"People do stupid things. That's what spreads HIV." This was a headline in a U.K. newspaper, The Guardian, not that long ago. I'm curious, show of hands, who agrees with it? Well, one or two brave souls.
「人們會做蠢事, 愛滋病就這樣傳播開來。」 這是不久前英國報紙 《衛報》的頭條標題。 我很好奇,有誰同意這句話? 舉個手吧! 嗯,有一兩位,真是勇敢。
This is actually a direct quote from an epidemiologist who's been in field of HIV for 15 years, worked on four continents, and you're looking at her.
這句話出自一位流行病學家, 她研究HIV已有15年, 足跡遍及四大洲, 這個人就是我
And I am now going to argue that this is only half true. People do get HIV because they do stupid things, but most of them are doing stupid things for perfectly rational reasons. Now, "rational" is the dominant paradigm in public health, and if you put your public health nerd glasses on, you'll see that if we give people the information that they need about what's good for them and what's bad for them, if you give them the services that they can use to act on that information, and a little bit of motivation, people will make rational decisions and live long and healthy lives. Wonderful.
我想說的是, 這句話只有一半是真的。 有些人的確是因為做了蠢事而感染HIV, 但其中大部分的人做出這些蠢事 是有完全合乎理性的原因 現在,理性在公共衛生上 是首要的準則。 如果你戴上了愚蠢的公共衛生檢視鏡, 你將會看到若我們提供人們所需的資訊, 告訴他們什麼對他們是好的,什麼是不好的, 或是我們提供服務, 讓他們可以根據所得的資訊來行動 加上一點點動機, 人們將可以做出理性的決定, 並過著健康長壽的生活 棒極了!
That's slightly problematic for me because I work in HIV, and although I'm sure you all know that HIV is about poverty and gender inequality, and if you were at TED '07 it's about coffee prices ... Actually, HIV's about sex and drugs, and if there are two things that make human beings a little bit irrational, they are erections and addiction.
這對我來講是有點問題的,因為我在愛滋病領域工作, 雖然我很確定你們都知道 HIV關乎著貧窮還有性別不平等, 如果你有參加2007年的TED, 就會知道愛滋病也和咖啡的價格息息相關。 事實上,HIV和性交、毒品脫不了關係。€ 若有兩樣東西 能讓人類喪失理智, 那就是勃起跟上癮。
(Laughter)
(笑聲)
So, let's start with what's rational for an addict. Now, I remember speaking to an Indonesian friend of mine, Frankie. We were having lunch and he was telling me about when he was in jail in Bali for a drug injection. It was someone's birthday, and they had very kindly smuggled some heroin into jail, and he was very generously sharing it out with all of his colleagues. And so everyone lined up, all the smackheads in a row, and the guy whose birthday it was filled up the fit, and he went down and started injecting people. So he injects the first guy, and then he's wiping the needle on his shirt, and he injects the next guy. And Frankie says, "I'm number 22 in line, and I can see the needle coming down towards me, and there is blood all over the place. It's getting blunter and blunter. And a small part of my brain is thinking, 'That is so gross and really dangerous,' but most of my brain is thinking, 'Please let there be some smack left by the time it gets to me. Please let there be some left.'" And then, telling me this story, Frankie said, "You know ... God, drugs really make you stupid."
我們先看看對於一個癮君子來說,什麼是不合理的。 我記得我跟一個印尼籍的朋友聊天,他叫做法蘭克。 我們當時正在吃午餐,他正在跟我分享 在巴里島獄中注射毒品的經驗。 那一天是某個人的生日,他們很體貼地 走私了一些海洛因到獄中。 他非常大方地跟獄中好友 分享這些海洛因。 於是每個人排成一排, 所有的癮君子排成一排。 而過生日的壽星 把注射器裝滿海洛因, 然後他走過來開始為大家注射。 他替第一個傢伙注射, 接著他將針頭往襯衫上擦一擦, 繼續幫下一個傢伙注射。 法蘭克說「我排在第22個, 我可以看到朝著我前進的針頭, 到處都有血跡, 針頭變得越來越鈍, 然後我大腦的一部分開始思考, 「這真的很令人作嘔, 真的很危險。」 但我大部份的腦子想的卻是 「輪到我的時候 請留一點點給我。 拜託留下一些海洛因給我。」 接著,故事說完後, 法蘭克說, 「天啊!你知道嗎? 毒品真的會讓你變得很蠢。」
And, you know, you can't fault him for accuracy. But, actually, Frankie, at that time, was a heroin addict and he was in jail. So his choice was either to accept that dirty needle or not to get high. And if there's one place you really want to get high, it's when you're in jail.
你也知道,你無法反駁他說的, 但事實上,那時的法蘭克 是個海洛因成癮者,而且他被關在監獄裡。 所以他只能選擇 接受骯髒的針頭或是不要吸毒 如果真有個地方會讓你想吸毒, 那一定是在監獄了
But I'm a scientist and I don't like to make data out of anecdotes, so let's look at some data. We talked to 600 drug addicts in three cities in Indonesia, and we said, "Well, do you know how you get HIV?" "Oh yeah, by sharing needles." I mean, nearly 100 percent. Yeah, by sharing needles. And, "Do you know where you can get a clean needle at a price you can afford to avoid that?" "Oh yeah." Hundred percent. "We're smackheads; we know where to get clean needles." "So are you carrying a needle?" We're actually interviewing people on the street, in the places where they're hanging out and taking drugs. "Are you carrying clean needles?" One in four, maximum. So no surprises then that the proportion that actually used clean needles every time they injected in the last week is just about one in 10, and the other nine in 10 are sharing.
我是個科學家, 我不根據八卦軼聞做數據, 所以讓我們來看看以下的數據吧。 我們訪談了在印尼三大城市的 600個毒癮者, 我們問:「你知道你是如何感染愛滋的嗎?」 「噢!那當然! 透過共用的針頭。」 幾乎全部的人都知道,是透過共用針頭感染的。 「你知道你可以在哪裡取得乾淨 而且你也負擔得起的針頭來避免感染愛滋病呢?」 「知道啊!」全部的人都知道。 「我們是吸毒的人,我們當然知道去哪弄到乾淨的針頭。」 「那你會隨身攜帶針頭嗎?」 我們真的就在馬路上採訪這些人, 他們就在這些地方出沒和買賣毒品。 「你隨身會帶著乾淨的針頭嗎?」 最多,四個中會有一個帶著。 這也就難怪 上週注射毒品時, 使用乾淨針頭的 比例只有十分之一, 其他的十分之九都是共用針頭。
So you've got this massive mismatch; everyone knows that if they share they're going to get HIV, but they're all sharing anyway. So what's that about? Is it like you get a better high if you share or something? We asked that to a junkie and they're like, "Are you nuts?" You don't want to share a needle anymore than you want to share a toothbrush even with someone you're sleeping with. There's just kind of an ick factor there. "No, no. We share needles because we don't want to go to jail." So, in Indonesia at this time, if you were carrying a needle and the cops rounded you up, they could put you into jail. And that changes the equation slightly, doesn't it? Because your choice now is either I use my own needle now, or I could share a needle now and get a disease that's going to possibly kill me 10 years from now, or I could use my own needle now and go to jail tomorrow. And while junkies think that it's a really bad idea to expose themselves to HIV, they think it's a much worse idea to spend the next year in jail where they'll probably end up in Frankie's situation and expose themselves to HIV anyway. So, suddenly it becomes perfectly rational to share needles.
你看這是多麼地矛盾, 大家都知道 如果他們共用針頭就會感染HIV, 但他們會共用針頭 那到底是為什麼呢? 是不是共用東西會讓你比較過癮嗎? 我們問這些吸毒者,他們會說「你瘋了不成?」 你當然不會想跟別人共用一個針頭 就像是你也不想跟別人共用牙刷,就算是枕邊人也一樣 會共用針頭只有一個令人討厭的原因。 不,不。我們共用針頭是因為我們不想進監獄。 所以,現在的印尼, 如果你隨身帶著針頭,那警察就會把你圍起來, 然後把你丟到牢裡。 這有點改變了整件事,對吧? 因為當下你的選擇 我可以用自己的針頭 不然就是共用針頭, 然後染上愛滋病, 很可能在十年後就因此死掉, 或是用我自己的針頭, 然後明天就進監牢。 雖然毒蟲們覺得 把自己暴露在愛滋病病毒下是個極糟的主意, 但他們深信在牢裡度過一年 會是個更糟的決定, 他們很可能在牢裡會面對到法蘭克遇到的狀況, 然後不管怎樣,還是暴露在HIV的威脅下。 突然間,共用針頭似乎 是個相當理性的決定。
Now, let's look at it from a policy maker's point of view. This is a really easy problem. For once, your incentives are aligned. We've got what's rational for public health. You want people to use clean needles -- and junkies want to use clean needles. So we could make this problem go away simply by making clean needles universally available and taking away the fear of arrest. Now, the first person to figure that out and do something about it on a national scale was that well-known, bleeding heart liberal Margaret Thatcher. And she put in the world's first national needle exchange program, and other countries followed suit: Australia, The Netherlands and few others. And in all of those countries, you can see, not more than four percent of injectors ever became infected with HIV.
現在,讓我們從決策者的角度來看這個問題。 這真的是個很簡單的問題。 有那麼一度,你有很足夠的動機做對的決定。 我們已經知道就公共衛生而言何謂理性。 政府想要人們使用乾淨的針頭, 這些毒癮者也想要使用乾淨的針頭。 所以我們很簡單地就可以解決這個問題, 就是讓大家廣泛地拿到乾淨的針頭, 他們也不用擔心被捕的問題。 第一個想出這一個方法的 並把它全國性推廣的 就是眾所皆知、心腸善良的民主主義者, 瑪格麗特·柴契爾夫人。 她實施的世界上第一個 全國性的針頭交換計畫, 其他的國家也跟進,包含澳洲、紐西蘭還有一些其他國家, 在這些國家中,你可以看到的, 注射者之中 感染上HIV的不超過4%
Now, places that didn't do this -- New York City for example, Moscow, Jakarta -- we're talking, at its peak, one in two injectors infected with this fatal disease. Now, Margaret Thatcher didn't do this because she has any great love for junkies. She did it because she ran a country that had a national health service. So, if she didn't invest in effective prevention, she was going to have pick up the costs of treatment later on, and obviously those are much higher. So she was making a politically rational decision. Now, if I take out my public health nerd glasses here and look at these data, it seems like a no-brainer, doesn't it? But in this country, where the government apparently does not feel compelled to provide health care for citizens, (Laughter) we've taken a very different approach. So what we've been doing in the United States is reviewing the data -- endlessly reviewing the data. So, these are reviews of hundreds of studies by all the big muckety-mucks of the scientific pantheon in the United States, and these are the studies that show needle programs are effective -- quite a lot of them. Now, the ones that show that needle programs aren't effective -- you think that's one of these annoying dynamic slides and I'm going to press my dongle and the rest of it's going to come up, but no -- that's the whole slide.
目前,沒有實施這項政策的地方,像是紐約, 莫斯科,雅加達, 我們講的是高峰期, 每兩個注射者 就有一個會感染上這個致命的疾病。 瑪格麗特·柴契爾夫人並不是 出自於對毒癮者的愛而實施這個政策。 她這麼做是因為她治理著一個 實施全國性健康福利的國家。 所以,如果她不先投資來做有效的預防, 她就得為後來的治療 付出昂貴的代價, 很明顯的,後者的代價也高多了。 所以她做了一個很理性的政治決定。 現在,如果我戴上了 公共衛生怪胎眼鏡, 再看看這些數據, 這一切看起來很簡單,不是嗎? 但在這個國家, 政府很明顯地覺得並沒有這樣的迫切性 去為大眾提供健康醫療, 於是我們採取了一個很不一樣的解決方法。 我們在美國一直做的事就是 驗證這些數據,不停地驗證。 你看到的就是數百篇研究的驗證, 都是由美國頂尖科學界中的 菁英科學家們所整理出來的, 這裡則是一些研究指出 針頭交換計畫是有用的,絕大部分都有。 現在,這些秀出了針頭交換計畫沒有成效的研究, 你們可能會認為這只是一張煩人的幻燈片, 而我接著會按下控制,然後其他的幻燈片會接著播放, 不過並沒有,這就是全部了
(Laughter)
(笑聲)
There is nothing on the other side. So, completely irrational, you would think. Except that, wait a minute, politicians are rational, too, and they're responding to what they think the voters want. So what we see is that voters respond very well to things like this and not quite so well to things like this.
另外一面沒有東西了 所以,這是非常不理性的, 你會想, 甚至期待,政客也是有理性的, 而且他們會回應選民所想要的。 所以我們看到選民會 很樂於回應像這樣的情況, 而不願意看到這樣的狀況。
(Laughter)
(為孩童創造美好世界) (為毒蟲創造美好世界)
So it becomes quite rational to deny services to injectors. Now let's talk about sex. Are we any more rational about sex? Well, I'm not even going to address the clearly irrational positions of people like the Catholic Church, who think somehow that if you give out condoms, everyone's going to run out and have sex. I don't know if Pope Benedict watches TEDTalks online, but if you do, I've got news for you Benedict -- I carry condoms all the time and I never get laid. (Laughter) (Applause) It's not that easy! Here, maybe you'll have better luck.
所以拒絕提供針頭給成癮者 變得相當有道理。 現在讓我們來談談性。 我們面對性會更有理性? 我甚至不會去講到 那些天主教教會 完全不合邏輯的論點。 他們認為如果你發送保險套, 那麼人們就會跑出去性交。 我不知道教皇班尼迪克 會不會在線上看TEDTalks 但如果你有在看,那我有話想跟你說。 我隨身都帶著保險套, 我卻從沒有機會使用過。 (笑聲) 這沒那麼簡單。 也許你運氣會好些。
(Applause)
(掌聲)
Okay, seriously, HIV is actually not that easy to transmit sexually. So, it depends on how much virus there is in your blood and in your body fluids. And what we've got is a very, very high level of virus right at the beginning when you're first infected, then you start making antibodies, and then it bumps along at quite low levels for a long time -- 10 or 12 years -- you have spikes if you get another sexually transmitted infection. But basically, nothing much is going on until you start to get symptomatic AIDS, and by that stage, you're not looking great, you're not feeling great, you're not having that much sex.
好的,嚴格來說, HIV不是這麼簡單 就透過性交傳染的。 是否會傳染是要看你的血液和體液裡 含著多少愛滋病的病毒。 當感染上的最初期,就在一開始, 我們身體內會有非常非常高量的病毒數, 然後你會開始製造抗體, 之後很長的時間內,10年或12年, 病毒的數量都會維持在相當低的數目, 如果你又因性交感染到,那病毒數量會再向上衝。 但基本上來說,身體並不會產生變化 直到你開始有愛滋病的症狀。 但到了這個階段,就在這, 你看起來狀況不會太好,你也會覺得不舒服, 你也不會像以往性交地那樣頻繁。
So the sexual transmission of HIV is essentially determined by how many partners you have in these very short spaces of time when you have peak viremia. Now, this makes people crazy because it means that you have to talk about some groups having more sexual partners in shorter spaces of time than other groups, and that's considered stigmatizing. I've always been a bit curious about that because I think stigma is a bad thing, whereas lots of sex is quite a good thing, but we'll leave that be. The truth is that 20 years of very good research have shown us that there are groups that are more likely to turnover large numbers of partners in a short space of time. And those groups are, globally, people who sell sex and their more regular partners. They are gay men on the party scene who have, on average, three times more partners than straight people on the party scene. And they are heterosexuals who come from countries that have traditions of polygamy and relatively high levels of female autonomy, and almost all of those countries are in east or southern Africa. And that is reflected in the epidemic that we have today.
所以人們是否因性交而感染HIV 基本上是取決於這些為期相當短的階段中 你有多少個性伴侶, 而這時你體內的病毒數量正值高峰期 現在,這就會讓大家抓狂了, 因為這意味著你必須討論 有些人會在較短的時間內 比其他人擁有更多性伴侶, 而這是很侮辱人的。 我一直很好奇, 因為我覺得恥辱是一件不好的事, 而頻繁的性交是相當好的一件事, 不過我們姑且先不討論這個吧。 事實是,耗時20年的 詳盡研究 告訴我們 有一群人會更傾向於在短時間內 換大量的性伴侶, 而這些人,基本上來說 是賣春者,他們的性伴侶 多半是舞會上的同性戀者, 而這些人,平均而言都有著比異性戀 多上三倍的性伴侶, 這其中有異性戀, 他們的國家有著 一妻多夫制的傳統, 而女性相對地有較高的女性自主權, 這些國家大部分都是在南非的東岸。 這都反映在我們今天面對的傳染病上。
You can see these horrifying figures from Africa. These are all countries in southern Africa where between one in seven, and one in three of all adults, are infected with HIV. Now, in the rest of the world, we've got basically nothing going on in the general population -- very, very low levels -- but we have extraordinarily high levels of HIV in these other populations who are at highest risk: drug injectors, sex workers and gay men. And you'll note, that's the local data from Los Angeles: 25 percent prevalence among gay men. Of course, you can't get HIV just by having unprotected sex. You can only HIV by having unprotected sex with a positive person.
你可以看到這些從非洲得到的可怕數據。 這些都是在南非的國家, 在這裡的成年人 3分之一 到7分之一 比例感染HIV 現在,在世界上其他的國家, 基本上人口沒有太大的變化, 變動的比例相當相當低, 但是在高危險群中 卻有相當大比例的人感染到HIV 更不用說毒品注射者、性工作者、 還有同性戀者。 你會看到洛杉磯的數據中, 同性戀者中有25%的人感染上愛滋。 當然,你不會光是因為不安全的性交而感染HIV 你只會因為跟一個呈陽性反應的HIV患者 有不安全的性交而染上HIV
In most of the world, these few prevention failures notwithstanding, we are actually doing quite well these days in commercial sex: condom use rates are between 80 and 100 percent in commercial sex in most countries. And, again, it's because of an alignment of the incentives. What's rational for public health is also rational for individual sex workers because it's really bad for business to have another STI. No one wants it. And, actually, clients don't want to go home with a drip either. So essentially, you're able to achieve quite high rates of condom use in commercial sex.
在世界上大部分的地方, 極少數的預防措施失效了, 沒有抵抗愛滋成功, 但實際上針對性交易中的預防措施, 我們這些日子以來其實做得還不錯。 在大部分國家性交易中 保險套的使用率介於80%~100% 再一次地說,這都是因為這一連串的鼓勵措施。 對公共衛生而言這是理智的, 對個人的性工作者也是理性的選擇。 因為染上性病對生意是很不好的 沒有人想要這樣。 而且,事實上,顧客也不想染病回家。 所以本質上來說,在性交易這行業中 是可以達到相當高的保險套使用率。
But in "intimate" relations it's much more difficult because, with your wife or your boyfriend or someone that you hope might turn into one of those things, we have this illusion of romance and trust and intimacy, and nothing is quite so unromantic as the, "My condom or yours, darling?" question. So in the face of that, you really need quite a strong incentive to use condoms.
但是在"親密"關係中, 這就困難多了, 因為你的太太或你的男友, 或那些你希望成為伴侶的人, 我們都有著對羅曼史的幻想, 信任還有親密度, 而再也沒有什麼話會比 「親愛的,要用誰的保險套呢?」這類的問題更掃興了。 所以,面對到這樣的問題, 你真的需要相當大的鼓勵 來讓你使用保險套。
This, for example, this gentleman is called Joseph. He's from Haiti and he has AIDS. And he's probably not having a lot of sex right now, but he is a reminder in the population, of why you might want to be using condoms. This is also in Haiti and is a reminder of why you might want to be having sex, perhaps. Now, funnily enough, this is also Joseph after six months on antiretroviral treatment. Not for nothing do we call it the Lazarus Effect. But it is changing the equation of what's rational in sexual decision-making. So, what we've got -- some people say, "Oh, it doesn't matter very much because, actually, treatment is effective prevention because it lowers your viral load and therefore makes it more difficult to transmit HIV." So, if you look at the viremia thing again, if you do start treatment when you're sick, well, what happens? Your viral load comes down. But compared to what? What happens if you're not on treatment? Well, you die, so your viral load goes to zero. And all of this green stuff here, including the spikes -- which are because you couldn't get to the pharmacy, or you ran out of drugs, or you went on a three day party binge and forgot to take your drugs, or because you've started to get resistance, or whatever -- all of that is virus that wouldn't be out there, except for treatment.
讓我們來舉個例子。這位男士名叫約瑟。 他來自海地,患有愛滋, 而他現在大概也沒有活躍的性生活, 但他卻提醒了大眾 需要使用保險套 的原因 這也是在海地,同樣提醒著 大家為何你會想要性交,也許會吧。 現在,還蠻好笑的是,這也是約瑟, 是在六個月的抗逆轉錄病毒藥物治療後。 這就是我們所說的拉薩路效應。 但這改變了等式, 在面對性交時, 作出怎樣的決定才算理智。 所以,我們得到這樣的回應。 有些人會說,「噢,這不太重要, 因為事實上,治療也是很有效的預防措施, 因為治療會降低你體內的病毒量, 因此也比較不容易感染到愛滋。」 如果大家再看看這些病毒報告, 如果在染病時,你真的有接受治療, 那麼,接著你的病毒攜帶量會下降。 但這是跟什麼數據相比?如果你沒有接受治療呢? 那,你會死亡, 所以你的病毒量會降到零。 還有這些綠色部分,包含這些數量衝高的部分, 這些都是因為你無法就診, 或你藥吃完了,或是你去派對狂歡了三天, 根本就忘了吃藥, 又或因為你開始有抗藥性,不管怎樣, 事實是,愛滋病病毒 是不會消失不見的,除非你接受治療。
Now, am I saying, "Oh, well, great prevention strategy. Let's just stop treating people." Of course not, of course not. We need to expand antiretroviral treatment as much as we can. But what I am doing is calling into question those people who say that more treatment is all the prevention we need. That's simply not necessarily true, and I think we can learn a lot from the experience of gay men in rich countries where treatment has been widely available for going on 15 years now. And what we've seen is that, actually, condom use rates, which were very, very high -- the gay community responded very rapidly to HIV, with extremely little help from public health nerds, I would say -- that condom use rate has come down dramatically since treatment for two reasons really: One is the assumption of, "Oh well, if he's infected, he's probably on meds, and his viral load's going to be low, so I'm pretty safe."
現在,難道我是在說「噢,好吧,這是很棒的預防策略! 我們乾脆停止治療吧?」 當然不是。當然不是這樣。 我們當然需要盡所可能地擴展這抑制病毒的治療。 但現在我要做的是 問問那些 說治療勝過預防的人 這根本就不是真相, 我認為我們可以從這些同性戀的經驗中學到更多, 他們身處的國家都有著更普及的治療, 也已施行15年了, 我們看到的是, 事實上,保險套的使用率 相當地高, 同性戀群對HIV的反應也很快, 幾乎不太需要 來自公共衛生人員的協助,我會說 自接受治療後,保險套的使用率明顯驟降, 主要是有兩個原因。 其中一個假設是,「噢, 如果他有感染愛滋,他可能在服藥了, 那他所攜帶的病毒量一定較低,所以我還蠻安全的。」
And the other thing is that people are simply not as scared of HIV as they were of AIDS, and rightly so. AIDS was a disfiguring disease that killed you, and HIV is an invisible virus that makes you take a pill every day. And that's boring, but is it as boring as having to use a condom every time you have sex, no matter how drunk you are, no matter how many poppers you've taken, whatever? If we look at the data, we can see that the answer to that question is, mmm.
另一種就是 人們就根本不怕HIV 就像他們也不怕愛滋病,的確如此。 愛滋病是會致死的疾病 而HIV是種看不見的病毒, 就只是讓你每天吃顆藥。 這是蠻無趣的, 但這有比 每次性交都使用保險套來得無聊嗎? 不管你喝得多醉, 不管你喝了多少杯。 如果我們看看數據,我們可以發現 問題的答案就是 呃....
So these are data from Scotland. You see the peak in drug injectors before they started the national needle exchange program. Then it came way down. And both in heterosexuals -- mostly in commercial sex -- and in drug users, you've really got nothing much going on after treatment begins, and that's because of that alignment of incentives that I talked about earlier. But in gay men, you've got quite a dramatic rise starting three or four years after treatment became widely available. This is of new infections.
這些是蘇格蘭的數據。 你可以看到毒品注射者染病的高峰期 是在他們開始推行全國性的針頭交換計畫之前。 然後數據一路下滑, 不管是異性戀,其中大多數是性工作者 或毒品施打者, 在治療開始後,其實不會有太多狀況發生, 這是因為我先前提到的 一連串的鼓勵措施。 但在同性戀中, 數值急遽上升 就在治療開始變得普及 的三四年間。 這是新的感染案例。
What does that mean? It means that the combined effect of being less worried and having more virus out there in the population -- more people living longer, healthier lives, more likely to be getting laid with HIV -- is outweighing the effects of lower viral load, and that's a very worrisome thing. What does it mean? It means we need to be doing more prevention the more treatment we have.
這意味著什麼? 這意味著人們一方面較不擔心愛滋, 另一方面在人群中也有著更多的愛滋病毒, 越來越多人活得更久,更健康, 也更可能帶著HIV 與別人性交 這兩種影響遠大於較低病毒攜帶量所帶來的影響, 而這是件很值得我們擔心的問題。 這到底指的是什麼? 這說明了當我們有著更好的治療,我們卻也需要做更多的預防措施。
Is that what's happening? No, and I call it the "compassion conundrum." We've talked a lot about compassion the last couple of days, and what's happening really is that people are unable quite to bring themselves to put in good sexual and reproductive health services for sex workers, unable quite to be giving out needles to junkies. But once they've gone from being transgressive people whose behaviors we don't want to condone to being AIDS victims, we come over all compassionate and buy them incredibly expensive drugs for the rest of their lives. It doesn't make any sense from a public health point of view.
實際狀況是這樣嗎? 不,而且我稱這現象叫同情謎團。 我們過去這幾天談了很多關於同情的話題。 而實際的狀況是 人們無法真的提供 良好的性交及生育健康服務給性工作者, 也無法發放針頭給毒癮者, 但一旦他們不再是 不可饒恕的毒蟲或賣春者 而是愛滋病受害者時 我們就能有同情心 來為他們一輩子購買這些極為昂貴的藥物, 從公共衛生的角度看, 這一點都沒道理。
I want to give what's very nearly the last word to Ines. Ines is a a transgender hooker on the streets of Jakarta; she's a chick with a dick. Why does she do that job? Well, of course, because she's forced into it because she doesn't have any better option, etc., etc. And if we could just teach her to sew and get her a nice job in a factory, all would be well. This is what factory workers earn in an hour in Indonesia: on average, 20 cents. It varies a bit province to province. I do speak to sex workers, 15,000 of them for this particular slide, and this is what sex workers say they earn in an hour. So it's not a great job, but for a lot of people it really is quite a rational choice. Okay, Ines.
我想要跟伊恩絲說些話,這幾乎是最後所說的話了。 伊恩絲是個變性人,在雅加達的路上當妓女。 她是個有小雞雞的女生。 為什麼她要作妓女呢? 當然,這是因為她迫於無奈。 因為她沒有比較好的選擇,等等等。 如果我們可以教她縫紉, 幫她在工廠找到工作,這一切都會好轉。 這是印尼的工廠員工一天的所得, 平均20分。 會因省份有所不同。 我跟性工作者訪談,在15,000個訪談後, 我得到這張幻燈片。 這是她們說賣春者在 一個小時中所賺到的。 所以,這不是件好差事,但對很多人來說, 這真的是相當理性的選擇。 好的,伊恩絲。
We've got the tools, the knowledge and the cash, and commitment to preventing HIV too.
我們有工具,知識,也有現金, 也有著要預防愛滋病病毒的決心。
Ines: So why is prevalence still rising? It's all politics. When you get to politics, nothing makes sense.
伊恩絲:那為何愛滋病患者的數目還在上升? 這都是政治問題。 當牽扯到政治,一切都毫無道理了。
Elizabeth Pisani: "When you get to politics, nothing makes sense." So, from the point of view of a sex worker, politicians are making no sense. From the point of view of a public health nerd, junkies are doing dumb things. The truth is that everyone has a different rationale. There are as many different ways of being rational as there are human beings on the planet, and that's one of the glories of human existence. But those ways of being rational are not independent of one another, so it's rational for a drug injector to share needles because of a stupid decision that's made by a politician, and it's rational for a politician to make that stupid decision because they're responding to what they think the voters want. But here's the thing: we are the voters. We're not all of them, of course, but TED is a community of opinion leaders. And everyone who's in this room, and everyone who's watching this out there on the web, I think, has a duty to demand of their politicians that we make policy based on scientific evidence and on common sense. It's going to be really hard for us to individually affect what's rational for every Frankie and every Ines out there, but you can at least use your vote to stop politicians doing stupid things that spread HIV.
伊麗莎白 ˙皮薩尼:「當牽扯到政治,一切都毫無道理了。」 所以,從性工作者的角度來看, 政客讓這一切變得很沒有道理。 從公共衛生學者的角度看, 毒癮者只是在做蠢事。 我的意思是,事實是每個人都有不同的合理解釋。 這個星球有多少人 就會有同樣多的各種理性決定, 這也是人類存在的光輝之一。 但這些不同的理性決定 並不是完全和彼此不相干。 對一個毒品注射者來說, 分享針頭是理智的, 而這全是因為政治家所做出的一個蠢決定。 對一個政治家而言, 做出這個蠢決定也是理智的, 因為他們必須對選民的需求 做出回應。 但重點是: 我們就是選民。 我們當然不是全部的選民,但是TED是一個有著思想領導者的群體, 在這房間的每一個人, 還有在線上收看的每一個人, 我想我們都有責任要求這些政治家 根據科學證據和常識 來做出決策。 對我們來說, 單獨影響在世界各地,像法蘭克、伊恩絲 這些人,是真的很困難的 但你可以,至少用你的選票 來阻止政治家做出傳播HIV 這樣的蠢事
Thank you.
謝謝!
(Applause)
(掌聲)