健康革命 人類比較大的福祉

The highest life expectancy recorded for womenanywhere in the world has risen by a year every fouryears since 1840. This inexorable advance inlongevity is, arguably, the most important of all thechanges to human life in the past two centuries.

自從1840年以來，全球女性預(yù)期壽命的最高紀(jì)錄每四年就增加一歲。人類在延長(zhǎng)自身壽命方面的這種持續(xù)不斷的進(jìn)步，也許就是過去兩個(gè)世紀(jì)人類生活所有變化中最重大的變化。

 

 

These gains in health are also widely shared: “India today has a higher life expectancy thanScotland in 1945 — in spite of a per-capita income that Britain had achieved as early as 1860.”This remark comes from a wonderful book, The Great Escape: Health, Wealth, and the Originsof Inequality, by Princeton University’s Angus Deaton, published last year, which documents therevolution in both health and wealth since the early 19th century. Of the two, the former is themore important. Who would not give up many material comforts if, in return, they could avoidthe agony of watching their children die or enjoy the company of their loved ones in old age?

人類健康方面的進(jìn)步也具有廣泛性：“今日印度人的預(yù)期壽命高于1945年的蘇格蘭人，盡管在人均收入方面，英國早在1860年就達(dá)到了印度今日的水平。”這句話出自去年出版的一本精彩著作：《逃離不平等：健康、財(cái)富及不平等的起源》(The Great Escape: Health, Wealth, and the Origins of Inequality)，作者是美國普林斯頓大學(xué)(Princeton University)的安格斯•狄頓(Angus Deaton)，書里講述了自19世紀(jì)初以來人類健康和財(cái)富方面發(fā)生的革命。在這二者之中，前者更加重要。如果能夠避免目睹孩子死去的悲痛，或者能夠享有長(zhǎng)壽父母的陪伴，誰不愿放棄更多物質(zhì)享受來交換呢?

No blessing is unmixed. Prolonged survival “sans teeth, sans eyes, sans taste, sanseverything” is to be neither envied nor desired. Yet the revolution in health is still a blessing.As Professor Deaton notes: “Of all the things that make life worth living, extra years of life aresurely among the most precious.” Someone whose standard of living is twice as high andexpects to live twice as long as someone else could even be deemed to be four times better off.

任何好事都不是純粹的。延長(zhǎng)“沒有牙齒、沒有視力，沒有味覺，沒有一切”的殘生既不值得羨慕也不令人期望。然而健康革命仍是人類一大福祉。正如狄頓教授所說：“在所有讓生活有價(jià)值的事物中，多活幾年肯定屬于最珍貴的那一類。”有些人生活水平高出常人一倍，并且預(yù)計(jì)要比別人多活一倍時(shí)間，人們大概可以認(rèn)為，他們比常人幸福四倍。

So what has happened?

那么，人類的健康都發(fā)生了哪些變化呢?

Start with mortality rates (deaths per thousands) over time of three of today’s high-incomecountries: Sweden in 1751; the US in 1933; and the Netherlands and the US in 2000 (seechart). Back in 1751 the mortality rate of Swedish newborns was more than 160 per thousandpeople. It was more than 40 per thousand in the US in 1933. By 2000 it was below 10 perthousand. At subsequent ages mortality rates have become consistently lower over time, withthe lowest rates of all for children aged about 10. Today we see a rise of mortality rates in thelate teens, largely because of the riskier behaviour of young men. After a plateau in the late20s and early 30s, death rates rise, but they do not reach 10 per thousand before age 60. USmortality rates are higher than those in the Netherlands, except for the over 80s. That iswhere the US concentrates its resources.

首先來看看當(dāng)今三個(gè)高收入國家人口死亡率(每千人死亡人數(shù))不同年份的情況：1751年的瑞典，1933年的美國，以及2000年的荷蘭和美國(見右圖)。1751年瑞典新生兒死亡率超過160人/千人。1933年美國新生兒死亡率超過40人/千人，到了2000年低于10人/千人。各年齡段兒童死亡率均在不斷降低，其中10歲左右的兒童死亡率最低。我們看到較大年齡的少年死亡率現(xiàn)在有所上升，大部分是因?yàn)槟泻⒆觽兊奈ｋU(xiǎn)行為。在三十歲左右的年齡段經(jīng)歷了一段平臺(tái)期后，死亡率又開始上升，但60歲以下死亡率不足10人/千人。美國的死亡率比荷蘭的高，但80歲以上年齡段例外，美國的醫(yī)療資源主要集中在這一年齡段中。

Back in 1850 life expectancy was about age 40 in England and Wales. Today it is close to 80. Inthe case of Italy it has risen from 30 in 1875 to above the English level. The chart also showsthe devastating effects of the Spanish flu epidemic of 1918. This is explained by how lifeexpectancy is computed: the assumption is that the risks of dying at a particular age areproduced by the ages of death of the population in a specific year. In 1918 a largeproportion of young people died in the epidemic. This reduced life expectancy drastically. Butthose born in 1918 had far longer lives than these figures suggest. Similarly, a smallproportion of the English and Welsh population actually died at 40 in 1850. Instead, a greatmany died aged as babies and many lived to be more than 60. Forty was merely the averageage of death. Finally, notes Prof Deaton: “Saving the lives of children has a bigger effect on lifeexpectancy than saving the lives of the elderly.” Thus, as death “ages”, the rise in lifeexpectancy slows.

1850年英格蘭和威爾士的人口預(yù)期壽命在40歲左右，如今已接近80歲。意大利的人口預(yù)期壽命從1875年的30歲一路上升，直到高于英國水平。圖表還顯示了1918年西班牙流感的災(zāi)難性后果。這可以從預(yù)期壽命的計(jì)算方法得到解釋，它假設(shè)某個(gè)年齡的死亡風(fēng)險(xiǎn)是由某年人口死亡年齡來決定的。1918年有很大一部分比例的年輕人死于西班牙流感，導(dǎo)致預(yù)期壽命大大降低。但1918年出生的人壽命遠(yuǎn)高于圖表所顯示的年齡。同樣地，1850年英格蘭和威爾士實(shí)際上只有一小部分人死于40歲，死亡人口中有許多是嬰兒。還有很多人活到了60歲以上，40歲只是平均死亡年齡。最后，狄頓教授指出：“在提高預(yù)期壽命方面，拯救兒童生命的作用遠(yuǎn)大于拯救老年人生命。”因此，隨著死亡年齡提高，預(yù)期壽命上升減緩。

The health revolution has spread worldwide since the middle of the 20th century —dramatically so in east Asia; least so, alas, in sub-Saharan Africa partly because of HIV/Aids. Abig element has been the collapse in child mortality. According to the Gapminder website,mortality among Indian children under five fell from 267 per thousand in 1950 to 56 in 2012.Over the same period it fell from 317 to 14 in China. These improvements occurred at muchlower income levels than was the case in today’s high-income countries. This is partly becauseof improved knowledge (oral rehydration, for example), partly because of medical technology(vaccination, for example) and partly because of public services (clean water and sanitation,for example).

健康革命自20世紀(jì)中葉起席卷了全球，東亞地區(qū)變化尤為劇烈，撒哈拉以南非洲地區(qū)變化最小，原因在于艾滋病毒/艾滋病(HIV/Aids)。兒童死亡率大幅下降占了很大因素。根據(jù)Gapminder網(wǎng)站的數(shù)據(jù)，印度5歲以下兒童死亡率從1950年的267人/千人下降到2012年的56人/千人。同時(shí)期中國的這一指標(biāo)從317人/千人下降到14人/千人。這些進(jìn)步發(fā)生在那些收入水平較低的國家，而不是現(xiàn)在的高收入國家。一部分原因在于知識(shí)水平提高(如口服補(bǔ)液)，一部分原因在于醫(yī)療技術(shù)(如接種疫苗)，還有部分原因在于公共服務(wù)(如潔凈水和衛(wèi)生設(shè)施)。

Unfortunately, the improvements are not as complete as they should be. In Angola the under-five mortality rate is 164 per thousand. In Nigeria it is 124. Yet these are relatively well-offcountries. In general, a link exists between prosperity and health. Yet greater prosperity isneither a necessary nor a sufficient condition for improved health outcomes. It just makes itrather easier.

遺憾的是，這種改善還沒有達(dá)到應(yīng)有的普及程度。在安哥拉，5歲以下嬰幼兒死亡率為千分之164。在尼日利亞，這個(gè)數(shù)字為千分之124。不過，這些還是相對(duì)富裕的國家。一般而言，富裕程度和健康狀況存在關(guān)聯(lián)。然而，富裕程度更高既非健康狀況改善的必要條件，也非其充分條件。前者只不過使得后者更容易實(shí)現(xiàn)。

The health revolution is not just a good in itself. It has beneficial consequences, the mostimportant of which is the transformation of women’s lives. As child mortality tumbles, sodoes fertility: fewer births are needed to achieve a given family size. This is irrespective ofreligion: in Muslim Iran, for example, the number of children per woman fell from 6.5 in 1980 to1.9 in 2012; similarly, in Catholic Brazil it fell from 6.2 in 1960 to 1.8 in 2012. As women livelonger and have fewer children, they can invest more in each child and pursue their owncareers. Thus the health revolution underpins another of the revolutions of our era: thechange in the role of women.

健康革命的好處并不僅限于改善健康狀況本身。它帶來多種好處，其中最重要的一點(diǎn)是改變了女性的生活。隨著兒童死亡率大幅下跌，生育率也大幅下降：創(chuàng)建一定規(guī)模的家庭所需生育的孩子減少了。這種現(xiàn)象不受宗教影響：比如，在信仰伊斯蘭教的伊朗，每個(gè)女性生育的孩子的數(shù)量，從1980年的6.5個(gè)降至2012年的1.9個(gè);類似的，在信仰天主教的巴西，這個(gè)數(shù)字從1960年的6.2個(gè)降至2012年的1.8個(gè)。隨著女性壽命延長(zhǎng)、生育孩子的數(shù)量減少，她們可以在每個(gè)孩子身上投入的更多，也可以追求自己的事業(yè)。因此，健康革命支撐了我們這個(gè)時(shí)代的另一場(chǎng)革命：女性角色的改變。

What has driven the improvements in health, particularly among the middle aged? A decline insmoking is a factor. Improved treatment for heart disease is another. Even cancer issuccumbing to treatment. Increasingly, in high-income countries, the remaining diseases arethose of old age, including dementia. But in most developing countries the old afflictions linger,including poor sanitation, contaminated water and malaria.

健康狀況改善的主要驅(qū)動(dòng)因素是什么，尤其是在中年人中間?吸煙人數(shù)減少是一個(gè)因素。心臟病治療水平提高則是另外一個(gè)因素。就連癌癥也不再是不治之癥。在高收入國家，老年病(包括老年癡呆癥)在剩下的疾病中占比越來越高。但在大多數(shù)發(fā)展中國家，各種老問題依然存在，包括公共衛(wèi)生狀況差、水污染、以及瘧疾。

Yet for all that remains to be done, and all the inequality of health services across the globe, itis important to appreciate the great and increasingly widely shared improvement in health. Anincreasing proportion of humanity has a good chance of living healthily into what hastraditionally been viewed as old age. A rising proportion of children is reaching maturity. Wecannot escape death. But we do keep out of its grasp for ever longer. That is to becelebrated.

盡管仍然存在種種需要解決的問題，世界各地的醫(yī)療服務(wù)仍然發(fā)展不均，但非常重要的一點(diǎn)是，要認(rèn)識(shí)到人類健康狀況出現(xiàn)了巨大的改善，而且這種改善覆蓋到越來越多的人。越來越多的人有很大機(jī)會(huì)以健康的身體步入傳統(tǒng)觀點(diǎn)中的老年期。成年前夭折的兒童比率越來越低。死亡是無法逃避的。但我們?cè)诒凰郎褡プ≈暗纳鏁r(shí)間比以往任何時(shí)候都更長(zhǎng)了。這是值得慶祝的。