I'm a physician trained in infectious diseases, and following my training, I moved to Somalia from San Francisco. And my goodbye greeting from the chief of infectious diseases at San Francisco General was, "Gary, this is the biggest mistake you'll ever make."
我是一名治療傳染性疾病的醫生 學業結束以後 我從舊金山 搬到索馬利亞 當時舊金山綜合醫院的 傳染科主任 送給我的離別致辭是 ”蓋瑞,這是你一生中最錯的決定。“
But I landed in a refugee situation that had a million refugees in 40 camps, and there were six of us doctors. There were many epidemics there. My responsibilities were largely related to tuberculosis, and then we got struck by an epidemic of cholera. So it was the spread of tuberculosis and the spread of cholera that I was responsible for inhibiting. And in order to do this work, we, of course, because of the limitation in health workers, had to recruit refugees to be a specialized new category of health worker. Following three years of work in Somalia, I got picked up by the World Health Organization, and got assigned to the epidemics of AIDS. My primary responsibility was Uganda, but also I worked in Rwanda and Burundi and Zaire, now Congo, Tanzania, Malawi, and several other countries. And my last assignment there was to run a unit called intervention development, which was responsible for designing interventions.
當我在難民營落腳時 那裏有40個難民營收容了100萬難民 卻只有我們6個醫生 流行病隨處可見 我的職責主要是 肺結核 但我們隨即遇上了流行性霍亂。 我負責阻止肺結核 和霍亂的 大幅擴散。 為了讓工作得以順利進行, 我們數量有限的醫護人員 不得不從難民中招人 特訓成醫護人員。 在索馬利亞工作了三年以後, 我被世界衛生組織選中 從事防治愛滋病流行的工作。 我的主要工作是在烏干達。 我也在盧安達、蒲隆地、 薩伊、現在的剛果、 坦尚尼亞、馬拉威和其他幾個國家。 我最後一個任務是負責一個 叫介入性發展的機構。 這個機構主要負責設計介入性治療。
After 10 years of working overseas, I was exhausted. I really had very little left. I had been traveling to one country after another. I was emotionally feeling very isolated. I wanted to come home. I'd seen a lot of death, in particular epidemic death, and epidemic death has a different feel to it. It's full of panic and fear, and I'd heard the women wailing and crying in the desert. And I wanted to come home and take a break and maybe start over.
10年的海外工作 令我身心俱疲 我幾乎身無分文 常年的四處奔波, 令我倍感孤獨無助。 我想回家歇歇。 我看過太多的死亡, 尤其是流行病造成的死亡, 它與一般死亡有些不同。 它充滿痛苦和恐懼 我在沙漠中聽過女人的 慟哭和哀號。 我很想回家歇歇 也許重新開始。
I was not aware of any epidemic problems in America. In fact, I wasn't aware of any problems in America. In fact -- seriously. And in fact I would visit friends of mine, and I noticed that they had water that came right into their homes. How many of you have such a situation? (Laughter) And some of them, many of them actually, had water that came into more than one room. And I noticed that they would move this little thermoregulatory device to change the temperature in their home by one degree or two degrees. And now I do that.
在美國,我沒發現任何 流行病的問題。 實際上,我沒覺得美國有任何問題。 我是說真的。 我去拜訪我的朋友時 我看到他們家裏有水 直接地流到家裏來 你們當中有多少人有這種設備? (笑聲) 有些朋友,其實是很多朋友, 可以在家裏的不同房間取用水。 我還發現他們在家裏安裝了 小巧的溫度調節器, 可以一度一度地或者兩度兩度地調節 家裏的室內溫度。 我家現在也是這樣。
And I really didn't know what I would do, but friends of mine began telling me about children shooting other children with guns. And I asked the question, what are you doing about it? What are you in America doing about it? And there were two essential explanations or ideas that were prevalent.
所以我不知道我該做什麽好。 但我的一個朋友告訴我 關於青少年之間的槍擊事件。 我就想 對這樣的事件你該做些什麽? 在美國你該些做什麼? 大家都知道主要有兩種方案 或者說方法。
And one was punishment. And this I had heard about before. We who had worked in behavior knew that punishment was something that was discussed but also that it was highly overvalued. It was not a main driver of behavior, nor was it a main driver of behavior change. And besides that, it reminded me of ancient epidemics that were previously completely misunderstood because the science hadn't been there before, epidemics of plague or typhus or leprosy, where the prevalent ideas were that there were bad people or bad humors or bad air, and widows were dragged around the moat, and dungeons were part of the solution.
一個是懲罰。 我以前就聽說過的方法。 我們以前研究行為學 知道懲罰是經常被探討的方法。 但它也是個被高估的方法。 它不是行為的主要動力, 也不是改變行為的主要動力。 而且,它讓我意識到 過去歷史上的流行病 就曾經被完全曲解。 因為當時的科學尚未發展足夠 瘟疫、 斑疹傷寒和麻瘋病的疫區中 大家都普遍認為 疫區裡有不好的人、不好的環境、或不好的空氣 解決方式之一是 把寡婦被拖到護城河或地牢中
The other explanation or, in a way, the solution suggested, is please fix all of these things: the schools, the community, the homes, the families, everything. And I'd heard this before as well. I'd called this the "everything" theory, or EOE: Everything On Earth. But we'd also realized in treating other processes and problems that sometimes you don't need to treat everything.
另一種方案,或者說, 解決方法是 改善所有的設施: 學校、公共場所、私人住處、各個家庭,以及 所有的東西。 我也同樣知道這個方法 我把這叫做“凡事”理論 又稱世上萬物 但是我們也認識到 在治療的過程中 有時候你並不需要改變所有的東西。
And so the sense that I had was there was a giant gap here. The problem of violence was stuck, and this has historically been the case in many other issues. Diarrheal diseases had been stuck. Malaria had been stuck. Frequently, a strategy has to be rethought. It's not as if I had any idea what it would look like, but there was a sense that we would have to do something with new categories of workers and something having to do with behavior change and something having to do with public education.
所以我感覺 人們的認知上有一個鴻溝。 暴力問題陷入僵局 這歷來都是 其他重大問題的特點。 腹瀉病曾陷入僵局 瘧疾也曾陷入僵局 通常情況下,一個治療方案必需進行反思。 不是說我知道應該怎麽做, 我是覺得我們需要 和新類型的工作者一起來解決這個問題, 改變人們的行事態度, 與公家教育體制一起合作。
But I began to ask questions and search out the usual things that I had been exploring before, like, what do the maps look like? What do the graphs look like? What does the data look like? And the maps of violence in most U.S. cities looked like this. There was clustering. This reminded me of clustering that we'd seen also in infectious epidemics, for example cholera. And then we looked at the maps, and the maps showed this typical wave upon wave upon wave, because all epidemics are combinations of many epidemics. And it also looked like infectious epidemics. And then we asked the question, well what really predicts a case of violence? And it turns out that the greatest predictor of a case of violence is a preceding case of violence. Which also sounds like, if there is a case of flu, someone gave someone a case of flu, or a cold, or the greatest risk factor of tuberculosis is having been exposed to tuberculosis.
我開始提出問題, 和搜尋以前研究過的 一些常見指標 比如說,分布圖是什麽樣的? 圖表是什麽樣的? 數據又是什麽樣的? 在美國大部分的城市, 暴力事件的分布圖 就像這個。 是叢集分布的 這讓我意識到我們以前見過的流行傳染病 就是叢集分布的。 比如說霍亂 我們觀察曲線圖發現 曲線圖裏有這樣的典型曲線。 一個波形疊著一個波形的分布。 因為所有的流行病 都跟著其他流行病發生。 而暴力事件的曲線圖和流行病的曲線圖也很相似。 然後我們問, 怎樣預警暴力案件呢? 結果我們發現 對一個暴力事件的最好預警 就是上一次的暴力事件 這就跟流感疫情相似, 就像某人把流感,或者感冒傳給別人 結核病最大的罹患因素就是 結核病的接觸史。
And so we see that violence is, in a way, behaving like a contagious disease. We're aware of this anyway even in our common experiences or our newspaper stories of the spread of violence from fights or in gang wars or in civil wars or even in genocides.
我們發現暴力事件,在某種程度上, 很像傳染病的爆發。 其實,我們可以了解到 在日常生活中 或者媒體的報導中 爭吵中的暴力會蔓延成 幫派鬥爭,內戰, 甚至種族屠殺。
And so there's good news about this, though, because there's a way to reverse epidemics, and there's really only three things that are done to reverse epidemics, and the first of it is interrupting transmission. In order to interrupt transmission, you need to detect and find first cases. In other words, for T.B. you have to find somebody who has active T.B. who is infecting other people. Make sense? And there's special workers for doing that. For this particular problem, we designed a new category of worker who, like a SARS worker or someone looking for bird flu, might find first cases. In this case, it's someone who's very angry because someone looked at his girlfriend or owes him money, and you can find workers and train them into these specialized categories.
但有個好消息,就是 我們有治療傳染病的方式。 只要做好三件事就可以 阻止傳染病的發生。 第一點就是切斷傳播途徑。 為了切斷傳播途徑, 我們需要找到第一個案例。 就是說,如果是結核病,你必須要找到 誰有活動性結核病菌,誰會把結核病傳染給別人。 合理吧? 我們有專業人員來做這個工作。 對這樣特定的問題, 我們設計出新類型的工作者 就像 SARS (非典) 的工作者, 或禽流感的工作者, 他們可能找到首例患病者 在暴力事件裏,起因是有人 因為別人看了他的女朋友一眼 或者欠了他的錢而動怒 你可以找到一些人,訓練他們成為 特殊類型的工作者。
And the second thing to do, of course, is to prevent further spread, that means to find who else has been exposed, but may not be spreading so much right now like someone with a smaller case of T.B., or someone who is just hanging out in the neighborhoods, but in the same group, and then they need to be, in a way, managed as well, particular to the specific disease process.
第二點呢,當然就是 防止擴散。 就是說,要找到誰有可能被牽涉進去。 雖然他可能不會很快被牽涉 就像在結核病傳染的小型案例裏一樣。 有人可能只是的街頭鄰居 但是在同個活動範圍裏 那麽這些人就需要以某種方式, 被好好管理 就象處理某些特殊疾病的過程一樣
And then the third part, the shifting the norms, and that means a whole bunch of community activities, remodeling, public education, and then you've got what you might call group immunity. And that combination of factors is how the AIDS epidemic in Uganda was very successfully reversed.
第三點就是,恢復到正常。 就是整個社區活動的 重新建構和公共教育 然後你可以做到所謂的 “群體免疫”。 這幾個因素的結合 當年使我們成功地阻止了 愛滋病在烏干達的擴散
And so what we decided to do in the year 2000 is kind of put this together in a way by hiring in new categories of workers, the first being violence interruptors. And then we would put all of this into place in one neighborhood in what was the worst police district in the United States at the time. So violence interruptors hired from the same group, credibility, trust, access, just like the health workers in Somalia, but designed for a different category, and trained in persuasion, cooling people down, buying time, reframing. And then another category of worker, the outreach workers, to keep people in a way on therapy for six to 24 months. Just like T.B., but the object is behavior change. And then a bunch of community activities for changing norms.
在2000年我們決定嘗試 把這些因素結合起來。 首先我們雇用了一些新類型的工作者, 也就是首起暴力事件的阻止人。 然後我們把三個因素全部運用到 某個社區, 也就是美國國內 某個治安最差的地區。 暴力阻止者是從同一社區子裡選出來 有信譽、值得信任、能接近他人, 就像在索馬利亞的那些醫護工作者一樣 只不過他們為不同的目的而工作 他們受訓學習如何勸說別人, 讓人息怒,拖延時間,轉變他的態度。 還有其他類別的員工, 外展服務人員 讓人接受6到24個月的“治療”。 就像結核病的治療,但目標是行為上的改變。 然後一些社區活動就會 恢復正常
Now our first experiment of this resulted in a 67-percent drop in shootings and killings in the West Garfield neighborhood of Chicago.
我們首次實驗結果 顯示在芝加哥的西加菲爾德地區 槍擊和殺人案件 減少了67%
(Applause)
(掌聲)
And this was a beautiful thing for the neighborhood itself, first 50 or 60 days, then 90 days, and then there was unfortunately another shooting in another 90 days, and the moms were hanging out in the afternoon. They were using parks they weren't using before. The sun was out. Everybody was happy.
這對一個社區來說 是一件非常好的事 剛開始堅持了50或60天,然後是90天, 在接下來的90天中 僅發生了一件不幸的槍擊事件。 那些社區裏的媽媽們開始在下午一起出來散步 他們開始利用他們以前不曾利用的公園 太陽出來了。每個人都很開心。
But of course, the funders said, "Wait a second, do it again." And so we had to then, fortunately, get the funds to repeat this experience, and this is one of the next four neighborhoods that had a 45-percent drop in shootings and killings. And since that time, this has been replicated 20 times. There have been independent evaluations supported by the Justice Department and by the CDC and performed by Johns Hopkins that have shown 30-to-50-percent and 40-to-70-percent reductions in shootings and killings using this new method. In fact, there have been three independent evaluations of this now.
當然,有些捐款人會說 “等等,再試一次。” 所以呢,我們幸運地 拿到了資金來重複這個實驗。 在實驗中的四個社區之一 槍擊和殺人案件減少了45% 從那時開始,這個實驗已經被重複了 20次 我們的實驗被獨立評估過 評估是由司法部門和 疾病預防控制中心和約翰霍普金斯大學來進行 評估結果顯示,使用我們的新方法 槍擊和殺人案件 減少到了 30~50% 和 40~60% 實際上,我們的工作到目前為止已經通過了 三次的獨立評估。
Now we've gotten a lot of attention as a result of this, including being featured on The New York Times' Sunday magazine cover story. The Economist in 2009 said this is "the approach that will come to prominence." And even a movie was made around our work. [The Interrupters]
我們的工作也因此受到了很多人的矚目 其中包括 《紐約時報》周日雜誌的封面故事 2009年的《經濟學家》雜誌曾說 "這種方法將被廣泛使用“ 甚至有一部電影是講述關於我們的工作 [中斷]
However, not so fast, because a lot of people did not agree with this way of going about it. We got a lot of criticism, a lot of opposition, and a lot of opponents. In other words, what do you mean, health problem? What do you mean, epidemic? What do you mean, no bad guys? And there's whole industries designed for managing bad people. What do you mean, hiring people who have backgrounds? My business friends said, "Gary, you're being criticized tremendously. You must be doing something right."
但是,先不要急, 因為很多人還不同意 我們的做法。 我們受到了很多的批評, 很多的反對意見, 很多的敵對態度。 像是,為什麼你說這是健康問題? 為什麼你稱它為流行病? 為什麼你說沒有壞人? 整個業界早已經有 管理壞人的方法 你說雇用有(不良)背景的人 是什麽意思? 我商界的朋友說, ”蓋瑞,你竟然受到這麼多批評 你一定是做了一些好事!“
(Laughter)
(笑聲)
My musician friends added the word "dude."
我的音樂家朋友還外加了 ”兄弟“ 一詞
So anyway, additionally, there was still this problem, and we were getting highly criticized as well for not dealing with all of these other problems. Yet we were able to manage malaria and reduce HIV and reduce diarrheal diseases in places with awful economies without healing the economy.
總之 這仍然是個問題 還有另外一種批評是 我們的工作無法處理所有的問題。 目前為止,我們能控制瘧疾, 減少愛滋病和腹瀉的發病, 在那些貧困的 經濟沒有復甦的地區。
So what's actually happened is, although there is still some opposition, the movement is clearly growing. Many of the major cities in the U.S., including New York City and Baltimore and Kansas City, their health departments are running this now. Chicago and New Orleans, the health departments are having a very large role in this. This is being embraced more by law enforcement than it had been years ago. Trauma centers and hospitals are doing their part in stepping up. And the U.S. Conference of Mayors has endorsed not only the approach but the specific model. Where there's really been uptake even faster is in the international environment, where there's a 55-percent drop in the first neighborhood in Puerto Rico, where interruptions are just beginning in Honduras, where the strategy has been applied in Kenya for the recent elections, and where there have been 500 interruptions in Iraq.
所以實際上, 儘管有一些反對意見, 很明顯大家都行動起來了。 美國的很多大城市, 包括紐約市、巴爾的摩 和堪薩斯城 他們的衛生部門在開展著類似的工作 芝加哥和紐奧良的衛生部門 扮演著重大的角色 執法單位也比過去 更能接受這些做法 創傷中心和醫院 也在不斷跟進 美國市長聯會 已經核准不僅要開展類似的工作 而且要作為特別模式來做 在國際上 有著更迅速的行動 在波多黎各的第一個施行社區 案件減少了55% 在宏都拉斯的工作正在著手進行 在肯亞最近的選舉活動中 我們的方式也被列入政策中 伊拉克已經完成了500次阻斷犯罪的工作
So violence is responding as a disease even as it behaves as a disease. So the theory, in a way, is kind of being validated by the treatment. And recently, the Institute of Medicine came out with a workshop report which went through some of the data, including the neuroscience, on how this problem is really transmitted.
所以,暴力事件可以當作疾病來對待, 它的表現形式就像是疾病一樣 這個理論在某方面來說 在處理的過程中得到了驗證 最近,美國醫學研究所 (IOM) 提出一個研究報告 根據一些數據 其中包括神經科學 來解釋暴力是如何傳播的
So I think this is good news, because it allows us an opportunity to come out of the Middle Ages, which is where I feel this field has been. It gives us an opportunity to consider the possibility of replacing some of these prisons with playgrounds or parks, and to consider the possibility of converting our neighborhoods into neighborhoods, and to allow there to be a new strategy, a new set of methods, a new set of workers: science, in a way, replacing morality. And moving away from emotions is the most important part of the solution to science as a more important part of the solution.
我認為這是一個好消息 因為這些研究讓我們有機會 走出以往的 中世紀般的陳舊思維。 這些研究給我們重新考慮 把一些監獄變成 休閒場所和公園的可能性。 重新考慮 重建我們的社區的可能性 採用新的策略 新的方法,新類型的工作者 某方面用科學的方法來替代道德 平息情緒 是解決問題中最重要的一部分 用科學的方法是更加重要的。
So I didn't mean to come up with this at all. It was a matter of, I wanted actually a break, and we looked at maps, we looked at graphs, we asked some questions and tried some tools that actually have been used many times before for other things. For myself, I tried to get away from infectious diseases, and I didn't.
我不是說全部都能用我們的方法來解決 重要的是, 我想要突破, 讓我們能夠看著分布圖,看著圖表, 提出一些問題, 然後使用一些 以前在其他方面運用過很多次的 方法。 對我自己來說,我曾試圖從 感染性疾病中脫身 可是我沒有。
Thank you.
謝謝大家!
(Applause)
(掌聲)