醫療制度變革中的中國和古巴
Two countries that are models of effective public health intervention, China and Cuba, have recently embarked on important policy changes, leaving some experts wondering whether citizens will be left worse off.
中國和古巴是有效實施公共衛生干預措施的模範國家，但最近它們開始進行一些重大的政策調整。一些專家想知道，這是否會給兩國的公衆帶來不利影響。
In September, Cuba and the Obama administration began moving closer to normalized relations, which may expose Cuba’s vaunted medical system to powerful new market pressures. In October, China renounced its one-child policy, under which most families were forbidden to have more than a single child.
今年9月，古巴和奧巴馬政府開始向關係正常化邁進，而這可能給古巴引以爲豪的醫療制度帶來巨大的市場壓力。而在10月，中國取消了禁止大多數家庭擁有多個孩子的獨生子女政策。
Both countries enshrine health care as a fundamental right.
這兩個國家均把醫療奉爲一項基本權利。
Cuba is a well-known anomaly: so poor that it is barely able to feed its people, yet able to equal or beat the United States in two important health indicators — life expectancy and child mortality.
古巴是一個衆所周知的反常例子：該國非常貧困，只能勉強讓公衆餬口，但卻仍然在兩個重要的健康指標上擊敗了美國——預期壽命和嬰幼兒死亡率。
The nation has 30,000 family doctors and 500 local clinics, and every Cuban sees a doctor at least once a year. Former Senator Bill Frist of Tennessee, a doctor, visited last year and praised aspects of Cuba’s primary care system, saying it “harkens back to the days of family physicians making house calls armed only with their deep personal patient knowledge and their stethoscope.”
古巴擁有3萬名家庭醫生和500間地方診所，每個古巴人每年至少看一次醫生。來自田納西州的前聯邦參議員比爾·弗里斯特(Bill Frist)是一名醫生，去年訪問古巴時，他對該國初級醫療系統的一些方面讚賞有加，說它“讓人回想起當年，家庭醫生在出診的時候，依靠的只有聽診器和自己對病人的深入瞭解。”
In the last decade, Cuba has sent thousands of doctors on overseas aid missions. They have treated 3.5 million patients. During last year’s Ebola outbreak in West Africa, one American-built hospital was staffed by Cubans.
在過去的十年裏，古巴派出數以千計的醫生參加海外援助任務。他們治療的病患達350萬人。去年的埃博拉疫情在西非肆虐的時候，美國援建的一家醫院裏的工作人員就是古巴人。
China, too, has made enormous strides. As the nation turned itself into the world’s factory town, the megacities intended to house millions of workers were built with water and sewer pipes, screened windows, air-conditioning and nearby hospitals — amenities mostly missing in the farm villages the workers came from.
中國也取得了巨大的進步。隨着中國把自己打造成世界工廠，特大城市容納了數以百萬計的工人。那裏建有供水和排污管道，安裝了紗窗、空調，而且附近就有醫院——而在工人的農村老家地區，很多都沒有這樣的設施。
Clean water reduces deaths from cholera, dysentery and a dozen other intestinal pathogens. Stopping mosquitoes and flies reduces deaths and disability from malaria, yellow fever, trachoma, leishmaniasis and more.
有了清潔飲水，霍亂、痢疾等十多種腸道病原體導致的死亡案例減少了。蚊蠅的消滅，也降低了瘧疾、黃熱病、沙眼、利什曼等病的死亡率和致殘率。
Whenever epidemiologists talk about how much the world has improved in the last 20 years — millions fewer children dying, being stunted by worm Disease or living without running water — they usually have to add: “Of course, most of that progress was in China.”
每當流行病學家談到全球在過去20年中取得的進步時——因腸蟲病或生活在沒有自來水的地方而死亡或發育不良的兒童人數減少了成百上千萬——他們通常不得不加上：“當然，這樣的進步主要發生在中國。”
Chinese researchers now routinely publish work in top medical journals. In 2003, China crushed its exploding SARS outbreak and in 2009 largely held off the swine flu pandemic while scientists brewed a vaccine.
中國的科研人員現在經常在頂級醫學雜誌發表成果。2003年，中國抑制了非典疫情的爆發，2009年，中國又在科學家忙於研製豬流感疫苗的時候在很大程度上阻止了這種疾病的大規模流行。
Yet public health interventions in both countries have often had a coercive edge.
然而，這兩個國家的公共衛生干預措施往往帶有強制色彩。
When Mao decreed a campaign to wipe out rural worm diseases, authorities mixed deworming drugs into salt. Health teams arrived in Chinese villages with soldiers and ordered families to bring their salt to the public square. It was washed away with fire hoses and replaced.
當年毛澤東發起一場運動，要消滅農村的腸蟲病，於是當局把驅蟲藥物混在鹽中。衛生隊與軍人一起去往中國各地的鄉村，命令各家各戶把食鹽帶到廣場上。然後他們用消防水管沖走那些食鹽，再把混了藥的鹽分給大家。
To stem its SARS outbreak, China closed every school and most large venues in Beijing. To keep the swine flu at bay, it escorted all foreign visitors with fevers off planes into quarantine.
爲了抑制非典疫情，中國關閉了北京的所有學校和大多數大型場館。爲了控制豬流感，所有乘機抵達中國的外國遊客如有發熱症狀，一概被送入隔離區。
Cuba relied on harsh methods, too, to suppress its AIDS epidemic — and with great success.
古巴也是依靠嚴厲的手段抑制了艾滋病的流行——並取得了巨大成功。
Until 1993, H.I.V.-positive Cubans were forced to live in bungalow colonies. Even now, at mandatory annual checkups, patients find it hard to avoid tests for sexually transmitted diseases if the doctor thinks they are warranted.
在1993年之前，艾滋病毒檢測呈陽性的古巴人會被迫住在專門的平房區。即便是現在，在強制進行的年度體檢中，如果醫生認爲有必要做性傳播疾病檢測，患者也很難逃避。
Experts are just beginning to debate the effects of changing policies on public health in these two countries.
對於這兩個國家的政策變化將給公衆衛生帶來怎樣的影響，專家們的辯論纔剛剛開始。
China has almost a fifth of the world’s population. The one-child policy, in place since 1980, has averted an estimated 400 million births.
中國人口占全世界的近五分之一。從1980年開始實施的獨生子女政策避免了大約4億人口的降生。
It also lowered child mortality. One infant doted on by parents and grandparents is far more likely to survive than one of five children — to be taken to a doctor for pneumonia, for instance.
這也導致了嬰幼兒死亡率的降低。受到父母和祖父母悉心照料的獨生嬰孩，如果患上肺炎之類的疾病，被送去看醫生而存活下來的可能性，要遠遠高於五個孩子的家庭。
Even after ending the one-child policy, China is very likely to hold onto its gains in public health, said Dr. Christopher J.L. Murray, director of the Institute for Health Metrics and Evaluation at the University of Washington.
克里斯托弗·J·L·默裏(Christopher J.L. Murray)是華盛頓大學健康指標和評估研究所(Institute for Health Metrics and Evaluation)的所長。他認爲，即使在取消獨生子女政策之後，中國在公共衛生方面已經獲得的改善也很有可能會保持下去。
China’s “blistering rate of decline” in child mortality resulted more from new wealth than from low birthrates, Dr. Murray said.
默裏博士表示，相比於低出生率，中國嬰幼兒死亡率“迅猛下降”更多是因爲有了新的財富。
Over the last 25 years, according to a study by the institute and China’s Center for Disease Control and Prevention, the gross domestic product went from $60 per capita to $6,800. Health improved most in the wealthiest cities, despite drawbacks like the air pollution that has plagued Beijing.
該研究所和中國疾病預防控制中心共同進行的一項研究顯示，過去25年，中國人均國內生產總值從60美元增長到6800美元。在最富裕的那些城市，健康狀況改善最爲明顯，儘管這類地方也存在一些弊端，諸如困擾北京的大氣污染。
Also, because of exceptions for ethnic groups and rural families, the real birthrate was never just one child per woman, but closer to 1.7. While there may be some pent-up demand for more children, fertility “is almost a one-way street,” Dr. Murray said. Once countries prosper, fallen birthrates rarely rise again.
而且，因爲少數民族和農村家庭不受獨生子女的限制，真實的出生率從來不是平均每個女性生育一個子女，而是更接近平均1.7個。雖然存在一些受到壓抑的多胎需求未來可能會釋放，但默裏稱，生育率的變化“幾乎可以說是一條單行道”。一旦國家繁榮起來，已經下降的出生率很少會再度上升。
Cuba’s path is a little harder to predict.
古巴的未來則更加難以預測。
The island protects children so well that it could improve only in neonatal intensive care, Dr. Murray said. An end to the United States’ economic embargo could help Cuba’s hospitals receive the advanced equipment they desperately need, along with new drugs for cancer and other illnesses.
默裏博士表示，這個島國對兒童的保護非常之好，在這方面只剩下新生兒重症監護可以進一步提高。美國的貿易禁令解除後，或將有助於古巴醫院獲得他們急需的先進醫療設備，還有治療癌症等疾病的新型藥物。
Cuba also has medical products to sell, including meningitis vaccines, a drug for diabetic foot ulcers and a lung cancer treatment, said Gail Reed, the American founder of Medical Education Cooperation With Cuba and editor of a medical journal there.
在古巴一家醫學雜誌擔任編輯的美國人、古巴醫學教育合作項目(Medical Education Cooperation With Cuba)創始人蓋爾·裏德(Gail Reed)表示，古巴也有醫療產品可以對外銷售，包括腦膜炎疫苗、一種用於治療糖尿病足部潰瘍的藥物和一種肺癌的療法。
But ending the embargo also poses serious risks.
但解除貿易禁令也會帶來重大風險。
The primary care doctors Cuba’s system depends on are poorly paid, even though salaries tripled recently. Earlier this month, the Cuban government reinstated a requirement that doctors traveling outside the country receive a special permit. The nation has lost thousands of doctors since 2013, the government said.
儘管最近已經漲了兩倍，但古巴的醫療系統依賴的初級保健醫師的薪水依然很低。本月早些時候，政府重新要求古巴醫生在去往海外時要獲得特別批准。政府表示，自2013年起，古巴已經流失數千名醫生。
And prosperity itself brings risks. In Mexico, obesity, diabetes and heart disease soared as incomes rose; Cuba could face the same fate. The nation’s doctors do not manage blood pressure or cholesterol aggressively, and its cancer death rates are about equal to those in the United States.
繁榮本身也會帶來風險。在墨西哥，隨着人們收入增加，肥胖症、糖尿病和心臟病患病人數也激增；古巴可能也會面臨同樣的命運。古巴的醫生不太注意控制血壓和膽固醇，該國癌症死亡率也很快會和美國持平。
“Cuba’s whole system has historically focused on top-quality outcomes for kids and mothers,” Dr. Murray said. “There’s not much emphasis on managing chronic disease in adults.”
“在過去，古巴整套醫療系統集中於給孩子和母親提供最高品質的醫療成果，”默裏說。“他們不太重視控制成人的慢性疾病。”
