這幾年，你想必已經(jīng)聽到過這樣的說法：“第一個(gè)能活到150歲的孩子已經(jīng)出生了?！边@確實(shí)是一種令人興奮的說法。不管這一論斷是否屬實(shí)，這都說明了全球人口的平均預(yù)期壽命在20世紀(jì)已經(jīng)有了顯著提升。據(jù)來自世界衛(wèi)生組織的數(shù)據(jù)顯示，光是從2000年到2015年，全球人口的平均預(yù)期壽命就增長了5歲。這種趨勢在美國也不例外。就在上個(gè)月，美國疾病控制與預(yù)防中心發(fā)布報(bào)告稱，從2000年到2014年，美國人口的總體預(yù)期壽命增長了2歲。這一增幅基本上與美國前幾十年的增長情況保持了一致，呈穩(wěn)步上升態(tài)勢。在1900年時(shí)，美國人口的平均預(yù)期壽命約為47歲，目前已經(jīng)接近79歲。以這樣的增長速度看，我們的兒孫顯然會比我們更加長壽，而且健康狀況也會超越我們這一代人。但事實(shí)果真如此嗎？

要回答這個(gè)問題，首先要看看歷史上是哪些因素推動了居民預(yù)期壽命的增長。很多人可能立刻會想到醫(yī)療技術(shù)的進(jìn)步。畢竟20世紀(jì)出現(xiàn)的醫(yī)療突破實(shí)在是不勝枚舉——從喬納斯·索爾克的小兒麻痹癥疫苗，到艾滋病治療技術(shù)的進(jìn)步，再到心血管疾病與干細(xì)胞研究出現(xiàn)的新的曙光，無不大幅延長了相關(guān)患者的生命。然而，全球人口預(yù)期壽命的增長，從時(shí)間要早于其中許多醫(yī)學(xué)成就的應(yīng)用。以英國為例，該國人口預(yù)期壽命的增長始于19世紀(jì)的工業(yè)革命時(shí)期。歷史學(xué)家托馬斯·麥基翁認(rèn)為，工業(yè)革命提高了人們的生活標(biāo)準(zhǔn)，尤其是人們的營養(yǎng)水平——而這也正是推動人口預(yù)期壽命的最主要的因素。此外，工業(yè)革命也為勞動力的普遍就業(yè)以及城鎮(zhèn)化創(chuàng)造了條件。然而在城鎮(zhèn)化的過程中，如果沒有適當(dāng)?shù)男l(wèi)生標(biāo)準(zhǔn)，城鎮(zhèn)就會成為各種傳染病的溫床。為了控制傳染病的傳播，英國的改革派創(chuàng)立了一種綜合性的公共衛(wèi)生管理方法，即1848年的《公共衛(wèi)生法案》。根據(jù)該法案，英國從中央到地方都建立了主管公共衛(wèi)生事務(wù)的委員會，后續(xù)的許多公共衛(wèi)生規(guī)定也相繼出臺。需要指出的是，《公共衛(wèi)生法案》并不是一項(xiàng)醫(yī)學(xué)上的創(chuàng)新，而是特定社會經(jīng)濟(jì)背景下的一種政治反應(yīng)。它是在城鎮(zhèn)化和工業(yè)革命的影響下，通過創(chuàng)造更加清潔的公共衛(wèi)生環(huán)境，鼓勵(lì)社會更加積極地捍衛(wèi)自身健康，從而系統(tǒng)性地解決致病因素而設(shè)計(jì)的一種方案。

從很多方面看，我們這個(gè)時(shí)代正在經(jīng)歷的另一次工業(yè)革命——即數(shù)字革命，并非完全是為了提升我們的衛(wèi)生和健康條件，更主要的是要發(fā)揮科學(xué)技術(shù)的潛能，解決我們生活中遇到的種種問題。在健康領(lǐng)域，我們將數(shù)額極為驚人的投資投向了一些成本越來越高昂的先進(jìn)療法，而不是用來解決社會、經(jīng)濟(jì)和環(huán)境領(lǐng)域的致病因素。在美國，高達(dá)90%的醫(yī)療衛(wèi)生支出都投入到了疾病的治療和護(hù)理上，對公共衛(wèi)生建設(shè)的關(guān)注則退居末流。我們把大量資金投入到了如何治病而不是如何防病上，這種做法已經(jīng)帶來了現(xiàn)實(shí)的影響。雖然美國花在醫(yī)療衛(wèi)生上的錢比任何國家都多，但這些醫(yī)療投資的規(guī)模與其成果卻是不相稱的。在總體健康水平上，美國仍然落后于許多同等發(fā)達(dá)程度的國家。雖然美國的總體國民預(yù)期壽命仍在提高，但提高的速度卻比其他發(fā)達(dá)國家慢了不少。比如在1979年，美國的女性預(yù)期壽命還排在發(fā)達(dá)國家的中游，經(jīng)歷了這幾十年，到了2006年，美國的女性預(yù)期壽命已經(jīng)在發(fā)達(dá)國家里墊底了。

由于我們不愿意解決那些最基礎(chǔ)的致病因素，導(dǎo)致整個(gè)社會都遭到了更深的影響。由于忽略了對社會、經(jīng)濟(jì)和環(huán)境等方面的致病因素的影響，美國已經(jīng)成了一個(gè)連醫(yī)療衛(wèi)生上都存在貧富差距的國家，一部分居民享受著比另一部分居民活得更加健康長壽的機(jī)會。由于選擇了將重點(diǎn)放在“治病”而非“防病”上，我們縱容了這種醫(yī)療不公的惡化，擴(kuò)大了醫(yī)療衛(wèi)生上的貧富差距。從最近的人均預(yù)期壽命數(shù)據(jù)上尤其能看出這一點(diǎn)。在美國，如果你是個(gè)白人，你的預(yù)期壽命還有可能會繼續(xù)增長，但其他族群就不一定了。比如2010年，美國男性黑人的平均預(yù)期壽命比白人整整低了5年。與此同時(shí)，部分白人群體也見證了醫(yī)療不公的影響。去年，《美國國家科學(xué)院院刊》上發(fā)表的一篇論文揭示，在1998年到2013年間，美國中年男性特別是擁有高中以下學(xué)歷者的死亡率，平均每年都遞增0.5%，原因包括自殺率升高、吸毒過量、酗酒等等。根據(jù)該研究的計(jì)算，如果在那段時(shí)間里，美國白人中年男性的死亡率能夠與其他西方工業(yè)國家持平的話，那么足足有96,000人就不會中年早逝。在這種情形下，美國白人的平均預(yù)期壽命在2013年和2014年間實(shí)際上還下跌了0.1歲。

“醫(yī)療不公”反映的并非醫(yī)學(xué)的失敗，而反映了投資與政策的失敗。在工業(yè)革命期間，英國的改革者們準(zhǔn)確地發(fā)現(xiàn)，造就了龐大的工業(yè)和財(cái)富的那只經(jīng)濟(jì)上的“看不見的手”，也正是造就了不健康的城市環(huán)境的幕手黑手。工業(yè)時(shí)代的英國改革者們對疾病的了解或許是有限的，但他們出臺的對環(huán)境的結(jié)構(gòu)性整治政策，卻有益于控制疾病的傳播。然后他們才通過政治活動、公共宣傳和基本的衛(wèi)生規(guī)定來改善這些條件。如今這個(gè)時(shí)代，醫(yī)療衛(wèi)生事業(yè)也同樣受強(qiáng)大的結(jié)構(gòu)性力量的影響。漫長的種族歧視歷史影響了美國幾十代黑人的健康水平；強(qiáng)大的經(jīng)濟(jì)力量導(dǎo)致了很多工人階級陷入失業(yè)?？梢哉f，我們的健康水平就反映了我們生活于其中的這個(gè)社會。

為了讓我們的孩子們過上更加健康長壽的生活，我們必須解決根子上的原因。健康說到底是由生活環(huán)境中的政治、社會、文化和經(jīng)濟(jì)條件決定的。除非我們從根本上改善這些條件，否則我們的預(yù)期壽命水平必將撞上天花板。要解決這些根子上的問題，就得采用19世紀(jì)的英國人解決骯臟的街道的方法，因?yàn)榻】祮栴}是絕對值得我們的關(guān)注和投資的。在上述因素中有任何一點(diǎn)做得不夠，都會影響我們所有人過上健康長壽的生活。 （財(cái)富中文網(wǎng)）

譯者：樸成奎

In recent years, you may have heard the phrase “the first child to live to 150 has already been born.” It is an exciting thought. Regardless of whether or not it turns out to be true, it is a fact that global average life expectancy has risen dramatically over the last century. According to the World Health Organization, it increased by five years between 2000 and 2015 alone. The United States is no exception to this trend. Last month, the Centers for Disease Control and Prevention reported that, between 2000 and 2014, overall life expectancy in the US increased by two years. This advance is in keeping with prior national life expectancy gains, steadily trending up. In 1900, US life expectancy was about 47 years. It is now close to 79 years. Given this increase, it seems reasonable to expect that our children will live longer lives than we will, lives characterized by significantly greater wellbeing. But is this really the case?

The best way to answer this question is to look back at what has historically driven the rise in life expectancy. It would be easy to think that medicine made the difference. The 20th century, after all, was a time of tremendous medical advances — from Jonas Salk’s polio vaccine, to advances in the treatment of HIV/AIDS, to new horizons in cardiology and stem cell research. However, the rise in global life expectancy predates many of these achievements. In Britain, for example, this rise began in the 19th century, when the country was being transformed by the Industrial Revolution. The historian Thomas Mckeown has argued that the Industrial Revolution led to an improvement in living standards — particularly with regard to nutrition — which was the primary driver behind the rise in life expectancy. In addition to its benefits, though, the Industrial Revolution also created the conditions for widespread worker exploitation, and a level of urbanization that, without proper hygiene standards, became a breeding ground for infectious disease. To ameliorate these conditions, English reformers pioneered a comprehensive public health approach; notably in the form of the Public Health Act of 1848. It established boards of health, both centrally and locally, which handled matters of sanitation and water quality, and was the forerunner of many successive public health regulations. It is important to note that the Act was not a medical innovation. It was, rather, a political response, arising from a specific socioeconomic context. Prompted by the effects of urbanization and the Industrial Revolution, it was designed to tackle the structural drivers of disease by creating cleaner built environments and encouraging communities to take a more active role in safeguarding their health.

In many ways, our own revolution — the digital revolution— has diverted our attention away from the factors that may indeed improve the conditions that make us healthy, as we focus more on the potential of science and technology to solve our problems. In the area of health, this translates to a disproportionate investment in increasingly costly treatments, at the expense of measures that address the social, economic, and environmental causes of disease. In the US, almost 90% of our health expenditure is on medical care and treatment, with public health too often falling by the wayside. We are investing significantly more on what may cure us of disease if we get sick than in what may keep us healthy to begin with. This has real consequences. Despite the fact that we spend far more on health than any other country, our health outcomes are not commensurate with our investment; we lag behind many comparable countries in terms of overall wellbeing. And while our national life expectancy continues to improve, it improves at a much slower rate than that of our peers. In 1979, for example, female life expectancy at birth was in the middle range, relative to other high-resource countries. But we were outpaced in the intervening decades, eventually, in 2006, ranking last.

Our unwillingness to address the foundational causes of disease has even deeper implications. Overlooking the power of social, economic, and environmental determinants to shape well-being has created a country of health “haves” and “have nots,” where certain groups stand a better chance than others of living well and longer. By choosing to focus on cure, rather than on what can keep us healthy, we have allowed health inequality to thrive, widening the gap between the “haves” and “have nots.” As recent life expectancy numbers demonstrate, this is especially true in the case of race. In the US, if you are white, your likelihood of living longer continues to increase. That is not the case for other groups. In 2010, for example, the average black man could expect to live a full five years less than the average white man. Increasingly, however, certain segments of the white population are also seeing the effects of health inequality. A study published last year in the Proceedings of the National Academy of Sciences of the United States of America revealed that between 1998 and 2013 the death rate for middle-aged American whites, particularly those with a high-school degree or less, rose by half a percent each year, fueled by an uptick in suicide, drug overdose, and alcoholism. According to the study, if, during that time, white mortality had gone down at the rate it had in other industrialized nations, 96,000 deaths need not have occurred. It was under these circumstances that white life expectancy actually declined by 0.1 years between 2013 and 2014.

These heath inequities do not reflect a failure of medicine; they reflect a failure of investment and policy. During the Industrial Revolution, reformers correctly identified that the same economic forces that were creating vast industries and wealth were also creating unhealthy urban environments. While their understanding of disease may have been limited, their interventions targeted the structural conditions that had been conducive to the spread of sickness. They then worked to improve these conditions through political action, public awareness, and basic, hygiene-centered regulations. We are likewise living in an age when health is shaped by powerful structural forces. From a history of racism that has undermined the health of the black population in the US for generations, to the economic forces that have driven so many in the working class to unemployment, our well-being is a reflection of the society in which we live.

To ensure that our children live longer, healthier lives, we must address these root causes. Health is ultimately produced by the political, social, cultural, and economic conditions within which we live; unless we tend to these forces, our health achievement shall remain ceilinged. This means approaching foundational issues the same way 19th century Britons approached the problem of filthy streets—as health concerns worthy of attention and investment. To do any less would lead us collectively to shorter, sicker lives.