So have you ever wondered what it would be like to live in a place with no rules? That sounds pretty cool.
大家有没有想过生活在一个 没有约束管制的世界 将会是怎么样一种情形? 这听起来很酷。
(Laughter)
(笑声)
You wake up one morning, however, and you discover that the reason there are no rules is because there's no government, and there are no laws. In fact, all social institutions have disappeared. So there's no schools, there's no hospitals, there's no police, there's no banks, there's no athletic clubs, there's no utilities.
当有一天你一觉醒来, 发现没任何约束的原因, 是因为没有政府也没有法律。 事实上,整个社会体系都消失了。 所以没有了学校, 没有医院, 没有警察, 没有银行, 没有体育俱乐部, 没有公共设施。
Well, I know a little bit about what this is like, because when I was a medical student in 1999, I worked in a refugee camp in the Balkans during the Kosovo War. When the war was over, I got permission -- unbelievably -- from my medical school to take some time off and follow some of the families that I had befriended in the camp back to their village in Kosovo, and understand how they navigated life in this postwar setting.
其实我对这种状况有一些了解, 因为在1999年科索沃战争期间, 我曾作为一个医科学生 在巴尔干半岛的一个难民营工作过。 战争结束时, 没想到学校竟然批准了 我请假的请求, 允许我跟随难民营家庭的一些朋友 返回他们在科索沃的家乡, 我因此目睹了他们 如何在战后环境中生活。
Postwar Kosovo was a very interesting place because NATO troops were there, mostly to make sure the war didn't break out again. But other than that, it was actually a lawless place, and almost every social institution, both public and private, had been destroyed. So I can tell you that when you go into one of these situations and settings, it is absolutely thrilling ... for about 30 minutes, because that's about how long it takes before you run into a situation where you realize how incredibly vulnerable you are.
战后的科索沃是个很有意思的地方, 一方面北约军队在这里 最大程度地保证这里 不再重燃战火。 但另一方面, 其实它是一个无法无天的地方, 几乎所有的公共的和 私有的社会机构 都被摧毁了。 所以可以这样说: 当刚步入这种处境的时候, 毫无疑问是, 你会感到毛骨悚然, 这种感觉会持续大约半个小时, 因为这是适应一个新环境 所需要的时间, 这个环境会使你意识到自己是 多么难以置信的脆弱。
For me, that moment came when I had to cross the first checkpoint, and I realized as I drove up that I would be negotiating passage through this checkpoint with a heavily armed individual who, if he decided to shoot me right then and there, actually wouldn't be doing anything illegal. But the sense of vulnerability that I had was absolutely nothing in comparison to the vulnerability of the families that I got to know over that year.
而当我通过第一个哨卡的时候 就体会到了这种感觉, 当我逐渐开近这个哨卡, 我突然意识到一会儿要与 哨卡里有全副武装的哨兵交涉, 如果他此时此刻要射杀我的话, 我确定那根本 算不上什么违法的事情。 然而我感受到的这种脆弱 丝毫比不上 我在那年认识的那些家庭所承受的 脆弱感。
You see, life in a society where there are no social institutions is riddled with danger and uncertainty, and simple questions like, "What are we going to eat tonight?" are very complicated to answer. Questions about security, when you don't have any security systems, are terrifying. Is that altercation I had with the neighbor down the block going to turn into a violent episode that will end my life or my family's life?
大家知道,一个没有社会机构的环境 会让你的生活 充满危险和未知, 像一些很简单的问题, 譬如:今晚我们吃什么, 都会变得很难回答。 而如果没有了安保系统, 安保问题同样是件很恐怖的事情。 我和楼下邻居的几句口角 会演变成使我或我的家人丧命 的暴力事件吗?
Health concerns when there is no health system are also terrifying. I listened as many families had to sort through questions like, "My infant has a fever. What am I going to do?" "My sister, who is pregnant, is bleeding. What should I do? Who should I turn to?" "Where are the doctors, where are the nurses? If I could find one, are they trustworthy? How will I pay them? In what currency will I pay them?" "If I need medications, where will I find them? If I take those medications, are they actually counterfeits?" And on and on. So for life in these settings, the dominant theme, the dominant feature of life, is the incredible vulnerability that people have to manage day in and day out, because of the lack of social systems.
当没有了健康体系, 关于健康问题的担忧 也同样令人惊恐。 我听到过很多家庭的各种问题, 不得不把它们进行分类, 譬如:我的孩子发烧了, 我该怎么办? 我怀孕的姐姐大出血了, 我该怎么办? 我该找谁帮忙? 哪儿有医生,哪儿有护士? 如果我找到了医生, 他们值得信任吗? 我该付给他们多少钱, 付哪种货币? 如果我需要用药, 我该去哪儿买? 如果我买到了药, 它们会不会是假的? 很多这样或那样的问题。 在这样环境下的生活 生活的主题 就是人们每天都要去面对的 难以置信的脆弱感, 而这正是因为社会体系的缺失。
And it actually turns out that this feature of life is incredibly difficult to explain and be understood by people who are living outside of it. I discovered this when I left Kosovo. I came back to Boston, I became a physician, I became a global public health policy researcher. I joined the Harvard Medical School and Brigham and Women's Hospital Division of Global Health. And I, as a researcher, really wanted to get started on this problem right away. I was like, "How do we reduce the crushing vulnerability of people living in these types of fragile settings? Is there any way we can start to think about how to protect and quickly recover the institutions that are critical to survival, like the health system?" And I have to say, I had amazing colleagues. But one interesting thing about it was, this was sort of an unusual question for them. They were kind of like, "Oh, if you work in war, doesn't that mean you work on refugee camps, and you work on documenting mass atrocities?" -- which is, by the way, very, very, very important.
事实证明, 这种生活方式非常难以描述, 局外人也无法理解。 在我离开科索沃的时候 得出了以上这些结论。 后来我回到了波士顿, 成为了一名医生。 同时也成为了一名 全球公共卫生政策研究员。 我加入了哈佛医学院 和布莱根妇女医院的全球卫生部。 而我作为一个研究员, 非常想马上开始解决这个问题。 我在想:“我们要如何改善 生活在如此匮乏环境下 人们的脆弱感? 有没有什么方法能让我们开始考虑 去保护和快速重建 那些对于生存至关重要的体系, 譬如说卫生系统?” 我不得不说, 我有一群特别棒的同事。 但有意思的是, 在他们看来 这竟然是个非常规问题。 他们是这样认为的: 如果你在战争中工作, 那不意味着你应该为难民营工作, 去记录那些战争暴行吗? 这些是非常非常重要的事情。
So it took me a while to explain why I was so passionate about this issue, until about six years ago. That's when this landmark study that looked at and described the public health consequences of war was published. They came to an incredible, provocative conclusion. These researchers concluded that the vast majority of death and disability from war happens after the cessation of conflict. So the most dangerous time to be a person living in a conflict-affected state is after the cessation of hostilities; it's after the peace deal has been signed. It's when that political solution has been achieved. That seems so puzzling, but of course it's not, because war kills people by robbing them of their clinics, of their hospitals, of their supply chains. Their doctors are targeted, are killed; they're on the run. And more invisible and yet more deadly is the destruction of the health governance institutions and their finances.
所以我总是需要花费一些时间去解释 为什么我对这件事情如此关心, 直到六年前。 当时, 这一具里程碑意义的研究被发表, 内容探讨了战争对于 公共卫生的影响。 他们的得出了一个不可思议的, 爆炸性的结论。 这些研究者推断 大部分的死亡和残疾 产生于冲突结束之后。 所以对于一个处在战乱国家的人来说, 最危险的时段 是在停战之后; 在和平协议签订之后。 在政治解决方案已被各方所接受之后。 这看起来很莫名其妙,但其实不然, 因为战争会使人们失去他们的诊所、 医院和 相关的供应链体系, 从而造成人的死亡。 医生们成为了被屠杀的靶子; 他们在不停的逃亡。 难以察觉然而却更致命的是 对卫生管理机构及其 财政体系的破坏。
So this is really not surprising at all to me. But what is surprising and somewhat dismaying, is how little impact this insight has had, in terms of how we think about human suffering and war. Let me give you a couple examples.
所以这个结论对于我来说 并没什么吃惊的。 但令人惊讶甚至沮丧的是 这种深刻的见解 对我们对人类苦难和战争的认知, 并没什么影响。 我来举几个例子,
Last year, you may remember, Ebola hit the West African country of Liberia. There was a lot of reporting about this group, Doctors Without Borders, sounding the alarm and calling for aid and assistance. But not a lot of that reporting answered the question: Why is Doctors Without Borders even in Liberia? Doctors Without Borders is an amazing organization, dedicated and designed to provide emergency care in war zones. Liberia's civil war had ended in 2003 -- that was 11 years before Ebola even struck. When Ebola struck Liberia, there were less than 50 doctors in the entire country of 4.5 million people. Doctors Without Borders is in Liberia because Liberia still doesn't really have a functioning health system, 11 years later.
大家可能还记得去年 埃博拉病毒席卷了 西非国家利比里亚。 有很多新闻报道 关于无国界医生 得到消息后响应号召去参加援助。 但是很少有报道解释这个问题: 为什么是无国界医生 在利比里亚做这些事? 无国界医生是个不可思议的组织, 它致力于提供战区急救。 利比里亚内战 早在2003年就结束了, 那是埃博拉病毒来袭的11年前。 然而当埃博拉病毒席卷 整个利比里亚的时候, 这个有着450万人口的国家却 仅仅只有不到50名医生。 无国界医生在来到利比里亚 是因为这个国家在战争结束11年后 仍然没有一个 能够正常运转的卫生体系。
When the earthquake hit Haiti in 2010, the outpouring of international aid was phenomenal. But did you know that only two percent of that funding went to rebuild Haitian public institutions, including its health sector? From that perspective, Haitians continue to die from the earthquake even today.
当2010年海地发生地震的时候, 国际援助发挥的作用是惊人的。 但是大家知道吗,仅有2%的救援资金 被用作重建包含卫生部门在内的 所有公共机构。 正因如此, 至今仍不断地有海地人 因为那次地震而死亡。
I recently met this gentleman. This is Dr. Nezar Ismet. He's the Minister of Health in the northern autonomous region of Iraq, in Kurdistan. Here he is announcing that in the last nine months, his country, his region, has increased from four million people to five million people. That's a 25 percent increase. Thousands of these new arrivals have experienced incredible trauma. His doctors are working 16-hour days without pay. His budget has not increased by 25 percent; it has decreased by 20 percent, as funding has flowed to security concerns and to short-term relief efforts. When his health sector fails -- and if history is any guide, it will -- how do you think that's going to influence the decision making of the five million people in his region as they think about whether they should flee that type of vulnerable living situation?
最近我有幸结识了 Nezar Ismet博士。 他是伊拉克北部 克库尔德斯坦自治区域 的卫生部长。 他表示在过去的九个月内, 他所在的区域人口从400万 飙升到了500万。 增长率高达25%。 数以千计的新移民 经历了令人无法想象的创伤。 那里的医生每天工作16个小时, 而且还没有任何酬劳。 而他们的财政预算 不仅没有按照25%的比例进行增长 反而削减了20%, 因为资金都被用来维持安保 以及提供短期救助了。 一旦他们的卫生系统崩塌—— 历史证明必将如此—— 大家认为这将对 这里的500万人 考虑是否逃离 这个脆弱的环境时产生什么样的影响。
So as you can see, this is a frustrating topic for me, and I really try to understand: Why the reluctance to protect and support indigenous health systems and security systems? I usually tier two concerns, two arguments. The first concern is about corruption, and the concern that people in these settings are corrupt and they are untrustworthy. And I will admit that I have met unsavory characters working in health sectors in these situations. But I will tell you that the opposite is absolutely true in every case I have worked on, from Afghanistan to Libya, to Kosovo, to Haiti, to Liberia -- I have met inspiring people, who, when the chips were down for their country, they risked everything to save their health institutions. The trick for the outsider who wants to help is identifying who those individuals are, and building a pathway for them to lead.
如你所见, 对我来说这是个令人沮丧的话题, 我尽全力去寻求原因: 为什么人们不愿意去保护和支持 本地的卫生和安全体系? 我通常有两个论点, 第一个是腐败, 人们担心在这系统中工作的人 都是腐败且 不值得信任。 我承认在那种环境中的卫生部门中 遇到过 一些令人讨厌的人。 但我可以肯定的告诉大家, 相反的例子绝对存在, 而且在我参与过的案件中都发生过。 无论是阿富汗、利比亚、科索沃、 还是海地、利比里亚。 我遇到很多鼓舞人心的人, 他们在国家危难之际, 他们不顾一切地去拯救卫生机构。 对于外界力量来讲, 如果想支持这种行为, 一个方法就是要辨别出这样的人, 并且帮他们铺就一条 通向领导岗位的道路。
That is exactly what happened in Afghanistan. One of the unsung and untold success stories of our nation-building effort in Afghanistan involved the World Bank in 2002 investing heavily in identifying, training and promoting Afghani health sector leaders. These health sector leaders have pulled off an incredible feat in Afghanistan. They have aggressively increased access to health care for the majority of the population. They are rapidly improving the health status of the Afghan population, which used to be the worst in the world. In fact, the Afghan Ministry of Health does things that I wish we would do in America. They use things like data to make policy. It's incredible.
这种情况确实在阿富汗发生过。 我们在为阿富汗的国家建设所作的努力中 就有这样一个不为人知的成功案例, 涉及世界银行在2002年投巨资 识别、培训并推举 人们成为阿富汗卫生部门领导。 这些卫生部门的领导人在阿富汗取得了 令人叹为观止的成就。 他们积极为大多数人增加 获得医疗保健的权益。 他们使阿富汗人民的健康状况 得到了快速的改善, 那里的健康状况曾经是 全世界最差的。 事实上,阿富汗卫生部长做了 我希望在美国也可以实施的事情。 他们根据数据去制定相关政策。 太不可思议了。
(Laughter)
(笑声)
The other concern I hear a lot about is: "We just can't afford it, we just don't have the money. It's just unsustainable." I would submit to you that the current situation and the current system we have is the most expensive, inefficient system we could possibly conceive of. The current situation is that when governments like the US -- or, let's say, the collection of governments that make up the European Commission -- every year, they spend 15 billion dollars on just humanitarian and emergency and disaster relief worldwide. That's nothing about foreign aid, that's just disaster relief. Ninety-five percent of it goes to international relief agencies, that then have to import resources into these areas, and knit together some type of temporary health system, let's say, which they then dismantle and send away when they run out of money.
关于另外一个担忧, 我听到过很多的就是: 我们负担不起, 我们没有足够的钱。 这根本持续不下去。 在这里我不得不指出, 我们现有的状况和体系 是我们所能想到的最昂贵, 也是最低效的。 现在的情况是,像美国 或者是欧盟 这样的政府团体 他们每年仅在 人道援助、应急救援和全球赈灾上 就花费了150亿美元。 这还不是所有的援外资金, 仅仅是赈灾资金。 95%的赈灾资金 流向了国际救援组织, 然后他们必须得这些区域运送物资, 并且组建起一些临时的卫生系统, 当钱用完以后, 这些卫生系统人员会被解散遣返。
So our job, it turns out, is very clear.
所以,讲到这里, 我们要做的工作就很清晰了。
We, as the global health community policy experts, our first job is to become experts in how to monitor the strengths and vulnerabilities of health systems in threatened situations. And that's when we see doctors fleeing, when we see health resources drying up, when we see institutions crumbling -- that's the emergency. That's when we need to sound the alarm and wave our arms. OK? Not now. Everyone can see that's an emergency, they don't need us to tell them that.
我们作为全球公共健康政策专家, 首要的目标是专注监控 受到严重威胁下的卫生系统的 各项强度和漏洞。 当我们看到医护人员纷纷逃离, 卫生保障资源枯竭, 卫生机构摇摇欲坠 , 这就是危机到来的时刻。 那就是我们就应该拉响警钟, 开始行动的时刻了。 对吧? 并不是这个时候。 谁都能看出来这是个危机, 不需要我们来告知他们。
Number two: places like where I work at Harvard need to take their cue from the World Bank experience in Afghanistan, and we need to -- and we will -- build robust platforms to support health sector leaders like these. These people risk their lives. I think we can match their courage with some support.
第二点: 类似我工作过的哈佛这样的机构, 应该从世界银行在阿富汗的经验中 得到一些提示。 我们现在需要,将来也一定会 需要建立强大的平台 去扶植那些卫生部门的领导人。 这些人冒着生命危险去做这些事情。 我认为我们要用我们的支持来 回应他们的勇气。
Number three: we need to reach out and make new partnerships. At our global health center, we have launched a new initiative with NATO and other security policy makers to explore with them what they can do to protect health system institutions during deployments. We want them to see that protecting health systems and other critical social institutions is an integral part of their mission. It's not just about avoiding collateral damage; it's about winning the peace.
第三点: 我们应该着手去建立新型的伙伴关系。 在我们的全球卫生中心, 我们同北约和其他安保政策制定机构 发起了一项新的倡议, 去与他们探究在进行安保部署时, 能为保护卫生系统的机构 做些什么。 我们希望他们能够明白 保护卫生系统及其他关键的社会机构 也是他们使命中不可分割的一部分。 这不仅仅是为了避免受到牵连的损害, 而是为了赢得最终的和平。
But the most important partner we need to engage is you, the American public, and indeed, the world public. Because unless you understand the value of social institutions, like health systems in these fragile settings, you won't support efforts to save them. You won't click on that article that talks about "Hey, all those doctors are on the run in country X. I wonder what that means. I wonder what that means for that health system's ability to, let's say, detect influenza." "Hmm, it's probably not good." That's what I'd tell you.
但我们最需要团结的伙伴是你们, 是全体美国人民, 事实上也是全世界人民。 因为只有你明白了社会机构, 比如说卫生系统, 它们在脆弱环境中的价值, 你才会去付出努力去支持拯救它们。 只有这样,你才能不去理会 《X国所有医生都在逃命》这样的文章。 文章说,“我想知道这意味着什么? 我想知道 X国的卫生系统是否可以检测 比如说流感这样的疾病?” 要我说,“嗯,情况不那么乐观。“
Up on the screen, I've put up my three favorite American institution defenders and builders. Over here is George C. Marshall, he was the guy that proposed the Marshall Plan to save all of Europe's economic institutions after World War II. And this Eleanor Roosevelt. Her work on human rights really serves as the foundation for all of our international human rights organizations. Then my big favorite is Ben Franklin, who did many things in terms of creating institutions, but was the midwife of our constitution.
在屏幕上, 我已经放上了我最喜欢的三个 美国的机构创建者及捍卫者。 这个是乔治·卡特莱特·马歇尔, 他是马歇尔计划的提出者, 在二战后拯救了 所有欧洲的经济体系。 这个是埃莉诺·罗斯福。 她在人权方面所做的工作是 我们所有国际人权组织的基石。 接下来这个是我最喜欢的 本杰明·富兰克林 他在机构创建上面做了很多工作, 同时也是我们宪法的起草者。
And I would say to you that these are folks who, when our country was threatened, or our world was threatened, they didn't retreat. They didn't talk about building walls. They talked about building institutions to protect human security, for their generation and also for ours. And I think our generation should do the same.
我想告诉大家的是 这些就是当我们的国家, 我们的世界受到威胁时 永不退缩的人。 他们不讨论筑城墙。 而是通过建立机构去保护人们的安全, 功在当代,利在千秋。 我们应当以他们为楷模。
Thank you.
谢谢。
(Applause)
(掌声)