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.
請大家想像一下這樣的情境 有兩個人, 名叫 拉胡跟拉吉 住在同一個區域 有相同的教育背景, 從事相似的職業 兩個人同樣的都出現在同一個區域急救中心 主訴症狀都是劇烈的胸痛 拉胡被施以心血管的療程 而拉吉被告知直接回家
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.
這兩個幾乎相同的人, 為什麼會有截然不同的醫療待遇呢? 拉吉的症狀是心理疾病所造成的 在醫療照護方面的品質落差 是造成心理疾病患者的壽命比較短, 的眾多原因之一 相較於沒有心理疾病的人 就算是在世界上資源充分的國家裡 這樣的壽命差異仍可以高達20年 若是在開發中的國家, 這項差異 還會更大
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.
當然了, 心理疾病也可能更直接致命 最常見的例子就是自殺 你可能會大吃一驚, 就如同我當時 發現自殺是造成年輕人死亡清單中 榜上有名的 在全世界的每個國家都是如此 包括世界上最貧窮的那些國家
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.
心理疾病除了影響人的健康 影響人的壽命, 我們更關切的是 對生活品質的影響 我們為了要調查心理疾病對健康的整體影響 包括壽命(餘命), 還有 生活的品質, 我們採用了 一個量表, 縮寫字首是DALY 全名是失能修正餘命年數 透過這樣的研究, 我們發現一些驚人的事實 是關於心理疾病, 從全球的觀點來看 我們發現到, 比方說, 心理疾病 是造成失能的主要原因之一 以精神抑鬱來說, 是失能的第三主因 前兩名分別是 兒童的痢疾(腹瀉)與肺炎 綜觀所有心理疾病 約佔全球疾病負擔 15%之多 很明顯, 心理疾病對於人的生活構成很大的傷害 除了造成疾病負擔外 我們也來看看一些實際的數據 世界衛生組織(WHO)估計 大約有四到五億人 在這個地球上 正受到心理疾病的影響 在座各位 看起來對這樣的數字有些吃驚 但若試想一下, 心理疾病有如此多的種類 從童年期的自閉症及智能障礙 到成年期的抑鬱與焦慮 藥物濫用與精神失調 一直到老年期的失智症 我非常肯定, 今天在這裡的每一個人 至少都能夠想出一個人, 至少有一個人, 曾受到心理疾病的影響 就在我們最親近的社交圈裡 我看到有些人在點頭
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.
除了這些令人驚愕的統計數字之上 從全球健康的觀點來看, 更關鍵的是什麼? 更值得擔憂的是什麼? 就是這些受到心理疾病影響的個人, 絕大部分 都沒有接受治療照護 我們明明知道治療照護可以改變這些人的人生 也清楚一些醫療措施明確證實 像是藥物, 心理方面的措施 社會方面的措施, 可以產生重大的改善 但是, 就算是在資源最豐富的國家裡 例如在歐洲這裡, 仍然有將近一半的 受心理疾病影響的人, 沒有受到任何措施的協助 在我工作的那些國家裡 這種所謂的醫療缺口 逼近到驚人的90% 如果你跟一個受到心理疾病所苦的人談談 不出人意表地,你往往會聽到 他們的故事裡充滿了 壓抑的苦痛, 恥辱, 還有歧視 發生在他們生活的每環節 但或許最讓人心碎的 是那些關於被虐待的故事 連最基本的人權都被剝奪 如同這張照片裡的年輕女子的遭遇 令人遺憾的, 每天 都在發生, 就在這些專門為照護 心理疾病患者的機構,精神專科醫院裡面
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.
就是這種不公義, 驅使我投入了一個願景 試著改變這些人的生活 幫助這些受到心理疾病影響的人, 特別著重在 一個關鍵環節, 就是彌補其間的鴻溝 一方面是改變他們生活所需的知識, 有效療法的知識, 另一方面在於如何實際地 在日常生活裡運用這些知識 而我們所要面對的一個特別重要的挑戰 就是心理衛生專業人員的嚴重不足 例如精神病學家與心理學家 特別是在開發中世界
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.
我在印度接受醫學教育的, 後來 我選擇了精神病學作為專科, 違背了 我母親和家庭成員的期待, 他們多少會覺得這麼聰明的孩子, 應該選擇神經外科才比較有出息 不管怎麼說, 我還是堅持, 投入了精神病學 並且有幸到英國 最頂尖的醫院裡接受訓練 與一群非常具有天份, 非常熱情的成員共事 更重要的, 是受過高度的專業訓練的 心理健康方面的專業人士
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.
受完訓練之後, 我開始的第一項工作 是在辛巴威, 然後回到印度. 那時我面對的 是一個全然陌生的現實狀況 在這個現實狀況中,幾乎找不到任何的 精神衛生專業人員。 例如: 在辛巴威,大約只有 十幾個精神病醫生,其中大多在哈拉雷市(Harare)居住 和執業(行醫), 只剩下一兩個 去服務住在農村的900 萬人 的精神衛生保健需要
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.
在印度,我發現情況也好不到哪裡去 打個比方比較好理解,如果我用 精神科醫生在人口中所占的比例來說明 如果以英國的比例來套用到印度 那麼印度應該大約有150,000 個精神病醫生。 在現實中,大家猜一猜。 實際的精神病醫生的數目約3000個, 只有英國的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.
很快地我就認清了沒有辦法按照 先前我所學的那些精神健康護理模式 其中高度依賴專業且所費不貲的 精神衛生專業人員來提供心理衛生保健 在印度和辛巴威這樣的國家。 我必須跳脫既有的框架, 想出其他模式的 護理服務。
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.
就在那時候, 我偶然看到這些書, 在這些書中發現了所謂 "任務轉移" 的想法 可用在全球保健上。 這種想法實際上很簡單。就是 當你缺乏專門的醫護專業人員的時候 就直接從社區裡找可用的人選 培訓他們來提供一個特定範圍的各種保健措施 其中有些很具啟發性的例子 例如, 如何培訓一般人 去接生嬰兒 學會診斷和治療早期肺炎,以發揮大效用。 這讓我目瞪口呆,如果你可以訓練普通百姓 來提供如此複雜的衛生保健措施, 那麼, 也許一般人也可以做到相同的地步 在精神衛生保健這方面。
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,我很高興向各位報告 有許多關於"任務轉移" 的實驗被執行 在精神衛生保健這方面, 在開發中世界的許多地方 在過去十年裡,我想在這裡與你們分享 這三個特別的實驗 這三個都是以抑鬱症為主題 這是所有的精神疾病中, 最常見的。 在烏干達的鄉下、 保羅·博爾頓(Paul Bolton)和他的同事們, 與一些村民合作,證明了他們可以提供 抑鬱症的人際心理治療方式 而且, 透過隨機對照組的實驗設計 觀察到了接受這種治療的人, 有90% 的治癒率, 相較之下 那些對照組的村莊, 大約是40%。 在巴基斯坦鄉下,也進行了類似的隨機對照試驗 據阿替夫·拉赫曼(Atif Rahman)和他的同事們發現到 女性健康訪視員, 就是社區內孕產婦的保健員 是屬於巴基斯坦的衛生保健系統的一部份, 可以為有抑鬱症狀的母親, 提供認知行為療法 結果也再次展示了很大的差異 以治癒率來看。採用村莊大約是75%的治癒率 相較於只有45%的治癒率 在對照組的村莊。 而我自己的試驗,在印度的果阿(Goa),我們再一次顯示 培訓來自當地社區的輔導員 來提供心理社會干預措施 針對抑鬱,焦慮,可得70% 的治癒率, 相較 在那些對照組的初級保健中心的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.
現在,如果我必須總結這些各式各樣的 任務轉移的實驗,當然在此之外 還有許多其他的例子,嘗試著歸納出 一些關鍵要素, 讓我們可以學習並促成 任務轉換的成功運作 我創造了這個特別的首字母縮寫詞,SUNDAR 這個字在印度語的意思是 "吸引力"。 我用這個字來代表五個主要關鍵要素 列在這張投影片上,對於有效進行任務轉移 是非常重要的 第一個是, 我們需要簡化用詞 拿掉那些學界裡慣用的術語 只有醫學院的人才聽得懂的 我們還需要解構整個複雜的保健干預措施 分成較小的元件,可以更容易地 轉移給受過簡易訓練的個人。 我們所要提供的衛生保健, 並不是在大型機構, 而是要貼近人們的家園,我們提供衛生保健的方式 是運用所有可得的與可負擔的, 在地的資源 也很重要的是,要重新配置這些數量有限的專家 讓他們扮演的角色 負責建立生產力還有監導
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.
現在對我來說,轉移任務是一個 具有真正影響全球的想法 因為即使它源自於 開發中國家資源缺乏的情境下 但我認為它對於資源較充足的國家來說 也是非常重要的。為什麼呢? 嗯,有部份原因, 是因為在已開發世界 的衛生保健費用 快速攀升直超出控制, 其中的一大部分 是人力資源成本。 但同樣重要的是,因為衛生保健已發展成 如此令人難以置信地專業化, 以至於變成和 當地社區越離越遠, 甚至完全脫節. 對我來說,任務轉移這想法真正順達(有吸引力)的 並不僅僅是讓衛生保健 更容易取得且更能夠負擔 而是能夠從根本上授權 它使普羅大眾能夠更有效的 在他們的社區照顧大眾的健康, 也因為如此做, 能成為在地人的健康導師 所以, 對於我來說,任務轉移 是民主化的最典型的例子 把醫學知識, 連帶著醫療能量, 都民主化了
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.
30 多年前(1978年),世界各國聚集在 在阿拉木圖(哈薩克共和國城市)開會, 作出這樣的宣言 嗯,我想大家都猜得到 已經超過了宣言期限12年了, 我們還離這目標很遙遠 不過如今呢, 透過基本知識的裝備訓練 讓在社區的一般人 在充分的監督和支援下 可以有效地提供一系列保健干預措施 或許當初的宣言有達成的可能了 事實上,為了落實"全民健康" 這個口號 我們必須讓全民都能 參與這個特別的過程 而在心理保健方面,我們特別需要讓 受精神疾病影響的人, 還有他們的照護者 都參與進來
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.
這也是為什麼在幾年前 全球精神衛生運動開始推動 扮演一種虛擬平臺的角色, 讓像我這樣的專業人員, 和受精神疾病影響的人 能並肩而站 宣揚心理疾病患者的權利 一個得到改善生活照護的權力 並且有尊嚴地活下去
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)
最後,當你有片刻的寧靜時 在這幾個忙碌的日子, 或是在往後 花些心思在那個你想到的, 受心理疾病影響的人 或是那群你想到的 受心理疾病影響的人們 勇於關心他們吧.謝謝(掌聲) (掌聲)