So have you ever wondered what it would be like to live in a place with no rules? That sounds pretty cool.
請問你有曾想過, 生活在一個不受管制的地方 是怎樣感覺嗎? 聽來是蠻酷的。
(Laughter)
(笑聲)
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.
可是,大早醒來後, 你發現沒有管制的原因 卻是因為已沒有政府了, 而且也沒有任何法律了, 甚至一切社會體制都不存在了: 沒有學校, 沒有醫院, 沒有警察, 沒有銀行, 沒有健身會所, 沒有水電等供應。
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.
我倒是知道這是什麼的感覺。 因為在 1999 年, 我為醫學院學生時, 在科索沃戰爭中,曾在巴爾幹的 一個難民收留中心工作。 當戰爭結束後, 難以置信, 我居然獲得醫學院的允許, 拿到假期, 跟著我在營地結識的一些家庭, 回到他們在科索沃的家鄉。 去觀察他們在戰火後, 是如何作生活的安排。
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.
戰後的科索沃 是一個非常有趣的地方, 因為有北約部隊在那裡, 目的是為了確保戰爭 不會再度爆發。 但除此之外,科索沃實際上已是 一個無法無天的地方, 而且幾乎所有的社會體制, 不論是公營或私營, 都已被毀掉了。 所以我可以告訴你, 當你置身在這種情況和環境中, 它是會令你絕對毛骨悚然...... 長達 30 分鐘左右, 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, 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.
個人來說,那一刻發生在當我要 通過第一個檢查站時, 當車子開近時,我就意識到 我必須跟一名全副武裝的人討價還價 才能通過這個檢查點; 如他想在此時此地把我射殺的話, 也是完全合法之事。 但當時我體會到的脆弱感, 是絲毫比不上 我將在未來一年認識的家庭 所體會的脆弱感。
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?
你要明白,生活在一個沒有 任何社會體制的社會裡, 是充滿危險和不確定性的。 甚至一個簡單的問題, 像「今晚我們要吃什麼呢?」 要回答也很複雜了。 至於安全問題, 當你沒有任何保安系統時, 是非常可怕的。 我與街頭那邊的鄰居吵得面紅耳赤, 會不會演變成暴力事件, 終結我的生命 或我家人的生命呢?
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.
沒有衛生系統時,健康問題 也是非常可怕的。 我聽到很多家庭必須解決這類問題: 「我的嬰兒在發燒。我該怎麼辦?」 「我懷孕的姐姐正在出血, 我該怎麼辦? 我該去找誰呢?」 「醫生在哪裡?護士在哪裡?」 如果我能找到一位,會可靠嗎? 我該怎麼付錢? 我要用哪國貨幣支付?」 「如果我需要藥物, 我在哪裡可以找到? 如果我服用了這些藥物, 它會是假冒的嗎?」 連綿不斷的問題。 所以在這環境之下生活, 生活的主要特徵, 就是人民日以繼夜要懂得掌控 這難以置信的脆弱感, 起因就是缺乏社會制度。
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.
原來, 這生活特徵是很難解釋的, 難以得到身置其外的人理解的。 當我離開科索沃時, 我才發現這一點。 我回到了波士頓,我成了一名醫生, 我成了一名 環球公共衞生政策研究員。 我加入了哈佛醫學院 和布萊根婦女醫院的全球衞生部門。 我作為研究員, 真的很想立即就研究這問題。 我在想: 「對生活在這種匱乏環境的人, 我們如何能減少 這令人窒息的脆弱感? 我們可以開始思考用什麼方法 去保護和迅速恢復 這些對生存至關重要的體制, 像醫療衞生系統?」 我不得不說,我有了不起的同事, 但有一件有趣的事情是: 對他們來說, 這是一種不尋常的問題。 他們的反應是: 「哦,你在戰場中工作, 那是不是你是在難民營工作? 在記錄戰爭暴行?」 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, 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.
所以我必得花上一段時間來解釋 我為什麼對這個問題那麼熱衷, 直至大約六年前。 當時這份重點研究被發表, 內容是探討和描述戰爭對公共衞生 所帶來的後果。 研究人員作出一個 意想不到的驚世結論: 這些研究人員的結論 就是絕大多數因戰爭 死亡和殘疾的事情 是發生在衝突停止之後。 所以活在受衝突影響的國家中 最危險的時候, 是在敵對行動停止之後; 是在和平協議簽署之後; 是在政治解決方案已經實現之後。 這表面看來令人費解,但當然不是, 因為戰爭之所以殺人, 是因為它摧毀了診所, 摧毀了醫院, 摧毀了供應鏈。 醫生們被狙擊、殺害,以至逃命。 而且雖無形但更致命的, 就是衞生管治體制及其財政崩潰。
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.
我對這些並不驚訝, 但令我驚訝和有一點沮喪的是: 從這份研究得出的見解, 只能稍微改變 我們對人類苦難和戰爭的看法。 讓我給你幾個例子。
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.
你可能會記得去年 伊波拉病毒侵襲西非國家賴比瑞亞。 當時有很多關於 無國界醫生這個組織的報導, 叫人提高警覺並呼籲作出援助。 但沒有很多報導解答到這個問題: 為什麼無國界醫生會在賴比瑞亞呢? 無國界醫生是一個令人敬佩的組織, 盡心盡力在戰區提供緊急護理。 賴比瑞亞的內戰在 2003 年已結束, 亦是伊波拉病毒爆發的 11 年前。 當伊波拉病毒衝擊賴比瑞亞時, 在全國 450 萬人口之中, 醫生不到 50 名。 無國界醫生駐守在賴比瑞亞, 是因為賴比瑞亞依然沒有 一個能運作的醫療系統, 在 11 年後仍沒有。
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.
在 2010 年,地震衝擊海地後, 來自國際社會的援助排山倒海。 但你知不知道國際社會 捐款中只有 2% 用去重建海地的公共體制, 包括衞生部門? 從這個角度看, 海地人民可謂到了今天 還因地震而繼續死亡。
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?
我最近認識了這位先生, 他是尼薩‧伊斯密特醫生。 他是伊拉克北部自治區庫爾德斯坦的 衞生部長。 他正在宣佈在過去九個月中, 他所屬地區的人口從 400 萬 增加到 500 萬。 這是增加 25% 之多。 這些數以千計的新移民 經歷了難言的創傷。 他轄下的醫生們 每天無薪的工作 16 小時。 可是他的財政預算 並沒有增加 25 %, 而是減少了 20%。 因為撥款已調去應付保安問題 和短期救援工作。 所以當他的衞生部門崩潰時— 如果歷史有任何預告能力, 它是一定會的—— 你覺得這會怎樣影響 當地 500 萬居民的決定呢? 他們正在考量是否應該逃跑, 離開這危機重重的生活環境。
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.
所以你可以看到, 這是個令我沮喪的議題。 我很用心去嘗試理解: 大家為什麼不願意維護和支持 本土的衞生和保安系統呢? 我常聽到兩個關注點或論點。 第一個關注點是貪污: 在這些系統工作的人都是腐敗的, 都是不可信的。 我承認我是有見過品德不良的人物, 在這種情況下之衞生部門工作。 但我也可告訴你, 相反的也是絕對有的, 在我有參與的每一個案件中都有—— 從阿富汗到利比亞、到科索沃、 到海地、到賴比瑞亞—— 我都遇到鼓舞人心的人, 他們都在國家存亡的一刻, 冒著一切風險來 挽救他們的衞生體制。 所以,對真心想幫忙的局外人來說, 難題是如何識別這些人, 並建立渠道讓他們走上領導位置。
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.
這也正是在阿富汗能做到的。 我們在阿富汗國家建設上付出的努力 其中一個無聲無聞的成功故事, 就是世界銀行在 2002 年 投放大量資金 去發掘、培訓和提拔 阿富汗的衞生部門領袖。 這些衞生部門領袖在阿富汗 排除萬難完成壯舉。 他們積極增加醫療服務 讓大部分人口可以使用。 他們正在迅速改善 阿富汗人口的健康狀況, 而它曾經是世界上最糟糕的。 事實上,阿富汗衞生部所做的事 是我希望我們也能在美國做到的。 他們用數據資料來製定政策。 簡直不可思議。
(Laughter)
(笑聲)
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.
我經常聽到的另外一個關注點是: 「我們負擔不起,我們真的沒錢。 這是不可能持續的。」 但讓我告訴你:我們現有的情況 和我們現有的制度 是我們可以想像 最昂貴、效率最低的制度。 目前的情況是美國等多國政府—— 或者說組成歐盟委員會的 一眾成員國政府—— 每年就要花費 150 億美元 在全球的人道、緊急和災難救援上。 這數字不包括外援,只是賑災而已。 這費用 95% 給了國際救援機構, 然後他們必須把資源引進這些地區, 並且拼湊一個臨時衞生系統, 錢用光後就要把它瓦解, 把人員遣散。
So our job, it turns out, is very clear.
所以我們的工作原來是非常清楚的。
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.
我們作為全球衞生政策專家, 首要工作就是要專注監控 在政局不定環境下,衞生部門的 各個強項和弱項。 當我們看到醫生逃跑時, 當我們看到衞生資源枯竭時, 當我們看到體制崩潰時, 這就是緊急情況。 這就是我們需要發出警報 並揮手求救之時。 行嗎? 還等什麼? 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。
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.
第二點: 我在哈佛任職的機構和類似機構 需要從世界銀行 在阿富汗的經驗中學習, 我們需要並將會 建立一個強大的平台來支援 這些衞生部門領袖。 這些人都是冒著生命危險, 我們應該以行動來支持他們的勇氣。
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.
第三點: 我們需要積極溝通, 並建立新的伙伴關係。 在我們的環球衞生中心, 我們與北約和其它安全決策者 發起了一個新舉措, 與他們探討如何 在部署期間維護當地的衞生系統。 我們希望他們明白, 維護當地衞生系統和 其它關鍵社會體制 是他們任務的重要一環。 這不僅是為了避免附帶損害, 更是為了締造和平。
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.
但我們最需要的合作夥伴還是你們: 美國大眾,以至世界大眾。 除非你們能明白 社會體制的寶貴價值, 就像政局不穩環境下的衞生體制, 否則你們是不會支持維護它們的。 你不會點擊那篇文章, 它在談論,「嘿,所有這些醫生 正從某國逃命。 我想知道這意味什麼: 究竟該國衞生系統 有沒有能力檢測流行性感冒爆發?」 「嗯,情況應該好不了那裡。」 我會這樣回答你。
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.
在螢幕上, 是我最喜歡的三位捍衞和建設 社會體制的美國人。 在這邊是喬治·卡特萊特·馬歇爾, 他就是提出馬歇爾計劃的人, 來拯救第二次世界大戰後 所有在歐洲的經濟制度。 這是愛蓮娜·羅斯福。 她的人權工作真正為 我們所有國際人權組織奠定基礎。 這是我最喜歡的班傑明·富蘭克林, 他在創造制度方面做了很多貢獻, 也是我們憲法得以誕生的助產士。
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.
我可以這麼說, 這些人在我們國家受到威脅之時, 或是我們世界受到威脅之時, 並沒有退縮。 他們並沒有談論建圍牆, 他們談論的是建設制度 來保障人類安全, 裨益他們那一代以至我們這一代。 所以我們這一代也應該 做同樣的事情。
Thank you.
謝謝。
(Applause)
(掌聲)