In the mid-'90s, the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for seven out of 10 of the leading causes of death in the United States. In high doses, it affects brain development, the immune system, hormonal systems, and even the way our DNA is read and transcribed. Folks who are exposed in very high doses have triple the lifetime risk of heart disease and lung cancer and a 20-year difference in life expectancy. And yet, doctors today are not trained in routine screening or treatment. Now, the exposure I'm talking about is not a pesticide or a packaging chemical. It's childhood trauma.
90 年代中期, 疾病防治中心和凱薩醫療機構 發現暴露於某種物質, 會使死亡風險劇增。 在美國,它占主要死亡原因的 70%。 暴露於高劑量時,會影響大腦發育、 免疫系統、激素系統、 甚至影響 DNA 讀取和轉錄方式。 暴露在高劑量下的人們, 有 3 倍風險患上心臟病和肺癌。 預期壽命減少 20 年。 但現時醫生未接受相關培訓, 對其進行常規檢查或治療。 這種病因指的不是農藥 或包裝上的化學物質, 而是童年創傷。
Okay. What kind of trauma am I talking about here? I'm not talking about failing a test or losing a basketball game. I am talking about threats that are so severe or pervasive that they literally get under our skin and change our physiology: things like abuse or neglect, or growing up with a parent who struggles with mental illness or substance dependence.
到底是哪種創傷呢? 不是考試不合格或輸掉籃球賽。 那種危害極其嚴重、無孔不入, 以致深入骨髓,改變了我們的生理: 例如虐待、忽視, 或童年受到患有精神病的父母影響, 或父母患物質依賴症。
Now, for a long time, I viewed these things in the way I was trained to view them, either as a social problem -- refer to social services -- or as a mental health problem -- refer to mental health services. And then something happened to make me rethink my entire approach. When I finished my residency, I wanted to go someplace where I felt really needed, someplace where I could make a difference. So I came to work for California Pacific Medical Center, one of the best private hospitals in Northern California, and together, we opened a clinic in Bayview-Hunters Point, one of the poorest, most underserved neighborhoods in San Francisco. Now, prior to that point, there had been only one pediatrician in all of Bayview to serve more than 10,000 children, so we hung a shingle, and we were able to provide top-quality care regardless of ability to pay. It was so cool. We targeted the typical health disparities: access to care, immunization rates, asthma hospitalization rates, and we hit all of our numbers. We felt very proud of ourselves.
很長一段時間裡, 我看待這些事的方式受教育影響, 將其視為社會問題, 交由社會服務解決, 或視為心理健康問題, 運用心理健康服務。 但有一件事, 重塑了我整個思維方式。 醫院實習結束後, 我想去一個真正需要我的地方, 一個我能有所作為的地方。 所以我去了 加利福尼亞太平洋醫療中心, 北加最好的私立醫院之一, 我們合作 在舊金山灣景區開了家診所, 那是舊金山最窮、 社區服務最差的區。 在這之前, 整個灣景區只有一位兒科醫生, 負責一萬多名兒童的醫療, 於是我們開始掛牌營業, 提供最優質的服務, 不論病人能否支付費用。 這很有意義, 我們旨在減少常見醫療服務的差距: 如:看護服務、 疫苗接種率、哮喘住院率, 每項我們都達標了, 我們感到很自豪。
But then I started noticing a disturbing trend. A lot of kids were being referred to me for ADHD, or Attention Deficit Hyperactivity Disorder, but when I actually did a thorough history and physical, what I found was that for most of my patients, I couldn't make a diagnosis of ADHD. Most of the kids I was seeing had experienced such severe trauma that it felt like something else was going on. Somehow I was missing something important.
但我注意到一個讓人憂心的趨勢。 很多孩子被診斷患有 「過動症」交給我, 或稱:「注意力不足過動症」。 但我給他們做 全面病史和身體檢查後, 發現大部分病人, 我難以斷定是過動症。 這些孩子多數受過嚴重的創傷, 讓我覺得另有起因。 我莫名地感覺遺漏了一個重要因素。
Now, before I did my residency, I did a master's degree in public health, and one of the things that they teach you in public health school is that if you're a doctor and you see 100 kids that all drink from the same well, and 98 of them develop diarrhea, you can go ahead and write that prescription for dose after dose after dose of antibiotics, or you can walk over and say, "What the hell is in this well?" So I began reading everything that I could get my hands on about how exposure to adversity affects the developing brains and bodies of children.
實習之前, 我取得過公共衛生碩士學位, 在學校裡,我學到的一點是: 如果你是個醫生 看到 100 個孩子喝了同一口井的水, 其中 98 個得了腹瀉, 你可以直接開張處方, 一劑又一劑的抗生素, 或問:「這井裡到底有什麼鬼東西?」 於是,我開始查閱 手上所有相關文獻, 研究長期暴露在逆境下 對成長期間的小孩 有何身心健康影響。
And then one day, my colleague walked into my office, and he said, "Dr. Burke, have you seen this?" In his hand was a copy of a research study called the Adverse Childhood Experiences Study. That day changed my clinical practice and ultimately my career.
有一天,我同事走進辦公室,說: 「柏醫生,妳看過這個嗎?」 他手裡是一份研究報告, 名字是《童年不良經驗研究》。 那一天,改變了我的醫療方法, 最終改變了我的職業生涯。
The Adverse Childhood Experiences Study is something that everybody needs to know about. It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC, and together, they asked 17,500 adults about their history of exposure to what they called "adverse childhood experiences," or ACEs. Those include physical, emotional, or sexual abuse; physical or emotional neglect; parental mental illness, substance dependence, incarceration; parental separation or divorce; or domestic violence. For every yes, you would get a point on your ACE score. And then what they did was they correlated these ACE scores against health outcomes. What they found was striking. Two things: Number one, ACEs are incredibly common. Sixty-seven percent of the population had at least one ACE, and 12.6 percent, one in eight, had four or more ACEs. The second thing that they found was that there was a dose-response relationship between ACEs and health outcomes: the higher your ACE score, the worse your health outcomes. For a person with an ACE score of four or more, their relative risk of chronic obstructive pulmonary disease was two and a half times that of someone with an ACE score of zero. For hepatitis, it was also two and a half times. For depression, it was four and a half times. For suicidality, it was 12 times. A person with an ACE score of seven or more had triple the lifetime risk of lung cancer and three and a half times the risk of ischemic heart disease, the number one killer in the United States of America.
童年不良經歷研究 是大家都需要了解的東西。 它由凱薩醫療機構的文醫生 (Vince Felitti) 和 疾控中心的安達醫生 (Bob Anda) 聯手完成。 他們詢問了 17500 名成年人, 了解他們的「童年不良經驗」, 簡稱 ACE。 包括身心上的不良經歷及性虐待; 生理或情感忽略; 父母患精神疾病、物質依賴或入獄; 父母分居或離婚; 或家庭暴力。 每經歷一種,ACE 指數就加 1。 接著, 他們把 ACE 指數 與健康現狀聯系起來。 他們得出驚人的結果。 其中有兩點: 一是 ACE 非常普遍。 67% 的人有至少一個 ACE, 12.6%,即八分之一的人 有 4 個以上的 ACE。 二是: ACE 經歷的多少與 健康狀況有關係: ACE 指數越高, 健康現狀越差。 ACE 指數為 4 或更高的人, 患慢性阻塞性肺疾病的相對機率, 是指數爲 0 的人的 2.5 倍。 患肝炎的機率也是 2.5 倍。 患憂鬱症的機率是 4.5 倍。 自殺傾向則是 12 倍。 ACE 指數為 7 或以上的人 患肺癌的終身風險為 3 倍, 患冠心病的終身風險為 3.5 倍, 這疾病是美國頭號殺手。
Well, of course this makes sense. Some people looked at this data and they said, "Come on. You have a rough childhood, you're more likely to drink and smoke and do all these things that are going to ruin your health. This isn't science. This is just bad behavior."
這當然說得通, 有些人看了這些數據會說: 「如果你有個痛苦的童年, 你抽煙喝酒的機率更高, 會做些毀掉健康的行為。 這不是科學,只是不健康行爲。」
It turns out this is exactly where the science comes in. We now understand better than we ever have before how exposure to early adversity affects the developing brains and bodies of children. It affects areas like the nucleus accumbens, the pleasure and reward center of the brain that is implicated in substance dependence. It inhibits the prefrontal cortex, which is necessary for impulse control and executive function, a critical area for learning. And on MRI scans, we see measurable differences in the amygdala, the brain's fear response center. So there are real neurologic reasons why folks exposed to high doses of adversity are more likely to engage in high-risk behavior, and that's important to know.
但這正是其科學性的所在。 現在我們比以前更清楚地知道, 童年遭遇不良經歷, 會影響兒童的身體及大腦發育, 它對腦部伏核産生影響, 這是大腦對快樂和獎勵的處理中心, 它與物質依賴有關。 不良經歷會抑制前額皮質, 這個部位對衝動控制 和行動力有影響, 對學習能力有決定性影響。 在核磁共振掃描上, 會發現杏仁核有明顯的差異, 它是大腦的恐懼反應中心。 因此,從神經學而言 遭遇較多不良經歷的人, 做出高風險行為的機率更大, 了解這一點很重要。
But it turns out that even if you don't engage in any high-risk behavior, you're still more likely to develop heart disease or cancer. The reason for this has to do with the hypothalamic–pituitary–adrenal axis, the brain's and body's stress response system that governs our fight-or-flight response. How does it work? Well, imagine you're walking in the forest and you see a bear. Immediately, your hypothalamus sends a signal to your pituitary, which sends a signal to your adrenal gland that says, "Release stress hormones! Adrenaline! Cortisol!" And so your heart starts to pound, Your pupils dilate, your airways open up, and you are ready to either fight that bear or run from the bear. And that is wonderful if you're in a forest and there's a bear. (Laughter) But the problem is what happens when the bear comes home every night, and this system is activated over and over and over again, and it goes from being adaptive, or life-saving, to maladaptive, or health-damaging. Children are especially sensitive to this repeated stress activation, because their brains and bodies are just developing. High doses of adversity not only affect brain structure and function, they affect the developing immune system, developing hormonal systems, and even the way our DNA is read and transcribed.
但事實上,即使你不做高風險行爲, 你依然容易患上心臟病或者癌症。 這點跟 下丘腦—垂體—腎上腺軸有關, 它是大腦和身體的應激反應系統。 影響著我們「戰還是逃」的決定。 這是怎麼運作的呢? 想像一下, 你在森林中看見一隻熊。 你的下丘腦會瞬間發送信號到腦垂體, 腦垂體向腎上腺發信號, 「釋放應激激素!腎上腺素!皮質醇!」 然後你開始心跳加快, 瞳孔放大,呼吸道大開, 你已經做好準備, 跟這只熊抗擊或逃跑。 這非常重要, 如果你在森林中,而那裡有隻熊。 (笑) 但問題是, 如果這只熊每天都來騷擾你, 這個應激系統 一而再再而三地啓動, 它從一種適應性或救命的系統,, 變成適應不良或有損健康的系統。 兒童對這種反復的應激激活很敏感, 因爲他們的大腦和身體 都還在發育階段, 大量的逆境 不單損傷他們的大腦結構和功能, 還會影響發育中的免疫系統、 激素系統, 甚至影響 DNA 的讀取和轉錄方式。
So for me, this information threw my old training out the window, because when we understand the mechanism of a disease, when we know not only which pathways are disrupted, but how, then as doctors, it is our job to use this science for prevention and treatment. That's what we do.
對我而言, 這個發現顛覆了我以前的認知, 因爲當我們明白了一種疾病的機制, 知道了被干擾的路徑及方式, 作爲醫生,我們理應運用科學 去預防和治療這種疾病。 是職責所在。
So in San Francisco, we created the Center for Youth Wellness to prevent, screen and heal the impacts of ACEs and toxic stress. We started simply with routine screening of every one of our kids at their regular physical, because I know that if my patient has an ACE score of 4, she's two and a half times as likely to develop hepatitis or COPD, she's four and half times as likely to become depressed, and she's 12 times as likely to attempt to take her own life as my patient with zero ACEs. I know that when she's in my exam room. For our patients who do screen positive, we have a multidisciplinary treatment team that works to reduce the dose of adversity and treat symptoms using best practices, including home visits, care coordination, mental health care, nutrition, holistic interventions, and yes, medication when necessary. But we also educate parents about the impacts of ACEs and toxic stress the same way you would for covering electrical outlets, or lead poisoning, and we tailor the care of our asthmatics and our diabetics in a way that recognizes that they may need more aggressive treatment, given the changes to their hormonal and immune systems.
於是,我們在舊金山 創立了青少年健康中心, 用以預防、檢查並治癒 因 ACE 及有害壓力所造成的影響。 我們開始對每個孩子做檢查, 作為常規體檢的一部分, 因爲我知道 如果病人有 4 分的 ACE 值, 她患肝炎或慢性阻塞性肺病 機率是 2.5 倍, 4.5 倍的機率患憂鬱, 12 倍的機率選擇自殺, 比那些 ACE 為 0 的人而言。 當她在檢查室裡,我就知道了。 檢查結果呈陽性的患者, 我們有支多學科的團隊, 致力於降低逆境的影響。 運用最好的療法, 包括家訪、協調護理、 心理保健及營養均衡、 全面干預措施, 以及藥物治療,有必要的話。 同時我們也向家長普及 ACE 和有害壓力的危害。 這危害可與觸電或鉛中毒相提並論。 同時我們調整對哮喘患者 和糖尿病患者的護理, 意識到他們可能需要更積極的治療, 因為他們的荷爾蒙 和免疫系統受到了影響。
So the other thing that happens when you understand this science is that you want to shout it from the rooftops, because this isn't just an issue for kids in Bayview. I figured the minute that everybody else heard about this, it would be routine screening, multi-disciplinary treatment teams, and it would be a race to the most effective clinical treatment protocols. Yeah. That did not happen. And that was a huge learning for me. What I had thought of as simply best clinical practice I now understand to be a movement. In the words of Dr. Robert Block, the former President of the American Academy of Pediatrics, "Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation today." And for a lot of people, that's a terrifying prospect. The scope and scale of the problem seems so large that it feels overwhelming to think about how we might approach it. But for me, that's actually where the hopes lies, because when we have the right framework, when we recognize this to be a public health crisis, then we can begin to use the right tool kit to come up with solutions. From tobacco to lead poisoning to HIV/AIDS, the United States actually has quite a strong track record with addressing public health problems, but replicating those successes with ACEs and toxic stress is going to take determination and commitment, and when I look at what our nation's response has been so far, I wonder, why haven't we taken this more seriously?
知道這個科學道理後, 你會想要廣而告之, 因爲這不僅是灣景區孩子們的問題。 我以為每個人明白這道理後, 相關檢查會變為常規, 多學科團隊會組成, 大家爭先尋找有效治療方案。 但這些都沒有發生。 對我而言,這是個大教訓。 我簡單地認為 找到最好的治療方法就能解決。 現在我明白了,這是一場運動。 如美國兒科學會的前會長 羅伯特博士所說: 「不良的童年經歷 是現時我國唯一一個最大的 未解決的公共健康威脅。」 對於大多數人而言, 這個前景並不樂觀。 這個問題的範圍和規模似乎太大了, 以至讓人感覺這難以解決。 但於我而言,那正是希望之所在, 因爲當我們有正確的框架, 並意識到這是個公眾健康危機, 我們就可以開始運用合適的工具 去找出解決辦法。 例如煙草、鉛中毒、愛滋病, 美國在解決公共健康問題方面, 實際上保持了良好的記錄, 若要在 ACE 和有害壓力方面也成功, 將需要決心和承諾, 基於現時我看到民眾對此的反響, 我想知道, 爲什麽我們沒有 更嚴肅地看待這個問題? 起初我以為我們忽略了這個問題,
You know, at first I thought that we marginalized the issue because it doesn't apply to us. That's an issue for those kids in those neighborhoods. Which is weird, because the data doesn't bear that out. The original ACEs study was done in a population that was 70 percent Caucasian, 70 percent college-educated. But then, the more I talked to folks, I'm beginning to think that maybe I had it completely backwards. If I were to ask how many people in this room grew up with a family member who suffered from mental illness, I bet a few hands would go up. And then if I were to ask how many folks had a parent who maybe drank too much, or who really believed that if you spare the rod, you spoil the child, I bet a few more hands would go up. Even in this room, this is an issue that touches many of us, and I am beginning to believe that we marginalize the issue because it does apply to us. Maybe it's easier to see in other zip codes because we don't want to look at it. We'd rather be sick.
以為它和我們無關, 那只是鄰居家孩子的問題。 這很奇怪, 因爲數據不支持這個說法。 在最早的 ACE 研究中, 白種人占 70%, 受過大學教育的占 70%。 但我愈向人們談論此問題, 我愈認為我可能本末倒置了。 若我問在座各位有多少人 與患有心理疾病的家人一起長大, 我打賭有幾個人會舉起手。 若我問有多少人的父母經常喝醉酒, 或認為你不打孩子就是溺愛他們, 我打賭會有更多人舉起手。 即使是在這個會場, 這個問題也影響了很多人, 我開始認為,我們忽視這個問題 正因爲它影響著我們。 或許作為旁觀者更易看清, 因爲我們寧願生病, 也不想面對這個問題。
Fortunately, scientific advances and, frankly, economic realities make that option less viable every day. The science is clear: Early adversity dramatically affects health across a lifetime. Today, we are beginning to understand how to interrupt the progression from early adversity to disease and early death, and 30 years from now, the child who has a high ACE score and whose behavioral symptoms go unrecognized, whose asthma management is not connected, and who goes on to develop high blood pressure and early heart disease or cancer will be just as anomalous as a six-month mortality from HIV/AIDS. People will look at that situation and say, "What the heck happened there?" This is treatable. This is beatable. The single most important thing that we need today is the courage to look this problem in the face and say, this is real and this is all of us. I believe that we are the movement.
幸運的是,科學的進步以及 坦率地說,經濟現實 逐漸使我們變得難以忽視它。 科學道理很明確: 童年逆境對健康 有著終身性的巨大影響。 現在我們開始了解如何阻止其發展, 從童年逆境發展到疾病和過早死亡, 現在開始未來 30 年裡, ACE 指數過高的小孩, 若其行為症狀無法確認, 哮喘治療未與 ACE 關聯, 逐漸發展成爲高血壓, 或是早期心臟病或癌症, 這將和患愛滋病六個月 就死亡一樣異常。 對此,人們會問: 「到底發生了什麼?」 這是可以治癒的。 可以戰勝的。 現在我們需要做最重要的一件事是 勇於直接面對這個問題, 接受這就是現實, 它和我們息息相關。 我認為我們就是這項運動的關鍵。
Thank you.
謝謝。
(Applause)
(掌聲)