医疗制度变革中的中国和古巴
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.
中国和古巴是有效实施公共卫生干预措施的模范国家，但最近它们开始进行一些重大的政策调整。一些专家想知道，这是否会给两国的公众带来不利影响。
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，古巴和奥巴马政府开始向关系正常化迈进，而这可能给古巴引以为豪的医疗制度带来巨大的市场压力。而在10月，中国取消了禁止大多数家庭拥有多个孩子的独生子女政策。
Both countries enshrine health care as a fundamental right.
这两个国家均把医疗奉为一项基本权利。
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.
古巴是一个众所周知的反常例子：该国非常贫困，只能勉强让公众糊口，但却仍然在两个重要的健康指标上击败了美国——预期寿命和婴幼儿死亡率。
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.”
古巴拥有3万名家庭医生和500间地方诊所，每个古巴人每年至少看一次医生。来自田纳西州的前联邦参议员比尔·弗里斯特(Bill Frist)是一名医生，去年访问古巴时，他对该国初级医疗系统的一些方面赞赏有加，说它“让人回想起当年，家庭医生在出诊的时候，依靠的只有听诊器和自己对病人的深入了解。”
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.
在过去的十年里，古巴派出数以千计的医生参加海外援助任务。他们治疗的病患达350万人。去年的埃博拉疫情在西非肆虐的时候，美国援建的一家医院里的工作人员就是古巴人。
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.
中国也取得了巨大的进步。随着中国把自己打造成世界工厂，特大城市容纳了数以百万计的工人。那里建有供水和排污管道，安装了纱窗、空调，而且附近就有医院——而在工人的农村老家地区，很多都没有这样的设施。
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.
有了清洁饮水，霍乱、痢疾等十多种肠道病原体导致的死亡案例减少了。蚊蝇的消灭，也降低了疟疾、黄热病、沙眼、利什曼等病的死亡率和致残率。
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.”
每当流行病学家谈到全球在过去20年中取得的进步时——因肠虫病或生活在没有自来水的地方而死亡或发育不良的儿童人数减少了成百上千万——他们通常不得不加上：“当然，这样的进步主要发生在中国。”
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.
中国的科研人员现在经常在顶级医学杂志发表成果。2003年，中国抑制了非典疫情的爆发，2009年，中国又在科学家忙于研制猪流感疫苗的时候在很大程度上阻止了这种疾病的大规模流行。
Yet public health interventions in both countries have often had a coercive edge.
然而，这两个国家的公共卫生干预措施往往带有强制色彩。
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.
当年毛泽东发起一场运动，要消灭农村的肠虫病，于是当局把驱虫药物混在盐中。卫生队与军人一起去往中国各地的乡村，命令各家各户把食盐带到广场上。然后他们用消防水管冲走那些食盐，再把混了药的盐分给大家。
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.
为了抑制非典疫情，中国关闭了北京的所有学校和大多数大型场馆。为了控制猪流感，所有乘机抵达中国的外国游客如有发热症状，一概被送入隔离区。
Cuba relied on harsh methods, too, to suppress its AIDS epidemic — and with great success.
古巴也是依靠严厉的手段抑制了艾滋病的流行——并取得了巨大成功。
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，艾滋病毒检测呈阳性的古巴人会被迫住在专门的平房区。即便是现在，在强制进行的年度体检中，如果医生认为有必要做性传播疾病检测，患者也很难逃避。
Experts are just beginning to debate the effects of changing policies on public health in these two countries.
对于这两个国家的政策变化将给公众卫生带来怎样的影响，专家们的辩论才刚刚开始。
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.
中国人口占全世界的近五分之一。从1980年开始实施的独生子女政策避免了大约4亿人口的降生。
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.
这也导致了婴幼儿死亡率的降低。受到父母和祖父母悉心照料的独生婴孩，如果患上肺炎之类的疾病，被送去看医生而存活下来的可能性，要远远高于五个孩子的家庭。
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·默里(Christopher J.L. Murray)是华盛顿大学健康指标和评估研究所(Institute for Health Metrics and Evaluation)的所长。他认为，即使在取消独生子女政策之后，中国在公共卫生方面已经获得的改善也很有可能会保持下去。
China’s “blistering rate of decline” in child mortality resulted more from new wealth than from low birthrates, Dr. Murray said.
默里博士表示，相比于低出生率，中国婴幼儿死亡率“迅猛下降”更多是因为有了新的财富。
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.
该研究所和中国疾病预防控制中心共同进行的一项研究显示，过去25年，中国人均国内生产总值从60美元增长到6800美元。在最富裕的那些城市，健康状况改善最为明显，尽管这类地方也存在一些弊端，诸如困扰北京的大气污染。
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，因为少数民族和农村家庭不受独生子女的限制，真实的出生率从来不是平均每个女性生育一个子女，而是更接近平均1.7个。虽然存在一些受到压抑的多胎需求未来可能会释放，但默里称，生育率的变化“几乎可以说是一条单行道”。一旦国家繁荣起来，已经下降的出生率很少会再度上升。
Cuba’s path is a little harder to predict.
古巴的未来则更加难以预测。
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.
默里博士表示，这个岛国对儿童的保护非常之好，在这方面只剩下新生儿重症监护可以进一步提高。美国的贸易禁令解除后，或将有助于古巴医院获得他们急需的先进医疗设备，还有治疗癌症等疾病的新型药物。
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.
在古巴一家医学杂志担任编辑的美国人、古巴医学教育合作项目(Medical Education Cooperation With Cuba)创始人盖尔·里德(Gail Reed)表示，古巴也有医疗产品可以对外销售，包括脑膜炎疫苗、一种用于治疗糖尿病足部溃疡的药物和一种肺癌的疗法。
But ending the embargo also poses serious risks.
但解除贸易禁令也会带来重大风险。
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.
尽管最近已经涨了两倍，但古巴的医疗系统依赖的初级保健医师的薪水依然很低。本月早些时候，政府重新要求古巴医生在去往海外时要获得特别批准。政府表示，自2013年起，古巴已经流失数千名医生。
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.
繁荣本身也会带来风险。在墨西哥，随着人们收入增加，肥胖症、糖尿病和心脏病患病人数也激增；古巴可能也会面临同样的命运。古巴的医生不太注意控制血压和胆固醇，该国癌症死亡率也很快会和美国持平。
“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.”
“在过去，古巴整套医疗系统集中于给孩子和母亲提供最高品质的医疗成果，”默里说。“他们不太重视控制成人的慢性疾病。”
