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对健康问题,应该用这个角度看

Sandro Galea 2019年05月14日

很少有人想到,健康是一种典型的公共产品。

本文是波士顿大学桑德罗·加利亚博士分析错综复杂的医疗和公共卫生问题的系列文章之一。

人们的健康是一种公共产品。

估计该说法与大多数读者与健康的看法并不一致。毕竟,健康难道不是由行为、饮食和运动量决定的吗?虽然事实确实如此,但从根本上讲,行为不可避免地由周围的世界决定。我来详细解释下。

公共产品是需要集体投资支持的公共资源。像图书馆、公园、高速公路、国家安全之类,都属于公共产品。全民支持,供全民使用。这些之所以是公共产品而非个人商品,是因为人们认为相关产品对全民福利非常重要,不应该完全由私人投资,也不应受市场力量左右。例如,教育可造福所有人,可以改善每个人的生活。因此,教育作为公共产品得到全民支持。

健康也属于同一类。每个人都看重健康,也渴望健康,不管是为了自己还是为了关心的人。不管政治立场如何,我还没有发现不希望孩子尽可能健康的人。

健康也得到了真金白银的支持。每年医疗保健方面耗资巨大。然而,正如我经常写到,绝大多数投资都用于开发药物和医疗技术,并未用于推动核心的社会、经济和环境力量,影响周围的世界从而影响人们的行为。如果相关努力缺失,就很难真正实现全民健康。

当然,人们很容易想到,健康不依赖集体投资,个体同样可以为健康支出。人们可能相信,如果能够请最好的医生、买最好的药品,健康就可以得到保障。

但这真有可能吗?毕竟,如果没有干净的空气和水、没有安全的社区、没有公平经济和提供支持的社区网络,很难保持健康。以上列出的条件全部都是公共产品,依赖集体投资才能发展。健康可以说是一种典型的公共产品,因为它依赖一系列由共同投资的组合产品。

可惜的是,过去30年里美国的公共产品投资不断衰退。投资不力的根源在于政治理念,主要由里根政府时期的思路主导,将个人自由置于其他自由之上,并将任何形式的公共投资视为对自由的潜在威胁。

然而,该理念的失误在于,世上有不同类型的自由。有“主动的自由”,例如言论自由、机会自由,自由选择想做的事以及做的时间,符合当前政治对自由的定义。但还有另一种自由,即“远离的自由”,指远离伤害和疾病、远离无知、远离可预防的损害健康的危险。

维护“远离的自由”就要投资公共产品。虽然过去35年里政治可能忽视了这一目标,但以前曾采取能引起共鸣的愿景努力实现。该愿景是雄心勃勃的罗斯福新政核心,在通过政府大规模干预改善美国社会各阶层的生活。

新政期间,富兰克林·罗斯福总统曾经表示,所有人都有四种基本自由:言论自由、宗教信仰自由、免于匮乏的自由和免于恐惧的自由。他倡导的理念在“主动的自由”和“远离的自由”之间取得了平衡,然而当前人们过于关注主动的自由,却失去平衡,忽视了远离的自由。

同时,如果没有集体投资创造条件推动自由,人们既不可能免于匮乏,也不可能免于恐惧。为了最大限度实现自由,就要恢复历史上国家对公共产品的尊重。

尽管政治上面临挑战,但公共产品在美国仍然可行,因为对人们的安全和健康来说,它非常必要。以道路安全为例。世纪之交,美国人开车的人数是1925年的6倍,路上的机动车数增加了11倍。然而在1925年至1997年期间,每年机动车导致死亡率下降了90%。为什么?是因为美国人驾驶技术提升了吗?

不完全如此。事实上,死亡率下降是因为我们选择将道路安全作为公共产品进行投资。通过法律,设立机构,向人们提供培训,建立健全的规则和安全流程以确保道路安全。确实很奏效。更重要的是,该体系一直在运转,基本上没有政治干预。很少有政客拿道路安全法规说事,攻击政府权力过度扩张。原因就在于道路安全法与人们的健康息息相关。

在道路上保护人们的法律法规与其他保护健康的法律差别能有多大?当缺乏教育缩短寿命,当污浊的空气导致疾病和死亡,当经济不公平扩大贫富之间健康差距,我们有充分的理由像对待危险道路一样,通过投资公共产品来解决影响健康的问题。

必须理清公共物品和健康之间的联系,要达到对安全带和安全关系的认识水平。此举对考虑全民医疗保健,对基础设施、住房、教育、交通和环境的投资选择影响深远。我们也从中明白,如果真想实现健康,一定要意识到公共产品是集体健康的关键。(财富中文网)

桑德罗·加利亚,医学博士,波士顿大学公共卫生学院教授和院长。他的最新著作是《谈起健康应该讨论什么》。

译者:冯丰

审校:夏林

This piece is part of an ongoing series by Boston University’s Dr. Sandro Galea on the intricacies of health care and public health.

Our health is a public good.

I suspect that statement runs at odds with how most readers think about their health. Is our health not, after all, determined by what we do, what we eat, and how much we exercise? While that is indeed the case, fundamentally, our behaviors are shaped by the world around us, inescapably so. Let me explain.

Public goods are common resources that need to be supported by collective investment. Libraries, parks, highways, national security—these are all examples of public goods, supported by all and accessible to all. The reason they are public goods, rather than individual commodities, is we have decided that they are so fundamental to our wellbeing that they should not be entirely the province of private investment or market forces. Education, for example, benefits everyone—there is no one whose life it does not stand to improve. It is therefore supported by everyone, as a public good.

Health falls in the same category. It is something everyone values—we all desire health, both for ourselves and for those we care about. I have yet to meet anyone, regardless of their political affiliation, who does not want their children to be as healthy as possible.

And we back up this with our money. We spend vast sums on health care each year. Yet, as I have often written, the overwhelming majority of this investment goes to developing drugs and medical technologies, rather than to the core social, economic, and environmental forces that shape health—the world around us that shapes our behavior, and without which our health cannot possibly flourish.

It is, of course, tempting to think that health does not depend on our collective investment, that we can, as individuals, simply buy health for ourselves. We may believe that, if we can just secure access to the best doctors and medicines, our health will be assured.

But is this really possible? After all, we cannot be healthy without clean air and water, safe neighborhoods, a fair economy, and supportive community networks. All of these conditions are themselves public goods, relying on our collective buy-in to thrive. Health is arguably the quintessential public good, depending as it does on a range of component goods, all of which are shaped by common investment.

Unfortunately, over the last 30 years, we in the US have allowed this investment to lapse. The roots of this disinvestment lie in a political philosophy, dominant since roughly the Reagan administration, that prioritizes individual freedom above practically all else, and sees any form of public investment as a potential threat to liberty.

What this philosophy misses, however, is that there are different kinds of freedom. There is “freedom to,” i. e. freedom to speak, to assemble, to do what we wish, when we wish. This form of freedom fits with how our current politics often defines the word. But there is another kind of freedom: “freedom from.” “Freedom from” means freedom from injury and disease, from ignorance, from the preventable hazards that undermine health.

Upholding “freedom from” means investing in public goods. While our politics may have neglected this goal over the last 35 years, our politics once embraced it with a vision that still resonates. This vision was at the heart of the New Deal, an ambitious suite of policies aimed at improving American life at all levels of society, through large-scale government effort.

Around the time of the New Deal, President Franklin Roosevelt said that all people are entitled to four basic freedoms: freedom of speech, freedom of worship, freedom from want, and freedom from fear. His freedoms strike a balance between “freedom to” and “freedom from,” a balance we have lost in our overwhelming focus on the former at the expense of the latter.

At the same time, neither freedom from want nor freedom from fear are possible without some measure of collective investment in creating the conditions for these freedoms to flourish. To maximize freedom, then, we must revive the country’s historic respect for public goods.

Despite political challenges, public goods remain viable in the US precisely because they are necessary for our safety and health. Take road safety. At the turn of the last century, there were six times as many Americans driving as there were in 1925, with an 11-fold increase in the number of motor vehicles on the road. Yet, between 1925 and 1997, the annual motor vehicle death rate fell by 90 percent. Why? Did Americans simply become better drivers?

Not quite. In fact, the death rate fell because we chose to invest in road safety as a public good. We passed laws, created agencies, and educated people, with the goal of creating a robust network of rules and safety procedures to keep our roads safe. And it worked. What is more, it keeps working, largely free of political meddling. It would be difficult to find the politician who attacks road safety as an example of government overreach. This is because road safety laws are so clearly tied to our health.

Are the laws that protect us on the road really so different from the laws that keep us healthy in other areas? When lack of education shortens lives, when dirty air causes disease and death, when economic unfairness widens health gaps between the wealthy and those with less, there is no reason why we should not treat these problems the same way we treat dangerous roads, by tackling them through investment in public goods.

We must make the link between public goods and health as clear as the link between seatbelts and safety. This has profound implications for our thinking about guaranteeing universal access to healthcare, about how we feel about selective investments in infrastructure, in housing, in education, in transportation, in the environment. And it teaches us that if we truly want to be healthy, we have no choice but to embrace public goods as the key to our collective health.

Sandro Galea, MD, DrPH, is Professor and Dean at the Boston University School of Public Health. His latest book is, Well: What we need to talk about when we talk about health.

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