ABOUT THE SPEAKER
Rishi Manchanda - Physician
Rishi Manchanda is an "upstreamist." A physician and public health innovator, he aims to reinvigorate primary care by teaching doctors to think about—and treat—the social and environmental conditions that often underly sickness.

Why you should listen

For a decade, Rishi Manchanda has worked as a doctor in South Central Los Angeles, treating patients who live and work in harsh conditions. He has worked at the Venice Family Clinic, one of the largest free clinics in the United States. He was the first director of social medicine at the St. John’s Well Child and Family Center in Compton, where he and his team provided high quality primary care to low-income families in the area. Currently, he is the medical director of a veterans’ clinic within the Greater Los Angeles Healthcare System, which he refers to as an “intensive caring unit.” He tells the National Health Corps Services, “The moment when a patient switches from despair to hopefulness is the greatest part of my service.” 

Manchanda is the author of the TED Book The Upstream Doctors, in which he looks at how health begins at home and in the workplace, with the social and environmental factors of our everyday lives. He shows how the future of our healthcare system depends on “upstreamists,” the doctors, nurses and other healthcare practitioners who look for the root cause of illness rather than just treating the symptoms.

Manchanda is the president and founder of Health Begins, a social network that teaches and empowers clinicians to improve health where it begins—in patients’ home and work environments. He also founded RxDemocracy, a nonpartisan coalition created to register voters in healthcare clinics. He serves on the board of the National Physicians Alliance, as well as on the board of Physicians for Social Responsibility in Los Angeles.

More profile about the speaker
Rishi Manchanda | Speaker | TED.com
TEDSalon NY2014

Rishi Manchanda: What makes us get sick? Look upstream

曼理希: 什麼讓我們生病?看看上游吧!

Filmed:
1,843,333 views

曼理希在南洛杉磯當了十多年醫師,在那裡他瞭解到:他的工作不只是治療病人的症狀,還要找出致病的根本原因:「上游」因素如營養不良、工作壓力,及缺乏新鮮空氣。他強烈呼籲醫師要多注意病人在診療室外的生活。
- Physician
Rishi Manchanda is an "upstreamist." A physician and public health innovator, he aims to reinvigorate primary care by teaching doctors to think about—and treat—the social and environmental conditions that often underly sickness. Full bio

Double-click the English transcript below to play the video.

00:12
For over a decade as a doctor醫生,
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當了十幾年的醫師,
00:14
I've cared照顧 for homeless無家可歸 veterans老兵,
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我照護過無家可歸的退伍軍人,
00:17
for working-class工人階級 families家庭.
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也照護過勞動階級的家庭。
00:19
I've cared照顧 for people who
live生活 and work in conditions條件
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我照護的人都住在或工作在
00:23
that can be hard, if not harsh苛刻,
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即使不惡劣也很糟的環境下。
00:25
and that work has led me to believe
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這樣的工作讓我相信
00:27
that we need a fundamentally從根本上 different不同 way
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我們需要以完全不同的方式
00:29
of looking at healthcare衛生保健.
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來看醫療的問題。
00:31
We simply只是 need a healthcare衛生保健 system系統
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我們需要的醫療系統
00:33
that moves移動 beyond just looking at the symptoms症狀
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不能只是單診療
00:35
that bring帶來 people into clinics診所,
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病人來診所時的症狀,
00:36
but instead代替 actually其實 is able能夠 to look
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而是要實際
從源頭查看及改善健康狀況。
00:39
and improve提高 health健康 where it begins開始.
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00:42
And where health健康 begins開始
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健康不是從
00:43
is not in the four walls牆壁 of a doctor's醫生 office辦公室,
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診療室的四面牆開始,
00:46
but where we live生活
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而是從我們居住及工作、
00:48
and where we work,
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00:50
where we eat, sleep睡覺, learn學習 and play,
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吃、喝、睡覺、
學習及享樂的地方開始,
00:53
where we spend the majority多數 of our lives生活.
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從我們花大把時間的地方開始。
00:56
So what does this different不同
approach途徑 to healthcare衛生保健 look like,
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所以這個不同的醫療方法
是什麼樣子?
00:59
an approach途徑 that can improve提高 health健康 where it begins開始?
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這個能從源頭改善健康的方法?
01:02
To illustrate說明 this, I'll tell you about Veronica維羅尼卡.
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為了解釋清楚,
我跟大家說說小維的故事。
01:06
Veronica維羅尼卡 was the 17th patient患者
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小維是我第 17 號病人,
01:08
out of my 26-patient-患者 day
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我每天要看 26 名病人,
01:10
at that clinic診所 in South Central中央 Los洛杉磯 Angeles洛杉磯.
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診所位於洛杉磯南區。
01:13
She came來了 into our clinic診所 with a chronic慢性 headache頭痛.
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她來我的診所看慢性頭痛。
01:15
This headache頭痛 had been going on
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這個頭痛已經持續好多年,
01:16
for a number of years年份, and this particular特定 episode插曲
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而這段經歷讓她非常非常困擾。
01:18
was very, very troubling令人不安.
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01:21
In fact事實, three weeks before she came來了 to visit訪問 us
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其實在她來看我們的三個星期前,
01:23
for the first time, she went to an
emergency room房間 in Los洛杉磯 Angeles洛杉磯.
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她才去過洛杉磯的某急診室。
01:27
The emergency room房間 doctors醫生 said,
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這個急診室的醫師說,
01:29
"We've我們已經 run some tests測試, Veronica維羅尼卡.
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「小維,我們做了幾項檢查,
01:31
The results結果 are normal正常, so
here's這裡的 some pain疼痛 medication藥物治療,
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結果都很正常,
所以我現在給你開一些止痛藥,
01:34
and follow跟隨 up with a primary care關心 doctor醫生,
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妳要回去看妳的家庭醫師,
01:36
but if the pain疼痛 persists仍然存在 or if it worsens惡化,
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但是如果還繼續痛,或是更痛,
01:38
then come on back."
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妳再回來找我們。」
01:40
Veronica維羅尼卡 followed其次 those standard標準 instructions說明
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小維謹遵這些制式的醫囑,
01:43
and she went back.
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最後還是回去急診室了。
01:45
She went back not just once一旦, but twice兩次 more.
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她回去不只一次,她去了三次。
01:48
In the three weeks before Veronica維羅尼卡 met會見 us,
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在小維來找我們前的那三個星期,
01:50
she went to the emergency room房間 three times.
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她回去急診室三次。
01:52
She went back and forth向前,
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她來來回回,
01:54
in and out of hospitals醫院 and clinics診所,
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進進出出各個醫院及診所,
01:56
just like she had doneDONE in years年份 past過去,
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就像之前一年一樣,
01:58
trying to seek尋求 relief浮雕 but still coming未來 up short.
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想要找解方卻徒勞無功。
02:01
Veronica維羅尼卡 came來了 to our clinic診所,
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小維來我們的診所,
02:03
and despite儘管 all these encounters遭遇
with healthcare衛生保健 professionals專業人士,
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無論她看了多少醫療專家,
02:06
Veronica維羅尼卡 was still sick生病.
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小維還是病著。
02:09
When she came來了 to our clinic診所, though雖然,
we tried試著 a different不同 approach途徑.
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她到我們的診所時,
我們試了一種不同的療法。
02:12
Our approach途徑 started開始 with our medical assistant助理,
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我們的療法從我們的醫務助理開始,
02:15
someone有人 who had a GED-levelGED級 training訓練
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這位助理有同等學歷的訓練,
02:17
but knew知道 the community社區.
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也很瞭解這個社區。
02:18
Our medical assistant助理 asked some routine常規 questions問題.
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我們的醫務助理問了幾個例行問題。
02:21
She asked, "What's your chief首席 complaint抱怨?"
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她問,「妳主訴的症狀是什麼?」
02:23
"Headache頭痛."
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「頭痛。」
02:25
"Let's get your vital重要 signs跡象" —
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「那我們量一下生命徵象」,
02:27
measure測量 your blood血液 pressure壓力 and your heart rate,
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量一下妳的血壓心跳。
02:29
but let's also ask something equally一樣 as vital重要
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但我們還要多問幾個問題,
02:31
to Veronica維羅尼卡 and a lot of patients耐心 like her
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對小維及許多類似的
洛杉磯南區病人,
02:33
in South Los洛杉磯 Angeles洛杉磯.
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就跟生命徵象一樣重要的問題。
02:35
"Veronica維羅尼卡, can you tell me about where you live生活?
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「小維,可不可以告訴我
妳住的地方的情況?
02:38
Specifically特別, about your housing住房 conditions條件?
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特別是妳住處的狀況?
02:39
Do you have mold模子? Do you have water leaks洩漏?
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有發霉嗎?有漏水嗎?
02:42
Do you have roaches蟑螂 in your home?"
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家裡有蟑螂嗎?」
02:44
Turns out, Veronica維羅尼卡 said yes
to three of those things:
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結果是,小維家三「有」:
02:46
roaches蟑螂, water leaks洩漏, mold模子.
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蟑螂、漏水、發霉。
02:49
I received收到 that chart圖表 in hand, reviewed回顧 it,
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我拿到那張病歷,看了一下,
02:52
and I turned轉身 the handle處理 on the door
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然後我轉轉門把
02:53
and I entered進入 the room房間.
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進入診間。
02:55
You should understand理解 that Veronica維羅尼卡,
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你得了解,小維
02:57
like a lot of patients耐心 that I have
the privilege特權 of caring愛心 for,
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就像我有幸照護的
大部分病人一樣,
02:59
is a dignified凝重 person, a formidable強大 presence存在,
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是個有尊嚴、不可輕忽,
03:02
a personality個性 that's larger than life,
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有著鮮明個性的人,
03:04
but here she was
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但在這裡,她坐在
03:05
doubled翻倍 over in pain疼痛 sitting坐在 on my exam考試 table.
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我的診療檯上痛苦地蜷縮著。
03:08
Her head, clearly明確地 throbbing悸動, was resting休息 in her hands.
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她的頭很明顯搏痛著,
擱在她的手上。
03:12
She lifted取消 her head up,
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她抬起頭,
03:14
and I saw her face面對, said hello你好,
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我看著她的臉,說了妳好,
03:17
and then I immediately立即 noticed注意到 something
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然後我立刻注意到
03:18
across橫過 the bridge of her nose鼻子,
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在她的鼻樑上,
03:20
a crease in her skin皮膚.
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皮膚有一道皺摺。
03:22
In medicine醫學, we call that crease the allergic過敏的 salute禮炮.
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在醫學上,我們稱這道皺摺為
「過敏性敬禮徵」。
03:25
It's usually平時 seen看到 among其中 children孩子
who have chronic慢性 allergies過敏.
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這通常發生在
有慢性過敏的兒童上。
03:28
It comes from chronically長期地 rubbing
one's那些 nose鼻子 up and down,
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起因是長期上下磨擦鼻子,
03:31
trying to get rid擺脫 of those allergy過敏 symptoms症狀,
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想要擺脫那些過敏症狀。
03:33
and yet然而, here was Veronica維羅尼卡, a grown長大的 woman女人,
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但是,在這的小維,
已經是成年婦女,
03:35
with the same相同 telltale揭秘 sign標誌 of allergies過敏.
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卻還是有過敏的示警徵兆。
03:38
A few少數 minutes分鐘 later後來, in asking
Veronica維羅尼卡 some questions問題,
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幾分鐘後,我一邊問小維問題,
03:41
and examining檢查 her and listening to her,
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一邊檢查及聽她說,
03:43
I said, "Veronica維羅尼卡, I think I know what you have.
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我說:「小維,
我想我知道妳得了什麼。
03:46
I think you have chronic慢性 allergies過敏,
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我認為妳是慢性過敏,
03:48
and I think you have migraine偏頭痛
headaches頭痛 and some sinus congestion擁塞,
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而且我認為妳還有偏頭痛及鼻塞,
03:50
and I think all of those are
related有關 to where you live生活."
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我想這些都跟妳住的地方有關。」
03:53
She looked看著 a little bit relieved安心,
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她看起來有點鬆了口氣,
03:55
because for the first time, she had a diagnosis診斷,
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因為這是她第一次得到真的診斷,
03:57
but I said, "Veronica維羅尼卡, now let's
talk about your treatment治療.
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但我說:「小維,
現在我們來談一下治療方法。
03:59
We're going to order訂購 some
medications藥物治療 for your symptoms症狀,
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我們會針對妳的症狀開幾款藥,
04:03
but I also want to refer參考 you to
a specialist專家, if that's okay."
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但我也想把妳轉診給一位專科,
如果妳同意。」
04:06
Now, specialists專家 are a little hard to find
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不過,專科
在洛杉磯南區有點難找,
04:09
in South Central中央 Los洛杉磯 Angeles洛杉磯,
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04:11
so she gave me this look, like, "Really?"
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所以她看了我一眼,好像在說,
「真的?」
04:13
And I said, "Veronica維羅尼卡, actually其實,
the specialist專家 I'm talking about
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我說,「小維,其實我說的這位專科
04:16
is someone有人 I call a community社區 health健康 worker工人,
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是我所謂的社區保健員,
04:18
someone有人 who, if it's okay with you,
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如果妳同意,這個人
04:20
can come to your home
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會到妳家試著了解情況,
04:21
and try to understand理解 what's going on
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04:22
with those water leaks洩漏 and that mold模子,
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看看為什麼漏水及發霉,
04:24
trying to help you manage管理 those conditions條件 in your housing住房 that I think are causing造成 your symptoms症狀,
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試著幫妳解決房子的狀況,
我認為是這些造成妳的症狀,
04:28
and if required需要, that specialist專家 might威力 refer參考 you
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如果有必要,這位專科還會幫妳轉診
04:30
to another另一個 specialist專家 that we
call a public上市 interest利益 lawyer律師,
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去另一位專科,我們叫他公益律師,
04:32
because it might威力 be that your landlord房東
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因為妳的房東很可能
04:34
isn't making製造 the fixes修復 he's required需要 to make."
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沒有按照法律規定替妳修房子。」
04:37
Veronica維羅尼卡 came來了 back in a few少數 months個月 later後來.
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小維幾個月後跑回來。
04:39
She agreed約定 to all of those treatment治療 plans計劃.
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她同意所有上述的治療計畫。
04:42
She told us that her symptoms症狀
had improved改善 by 90 percent百分.
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她告訴我們她的症狀
改善了 90%,
04:45
She was spending開支 more time at work
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她可以花更多時間在工作
04:47
and with her family家庭 and less time
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及跟家人相處上,不用常常
04:49
shuttling穿梭 back and forth向前 between之間
the emergency rooms客房 of Los洛杉磯 Angeles洛杉磯.
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在洛杉磯的急診室來回奔波。
04:54
Veronica維羅尼卡 had improved改善 remarkably異常.
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小維有很明顯的進步。
04:56
Her sons兒子, one of whom had asthma哮喘,
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她的幾個兒子,其中一個有氣喘,
04:58
were no longer as sick生病 as they used to be.
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不再像以前一樣病著。
05:00
She had gotten得到 better, and not coincidentally巧合,
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她好多了,而且一點也不意外,
05:02
Veronica's維羅尼卡的 home was better too.
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小維的房屋狀況也改善了。
05:06
What was it about this different不同 approach途徑 we tried試著
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我們採用的這種迥異的方法
05:08
that led to better care關心,
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為什麼能提供更好的照護?
05:11
fewer visits訪問 to the E.R., better health健康?
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讓病人少跑急診室,更健康?
05:15
Well, quite相當 simply只是, it started開始 with that question:
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很簡單,就從那個問題開始:
05:17
"Veronica維羅尼卡, where do you live生活?"
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「小維,妳住在哪?」
05:20
But more importantly重要的, it was that we put in place地點
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但更重要的是,我們推出
05:22
a system系統 that allowed允許 us to routinely常規 ask questions問題
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一種系統,讓我們能問小維
05:25
to Veronica維羅尼卡 and hundreds數以百計 more like her
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及數百計像小維那樣的人
幾個簡單問題,
05:27
about the conditions條件 that mattered要緊
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對她的社區很重要的環境問題,
05:29
in her community社區, about where health健康,
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健康的源頭問題,
05:31
and unfortunately不幸 sometimes有時 illness疾病, do begin開始
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因為不幸的是,有時候疾病的確
05:34
in places地方 like South L.A.
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從像南洛杉磯一樣的地方開始。
05:35
In that community社區, substandard等外 housing住房
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在那個社區,不合格的房屋
05:38
and food餐飲 insecurity不安全 are the major重大的 conditions條件
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及食物供給不穩定是最主要的問題,
05:39
that we as a clinic診所 had to be aware知道的 of,
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是我們身為診所必須注意到的事,
05:41
but in other communities社區 it could be
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但在其他的社區問題可能是
05:43
transportation運輸 barriers障礙, obesity肥胖,
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交通運輸的天然障礙、肥胖、
05:45
access訪問 to parks公園, gun violence暴力.
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家附近有沒有公園、槍枝暴力。
05:48
The important重要 thing is, we put in place地點 a system系統
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重要的是,我們推出的這種系統
05:50
that worked工作,
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有成效,
05:52
and it's an approach途徑 that I call an upstream上游 approach途徑.
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而這種方法我稱為上游管理。
05:54
It's a term術語 many許多 of you are familiar with.
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在座很多人都很熟悉的名詞。
05:56
It comes from a parable寓言 that's very common共同
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這來自一個很常聽到的
05:58
in the public上市 health健康 community社區.
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公共衛生界寓言。
06:00
This is a parable寓言 of three friends朋友.
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這是三個朋友的寓言。
06:03
Imagine想像 that you're one of these three friends朋友
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想像一下你是這三個朋友之一,
06:05
who come to a river.
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你們走到一條河。
06:07
It's a beautiful美麗 scene現場, but it's
shattered破滅 by the cries哭聲 of a child兒童,
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風景很美,
但有個小孩的哭聲劃破了寧靜,
06:10
and actually其實 several一些 children孩子,
in need of rescue拯救 in the water.
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而且其實有好幾個孩子
在水裡需要救援。
06:13
So you do hopefully希望 what everybody每個人 would do.
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所以你會去做
但願每個人都會做的事。
06:15
You jump right in along沿 with your friends朋友.
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你與你的朋友趕快跳進去。
06:17
The first friend朋友 says, I'm going to rescue拯救 those
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第一個朋友說,
我要去救那些快沉下去的,
06:18
who are about to drown,
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06:20
those at most risk風險 of falling落下 over the waterfall瀑布.
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那些快要掉到瀑布下面的幾個。
06:22
The second第二 friends朋友 says,
I'm going to build建立 a raft.
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第二個朋友說,我來造個木筏。
06:24
I'm going to make sure that fewer people
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我要確保
流到瀑布邊的人能少幾個。
06:25
need to end結束 up at the waterfall's瀑布的 edge邊緣.
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06:27
Let's usher招待員 more people to safety安全
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透過造木筏,
讓我們多領幾個人到安全區,
06:28
by building建造 this raft,
162
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06:29
coordinating協調 those branches分支機構 together一起.
163
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把幾根樹枝綁在一起。
06:31
Over time, they're successful成功, but not really,
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一段時間後,他們成功了,
但也不盡然,
06:34
as much as they want to be.
165
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902
因為成效不如預期。
06:35
More people slip through通過, and they finally最後 look up
166
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更多人成為漏網之魚,
所以他們終於往上游看,
06:37
and they see that their third第三 friend朋友
167
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發現他們第三個朋友
06:38
is nowhere無處 to be seen看到.
168
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不在視線範圍內。
06:39
They finally最後 spot her.
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最後他們終於看到她。
06:41
She's in the water. She's swimming游泳的 away from them
170
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她在水裡。她愈游愈遠,
06:43
upstream上游, rescuing營救 children孩子 as she goes,
171
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朝上游去,邊游邊救兒童,
06:45
and they shout to her, "Where are you going?
172
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他們對著她喊:「妳要去哪裡?
06:47
There are children孩子 here to save保存."
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這裡還有兒童要救。」
06:48
And she says back,
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她回答說:
06:50
"I'm going to find out
175
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「我要去找
06:51
who or what is throwing投擲 these children孩子 in the water."
176
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是誰或是什麼東西
丟這些兒童進水裡。」
06:55
In healthcare衛生保健, we have that first friend朋友
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在醫療界,我們有第一個朋友:
06:58
we have the specialist專家,
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我們有專科醫師,
06:59
we have the trauma外傷 surgeon外科醫生, the ICUICU nurse護士,
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我們有外傷外科醫師、
加護病房護士、
07:01
the E.R. doctors醫生.
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急診室醫師。
07:02
We have those people that are vital重要 rescuers救援人員,
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我們有搶救生命的人,
07:05
people you want to be there
when you're in dire可怕的 straits海峽.
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你在急難中最需要的人。
07:08
We also know that we have the second第二 friend朋友
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我們也知道我們有第二個朋友:
07:11
we have that raft-builder筏建設者.
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我們有造筏的人。
07:12
That's the primary care關心 clinician臨床醫生,
185
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那就是第一線的臨床醫師。
07:14
people on the care關心 team球隊 who are there
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那些人在醫療團隊裡
07:16
to manage管理 your chronic慢性 conditions條件,
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照護你的慢性疾病、
07:18
your diabetes糖尿病, your hypertension高血壓,
188
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你的糖尿病、你的高血壓、
07:19
there to give you your annual全年 checkups體檢,
189
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1406
幫你做年度健檢、
07:21
there to make sure your vaccines疫苗 are up to date日期,
190
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盯著你按時打疫苗。
07:23
but also there to make sure that you have
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同時也確保你有木筏可乘,
07:25
a raft to sit on and usher招待員 yourself你自己 to safety安全.
192
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把你帶到安全的地方。
07:28
But while that's also vital重要 and very necessary必要,
193
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雖然這些都很重要也很必要,
07:30
what we're missing失踪 is that third第三 friend朋友.
194
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但我們最缺的卻是第三個朋友。
07:32
We don't have enough足夠 of that upstreamistupstreamist.
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我們沒有足夠向上游的人。
07:34
The upstreamistsupstreamists are the health健康 care關心 professionals專業人士
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向上游的人是醫療照護專家,
07:36
who know that health健康 does begin開始
197
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但瞭解健康起始於
07:38
where we live生活 and work and play,
198
446300
1991
我們居住工作及玩樂的地方,
07:40
but beyond that awareness意識, is able能夠 to mobilize動員
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2532
但除了那樣的體認,
還能動員各種資源以創建系統,
07:42
the resources資源 to create創建 the system系統
200
450823
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07:45
in their clinics診所 and in their hospitals醫院
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1808
使他們的診所及醫院
07:46
that really does start開始 to approach途徑 that,
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能真正開始著手處理這個問題,
07:50
to connect people to the resources資源 they need
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2002
能將眾人與他們
07:52
outside the four walls牆壁 of the clinic診所.
204
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在診所的四面牆外
所需的資源連結在一起。
07:54
Now you might威力 ask, and it's
a very obvious明顯 question
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現在你可能會問個很明顯的問題,
07:56
that a lot of colleagues同事 in medicine醫學 ask:
206
464648
2655
有很多醫界同僚都這麼問:
07:59
"Doctors醫生 and nurses護士 thinking思維
about transportation運輸 and housing住房?
207
467303
3146
「醫師與護士還要去考慮
交通及住房的問題?
08:02
Shouldn't不能 we just provide提供 pills and procedures程序
208
470449
2310
我們不是只要提供藥丸及醫療處置,
08:04
and just make sure we focus焦點 on the task任務 at hand?"
209
472759
1732
並確定我們會專心
做手上的工作就好?」
08:06
Certainly當然, rescuing營救 people at the water's水的 edge邊緣
210
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2846
的確,將人從水邊救起
08:09
is important重要 enough足夠 work.
211
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已經是夠重要的工作。
08:12
Who has the time?
212
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1271
誰有那麼多時間?
08:13
I would argue爭論, though雖然, that if we
were to use science科學 as our guide指南,
213
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2891
我卻認為,假如我們以科學為指引,
08:16
that we would find an upstream上游
approach途徑 is absolutely絕對 necessary必要.
214
484616
2733
就知道找到上游管理方法
是絕對必要的。
08:19
Scientists科學家們 now know that
215
487349
1755
科學家現在知道
08:21
the living活的 and working加工 conditions條件 that we all
216
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2250
生活及工作條件,
08:23
are part部分 of
217
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1636
我們都是其中的部分,
08:24
have more than twice兩次 the impact碰撞 on our health健康
218
492990
2390
對我們健康的影響
08:27
than does our genetic遺傳 code,
219
495380
2127
比遺傳還超過兩倍之多,
08:29
and living活的 and working加工 conditions條件,
220
497507
1333
而且生活及工作條件,
08:30
the structures結構 of our environments環境,
221
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1386
我們環境的結構,
08:32
the ways方法 in which哪一個 our social社會 fabric is woven編織 together一起,
222
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我們的社交圈交織在一起的方式,
08:35
and the impact碰撞 those have on our behaviors行為,
223
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2182
及其對我們行為的影響,
08:37
all together一起, those have more than five times
224
505877
2313
通通加在一起,
對我們的健康影響
08:40
the impact碰撞 on our health健康
225
508190
965
08:41
than do all the pills and procedures程序
226
509155
2009
比醫師及醫院開出的
藥丸及醫療處置總合
08:43
administered管理 by doctors醫生 and hospitals醫院 combined結合.
227
511164
2049
超過五倍之多。
08:45
All together一起, living活的 and working加工 conditions條件
228
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3171
生活及工作條件加在一起,
08:48
account帳戶 for 60 percent百分 of preventable預防的 death死亡.
229
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4096
佔了可預防性死亡的 60%。
08:52
Let me give you an example of what this feels感覺 like.
230
520480
1580
讓我舉個例子來看看這是什麼感覺。
08:54
Let's say there was a company公司, a tech高科技 startup啟動
231
522060
2603
就說有家公司,一家科技新創公司
08:56
that came來了 to you and said, "We have a great product產品.
232
524663
1901
來你這裡說:「我們有個很棒的產品。
08:58
It's going to lower降低 your risk風險
of death死亡 from heart disease疾病."
233
526564
2824
會降低你死於心臟病的風險。」
09:01
Now, you might威力 be likely容易 to invest投資
234
529388
1901
那麼,你很可能會願意投資,
09:03
if that product產品 was a drug藥物 or a device設備,
235
531289
3184
如果那個產品是種藥或儀器的話,
09:06
but what if that product產品 was a park公園?
236
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2738
但是如果那個產品是座公園?
09:09
A study研究 in the U.K.,
237
537211
1556
在英國有項研究,
09:10
a landmark里程碑 study研究 that reviewed回顧 the records記錄
238
538767
2084
一項具里程碑意義的研究,檢閱了
09:12
of over 40 million百萬 residents居民 in the U.K.,
239
540851
3341
英國超過四千萬居民的紀錄,
09:16
looked看著 at several一些 variables變量,
240
544192
1828
他們看了幾項變數,
09:18
controlled受控 for a lot of factors因素, and found發現 that
241
546020
2567
即幾項管制因子,發現
09:20
when trying to adjust調整 the risk風險 of heart disease疾病,
242
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4083
當試著校正心臟病的風險,
09:24
one's那些 exposure曝光 to green綠色
space空間 was a powerful強大 influence影響.
243
552670
3031
一個人能否接觸綠地
有很大的影響。
09:27
The closer接近 you were to green綠色 space空間,
244
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1879
你越接近綠地、
09:29
to parks公園 and trees樹木,
245
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1342
公園及樹木,
09:30
the lower降低 your chance機會 of heart disease疾病,
246
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1495
你得心臟病的機會就愈低,
09:32
and that stayed true真正 for rich豐富 and for poor較差的.
247
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2807
無論貧富皆準。
09:35
That study研究 illustrates說明 what my friends朋友 in public上市 health健康
248
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2320
那項研究闡明了我在公衛界的朋友
09:37
often經常 say these days:
249
565544
1498
這些日子常常說的:
09:39
that one's那些 zip壓縮 code matters事項 more
250
567042
2068
就是一個人的郵遞區號
09:41
than your genetic遺傳 code.
251
569110
1676
比你的遺傳密碼還重要。
09:42
We're also learning學習 that zip壓縮 code
252
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1449
我們也了解到郵遞區號
09:44
is actually其實 shaping成型 our genetic遺傳 code.
253
572235
2435
其實會改變我們的遺傳密碼。
09:46
The science科學 of epigenetics表觀遺傳學 looks容貌
at those molecular分子 mechanisms機制,
254
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3217
表觀遺傳學就是要看這些分子機制,
09:49
those intricate錯綜複雜 ways方法 in which哪一個
our DNA脫氧核糖核酸 is literally按照字面 shaped成形,
255
577887
3033
那些真的會改變
我們 DNA 的複雜機制,
09:52
genes基因 turned轉身 on and off
256
580920
1568
基因開、關,
09:54
based基於 on the exposures曝光 to the environment環境,
257
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2194
基於其所暴露的環境,
09:56
to where we live生活 and to where we work.
258
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2744
及我們在哪裡生活在哪裡工作。
09:59
So it's clear明確 that these factors因素,
259
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1857
所以很清楚這些因素,
10:01
these upstream上游 issues問題, do matter.
260
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2083
這些上游的問題,的確至關重要。
10:03
They matter to our health健康,
261
591366
1703
它們對我們的健康至關重要,
10:05
and therefore因此 our healthcare衛生保健 professionals專業人士
should do something about it.
262
593069
2493
因此我們的醫療專家
應該為此出力。
10:07
And yet然而, Veronica維羅尼卡 asked me
263
595562
1768
但是,小維問了我
一個可說是長久以來
我一直難以回答的問題,
10:09
perhaps也許 the most compelling引人注目 question
264
597330
959
10:10
I've been asked in a long time.
265
598289
1408
10:11
In that follow-up跟進 visit訪問, she said,
266
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2138
在回診那天,她問:
10:13
"Why did none沒有 of my doctors醫生
267
601835
2152
「為什麼我的醫師
10:15
ask about my home before?
268
603987
2878
以前都不問我住家的狀況?
10:18
In those visits訪問 to the emergency room房間,
269
606865
2204
去急診室的那幾次,
10:21
I had two CAT scans掃描,
270
609069
1801
我做了兩次斷層掃瞄,
10:22
I had a needle placed放置 in the lower降低 part部分 of my back
271
610870
1957
有針穿刺進我的下背部
10:24
to collect蒐集 spinal fluid流體,
272
612827
1530
抽取脊髓液,
10:26
I had nearly幾乎 a dozen blood血液 tests測試.
273
614357
1474
我大概抽了將近一打的血。
10:27
I went back and forth向前, I saw
all sorts排序 of people in healthcare衛生保健,
274
615831
2654
我進進出出,
我看過各種醫療照護人員,
10:30
and no one asked about my home."
275
618485
4285
從來沒有人問過我的家。」
10:34
The honest誠實 answer回答 is that in healthcare衛生保健,
276
622770
1738
最誠實的答案是在醫療界,
10:36
we often經常 treat對待 symptoms症狀 without addressing解決
277
624508
1695
我們常常只是頭痛醫頭、腳痛醫腳,
10:38
the conditions條件 that make you sick生病 in the first place地點.
278
626203
3120
10:41
And there are many許多 reasons原因 for that, but the big three
279
629323
1844
有很多因素造成這樣,但三大點
10:43
are first, we don't pay工資 for that.
280
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4600
是第一,我們拿不到錢。
10:47
In healthcare衛生保健, we often經常 pay工資
for volume and not value.
281
635767
3385
在醫療界,我們計量不計質。
10:51
We pay工資 doctors醫生 and hospitals醫院 usually平時
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1788
我們通常付醫師及醫院的錢
10:52
for the number of services服務 they provide提供,
283
640940
1980
是以診療過多少人來算,
10:54
but not necessarily一定 on how healthy健康 they make you.
284
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3299
不見得是看他們有沒有醫好你。
10:58
That leads引線 to a second第二 phenomenon現象 that I call
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646219
2311
這就導致第二個現象我叫它
11:00
the "don't ask, don't tell" approach途徑
286
648530
1380
「你不說我不問」,
11:01
to upstream上游 issues問題 in healthcare衛生保健.
287
649910
2574
普遍存在醫療界的上游問題。
11:04
We don't ask about where you
live生活 and where you work,
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1744
我們不問你住哪、在哪工作,
11:06
because if there's a problem問題 there,
289
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1225
因為如果那裡有問題,
11:07
we don't know what to tell you.
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2896
我們也不知道要給你什麼建議。
11:10
It's not that doctors醫生 don't know
these are important重要 issues問題.
291
658349
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醫師不是不了解
這些是很重要的問題。
11:13
In a recent最近 survey調查 doneDONE in the U.S. among其中 physicians醫師,
292
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最近有項針對美國醫師的調查,
11:15
over 1,000 physicians醫師,
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1891
問了超過一千名醫師,
11:16
80 percent百分 of them actually其實 said that
294
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1812
其中有 80% 真的說
11:18
they know that their patients'耐心' upstream上游 problems問題
295
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1698
他們知道他們病人的上游問題
11:20
are as important重要 as their health健康 issues問題,
296
668441
1887
與他們的健康問題一樣重要,
11:22
as their medical problems問題,
297
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1692
也與醫療問題一樣重要。
11:24
and yet然而 despite儘管 that widespread廣泛 awareness意識
298
672020
2361
但儘管對上游問題的重要性
11:26
of the importance重要性 of upstream上游 issues問題,
299
674381
1934
有如此廣泛的意識,
11:28
only one in five doctors醫生 said they had
300
676315
2273
只有五分之一的醫師說他們有
11:30
any sense of confidence置信度 to address地址 those issues問題,
301
678588
2865
相當程度的信心應付這個問題,
11:33
to improve提高 health健康 where it begins開始.
302
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1848
找出改善健康的源頭。
11:35
There's this gap間隙 between之間 knowing會心
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1542
瞭解病人的生活,
11:36
that patients'耐心' lives生活, the context上下文
of where they live生活 and work,
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2429
即他們生活及工作的背景
11:39
matters事項, and the ability能力 to do something about it
305
687272
2808
很重要是一回事,
但有能力在我們工作的系統中
11:42
in the systems系統 in which哪一個 we work.
306
690080
1777
為之出力又是另一回事。
11:43
This is a huge巨大 problem問題 right now,
307
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2334
這是現在很大的問題,
11:46
because it leads引線 them to this next下一個 question, which哪一個 is,
308
694191
2148
因為這導引出下一個問題,就是
11:48
whose誰的 responsibility責任 is it?
309
696339
1587
這是誰的責任?
11:49
And that brings帶來 me to that third第三 point,
310
697926
1709
這也帶出我的第三點,
11:51
that third第三 answer回答 to Veronica's維羅尼卡的 compelling引人注目 question.
311
699635
3274
小維難題的第三個答案。
11:54
Part部分 of the reason原因 that we have this conundrum難題
312
702909
1586
造成我們這個難題的部分原因
11:56
is because there are not nearly幾乎 enough足夠 upstreamistsupstreamists
313
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3755
在於在醫療系統內,
12:00
in the healthcare衛生保健 system系統.
314
708250
2045
根本就沒有足夠的上游管理人。
12:02
There are not nearly幾乎 enough足夠 of that third第三 friend朋友,
315
710295
1900
根本就沒有足夠的第三個朋友,
12:04
that person who is going to find out
316
712195
1764
就是那個要去找出
12:05
who or what is throwing投擲 those kids孩子 in the water.
317
713959
2857
誰或什麼東西把孩子進水裡的人。
12:08
Now, there are many許多 upstreamistsupstreamists,
318
716816
1705
現在,的確有很多上游管理人,
12:10
and I've had the privilege特權 of meeting會議 many許多 of them,
319
718521
2441
我有幸遇過許多位,
12:12
in Los洛杉磯 Angeles洛杉磯 and in other parts部分 of the country國家
320
720962
2627
在洛杉磯及這個國家的其它地方
12:15
and around the world世界,
321
723589
1768
及全世界都遇到過,
12:17
and it's important重要 to note注意 that upstreamistsupstreamists
322
725357
2428
值得注意的是很多上游管理人
12:19
sometimes有時 are doctors醫生, but they need not be.
323
727785
2537
有時候的確是醫師,
但不一定得是醫師。
12:22
They can be nurses護士, other clinicians臨床醫生,
324
730322
2193
他們也可以是護士、其他臨床師、
12:24
care關心 managers經理, social社會 workers工人.
325
732515
2008
照護策劃管理人、社工。
12:26
It's not so important重要 what specific具體 degree
326
734523
1952
上游管理人在名字後面
12:28
upstreamistsupstreamists have at the end結束 of their name名稱.
327
736475
1799
掛什麼學位頭銜並不重要。
12:30
What's more important重要 is that they all seem似乎
328
738274
1756
重要的是他們幾乎
12:32
to share分享 the same相同 ability能力 to implement實行 a process處理
329
740030
4425
都有能力落實執行某種步驟
12:36
that transforms變換 their assistance幫助,
330
744455
1789
以改造他們援助的手法,
12:38
transforms變換 the way they practice實踐 medicine醫學.
331
746244
2346
改造他們行醫的方法。
12:40
That process處理 is a quite相當 simple簡單 process處理.
332
748590
1586
那種步驟是還滿簡單的步驟。
12:42
It's one, two and three.
333
750176
2373
就是一二三。
12:44
First, they sit down and they say,
334
752549
1651
第一,他們坐下來說,
12:46
let's identify鑑定 the clinical臨床 problem問題
335
754200
2024
我們來鑑別一下到底
為什麼某些病人會有這種臨床問題。
12:48
among其中 a certain某些 set of patients耐心.
336
756224
1343
12:49
Let's say, for instance,
337
757567
1743
舉個例,
12:51
let's try to help children孩子
338
759310
1934
讓我們試試幫助
12:53
who are bouncing蹦蹦 in and out of the hospital醫院
339
761244
1804
因為氣喘而在醫院
12:55
with asthma哮喘.
340
763048
2082
進進出出的兒童。
12:57
After identifying識別 the problem問題, they
then move移動 on to that second第二 step,
341
765130
2511
診斷出問題後,
他們就進到下一步,
12:59
and they say, let's identify鑑定 the root cause原因.
342
767641
2739
他們說,讓我們來找根源。
13:02
Now, a root cause原因 analysis分析, in healthcare衛生保健,
343
770380
3791
現在,根本原因分析,
在醫療界通常這麼說,
讓我們看一下你的基因,
13:06
usually平時 says, well, let's look at your genes基因,
344
774171
1715
13:07
let's look at how you're behaving行為.
345
775886
2458
看一下你的行為。
13:10
Maybe you're not eating healthy健康 enough足夠.
346
778344
2080
可能你吃得不夠健康。
13:12
Eat healthier健康.
347
780424
1016
那就吃健康點。
13:13
It's a pretty漂亮 simplistic簡單化
348
781440
1395
這是過度簡單化的
13:14
approach途徑 to root cause原因 analyses分析.
349
782835
1406
根本原因分析方法。
13:16
It turns out, it doesn't really work
350
784241
1665
結果是,這個方法根本沒有用
13:17
when we just limit限制 ourselves我們自己 that worldview世界觀.
351
785906
2464
因為我們限制了自己的視界。
13:20
The root cause原因 analysis分析 that an upstreamistupstreamist brings帶來
352
788370
2101
上游管理人提出的根本原因分析
13:22
to the table is to say, let's look at the living活的
353
790471
1937
會這麼說,讓我們看一下
13:24
and the working加工 conditions條件 in your life.
354
792408
3352
你的生活及工作條件。
13:27
Perhaps也許, for children孩子 with asthma哮喘,
355
795760
2082
也許,對有氣喘的孩童,
13:29
it's what's happening事件 in their home,
356
797842
1608
家裡的狀況是原因,
13:31
or perhaps也許 they live生活 close to a
freeway高速公路 with major重大的 air空氣 pollution污染
357
799450
2936
或是因為他們住在
空氣很糟的高速公路旁,
13:34
that triggers觸發器 their asthma哮喘.
358
802386
1824
引發了他們的氣喘。
13:36
And perhaps也許 that's what we should
mobilize動員 our resources資源 to address地址,
359
804210
2620
這大概是我們應該動員
所有資源來對付的事,
13:38
because that third第三 element元件,
that third第三 part部分 of the process處理,
360
806830
2373
因為第三個因素,
步驟的第三部分,
13:41
is that next下一個 critical危急 part部分 of what upstreamistsupstreamists do.
361
809203
2531
是上游管理人會做的
下一步關鍵部分。
13:43
They mobilize動員 the resources資源 to create創建 a solution,
362
811734
2239
他們會動員所有的資源
以找出解決的方法,
13:45
both within the clinical臨床 system系統,
363
813973
1721
無論在臨床系統內,
13:47
and then by bringing使 in people from public上市 health健康,
364
815694
2336
或是之後在公衛界找人、
13:50
from other sectors行業, lawyers律師,
365
818030
1342
其他部門、律師
13:51
whoever is willing願意 to play ball,
366
819372
1947
任何願意參與的人皆可,
13:53
let's bring帶來 in to create創建 a solution that makes品牌 sense,
367
821319
2083
讓我們把這些人引進,
找出合理的解決方法,
13:55
to take those patients耐心 who
actually其實 have clinical臨床 problems問題
368
823402
2810
把這些有實際臨床問題的病人
13:58
and address地址 their root causes原因 together一起
369
826212
2183
幫助他們治本,
14:00
by linking鏈接 them to the resources資源 you need.
370
828395
2542
把他們與你所需的資源連在一起。
14:02
It's clear明確 to me that there are so many許多 stories故事
371
830937
1777
對我而言這很清楚,有很多故事在說
14:04
of upstreamistsupstreamists who are doing remarkable卓越 things.
372
832714
2486
上游管理人所做卓越非凡的事。
14:07
The problem問題 is that there's just not
nearly幾乎 enough足夠 of them out there.
373
835200
2660
問題是這樣的人不夠多。
14:09
By some estimates估計, we need one upstreamistupstreamist
374
837860
2583
粗估我們在醫療系統內
每 20 至 30 位臨床醫師
14:12
for every一切 20 to 30 clinicians臨床醫生
in the healthcare衛生保健 system系統.
375
840443
2946
就需要一位上游管理人。
14:15
In the U.S., for instance, that would mean
376
843389
1255
在美國,舉個例,這意味著
14:16
that we need 25,000 upstreamistsupstreamists
377
844644
2096
我們在 2020 年前,
需要二萬五千名上游管理人。
14:18
by the year 2020.
378
846740
3467
14:22
But we only have a few少數 thousand upstreamistsupstreamists
out there right now, by all accounts賬戶,
379
850207
4110
但是現在據說我們只有少少的
幾千名上游管理人,
14:26
and that's why, a few少數 years年份 ago, my colleagues同事 and I
380
854317
2553
而這就是為什麼在幾年前,
我與幾位同僚說,
14:28
said, you know what, we need to train培養
381
856870
1917
你知道嗎,我們需要訓練出
14:30
and make more upstreamistsupstreamists.
382
858787
1973
更多上游管理人。
14:32
So we decided決定 to start開始 an organization組織
383
860760
1706
所以我們決定創辦一個組織,
14:34
called Health健康 Begins開始,
384
862466
2218
稱為「健康源」,
14:36
and Health健康 Begins開始 simply只是 does that:
385
864684
1746
「健康源」只作這件事:
我們訓練上游管理人。
14:38
We train培養 upstreamistsupstreamists.
386
866430
960
14:39
And there are a lot of measures措施
that we use for our success成功,
387
867390
1938
我們使用許多方法
評量我們是否成功,
14:41
but the main主要 thing that we're interested有興趣 in
388
869328
1361
但我們最主要的目標
14:42
is making製造 sure that we're changing改變
389
870689
1912
是確定我們要改變信心,
14:44
the sense of confidence置信度,
390
872601
1539
14:46
that "don't ask, don't tell" metric among其中 clinicians臨床醫生.
391
874140
1905
改變在臨床醫師間
「你不問我不說」的制式心態。
14:48
We're trying to make sure that clinicians臨床醫生,
392
876045
2299
我們試著要確定臨床醫師,
14:50
and therefore因此 their systems系統 that they work in
393
878344
1940
及他們工作的系統
14:52
have the ability能力, the confidence置信度
394
880284
2295
因而有能力、有信心
14:54
to address地址 the problems問題 in the living活的
395
882579
2675
能解決我們生活
14:57
and working加工 conditions條件 in our lives生活.
396
885254
3007
及工作條件的問題。
15:00
We're seeing眼看 nearly幾乎 a tripling三倍
397
888261
1979
我們看見在我們的努力下
信心增加了二倍。
15:02
of that confidence置信度 in our work.
398
890240
1581
15:03
It's remarkable卓越,
399
891821
1303
成效顯著,
15:05
but I'll tell you the most compelling引人注目 part部分
400
893124
1914
但我要告訴你們最有趣的部分
15:07
of what it means手段 to be working加工
401
895038
1569
就是與上游管理人合作
15:08
with upstreamistsupstreamists to gather收集 them together一起.
402
896607
4483
把他們集合在一起是什麼意思。
15:13
What is most compelling引人注目 is that every一切 day,
403
901090
2323
最有趣的是每一天,
15:15
every一切 week, I hear stories故事 just like Veronica's維羅尼卡的.
404
903413
3771
每一週我都聽到像小維的故事。
15:19
There are stories故事 out there of Veronica維羅尼卡
405
907184
2478
多的是像小維
15:21
and many許多 more like her,
406
909662
1919
一般的故事,
15:23
people who are coming未來 to the healthcare衛生保健 system系統
407
911581
1881
人們進入一個醫療系統
15:25
and getting得到 a glimpse一瞥 of what it feels感覺 like
408
913462
1378
窺視能參與
15:26
to be part部分 of something that works作品,
409
914840
2560
有成效系統的感覺,
15:29
a health健康 care關心 system系統 that stops停止
bouncing蹦蹦 you back and forth向前
410
917400
2473
一種醫療系統不再把你當足球踢,
15:31
but actually其實 improves提高 your health健康,
411
919873
1821
卻能實際改善你的健康,
15:33
listens監聽 to you who you are,
412
921694
1127
傾聽你的人生,
15:34
addresses地址 the context上下文 of your life,
413
922821
2303
處理你的生活背景,
15:37
whether是否 you're rich豐富 or poor較差的 or middle中間 class.
414
925124
4365
無論你是貧富還是中產階級。
15:41
These stories故事 are compelling引人注目 because
415
929489
1655
這些故事引人注意,因為
15:43
not only do they tell us that we're this close
416
931144
1980
它們不但告訴我們,我們有多接近
15:45
to getting得到 the healthcare衛生保健 system系統 that we want,
417
933124
2586
我們想要的醫療保健系統,
15:47
but that there's something
that we can all do to get there.
418
935710
2749
也告訴我們,
我們能合作達成這件事。
15:50
Doctors醫生 and nurses護士 can get better at asking
419
938459
1862
醫師及護士能做得更好,
只要他們問問病人的生活背景,
15:52
about the context上下文 of patients'耐心' lives生活,
420
940321
1844
15:54
not simply只是 because it's better bedside床頭 manner方式,
421
942165
2511
因為這不僅是更好的醫療服務態度,
15:56
but frankly坦率地說, because it's a better standard標準 of care關心.
422
944676
3082
但坦白說,這也是更好的照護標準。
15:59
Healthcare衛生保健 systems系統 and payers納稅人
423
947758
2342
醫療系統及醫療給付單位
16:02
can start開始 to bring帶來 in public上市 health健康 agencies機構
424
950100
2790
可以開始把公衛局
16:04
and departments部門 and say,
425
952890
1415
及衛生署帶進來並說,
16:06
let's look at our data數據 together一起.
426
954305
1538
讓我們一起來看看數據。
16:07
Let's see if we can discover發現 some patterns模式
in our data數據 about our patients'耐心' lives生活
427
955843
3526
看一看我們能否在數據中
發現病人的生活型態,
16:11
and see if we can identify鑑定 an upstream上游 cause原因,
428
959369
2471
看看我們能否找出發病的源頭。
16:13
and then, as importantly重要的, can we align對齊 the resources資源
429
961840
2561
然後,同樣重要的是,
我們能不能運用資源
16:16
to be able能夠 to address地址 them?
430
964401
2336
去解決這個問題?
16:18
Medical schools學校, nursing看護 schools學校,
431
966737
1394
醫學院、護理學院、
16:20
all sorts排序 of health健康 professional專業的 education教育 programs程式
432
968131
2296
各種專業醫療教育課程
16:22
can help by training訓練 the
next下一個 generation of upstreamistsupstreamists.
433
970427
3756
都可以訓練下一代的
上游管理人來達成目標。
16:26
We can also make sure that these schools學校
434
974183
1755
我們也要確定這些學校
16:27
certify證明 a backbone骨幹 of the upstream上游 approach途徑,
435
975938
3228
要認證上游管理的基礎,
16:31
and that's the community社區 health健康 worker工人.
436
979166
2195
即社區保健員。
16:33
We need many許多 more of them
in the healthcare衛生保健 system系統
437
981361
1519
在醫療系統內我們需要更多這種人,
16:34
if we're truly going to have it be effective有效,
438
982880
2353
如果我們真的想要有成效的話,
16:37
to move移動 from a sickcaresickcare system系統
439
985233
1507
要從「疾病」照護系統
16:38
to a healthcare衛生保健 system系統.
440
986740
1498
變成「健康」照護系統。
16:40
But finally最後, and perhaps也許 most importantly重要的,
441
988238
2048
但最後一點,
或許也是最重要的一點,
16:42
what do we do? What do we do as patients耐心?
442
990286
2559
我們要怎麼做?
身為病人我們要怎麼做?
16:44
We can start開始 by simply只是 going to our doctors醫生
443
992845
2265
我們可以這樣開始:去看醫生、
16:47
and our nurses護士, to our clinics診所,
444
995110
1709
看護理師、去診所時,
16:48
and asking, "Is there something in where I live生活
445
996819
2332
問他們,「在我居住
16:51
and where I work that I should be aware知道的 of?"
446
999151
2343
及工作的地方,
有什麼是我該注意的嗎?」
16:53
Are there barriers障礙 to health健康 that I'm just not aware知道的 of,
447
1001494
2848
有什麼讓我不健康的事物
是我從沒注意到的嗎?
16:56
and more importantly重要的, if there are barriers障礙
448
1004342
1958
更重要的是,如果真有這種障礙
16:58
that I'm surfacing堆焊, if I'm coming未來 to you
449
1006300
1981
我意識到了,如果我來你這裡,
17:00
and I'm saying I think have a problem問題 with
450
1008281
2119
而且告訴你,我認為在我的公寓
17:02
my apartment公寓 or at my workplace職場
451
1010400
2103
或我的工作場所的確有問題,
17:04
or I don't have access訪問 to transportation運輸,
452
1012503
2196
或是我無法搭公共交通工具,
17:06
or there's a park公園 that's way too far,
453
1014699
1631
或公園離我太遠,
17:08
so sorry doctor醫生, I can't take your advice忠告
454
1016330
1860
所以真抱歉醫師,
我無法採納你的建議
17:10
to go and jog慢跑,
455
1018190
2086
去慢跑,
17:12
if those problems問題 exist存在,
456
1020276
1881
如果這些問題的確存在,
17:14
then doctor醫生, are you willing願意 to listen?
457
1022157
3296
那醫師,你願意聽嗎?
17:17
And what can we do together一起
458
1025453
1413
我們能一同做什麼
17:18
to improve提高 my health健康 where it begins開始?
459
1026866
2570
從源頭改善我的健康?
17:21
If we're all able能夠 to do this work,
460
1029436
2444
如果我們能一同做這件事,
17:23
doctors醫生 and healthcare衛生保健 systems系統,
461
1031880
1539
醫師及醫療系統,
17:25
payers納稅人, and all of us together一起,
462
1033419
2080
醫療給付單位,及所有的人都一起,
17:27
we'll realize實現 something about health健康.
463
1035499
2194
我們就能瞭解健康的真義。
17:29
Health健康 is not just a personal個人
responsibility責任 or phenomenon現象.
464
1037693
3422
健康不僅是個人的責任或現象。
17:33
Health健康 is a common共同 good.
465
1041115
3502
健康是共有財。
17:36
It comes from our personal個人 investment投資 in knowing會心
466
1044617
1918
它始於我們個人付出心力瞭解
17:38
that our lives生活 matter,
467
1046535
2281
我們的生活非常重要,
17:40
the context上下文 of where we live生活 and where we work,
468
1048816
2128
我們生活及工作的地方的背景、
17:42
eat, and sleep睡覺, matter,
469
1050944
1736
我們吃、睡也非常重要,
17:44
and that what we do for ourselves我們自己,
470
1052680
1624
我們不但要為自己做,
17:46
we also should do for those
471
1054304
2120
我們同時也應該要為那些
17:48
whose誰的 living活的 and working加工 conditions條件
472
1056424
2016
生活及工作條件,
17:50
again, can be hard, if not harsh苛刻.
473
1058440
2618
再說一次,
即使不惡劣也很糟的人做這件事。
17:53
We can all invest投資 in making製造 sure that we improve提高
474
1061058
2486
我們要付出心力確保我們改善
17:55
the allocation分配 of resources資源 upstream上游,
475
1063544
2250
上游資源的分配,
17:57
but at the same相同 time work together一起
476
1065794
2183
但同時也要一同合作
17:59
and show顯示 that we can move移動 healthcare衛生保健
477
1067977
2733
證明我們能將醫療系統
18:02
upstream上游.
478
1070710
2037
帶往上游。
18:04
We can improve提高 health健康 where it begins開始.
479
1072747
3073
我們能從源頭改善健康。
18:07
Thank you.
480
1075820
2027
謝謝。
18:09
(Applause掌聲)
481
1077847
2554
(掌聲)
Translated by Regina Chu
Reviewed by Adrienne Lin

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ABOUT THE SPEAKER
Rishi Manchanda - Physician
Rishi Manchanda is an "upstreamist." A physician and public health innovator, he aims to reinvigorate primary care by teaching doctors to think about—and treat—the social and environmental conditions that often underly sickness.

Why you should listen

For a decade, Rishi Manchanda has worked as a doctor in South Central Los Angeles, treating patients who live and work in harsh conditions. He has worked at the Venice Family Clinic, one of the largest free clinics in the United States. He was the first director of social medicine at the St. John’s Well Child and Family Center in Compton, where he and his team provided high quality primary care to low-income families in the area. Currently, he is the medical director of a veterans’ clinic within the Greater Los Angeles Healthcare System, which he refers to as an “intensive caring unit.” He tells the National Health Corps Services, “The moment when a patient switches from despair to hopefulness is the greatest part of my service.” 

Manchanda is the author of the TED Book The Upstream Doctors, in which he looks at how health begins at home and in the workplace, with the social and environmental factors of our everyday lives. He shows how the future of our healthcare system depends on “upstreamists,” the doctors, nurses and other healthcare practitioners who look for the root cause of illness rather than just treating the symptoms.

Manchanda is the president and founder of Health Begins, a social network that teaches and empowers clinicians to improve health where it begins—in patients’ home and work environments. He also founded RxDemocracy, a nonpartisan coalition created to register voters in healthcare clinics. He serves on the board of the National Physicians Alliance, as well as on the board of Physicians for Social Responsibility in Los Angeles.

More profile about the speaker
Rishi Manchanda | Speaker | TED.com