I want you to imagine this for a moment. Two men, Rahul and Rajiv, living in the same neighborhood, from the same educational background, similar occupation, and they both turn up at their local accident emergency complaining of acute chest pain. Rahul is offered a cardiac procedure, but Rajiv is sent home.
让我们一起来想象一下, 有两个人,拉胡和拉吉, 住在一个小区, 教育程度相同,工作也差不多。 他俩都去当地的急诊室, 说他们有严重的胸部疼痛 急诊室给拉胡做了心脏检查, 却让拉吉回家。
What might explain the difference in the experience of these two nearly identical men? Rajiv suffers from a mental illness. The difference in the quality of medical care received by people with mental illness is one of the reasons why they live shorter lives than people without mental illness. Even in the best-resourced countries in the world, this life expectancy gap is as much as 20 years. In the developing countries of the world, this gap is even larger.
是什么原因让这两个几乎一样的人 有着不同的遭遇? 因为拉吉患有精神疾病。 得不到同等质量的医疗服务, 是导致精神疾病患者寿命 短于不罹患精神疾病的人 的原因之一。 即使是在世界上资源最为丰富的国家, 这一寿命差距也有20年之多。 而在发展中国家, 两者的寿命差距更大。
But of course, mental illnesses can kill in more direct ways as well. The most obvious example is suicide. It might surprise some of you here, as it did me, when I discovered that suicide is at the top of the list of the leading causes of death in young people in all countries in the world, including the poorest countries of the world.
然而,精神疾病当然也可以更直接地导致死亡。 最常见的例子就是自杀。 也许在座的一些朋友会感到吃惊,我那时也是, 因为我发现,自杀在引起青年死亡的主要原因中 排在第一位。 在每一个国家都是如此, 包括世界上最贫穷的国家。
But beyond the impact of a health condition on life expectancy, we're also concerned about the quality of life lived. Now, in order for us to examine the overall impact of a health condition both on life expectancy as well as on the quality of life lived, we need to use a metric called the DALY, which stands for a Disability-Adjusted Life Year. Now when we do that, we discover some startling things about mental illness from a global perspective. We discover that, for example, mental illnesses are amongst the leading causes of disability around the world. Depression, for example, is the third-leading cause of disability, alongside conditions such as diarrhea and pneumonia in children. When you put all the mental illnesses together, they account for roughly 15 percent of the total global burden of disease. Indeed, mental illnesses are also very damaging to people's lives, but beyond just the burden of disease, let us consider the absolute numbers. The World Health Organization estimates that there are nearly four to five hundred million people living on our tiny planet who are affected by a mental illness. Now some of you here look a bit astonished by that number, but consider for a moment the incredible diversity of mental illnesses, from autism and intellectual disability in childhood, through to depression and anxiety, substance misuse and psychosis in adulthood, all the way through to dementia in old age, and I'm pretty sure that each and every one us present here today can think of at least one person, at least one person, who's affected by mental illness in our most intimate social networks. I see some nodding heads there.
不过,除去健康状况对寿命的影响, 我们还关心 生活质量。 现在,为了让我们准确的知道 健康对寿命和生活质量的全面影响 我们需要用到 一个叫做DALY的度量单位, DALY是伤残调整生命年的缩写(Disability-Adjusted Life Year)。 当我们这么做时,我们发现了精神疾病的一些令人震惊的事实, 而这些事实是世界各国普遍存在的。 例如,我们发现了精神疾病是 引起生活不能自理的主要原因。 比如,抑郁正是第三大原因, 除此之外,还有 腹泻和儿童肺炎。 当把所有精神疾病看成一个整体, 全球15%的疾病负担 是由他们造成的。 事实上,精神疾病对人们的身体将抗具有很大的破坏性, 除了疾病负担, 让我们全面的了解一下精神疾病的破坏性。 世界卫生组织统计到 全世界有 接近四亿到五亿的人 受到精神疾病的影响。 你们中有一些人 对这个数字赶到震惊, 但是,仔细想一下,精神疾病有数以万计的种类, 从儿童时的自闭症、智障 到成年的抑郁、焦虑、 滥用药物和精神病, 再到老年的痴呆, 我敢肯定的说,今天在座的每一个人 都能想到至少一个人, 在我们最熟悉的人中,至少有一个人 受到精神疾病的影响。 我看到一些人在点头。
But beyond the staggering numbers, what's truly important from a global health point of view, what's truly worrying from a global health point of view, is that the vast majority of these affected individuals do not receive the care that we know can transform their lives, and remember, we do have robust evidence that a range of interventions, medicines, psychological interventions, and social interventions, can make a vast difference. And yet, even in the best-resourced countries, for example here in Europe, roughly 50 percent of affected people don't receive these interventions. In the sorts of countries I work in, that so-called treatment gap approaches an astonishing 90 percent. It isn't surprising, then, that if you should speak to anyone affected by a mental illness, the chances are that you will hear stories of hidden suffering, shame and discrimination in nearly every sector of their lives. But perhaps most heartbreaking of all are the stories of the abuse of even the most basic human rights, such as the young woman shown in this image here that are played out every day, sadly, even in the very institutions that were built to care for people with mental illnesses, the mental hospitals.
除了这些令人震惊的数字, 从全球健康的角度来看, 真正重要和真正令人担忧的是, 在受影响的这些人中有很大一部分 没有接受治疗 然而,这些治疗确实可以改变他们的生活,请注意, 我们有充分的证据表明, 一些干预、药物治疗、心理辅导和社会干预 确实对精神疾病的治疗有很大的作用。 但是,即使在资源丰富的国家 例如欧洲也有大约50%的人 不能接受治疗。 在我工作的一些国家, 甚至有90%的人 不能接受治疗。 因此,当你与 患有精神疾病的人交谈时, 你一般总是能听到他们说起 几乎在他们所有的生活领域, 他们都会有隐藏的痛苦、羞耻和被歧视的感觉。 但是,或许在他们的描述中, 最令人痛心的就是 对最基本的人权的践踏, 就像这张照片中的女子 这样的事情每天都会发生, 悲哀的是,即使是在本应该治疗人们精神疾病的 医院中也存在这种现象。
It's this injustice that has really driven my mission to try to do a little bit to transform the lives of people affected by mental illness, and a particularly critical action that I focused on is to bridge the gulf between the knowledge we have that can transform lives, the knowledge of effective treatments, and how we actually use that knowledge in the everyday world. And an especially important challenge that I've had to face is the great shortage of mental health professionals, such as psychiatrists and psychologists, particularly in the developing world.
这是这一点让我感觉到我应该 试着做一点努力来改变 遭受精神疾病折磨的人们的生活, 我做的一个主要的工作就是在 我们所拥有的改变生活、有效治疗的知识与 把知识运用到日常生活中之间 搭建一所桥梁。 我所要面对的一个重要挑战就是 极度缺乏像精神病专家和心理学专家这类的 精神健康专家, 而这一现在在发展中国家尤为严重。
Now I trained in medicine in India, and after that I chose psychiatry as my specialty, much to the dismay of my mother and all my family members who kind of thought neurosurgery would be a more respectable option for their brilliant son. Any case, I went on, I soldiered on with psychiatry, and found myself training in Britain in some of the best hospitals in this country. I was very privileged. I worked in a team of incredibly talented, compassionate, but most importantly, highly trained, specialized mental health professionals.
现在,我在印度学习了医学, 我选择了精神病治疗作为的专业, 这让我妈妈和我的亲戚觉得很失望, 因为在她们严重神经外科医生才 配得上他们聪明的儿子。 我始终坚持着做精神病治疗不论遇到什么病例, 并且我让自己在英国一些最好的医院得到了锻炼。 我十分的幸运。 我与一些十分有天赋、有工作热情的人一起工作, 但是最重要的是,他们也是接受了严格训练的、 专业的精神疾病专家。
Soon after my training, I found myself working first in Zimbabwe and then in India, and I was confronted by an altogether new reality. This was a reality of a world in which there were almost no mental health professionals at all. In Zimbabwe, for example, there were just about a dozen psychiatrists, most of whom lived and worked in Harare city, leaving only a couple to address the mental health care needs of nine million people living in the countryside.
在我学习完不久,我首先在津巴布韦工作, 之后到了印度, 我又需要面对一个新的事实。 我需要面对的是,有一些地方 根本就没有精神病专家。 例如,在津巴布韦,只有大约十来个精神病医生, 并且他们中的大部分居住在哈拉雷(津巴布韦首都), 使得只有几个精神病医生 负责生活在乡下的9百万人的 精神健康。
In India, I found the situation was not a lot better. To give you a perspective, if I had to translate the proportion of psychiatrists in the population that one might see in Britain to India, one might expect roughly 150,000 psychiatrists in India. In reality, take a guess. The actual number is about 3,000, about two percent of that number.
印度的情况不比津巴布韦好到哪里去。 具体地说,如果我把 英国精神病医生的人口比例 应用到印度 印度大约需要15万精神病医生。 然而事实又是怎样呢? 实际上,印度只有3千精神病医生, 只是15万的百分之2。
It became quickly apparent to me that I couldn't follow the sorts of mental health care models that I had been trained in, one that relied heavily on specialized, expensive mental health professionals to provide mental health care in countries like India and Zimbabwe. I had to think out of the box about some other model of care.
我很快的意识到,在像印度或津巴布韦这些国家,我不能 我不能再遵循我所学的那种精神病治疗模式了, 因为那种模式的精神病治疗, 只能在一个人有能力获得专业的、昂贵的精神病专家的治疗 的情况下才能成功。 我必须打破思维定势, 寻找其他方式。
It was then that I came across these books, and in these books I discovered the idea of task shifting in global health. The idea is actually quite simple. The idea is, when you're short of specialized health care professionals, use whoever is available in the community, train them to provide a range of health care interventions, and in these books I read inspiring examples, for example of how ordinary people had been trained to deliver babies, diagnose and treat early pneumonia, to great effect. And it struck me that if you could train ordinary people to deliver such complex health care interventions, then perhaps they could also do the same with mental health care.
那时,我接触了这些书, 在这些书中我发现了 全球健康任务转变这一观点。 这一想法十分的简单。就是, 当你缺少专业的健康专家时, 可以找社区中有空闲时间的人 教给他们一些保健干预的知识, 这些书中就有一些鼓舞我的例子。 例如,书中有写到怎样使普通人学会 接生、诊断并治疗早期肺炎, 这些都十分的有效。 于是,我想到,如果我们可以训练普通人去 完成这些复杂的保健干预, 或许他们也能进行 精神疾病治疗。
Well today, I'm very pleased to report to you that there have been many experiments in task shifting in mental health care across the developing world over the past decade, and I want to share with you the findings of three particular such experiments, all three of which focused on depression, the most common of all mental illnesses. In rural Uganda, Paul Bolton and his colleagues, using villagers, demonstrated that they could deliver interpersonal psychotherapy for depression and, using a randomized control design, showed that 90 percent of the people receiving this intervention recovered as compared to roughly 40 percent in the comparison villages. Similarly, using a randomized control trial in rural Pakistan, Atif Rahman and his colleagues showed that lady health visitors, who are community maternal health workers in Pakistan's health care system, could deliver cognitive behavior therapy for mothers who were depressed, again showing dramatic differences in the recovery rates. Roughly 75 percent of mothers recovered as compared to about 45 percent in the comparison villages. And in my own trial in Goa, in India, we again showed that lay counselors drawn from local communities could be trained to deliver psychosocial interventions for depression, anxiety, leading to 70 percent recovery rates as compared to 50 percent in the comparison primary health centers.
今天,我十分高兴的告诉你们 在过去十年,发展中国家有许多 精神疾病治疗任务转移的实验, 我想和你们分享3个特殊的实验 的成果, 这三个实验都是关于最普遍 的精神疾病——抑郁症。 在乌干达的郊区,Paul Bolton 和他的同事 对该村村民进行实验,发现他们可以 进行抑郁症的人际关系精神疗法, Paul 和他的同事进行了一些随机控制实验, 他们发现接受这种干预的90%的人恢复健康, 而与之相比在对照组,只有 大约40%的人恢复了健康。 类似的,Atif Rahman和他的同时在 巴基斯坦的郊区也进行了随机控制实验, 该实验表明在巴基斯坦保健系统 的社区女工作者 在对患有抑郁的母亲进行认知行为治疗时 也同样在康复比例上取得了显著的提高。 大约75%的母亲获得了康复,而 对照组中只有45% 恢复了健康。 我在印度果阿的实验再一次证明 从当地社区中寻找的普通人 在经过培训后可以对抑郁、焦虑进行心理干涉, 这些健康顾问可以让70%的人恢复健康, 而即使在主要的健康中心, 这一数据也只能达到50%。
Now, if I had to draw together all these different experiments in task shifting, and there have of course been many other examples, and try and identify what are the key lessons we can learn that makes for a successful task shifting operation, I have coined this particular acronym, SUNDAR. What SUNDAR stands for, in Hindi, is "attractive." It seems to me that there are five key lessons that I've shown on this slide that are critically important for effective task shifting. The first is that we need to simplify the message that we're using, stripping away all the jargon that medicine has invented around itself. We need to unpack complex health care interventions into smaller components that can be more easily transferred to less-trained individuals. We need to deliver health care, not in large institutions, but close to people's homes, and we need to deliver health care using whoever is available and affordable in our local communities. And importantly, we need to reallocate the few specialists who are available to perform roles such as capacity-building and supervision.
现在,总观这些关于任务转换的不同实验, 当然还有其他的实验, 当我试着寻找 成功的任务转换的 关键所在时, 我将其总结为这样一个缩略语:SUNDAR。 SUNDAR是什么意思呢?在印度语中是“诱人的意思”。 在我看来,对于一个有效的任务转换, 有五个关键之处, 请看幻灯片。 第一,我们需要简化信息, 将医学中的专业术语 剔除。 我们需要将复杂的,未经加工的保健干预 变成短小的内容,只有这样我们才能简单的将其 教授给缺乏专业训练的人员。 我们提供的健康治疗,并不是在一些大型的机构中提供, 而是在人们家附近提供,并且 我们用的是当地社区有空闲时间且有能力 的人。 重要的是,我们要将有时间的仅有的几个专家 也重新划定角色, 例如,让他们做一些能力培养和监督的工作。
Now for me, task shifting is an idea with truly global significance, because even though it has arisen out of the situation of the lack of resources that you find in developing countries, I think it has a lot of significance for better-resourced countries as well. Why is that? Well, in part, because health care in the developed world, the health care costs in the [developed] world, are rapidly spiraling out of control, and a huge chunk of those costs are human resource costs. But equally important is because health care has become so incredibly professionalized that it's become very remote and removed from local communities. For me, what's truly sundar about the idea of task shifting, though, isn't that it simply makes health care more accessible and affordable but that it is also fundamentally empowering. It empowers ordinary people to be more effective in caring for the health of others in their community, and in doing so, to become better guardians of their own health. Indeed, for me, task shifting is the ultimate example of the democratization of medical knowledge, and therefore, medical power.
对我来说,任务转换是一个 在全球都有重要性的想法, 即使,这一想法是在发展中国家 这些缺乏资源的条件下产生的, 它对资源充足的国家同样有 许多重要意义。为什么是这样呢? 一部分的原因是发达国家和发展中国家 疾病治疗的费用差距 正在呈现螺旋式的发展,而这一趋势已经控制不了了, 其中,人力资源的耗费占很大一部分。 还有一个同样重要的原因就是,随着健康治疗 变得越来越专业, 它与当地社区的距离也就越来越远。 对我来说,任务转变这一思想真正吸引人的地方 不是它可以使更多的人接受 健康治疗,而是 它的最基本的激励作用。 它激励普通人在治疗 本社区患者时变得更加有效, 同时,他们也成了患者们更好的 健康卫士。事实上,对我来说,任务转变是 医疗知识民主化的最终范例, 因此他也是医学力量民主化的最终范例。
Just over 30 years ago, the nations of the world assembled at Alma-Ata and made this iconic declaration. Well, I think all of you can guess that 12 years on, we're still nowhere near that goal. Still, today, armed with that knowledge that ordinary people in the community can be trained and, with sufficient supervision and support, can deliver a range of health care interventions effectively, perhaps that promise is within reach now. Indeed, to implement the slogan of Health for All, we will need to involve all in that particular journey, and in the case of mental health, in particular we would need to involve people who are affected by mental illness and their caregivers.
仅在30年前,世界各国聚集在 阿拉木图发表了如图这个图标式宣言。 我认为,你们都能想到 12年后,我们离那个目标还是很遥远。 然而,今天,我们有条件 在充足的监督和支持下, 使得社区中的普通人通过接受训练 可以进行一系列有效的健康干预, 或许那个承诺已在我们的能力范围之内。 事实上,为了贯彻实现所有人健康这一口号, 我们需要所有人 对此的参与, 在精神健康方面,我们格外 需要患有精神疾病的患者和 他们的护理者的参与。
It is for this reason that, some years ago, the Movement for Global Mental Health was founded as a sort of a virtual platform upon which professionals like myself and people affected by mental illness could stand together, shoulder-to-shoulder, and advocate for the rights of people with mental illness to receive the care that we know can transform their lives, and to live a life with dignity.
几年前,正是因为这个原因, 全球精神卫生运动成立了, 作为一个虚拟平台, 许多像我一样的专家和被精神疾病困扰着的人们 团结起来,肩并着肩, 倡导精神疾病患者获得 可以改变他们生活的治疗的权利, 让他们活的有尊严。
And in closing, when you have a moment of peace or quiet in these very busy few days or perhaps afterwards, spare a thought for that person you thought about who has a mental illness, or persons that you thought about who have mental illness, and dare to care for them. Thank you. (Applause) (Applause)
最后,我希望当你们空闲时或 在这不忙的几天或者以后的任何时候, 你们可以替你们认识的 患有精神疾病的 人或人们想想, 并尽可能的照顾他们。谢谢。(鼓掌) (鼓掌)