我們的環球衞生中心，

At our global health center,

我們與北約和其它安全決策者 發起了一個新舉措，

we have launched a new initiative with NATO and other security policy makers

與他們探討如何

to explore with them what they can do to protect health system institutions

在部署期間維護當地的衞生系統。

during deployments.

我們希望他們明白，