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RishiManchanda_2014S-_什么让我们生病_看看上游吧！_
For over a decade as a doctor, 当了十几年的医师,
I've cared for homeless veterans , for working-class families. 我照护过无家可归的退伍军人, 也照护过劳动阶级的家庭。
veterans:n.老兵;退伍军人(veteran的复数形式); working-class:adj.工人阶级的;劳动阶级的;
I've cared for people who live and work in conditions that can be hard, if not harsh , and that work has led me to believe that we need a fundamentally different way of looking at healthcare . 我照护的人都住在或工作在 即使不恶劣也很糟的环境下。 这样的工作让我相信 我们需要以完全不同的方式 来看医疗的问题。
harsh:adj.严厉的;严酷的;刺耳的;粗糙的;刺目的; fundamentally:adv.从根本上;基础地;重要地 healthcare:n.医疗保健;健康护理,健康服务;卫生保健;
We simply need a healthcare system that moves beyond just looking at the symptoms that bring people into clinics , but instead actually is able to look and improve health where it begins. 我们需要的医疗系统 不能只是单诊疗 病人来诊所时的症状, 而是要实际 从源头查看及改善健康状况。
symptoms:n.症状;征候;征兆;(symptom的复数) clinics:n.诊所(clinic的复数形式); improve:v.改进;改善;
And where health begins is not in the four walls of a doctor's office, but where we live and where we work, where we eat, sleep, learn and play, where we spend the majority of our lives. 健康不是从 诊疗室的四面墙开始, 而是从我们居住 及工作、 吃、喝、睡觉、学习及享乐的地方开始, 从我们花大把时间的地方开始。
majority:n.大部分:大多数:多数票:成年人:
So what does this different approach to healthcare look like, an approach that can improve health where it begins? 所以这个不同的医疗方法是什么样子？ 这个能从源头改善健康的方法？
approach:n.方法;路径;v.接近;建议;着手处理;
To illustrate this, I'll tell you about Veronica. 为了解释清楚,我跟大家说说小维的故事。
illustrate:v.解释;加插图于;给(书等)做图表;表明…真实;
Veronica was the 17th patient out of my 26-patient day at that clinic in South Central Los Angeles. 小维是我第 17 号病人, 我每天要看 26 名病人, 诊所位于洛杉矶南区。
patient:adj.有耐心的,能容忍的;n.病人;患者;
She came into our clinic with a chronic headache. 她来我的诊所看慢性头痛。
chronic:adj.慢性的;长期的;习惯性的;
This headache had been going on for a number of years, and this particular episode was very, very troubling. 这个头痛已经持续好多年, 而这段经历让她非常非常困扰。
episode:n.一段经历;片段,插曲;一集;
In fact, three weeks before she came to visit us for the first time, she went to an emergency room in Los Angeles. 其实在她来看我们的三个星期前, 她才去过洛杉矶的某急诊室。
emergency room:n.急诊室;
The emergency room doctors said, "We've run some tests, Veronica. 这个急诊室的医师说, 「小维,我们做了几项檢查,
The results are normal, so here's some pain medication , and follow up with a primary care doctor, but if the pain persists or if it worsens , then come on back." 结果都很正常,所以我现在给你开一些止痛药, 妳要回去看妳的家庭医师, 但是如果还继续痛,或是更痛, 妳再回来找我们。」
medication:n.药;药物; persists:vi.存留,坚持;持续,固执;vt.坚持说,反复说; worsens:vi.恶化;变得更坏;更坏;vt.使恶化;使变得更坏;
Veronica followed those standard instructions and she went back. 小维谨遵这些制式的医嘱, 最后还是回去急诊室了。
standard:n.标准;水准;旗;度量衡标准;adj.标准的;合规格的;公认为优秀的;
She went back not just once, but twice more. 她回去不只一次,她去了三次。
In the three weeks before Veronica met us, she went to the emergency room three times. 在小维来找我们前的那三个星期, 她回去急诊室三次。
She went back and forth , in and out of hospitals and clinics, just like she had done in years past, trying to seek relief but still coming up short. 她来来回回, 进进出出各个医院及诊所, 就像之前一年一样, 想要找解方却徒劳无功。
back and forth:前后移动的,来回的,反复的; seek:v.寻求;寻找;谋求; relief:n.救济;减轻,解除;安慰;浮雕;
Veronica came to our clinic, and despite all these encounters with healthcare professionals , 小维来我们的诊所, 无论她看了多少医疗专家,
despite:prep.尽管,不管;n.轻视;憎恨;侮辱; encounters:v.遭遇(encounter的第三人称单数);邂逅;n.遭遇战(encounter的复数);相见; professionals:n.[管理]专业人员(professional的复数);
Veronica was still sick. 小维还是病着。
When she came to our clinic, though, we tried a different approach. 她到我们的诊所时,我们试了一种不同的疗法。
Our approach started with our medical assistant, someone who had a GED-level training but knew the community . 我们的疗法从我们的医务助理开始, 这位助理有同等学历的训练, 也很瞭解这个社区。
community:n.社区;[生态]群落;共同体;团体;
Our medical assistant asked some routine questions. 我们的医务助理问了几个例行问题。
She asked, "What's your chief complaint ?" 她问,「妳主诉的症状是什么？」
complaint:n.抱怨;投诉;控告;不满;
'"Headache." 「头痛。」
'"Let's get your vital signs" — measure your blood pressure and your heart rate, but let's also ask something equally as vital to Veronica and a lot of patients like her in South Los Angeles. 「那我们量一下生命征象」, 量一下妳的血压心跳。 但我们还要多问几个问题, 对小维及许多类似的洛杉矶南区病人, 就跟生命征象一样重要的问题。
vital:adj.至关重要的;生死攸关的;有活力的; blood pressure:n.[医]血压; patients:n.接受治疗者,病人;(patient的复数)
'"Veronica, can you tell me about where you live? 「小维,可不可以告诉我妳住的地方的情况？
Specifically , about your housing conditions? 特别是妳住处的状况？
Specifically:adv.特别地;明确地;
Do you have mold ? Do you have water leaks ? 有发霉吗？有漏水吗？
mold:n.模具;模型;霉菌;类型;v.用可塑材料塑成;浇铸;发霉; leaks:n.泄漏; v.漏水; (leak的第三人称单数)
Do you have roaches in your home?" 家里有蟑螂吗？」
roaches:n.蟑螂(roach的复数);
Turns out, Veronica said yes to three of those things: roaches, water leaks, mold. 结果是,小维家三「有」: 蟑螂、漏水、发霉。
I received that chart in hand, reviewed it, and I turned the handle on the door and I entered the room. 我拿到那张病历,看了一下, 然后我转转门把 进入诊间。
reviewed:v.复习;评估;评论;检讨;(review的过去分词形式) handle:n.[建]把手;柄;手感;口实;v.处理;操作;运用;买卖;触摸;
You should understand that Veronica, like a lot of patients that I have the privilege of caring for, is a dignified person, a formidable presence , a personality that's larger than life , but here she was doubled over in pain sitting on my exam table. 你得了解,小维 就像我有幸照护的大部分病人一样, 是个有尊严、不可轻忽, 有着鲜明个性的人, 但在这里,她坐在 我的诊疗台上痛苦地蜷缩着。
privilege:n.特权;优待;v.给与…特权;特免; dignified:adj.端庄的; v.使有尊严; (dignify的过去分词和过去式) formidable:adj.强大的;可怕的;令人敬畏的;艰难的; presence:n.存在;出席;参加;风度;仪态; personality:n.性格;个性;人格;魅力;气质;名人;特色; larger than life:adj.(谚语)杰出的;
Her head, clearly throbbing , was resting in her hands. 她的头很明显搏痛着,搁在她的手上。
throbbing:n.跳动;阵阵的疼痛;v.抽动;跳动,搏动;(throb的现在分词)
She lifted her head up, and I saw her face, said hello, and then I immediately noticed something across the bridge of her nose, a crease in her skin. 她抬起头, 我看着她的脸,说了妳好, 然后我立刻注意到 在她的鼻樑上, 皮肤有一道皱折。
crease:n.折痕;折缝;v.起皱;弄皱;使起折痕;
In medicine, we call that crease the allergic salute . 在医学上,我们称这道皱折为「过敏性敬礼征」。
allergic:adj.对…过敏的;对…极讨厌的; salute:n.致敬,欢迎;敬礼;v.行礼致敬,欢迎;致意,打招呼;行礼;
It's usually seen among children who have chronic allergies . 这通常发生在有慢性过敏的儿童上。
allergies:n.变态反应;过敏反应;(allergy的复数)
It comes from chronically rubbing one's nose up and down, trying to get rid of those allergy symptoms, and yet, here was Veronica, a grown woman, with the same telltale sign of allergies. 起因是长期上下磨擦鼻子, 想要摆脱那些过敏症状。 但是,在这的小维,已经是成年妇女, 却还是有过敏的示警征兆。
chronically:adv.长期地;慢性地;习惯性地; rubbing:v.擦;磨;搓;(使)相互摩擦;摩擦;(rub的现在分词) allergy:n.过敏症;反感;厌恶; telltale:adj.报警的;泄密的;搬弄是非的;n.迹象;指示器;搬弄是非者;
A few minutes later, in asking Veronica some questions, and examining her and listening to her, 几分钟后,我一边问小维问题, 一边檢查及听她说,
I said, "Veronica, I think I know what you have. 我说:「小维,我想我知道妳得了什么。
I think you have chronic allergies, and I think you have migraine headaches and some sinus congestion , and I think all of those are related to where you live." 我认为妳是慢性过敏, 而且我认为妳还有偏头痛及鼻塞, 我想这些都跟妳住的地方有关。」
migraine:n.[内科]偏头痛; sinus:n.[生物]窦;静脉窦;下陷或凹下去的地方; congestion:n.拥挤;拥塞;充血;
She looked a little bit relieved , because for the first time, she had a diagnosis , but I said, "Veronica, now let's talk about your treatment . 她看起来有点鬆了口气, 因为这是她第一次得到真的诊断, 但我说:「小维,现在我们来谈一下治疗方法。
relieved:adj.释然的; v.缓解; diagnosis:n.诊断; treatment:n.治疗;疗法;对待;处理;讨论;
We're going to order some medications for your symptoms, but I also want to refer you to a specialist, if that's okay." 我们会针对妳的症状开几款药, 但我也想把妳转诊给一位专科,如果妳同意。」
medications:n.药;药物;(medication的复数) refer:v.参考;涉及;提到;查阅;
Now, specialists are a little hard to find in South Central Los Angeles, so she gave me this look, like, "Really?" 不过,专科 在洛杉矶南区有点难找, 所以她看了我一眼,好像在说,「真的？」
And I said, "Veronica, actually, the specialist I'm talking about is someone I call a community health worker, someone who, if it's okay with you, can come to your home and try to understand what's going on with those water leaks and that mold, 我说,「小维,其实我说的这位专科 是我所谓的社区保健员, 如果妳同意,这个人 会到妳家试着了解情况, 看看为什么漏水及发霉, 看看为什么漏水及发霉,
trying to help you manage those conditions in your housing that I think are causing your symptoms, and if required, that specialist might refer you to another specialist that we call a public interest lawyer, because it might be that your landlord isn't making the fixes he's required to make." 试着幫妳解决房子的状况,我认为是这些造成妳的症状, 如果有必要,这位专科还会幫妳转诊 去另一位专科,我们叫他公益律师, 因为妳的房东很可能 没有按照法律规定替妳修房子。」
landlord:n.房东;地主;东家;土地主;
Veronica came back in a few months later. 小维几个月后跑回来。
She agreed to all of those treatment plans. 她同意所有上述的治疗计画。
She told us that her symptoms had improved by 90 percent. 她告诉我们她的症状改善了 90%,
improved:adj.改良的:v.改进:改善(improve的过去分词和过去式)
She was spending more time at work and with her family and less time shuttling back and forth between the emergency rooms of Los Angeles. 她可以花更多时间在工作 及跟家人相处上,不用常常 在洛杉矶的急诊室来回奔波。
shuttling:v.频繁往来;往返运送;(shuttle的现在分词)
Veronica had improved remarkably . 小维有很明显的进步。
remarkably:adv.非常;极为;格外;出乎意料地
Her sons, one of whom had asthma , were no longer as sick as they used to be. 她的几个儿子,其中一个有气喘, 不再像以前一样病着。
asthma:n.[内科][中医]哮喘,气喘;
She had gotten better, and not coincidentally , 她好多了,而且一点也不意外,
coincidentally:adv.巧合地;一致地;
Veronica's home was better too. 小维的房屋状况也改善了。
What was it about this different approach we tried that led to better care, fewer visits to the E.R., better health? 我们采用的这种迥异的方法 为什么能提供更好的照护？ 让病人少跑急诊室,更健康？
Well, quite simply, it started with that question: "Veronica, where do you live?" 很简单,就从那个问题开始: 「小维,妳住在哪？」
But more importantly, it was that we put in place a system that allowed us to routinely ask questions to Veronica and hundreds more like her about the conditions that mattered in her community, about where health, and unfortunately sometimes illness, do begin in places like South L.A. 但更重要的是,我们推出 一种系统,让我们能问小维 及数百计像小维那样的人几个简单问题, 对她的社区很重要的环境问题, 健康的源头问题, 因为不幸的是,有时候疾病的确 从像南洛杉矶一样的地方开始。
routinely:adv.例行公事地;老一套地; unfortunately:adv.不幸地;
In that community, substandard housing and food insecurity are the major conditions that we as a clinic had to be aware of, but in other communities it could be transportation barriers , obesity , access to parks, gun violence . 在那个社区,不合格的房屋 及食物供给不稳定是最主要的问题, 是我们身为诊所必须注意到的事, 但在其他的社区问题可能是 交通运输的天然障碍、肥胖、 家附近有没有公园、枪枝暴力。
substandard:adj.不合规格的;标准以下的; insecurity:n.不安全;不牢靠;无把握;心神不定; communities:n.社区;社会;团体;共有(community的复数) transportation:n.运输;运输系统;运输工具;流放; barriers:n.障碍;栅栏;篱笆墙(barrier的复数形式); obesity:n.肥大,肥胖; violence:n.暴力;侵犯;激烈;歪曲;
The important thing is, we put in place a system that worked, and it's an approach that I call an upstream approach. 重要的是,我们推出的这种系统 有成效, 而这种方法我称为上游管理。
upstream:adv.逆流地;向上游;adj.向上游的;逆流而上的;n.上游部门;
It's a term many of you are familiar with. 在座很多人都很熟悉的名词。
familiar:adj.熟悉的;常见的;亲近的;n.常客;密友;
It comes from a parable that's very common in the public health community. 这来自一个很常听到的 公共卫生界寓言。
parable:n.寓言,比喻;隐晦或谜般的格言;
This is a parable of three friends. 这是三个朋友的寓言。
Imagine that you're one of these three friends who come to a river. 想像一下你是这三个朋友之一, 你们走到一条河。
It's a beautiful scene, but it's shattered by the cries of a child, and actually several children, in need of rescue in the water. 风景很美,但有个小孩的哭声划破了宁静, 而且其实有好几个孩子在水里需要救援。
shattered:adj.受到严重打击的; v.(使)破碎,碎裂; (shatter的过去式和过去分词) rescue:n.救援;抢救;营救;获救;v.抢救;营救;援救;
So you do hopefully what everybody would do. 所以你会去做但愿每个人都会做的事。
You jump right in along with your friends. 你与你的朋友赶快跳进去。
The first friend says, I'm going to rescue those who are about to drown , those at most risk of falling over the waterfall . 第一个朋友说, 那些快要掉到瀑布下面的几个。
are about to:眼看就要;即将;正要;行将; drown:v.淹没;溺死;浸透;浸泡; waterfall:n.瀑布;瀑布似的东西;
The second friends says, I'm going to build a raft . 第二个朋友说,我来造个木筏。
raft:n.筏;救生艇;(美)大量;vt.筏运;制成筏;vi.乘筏;
I'm going to make sure that fewer people need to end up at the waterfall's edge. 我要确保 流到瀑布边的人能少几个。
Let's usher more people to safety by building this raft, coordinating those branches together. 透过造木筏,让我们多领几个人到安全区, 把几树枝绑在一起。
usher:v.引入;引领;引导;把…引往;n.引座员;(法院的)传达员,门卫;男傧相; coordinating:v.使协调;使相配合;搭配,协调;(coordinate的现在分词)
Over time, they're successful, but not really, as much as they want to be. 一段时间后,他们成功了,但也不尽然, 因为成效不如预期。
More people slip through, and they finally look up and they see that their third friend is nowhere to be seen. 更多人成为漏网之鱼,所以他们终于往上游看, 发现他们第三个朋友 不在视线范围内。
slip:v.溜;下降;滑落;n.纸条;衬裙; finally:adv.终于;最终;(用于列举)最后;彻底地; nowhere:v.无处; n.无处; adj.不存在的;
They finally spot her. 最后他们终于看到她。
She's in the water. She's swimming away from them upstream, rescuing children as she goes, and they shout to her, "Where are you going? 她在水里。她愈游愈远, 朝上游去,边游边救儿童, 他们对着她喊:「妳要去哪里？
rescuing:v.营救;援救;抢救;(rescue的现在分词)
There are children here to save." 这里还有儿童要救。」
And she says back, "I'm going to find out who or what is throwing these children in the water." 她回答说: 「我要去找 是谁或是什么东西丢这些儿童进水里。」
In healthcare, we have that first friend — we have the specialist, we have the trauma surgeon , the ICU nurse, the E.R. doctors. 在医疗界,我们有第一个朋友: 我们有专科医师, 我们有外伤外科医师、加护病房护士、 急诊室医师。
trauma:n.[外科]创伤(由心理创伤造成精神上的异常);外伤; surgeon:n.外科医生;
We have those people that are vital rescuers , people you want to be there when you're in dire straits . 我们有抢救生命的人, 你在急难中最需要的人。
rescuers:n.救援者(rescuer的复数); dire:adj.可怕的;悲惨的;极端的; straits:n.[海洋]海峡;困难(strait的复数);
We also know that we have the second friend — we have that raft-builder. 我们也知道我们有第二个朋友: 我们有造筏的人。
That's the primary care clinician , people on the care team who are there to manage your chronic conditions, your diabetes , your hypertension , there to give you your annual checkups , there to make sure your vaccines are up to date , but also there to make sure that you have a raft to sit on and usher yourself to safety. 那就是第一线的临床医师。 那些人在医疗团队里 照护你的慢性疾病、 你的糖尿病、你的高血压、 幫你做年度健檢、 盯着你按时打疫苗。 同时也确保你有木筏可乘, 把你带到安全的地方。
clinician:n.临床医生; diabetes:n.糖尿病;多尿症; hypertension:n.高血压;过度紧张; annual:n.年报;年鉴;年刊;adj.每年的;年度的;一年的; checkups:n.审查,检查;健康检查; vaccines:n.[药][计]疫苗; up to date:adj.最新的;最近的;现代的;
But while that's also vital and very necessary, what we're missing is that third friend. 虽然这些都很重要也很必要, 但我们最缺的却是第三个朋友。
We don't have enough of that upstreamist. 我们没有足够向上游的人。
The upstreamists are the health care professionals who know that health does begin where we live and work and play, but beyond that awareness , is able to mobilize the resources to create the system in their clinics and in their hospitals that really does start to approach that, to connect people to the resources they need outside the four walls of the clinic. 向上游的人是医疗照护专家, 但瞭解健康起始于 我们居住工作及玩乐的地方, 但除了那样的体认, 还能动员各种资源以创建系统, 使他们的诊所及医院 能真正开始着手处理这个问题, 能将众人与他们 在诊所的四面墙外所需的资源连结在一起。
health care:n.卫生保健; awareness:n.意识,认识;明白,知道; mobilize:v.动员;动员;调动;组织;鼓动;调用; resources:n.[计][环境]资源; v.向…提供资金(resource的第三人称单数);
Now you might ask, and it's a very obvious question that a lot of colleagues in medicine ask: "Doctors and nurses thinking about transportation and housing? 现在你可能会问个很明显的问题, 有很多医界同僚都这么问: 「医师与护士还要去考虑交通及住房的问题？
obvious:adj.明显的;显著的;平淡无奇的; colleagues:n.同事;同行(colleague的复数);
Shouldn't we just provide pills and procedures and just make sure we focus on the task at hand?" 我们不是只要提供药丸及医疗处置, 并确定我们会专心做手上的工作就好？」
pills:n.药丸; v.起球; (pill的第三人称单数和复数) procedures:n.程序;规程(procedure的复数);
Certainly, rescuing people at the water's edge is important enough work. 的确,将人从水边救起 已经是够重要的工作。
Who has the time? 谁有那么多时间？
I would argue, though, that if we were to use science as our guide, that we would find an upstream approach is absolutely necessary. 我却认为,假如我们以科学为指引, 就知道找到上游管理方法是绝对必要的。
absolutely:adv.绝对地;完全地;
Scientists now know that the living and working conditions that we all are part of have more than twice the impact on our health than does our genetic code , and living and working conditions, the structures of our environments, 科学家现在知道 生活及工作条件, 我们都是其中的部分, 对我们健康的影响 比遗传还超过两倍之多, 而且生活及工作条件, 我们环境的结构,
impact:n.影响;效果;碰撞;冲击力;v.挤入,压紧;撞击;对…产生影响; genetic code:n.遗传密码; structures:n.结构; v.建造(structure的第三人称单数形式);
the ways in which our social fabric is woven together, and the impact those have on our behaviors, all together, those have more than five times the impact on our health than do all the pills and procedures administered by doctors and hospitals combined. 我们的社交圈交织在一起的方式, 及其对我们行为的影响, 通通加在一起,对我们的健康影响 比医师及医院开出的药丸及医疗处置总合
fabric:n.织物;布料;(社会,机构等的)结构; woven:v.编织;交织(weave的过去分词);编造;adj.织物的;n.机织织物; administered:v.管理;治理(国家);执行;给予;提供;(administer的过去分词和过去式)
All together, living and working conditions account for 60 percent of preventable death. 超过五倍之多。 占了可预防性死亡的 60%。
account for:对…负有责任;对…做出解释;说明…的原因;导致;(比例)占; preventable:adj.可预防的;可阻止的;可防止的;
Let me give you an example of what this feels like. 让我举个例子来看看这是什么感觉。
Let's say there was a company, a tech startup that came to you and said, "We have a great product. 就说有家公司,一家科技新创公司 来你这里说:「我们有个很棒的产品。
It's going to lower your risk of death from heart disease ." 会降低你死于心脏病的风险。」
disease:n.病,[医]疾病;弊病;vt.传染;使…有病;
Now, you might be likely to invest if that product was a drug or a device , but what if that product was a park? 那么,你很可能会愿意投资, 如果那个产品是种药或仪器的话, 但是如果那个产品是座公园？
invest:v.投资;(把资金)投入;投入(时间、精力等);授予; device:n.装置;策略;图案; what if:如果…怎么办?
A study in the U.K., a landmark study that reviewed the records of over 40 million residents in the U.K., looked at several variables , controlled for a lot of factors , and found that when trying to adjust the risk of heart disease, one's exposure to green space was a powerful influence . 在英国有项研究, 一项具里程碑意义的研究,檢阅了 英国超过四千万居民的纪录, 他们看了几项变数, 即几项管制因子,发现 当试着校正心脏病的风险, 一个人能否接触绿地有很大的影响。
landmark:n.[航]陆标; adj.有重大意义或影响的; residents:n.居民;住院医生;房客;(resident的复数) variables:n.[数]变量; factors:n.因素(factor的复数); v.做代理商; adjust:v.调整;调节;适应;习惯; exposure:n.暴露;显露;揭露;面临; influence:n.影响;势力;感化;有影响的人或事;v.影响;改变;
The closer you were to green space, to parks and trees, the lower your chance of heart disease, and that stayed true for rich and for poor. 你越接近绿地、 公园及树木, 你得心脏病的机会就愈低, 无论贫富皆准。
That study illustrates what my friends in public health often say these days: that one's zip code matters more than your genetic code. 那项研究阐明了我在公卫界的朋友 这些日子常常说的: 就是一个人的邮递区号 比你的遗传密码还重要。
illustrates:v.阐明;举例说明(illustrate的三单形式);给…加插图;
We're also learning that zip code is actually shaping our genetic code. 我们也了解到邮递区号 其实会改变我们的遗传密码。
The science of epigenetics looks at those molecular mechanisms , those intricate ways in which our DNA is literally shaped, genes turned on and off based on the exposures to the environment, to where we live and to where we work. 表观遗传学就是要看这些分子机制, 那些真的会改变我们 DNA 的复杂机制, 基因开、关, 基于其所暴露的环境, 及我们在哪里生活在哪里工作。
epigenetics:n.[胚]实验胚胎学,表观遗传学; molecular:adj.[化学]分子的;由分子组成的; mechanisms:n.机制;[机]机构(mechanism的复数);机械;[机]机构学; intricate:adj.复杂的;错综的,缠结的; literally:adv.按字面:字面上:确实地: genes:n.基因;(gene的复数) exposures:暴露;[摄]曝光;揭露;陈列(exposure的复数);
So it's clear that these factors, these upstream issues , do matter. 所以很清楚这些因素, 这些上游的问题,的确至关重要。
issues:n.重要议题;争论的问题;v.宣布;公布;发出;(issue的第三人称单数和复数)
They matter to our health, and therefore our healthcare professionals should do something about it. 它们对我们的健康至关重要, 因此我们的医疗专家应该为此出力。
And yet, Veronica asked me perhaps the most compelling question I've been asked in a long time. 但是,小维问了我 一个可说是长久以来我一直难以回答的问题,
compelling:adj.引人入胜的; v.强迫; (compel的现在分词)
In that follow-up visit, she said, "Why did none of my doctors ask about my home before? 在回诊那天,她问: 「为什么我的医师 以前都不问我住家的状况？
follow-up:adj.后续的;增补的;n.随访;跟进;后续行动;
In those visits to the emergency room, 去急诊室的那几次,
I had two CAT scans, 我做了两次断层扫瞄,
I had a needle placed in the lower part of my back to collect spinal fluid , 有针穿刺进我的下背部 抽取脊髓液,
needle:n.针;针头;指针;缝针;v.穿过;刺激;拿针缝;拿针穿; spinal:adj.脊髓的;脊柱的;针的;脊骨的;尖刺的;n.脊椎麻醉; fluid:adj.流动的;流畅的;不固定的;n.流体;液体;
I had nearly a dozen blood tests. 我大概抽了将近一打的血。
I went back and forth, I saw all sorts of people in healthcare, and no one asked about my home." 我进进出出,我看过各种医疗照护人员, 从来没有人问过我的家。」
The honest answer is that in healthcare, we often treat symptoms without addressing the conditions that make you sick in the first place . 最诚实的答案是在医疗界, 我们常常只是 头痛医头、脚痛医脚,
in the first place:首先;起初;
And there are many reasons for that, but the big three are first, we don't pay for that. 有很多因素造成这样,但三大点 是第一,我们拿不到钱。
In healthcare, we often pay for volume and not value. 在医疗界,我们计量不计质。
volume:n.体积;容积;音量;响度;一册;合订本
We pay doctors and hospitals usually for the number of services they provide, but not necessarily on how healthy they make you. 我们通常付医师及医院的钱 是以诊疗过多少人来算, 不见得是看他们有没有医好你。
necessarily:adv.必要地;必定地,必然地;
That leads to a second phenomenon that I call the "don't ask, don't tell" approach to upstream issues in healthcare. 这就导致第二个现象我叫它 「你不说我不问」, 普遍存在医疗界的上游问题。
phenomenon:n.现象;杰出的人;非凡的人(或事物);
We don't ask about where you live and where you work, because if there's a problem there, we don't know what to tell you. 我们不问你住哪、在哪工作, 因为如果那里有问题, 我们也不知道要给你什么建议。
It's not that doctors don't know these are important issues. 医师不是不了解这些是很重要的问题。
In a recent survey done in the U.S. among physicians , over 1,000 physicians , 80 percent of them actually said that they know that their patients' upstream problems are as important as their health issues, as their medical problems, and yet despite that widespread awareness of the importance of upstream issues, only one in five doctors said they had any sense of confidence to address those issues, to improve health where it begins. 最近有项针对美国医师的调查, 问了超过一千名医师, 其中有 80% 真的说 他们知道他们病人的上游问题 与他们的健康问题一样重要, 也与医疗问题一样重要。 但尽管对上游问题的重要性 有如此广泛的意识, 只有五分之一的医师说他们有 相当程度的信心应付这个问题, 找出改善健康的源头。
survey:n.调查;测量;审视;纵览;vt.调查;勘测;俯瞰;vi.测量土地; physicians:n.[内科]内科医生(physician的复数); widespread:adj.普遍的,广泛的;分布广的; confidence:n.信心;信任;秘密;adj.(美)诈骗的;骗得信任的;
There's this gap between knowing that patients' lives, the context of where they live and work, matters, and the ability to do something about it in the systems in which we work. 瞭解病人的生活, 即他们生活及工作的背景 很重要是一回事,但有能力在我们工作的系统中 为之出力又是另一回事。
gap:n.差距;间隙;缺口;间隔;v.使豁裂;豁开; context:n.环境;上下文;来龙去脉;
This is a huge problem right now, because it leads them to this next question, which is, whose responsibility is it? 这是现在很大的问题, 因为这导引出下一个问题,就是 这是谁的责任？
And that brings me to that third point, that third answer to Veronica's compelling question. 这也带出我的第三点, 小维难题的第三个答案。
Part of the reason that we have this conundrum is because there are not nearly enough upstreamists in the healthcare system. 造成我们这个难题的部分原因 在于在医疗系统内, 根本就没有足够的上游管理人。
conundrum:n.难题;谜语;
There are not nearly enough of that third friend, that person who is going to find out who or what is throwing those kids in the water. 根本就没有足够的第三个朋友, 就是那个要去找出 谁或什么东西把孩子进水里的人。
Now, there are many upstreamists, and I've had the privilege of meeting many of them, in Los Angeles and in other parts of the country and around the world, and it's important to note that upstreamists sometimes are doctors, but they need not be. 现在,的确有很多上游管理人, 我有幸遇过许多位, 在洛杉矶及这个国家的其它地方 及全世界都遇到过, 值得注意的是很多上游管理人 有时候的确是医师,但不一定得是医师。
They can be nurses, other clinicians , care managers, social workers. 他们也可以是护士、其他临床师、 照护策划管理人、社工。
clinicians:临床医生(clinician的名词复数);
It's not so important what specific degree upstreamists have at the end of their name. 上游管理人在名字后面 挂什么学位头衔并不重要。
What's more important is that they all seem to share the same ability to implement a process that transforms their assistance, transforms the way they practice medicine. 重要的是他们几乎 都有能力落实执行某种步骤 以改造他们援助的手法, 改造他们行医的方法。
implement:v.实施;执行;贯彻;使生效;n.工具; process:v.处理;加工;列队行进;n.过程,进行;方法,adj.经过特殊加工(或处理)的; transforms:v.[数][电]变换; n.语法转化规则;
That process is a quite simple process. 那种步骤是还满简单的步骤。
It's one, two and three. 就是一二三。
First, they sit down and they say, let's identify the clinical problem among a certain set of patients. 第一,他们坐下来说, 我们来鉴别一下到底 为什么某些病人会有这种临床问题。
identify:v.识别:鉴定:确认:发现: clinical:adj.临床的;诊所的;
Let's say, for instance , let's try to help children who are bouncing in and out of the hospital with asthma. 举个例, 让我们试试幫助 因为气喘而在医院 进进出出的儿童。
instance:n.实例;情况;建议;v.举...为例;
After identifying the problem, they then move on to that second step, and they say, let's identify the root cause. 诊断出问题后,他们就进到下一步, 他们说,让我们来找根源。
identifying:n.识别,标识;标识关系;v.识别;(identify的现在分词)
Now, a root cause analysis , in healthcare, usually says, well, let's look at your genes, let's look at how you're behaving . 现在,根本原因分析, 看一下你的行为。
analysis:n.分析;分解;验定; behaving:v.表现:表现得体:有礼貌:(behave的现在分词)
Maybe you're not eating healthy enough. 可能你吃得不够健康。
Eat healthier. 那就吃健康点。
It's a pretty simplistic approach to root cause analyses . 这是过度简单化的 根本原因分析方法。
simplistic:adj.过分简单化的;过分单纯化的; analyses:n.分析;解析;分解;梗概(analysis的复数形式);
It turns out, it doesn't really work when we just limit ourselves that worldview . 结果是,这个方法根本没有用 因为我们限制了自己的视界。
worldview:n.世界观;
The root cause analysis that an upstreamist brings to the table is to say, let's look at the living and the working conditions in your life. 上游管理人提出的根本原因分析 会这么说,让我们看一下 你的生活及工作条件。
Perhaps, for children with asthma, it's what's happening in their home, or perhaps they live close to a freeway with major air pollution that triggers their asthma. 也许,对有气喘的孩童, 家里的状况是原因, 或是因为他们住在空气很糟的高速公路旁, 引发了他们的气喘。
freeway:n.高速公路; triggers:n.[电子]触发器;触发物(trigger的复数);v.引起(trigger的单三形式);引爆;
And perhaps that's what we should mobilize our resources to address, because that third element , that third part of the process, is that next critical part of what upstreamists do. 这大概是我们应该动员所有资源来对付的事, 因为第三个因素,步骤的第三部分, 是上游管理人会做的下一步关键部分。
element:n.元素;要素;原理;成分;自然环境; critical:adj.鉴定的;[核]临界的;批评的,爱挑剔的;危险的;决定性的;评论的;
They mobilize the resources to create a solution , both within the clinical system, and then by bringing in people from public health, from other sectors , lawyers, whoever is willing to play ball , 他们会动员所有的资源以找出解决的方法, 无论在临床系统内, 或是之后在公卫界找人、 其他部门、律师 任何愿意参与的人皆可,
solution:n.解决方案;溶液;溶解;解答; sectors:n.部门; v.把…划成扇形; whoever:任何人:无论是谁: play ball:开始活动;开始赛球;
let's bring in to create a solution that makes sense, to take those patients who actually have clinical problems and address their root causes together by linking them to the resources you need. 让我们把这些人引进,找出合理的解决方法, 把这些有实际临床问题的病人 幫助他们治本, 把他们与你所需的资源连在一起。
It's clear to me that there are so many stories of upstreamists who are doing remarkable things. 对我而言这很清楚,有很多故事在说 上游管理人所做卓越非凡的事。
remarkable:adj.卓越的;非凡的;值得注意的;
The problem is that there's just not nearly enough of them out there. 问题是这样的人不够多。
By some estimates , we need one upstreamist for every 20 to 30 clinicians in the healthcare system. 粗估我们在医疗系统内每 20 至 30 位临床医师 就需要一位上游管理人。
estimates:n.估计;估价;估计的成本;v.估价;估算(estimate的第三人称单数和复数)
In the U.S., for instance, that would mean that we need 25,000 upstreamists by the year 2020. 在美国,举个例,这意味着 我们在 2020 年前,需要二万五千名上游管理人。
But we only have a few thousand upstreamists out there right now, by all accounts, and that's why, a few years ago, my colleagues and I said, you know what, we need to train and make more upstreamists. 但是现在据说我们只有少少的几千名上游管理人, 而这就是为什么在几年前,我与几位同僚说, 你知道吗,我们需要训练出 更多上游管理人。
So we decided to start an organization called Health Begins, and Health Begins simply does that: 所以我们决定创办一个组织, 称为「健康源」, 「健康源」只作这件事:
organization:n.组织;机构;体制;团体;
We train upstreamists. 我们训练上游管理人。
And there are a lot of measures that we use for our success, but the main thing that we're interested in is making sure that we're changing the sense of confidence, that "don't ask, don't tell" metric among clinicians. 我们使用许多方法评量我们是否成功, 但我们最主要的目标 是确定我们要改变信心, 改变在临床医师间「你不问我不说」的制式心态。
metric:adj.米制的;公制的;按公制制作的;用公制测量的;
We're trying to make sure that clinicians, and therefore their systems that they work in have the ability, the confidence to address the problems in the living and working conditions in our lives. 我们试着要确定临床医师, 及他们工作的系统 因而有能力、有信心 能解决我们生活 及工作条件的问题。
We're seeing nearly a tripling of that confidence in our work. 我们看见在我们的努力下信心增加了二倍。
tripling:v.成为三倍;使增至三倍;(triple的现在分词)
It's remarkable, but I'll tell you the most compelling part of what it means to be working with upstreamists to gather them together. 成效显着, 但我要告诉你们最有趣的部分 就是与上游管理人合作 把他们集合在一起是什么意思。
What is most compelling is that every day, every week, I hear stories just like Veronica's. 最有趣的是每一天, 每一周我都听到像小维的故事。
There are stories out there of Veronica and many more like her, people who are coming to the healthcare system and getting a glimpse of what it feels like to be part of something that works, 多的是像小维 一般的故事, 人们进入一个医疗系统 窥视能参与 有成效系统的感觉,
glimpse:v.瞥见;[诗]闪现;n.领悟;概况;见识;一睹;
a health care system that stops bouncing you back and forth but actually improves your health, listens to you who you are, addresses the context of your life, whether you're rich or poor or middle class . 一种医疗系统不再把你当足球踢, 却能实际改善你的健康, 倾听你的人生, 处理你的生活背景, 无论你是贫富还是中产阶级。
improves:v.改进;改善;(improve的第三人称单数) middle class:adj.中产阶级的;中层社会的;
These stories are compelling because not only do they tell us that we're this close to getting the healthcare system that we want, but that there's something that we can all do to get there. 这些故事引人注意,因为 它们不但告诉我们,我们有多接近 我们想要的医疗保健系统, 也告诉我们,我们能合作达成这件事。
Doctors and nurses can get better at asking about the context of patients' lives, not simply because it's better bedside manner , but frankly, because it's a better standard of care. 医师及护士能做得更好,只要他们问问病人的生活背景, 因为这不仅是更好的医疗服务态度, 但坦白说,这也是更好的照护标准。
bedside manner:n.(医护人员等)对待病人的态度;
Healthcare systems and payers can start to bring in public health agencies and departments and say, let's look at our data together. 医疗系统及医疗给付单位 可以开始把公卫局 及卫生署带进来并说, 让我们一起来看看数据。
payers:n.付款人;支付者; agencies:n.代理;代理处(agency的复数);
Let's see if we can discover some patterns in our data about our patients' lives and see if we can identify an upstream cause, and then, as importantly, can we align the resources to be able to address them? 看一看我们能否在数据中发现病人的生活型态, 看看我们能否找出发病的源头。 然后,同样重要的是,我们能不能运用资源 去解决这个问题？
align:vt.使结盟;使成一行;匹配;vi.排列;排成一行;
Medical schools, nursing schools, all sorts of health professional education programs can help by training the next generation of upstreamists. 医学院、护理学院、 各种专業医疗教育课程 都可以训练下一代的上游管理人来达成目标。
We can also make sure that these schools certify a backbone of the upstream approach, and that's the community health worker. 我们也要确定这些学校 要认证上游管理的基础, 即社区保健员。
certify:v.证明;保证; backbone:n.支柱;主干网;决心,毅力;脊椎;
We need many more of them in the healthcare system if we're truly going to have it be effective , to move from a sickcare system to a healthcare system. 在医疗系统内我们需要更多这种人, 如果我们真的想要有成效的话, 要从「疾病」照护系统 变成「健康」照护系统。
effective:adj.有效的,起作用的;实际的,实在的;给人深刻印象;
But finally, and perhaps most importantly, what do we do? What do we do as patients? 但最后一点,或许也是最重要的一点, 我们要怎么做？身为病人我们要怎么做？
We can start by simply going to our doctors and our nurses, to our clinics, and asking, "Is there something in where I live and where I work that I should be aware of?" 我们可以这样开始:去看医生、 看护理师、去诊所时, 问他们,「在我居住 及工作的地方,有什么是我该注意的吗？」
Are there barriers to health that I'm just not aware of, and more importantly, if there are barriers that I'm surfacing, if I'm coming to you and I'm saying I think have a problem with my apartment or at my workplace or I don't have access to transportation, or there's a park that's way too far, so sorry doctor, I can't take your advice to go and jog , if those problems exist, then doctor, are you willing to listen? 有什么让我不健康的事物是我从没注意到的吗？ 更重要的是,如果真有这种障碍 我意识到了,如果我来你这里, 而且告诉你,我认为在我的公寓 或我的工作场所的确有问题, 或是我无法搭公共交通工具, 或公园离我太远, 所以真抱歉医师,我无法采纳你的建议 去慢跑, 如果这些问题的确存在, 那医师,你愿意听吗？
workplace:n.工作场所;车间; jog:v.慢跑(尤指锻炼);(偶然地)轻击;轻碰;n.轻推;慢跑(尤指锻炼);轻碰;轻击
And what can we do together to improve my health where it begins? 我们能一同做什么 从源头改善我的健康？
If we're all able to do this work, doctors and healthcare systems, payers, and all of us together, we'll realize something about health. 如果我们能一同做这件事, 医师及医疗系统, 医疗给付单位,及所有的人都一起, 我们就能瞭解健康的真义。
Health is not just a personal responsibility or phenomenon. 健康不仅是个人的责任或现象。
Health is a common good. 健康是共有财。
It comes from our personal investment in knowing that our lives matter, the context of where we live and where we work, eat, and sleep, matter, and that what we do for ourselves, we also should do for those whose living and working conditions again, can be hard, if not harsh. 它始于我们个人付出心力瞭解 我们的生活非常重要, 我们生活及工作的地方的背景、 我们吃、睡也非常重要, 我们不但要为自己做, 我们同时也应该要为那些 生活及工作条件, 再说一次,即使不恶劣也很糟的人做这件事。
investment:n.投资;投入;封锁;
We can all invest in making sure that we improve the allocation of resources upstream, but at the same time work together and show that we can move healthcare upstream. 我们要付出心力确保我们改善 上游资源的分配, 但同时也要一同合作 证明我们能将医疗系统 带往上游。
allocation:n.分配,配置;安置; at the same time:同时;另一方面;与此同时;
We can improve health where it begins. 我们能从源头改善健康。
Thank you. 谢谢。
(Applause) （掌声）