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我一提出醫(yī)療離不開(kāi)政治，很多研究者很可能立刻想起十年來(lái)政界圍繞奧巴馬醫(yī)改的來(lái)回糾結(jié)。奧巴馬醫(yī)改的設(shè)計(jì)初衷是為更多的美國(guó)人提供醫(yī)療服務(wù)，確實(shí)很重要。但我認(rèn)為，這只是很小一個(gè)側(cè)面，從宏觀來(lái)看，醫(yī)療與政治之間其實(shí)關(guān)系密切。

我要向德國(guó)醫(yī)生魯?shù)婪颉の籂栃そ栌谩昂暧^”的概念。1848年，普魯士政府任命年輕的病理學(xué)家魏爾肖調(diào)查上西里西亞地區(qū)的斑疹傷寒流行病，現(xiàn)在該地區(qū)已屬于波蘭。魏爾肖只去調(diào)查了三周，但他的觀察結(jié)果卻對(duì)人們對(duì)疾病的理解產(chǎn)生了持續(xù)影響。魏爾肖并沒(méi)有寫(xiě)人們通常認(rèn)為的致病原因，如細(xì)菌和感染模式等等，而是更關(guān)注社會(huì)和經(jīng)濟(jì)因素。他的報(bào)告著重介紹了貧困、內(nèi)生障礙、教育機(jī)會(huì)缺乏導(dǎo)致的無(wú)知，以及社會(huì)經(jīng)濟(jì)領(lǐng)域的其他挑戰(zhàn)。

魏爾肖在報(bào)告中指出：“毫無(wú)疑問(wèn)，類(lèi)似的傷寒疫情只在特定條件下才可能發(fā)生，而特定條件就是上里西亞地區(qū)貧窮和不夠發(fā)達(dá)。我認(rèn)為如果相關(guān)條件能改變，疫情就不會(huì)再出現(xiàn)。”為了防止預(yù)防此類(lèi)流行病，上西里西亞要加強(qiáng)教育和就業(yè)，需要正常運(yùn)行的地方政府，還有改進(jìn)農(nóng)業(yè)。簡(jiǎn)而言之要改革，而且只有政治層面參與才真正可行。

這也是為何魏爾肖留下一句名言：“醫(yī)學(xué)是一門(mén)社會(huì)科學(xué)，政治只是宏觀層面的醫(yī)學(xué)?！蔽蚁肷陨孕薷南?，我認(rèn)為政治是宏觀層面的醫(yī)療衛(wèi)生。政治當(dāng)然與醫(yī)學(xué)密切相關(guān)。事實(shí)上，人們想到政治和醫(yī)療衛(wèi)生時(shí)，要聯(lián)系起來(lái)就得腦子轉(zhuǎn)個(gè)彎。從關(guān)于奧巴馬醫(yī)改的爭(zhēng)論，到政府管制藥品的價(jià)格，要追蹤政治決策與人們生病時(shí)依賴(lài)的藥物和治療關(guān)系相當(dāng)容易。但政治與醫(yī)學(xué)關(guān)系只是政治與醫(yī)療衛(wèi)生關(guān)系一個(gè)相對(duì)次要的方面。正如魏爾肖觀察到的，醫(yī)療衛(wèi)生由生活條件決定。生活條件又受到法律、制度、經(jīng)濟(jì)和文化影響，所有條件都受到政治影響。

可以舉個(gè)當(dāng)代很多人習(xí)以為常的例子，即道路安全。1999年，行駛在道路上的美國(guó)人是1925年的六倍，駕駛汽車(chē)行駛的里程已達(dá)到10倍。然而，從上世紀(jì)20年代中到90年代末，每年汽車(chē)導(dǎo)致死亡數(shù)量減少約90%。為什么？因?yàn)樯鲜兰o(jì)制定了安全帶法，為道路行駛和汽車(chē)制定了監(jiān)管標(biāo)準(zhǔn)，還設(shè)立了國(guó)家公路交通安全管理局和國(guó)家交通安全委員會(huì)等公共機(jī)構(gòu)?？傊?，種種法律和制度均為更安全駕駛創(chuàng)造了條件。

各種變化都是政治層面應(yīng)醫(yī)療衛(wèi)生的需求做出反應(yīng)。美國(guó)人不能繼續(xù)在危險(xiǎn)道路上行駛，因而醫(yī)療衛(wèi)生層面改進(jìn)的需求刺激政界采取行動(dòng)。政治行動(dòng)也確實(shí)在醫(yī)療層面發(fā)揮了重要作用。歷史過(guò)程中這種模式一再重演。舉個(gè)例子，20世紀(jì)60年代，蕾切爾·卡遜的《寂靜的春天》一書(shū)出版，揭露了農(nóng)藥對(duì)生態(tài)的破壞，協(xié)助環(huán)保運(yùn)動(dòng)推進(jìn)，激勵(lì)民眾積極支持改革。最終政治層面出現(xiàn)風(fēng)向變化，順利成立環(huán)境保護(hù)局。

政治也通過(guò)政治人物影響醫(yī)療衛(wèi)生，因?yàn)檎涂捎绊懝_(kāi)討論話(huà)題，以及由此產(chǎn)生的種種政策。政界高層可以讓之前看似不相關(guān)的想法為眾人接受。一旦接受，想法就可能變成政治政策，對(duì)醫(yī)療衛(wèi)生產(chǎn)生實(shí)際影響。

該過(guò)程又稱(chēng)為調(diào)整奧弗頓之窗，由政治學(xué)家約瑟夫·奧弗頓提出。簡(jiǎn)單來(lái)說(shuō)，奧弗頓之窗是指進(jìn)入主流公開(kāi)討論范圍的政治想法。窗外的想法只有兩種，一種特別極端所以不用考慮，另一種則廣為接受已成為政策。政治人物可利用高超的口才調(diào)整窗口方向，轉(zhuǎn)向希望人們接受的想法。

事實(shí)證明唐納德·特朗普特別擅長(zhǎng)這一招。他對(duì)弱勢(shì)群體，特別是穆斯林和移民的打擊就令?yuàn)W弗頓之窗發(fā)生巨大變化。因?yàn)樗乃魉鶠?，?dāng)前美國(guó)政府出臺(tái)的政策有不少違反了美國(guó)核心價(jià)值，例如將移民兒童與家人隔離，還有禁止穆斯林國(guó)家游客入境等。

這些例子或許也解釋了政治影響醫(yī)療衛(wèi)生最重要的方式，即政治可以提升也可以破壞人們的尊嚴(yán)。如果人們的基本尊嚴(yán)遭到剝奪，也失去了尊嚴(yán)的政治表達(dá)權(quán)即公民權(quán)利，就容易陷入偏見(jiàn)和煩擾，感覺(jué)社會(huì)不關(guān)心他們，從而嚴(yán)重影響身心健康。

美國(guó)最邊緣化群體之一——變性人一直如此。變性人經(jīng)常因?yàn)樯矸菔艿狡缫暎赡軙?huì)丟掉工作，人身安全受威脅，以及健康狀況不佳等等。在美國(guó)攜帶HIV病毒的變性人比例約為普通美國(guó)人平均比例的五倍，15%的變性人表示工作中受過(guò)騷擾或攻擊，40%嘗試過(guò)自殺。盡管存在種種挑戰(zhàn)，社會(huì)上對(duì)變性人的保護(hù)措施還是很難與歷史上其他邊緣化群體相比。

而且，偶有進(jìn)展也面臨倒退的威脅。2016年馬薩諸塞州曾通過(guò)法律，禁止在公共場(chǎng)所歧視變性人。這一進(jìn)展如今面臨危險(xiǎn)，反對(duì)者要求在11月就是否廢除該法律舉行投票。過(guò)兩個(gè)月，馬薩諸塞州選民將做出選擇，可以繼續(xù)維護(hù)變性人口的尊嚴(yán)、安全和幸福，也可以剝奪相關(guān)權(quán)利。不管如何選擇，政治都將對(duì)馬薩諸塞州變性人群的生活狀況發(fā)揮關(guān)鍵作用。

11月馬薩諸塞州做出正確選擇固然重要，但人們?cè)谒姓螞Q策中共同重視醫(yī)療衛(wèi)生同樣重要。這意味著對(duì)醫(yī)療衛(wèi)生提出系統(tǒng)性需求，如此一來(lái)政治力量才會(huì)認(rèn)識(shí)到醫(yī)療衛(wèi)生的關(guān)鍵作用。要切實(shí)做到，我們必須擴(kuò)大視野，不僅要認(rèn)識(shí)到政治可通過(guò)醫(yī)學(xué)影響醫(yī)療衛(wèi)生，但更重要的是，政治會(huì)影響決定人們生病還是健康的各種條件。

社會(huì)、經(jīng)濟(jì)、環(huán)境和法律的多樣性與詹姆斯·麥迪遜的想法相呼應(yīng)。麥迪遜在《聯(lián)邦黨人文集》中寫(xiě)道，政治的力量最終與其影響范圍有關(guān)。他認(rèn)為，要保持政體健康，就要盡可能“擴(kuò)大美國(guó)政治生活的范圍”。為了確保政治提升醫(yī)療衛(wèi)生，討論醫(yī)療衛(wèi)生和政治時(shí)“要拓展范圍”，這樣討論時(shí)才能完全覆蓋政治影響醫(yī)療衛(wèi)生的各種方式。（財(cái)富中文網(wǎng)）

桑德羅·加利是波士頓大學(xué)公共衛(wèi)生學(xué)院的教授和院長(zhǎng)。他著有《健康：關(guān)于人口健康基礎(chǔ)的五十個(gè)想法》一書(shū)，于2017年6月出版。本文是他對(duì)醫(yī)療和公共健康復(fù)雜關(guān)系的系列研究之一。

譯者：Pessy

審稿：夏林

When I suggest that health is linked to politics, many readers will likely think about the political back-and-forth around Obamacare that gripped the country for a decade. And Obamacare—designed as it was to provide as many Americans as possible with access to health care—matters indeed. But, I would argue, it is one very small piece of a larger picture. And that picture is that health is inextricably linked to politics, on a large scale.

I borrow the term “on a large scale” from the German physician Rudolf Virchow. In 1848, the Prussian government named Virchow, then a young pathologist, to investigate a typhus epidemic in the region of Upper Silesia, which is now part of Poland. Virchow’s visit there would be brief—he stayed just three weeks—but what he observed during that time would have a lasting effect on our understanding of disease. Rather than write about what we typically imagine makes people sick—namely, bacteria and patterns of infection—Virchow wrote about the social and economic conditions he witnessed. His report told a tale of poverty, civil dysfunction, ignorance stemming from lack of educational opportunities, and other socioeconomic challenges.

In the report, Virchow argued, “There cannot be any doubt that such a typhoid epidemic was only possible under these conditions and that ultimately they were the result of the poverty and underdevelopment of Upper Silesia. I am convinced that if you changed these conditions, the epidemic would not recur.” To prevent such epidemics, Upper Silesia needed education, employment, a functioning regional bureaucracy, agricultural improvement—in short, it needed reforms that are only possible at the political level.

This is what led Virchow to famously say, “Medicine is a social science and politics is nothing else but medicine on a large scale.” I would modify this slightly, and suggest that, in fact, politics is health on a large scale. It is, of course, true that politics is closely linked to medicine. Indeed, when we think of politics and health, it is often to this link that our minds first turn. From the debate over Obamacare, to the government regulating the price of pharmaceuticals, it is fairly easy to trace the line between political decision-making and the drugs and treatments we rely on when we are sick. But the link between politics and medicine is just one relatively minor aspect of the link between politics and health. Health, as Virchow observed, is shaped by the conditions in which we live. These conditions are, in turn, shaped by laws, institutions, economics, and culture—all of which are informed by politics.

Let us look at a contemporary example that many of us take for granted: the safety of our roads. In 1999, there were six times as many Americans on the road as there were in 1925, and the number of miles they traveled in motor vehicles had grown by a factor of 10. Yet in the years between the mid-1920s and the late 1990s, the number of annual motor vehicle deaths decreased by about 90 percent. Why? Because the last century saw the introduction of seat belt laws, regulatory standards for roads and vehicles, and the creation of public institutions like the National Highway Traffic Safety Administration and National Transportation Safety Board. Taken together, these laws and institutions created the conditions for safer driving.

These changes emerged at the political level as responses to a demand for healthier conditions. Americans could not well continue driving on unsafe roads; the necessity of improvement, of health, created the incentive for political action. And political action made all the difference in producing health. We have seen this pattern reoccur throughout our history. In the 1960s, for example, the publication of Rachel Carson’s book Silent Spring, which exposed the scope of the ecological damage caused by pesticide use, helped galvanize the environmental movement, creating a groundswell of support for reform. This would eventually lead to political change, in the creation of the Environmental Protection Agency.

Politics also affects health through the words of political actors, which can influence the public debate and the policies that emerge from it. People who engage in politics at a high level have the power to make acceptable ideas that were once considered beyond the pale. As a result of this acceptance, these ideas can become political policy, with consequences for health.

This process is known as shifting the Overton window. Conceived by the political scientist Joseph Overton, the Overton window is simply the range of political ideas that are considered within the mainstream of the public debate. Outside the window, on one side, are ideas seen as so extreme as to be almost unthinkable. On the other, are ideas that are so well accepted that they have become settled policy. Political actors can use rhetoric to nudge the window toward the ideas they wish to make more credible.

Donald Trump has proven to be especially adept at this. His attacks on vulnerable populations, particularly Muslims and immigrants, has shifted the Overton window to a dramatic degree. Thanks to him, we have seen practices that would likely once have been dismissed as violations of our core national values—such as separating immigrant children from their families and banning travelers from predominantly Muslim countries—adopted as official policies of the U.S. government.

These practices speak to what is perhaps the most fundamental way that politics shapes health: politics has the power to uphold or undermine human dignity. When people are denied their basic dignity, and the political expression of that dignity—their civil rights—they are made vulnerable to bigotry, harassment, and a general sense that society does not care about them. These conditions take an immense toll on physical and mental health.

This has long been the case for one of America’s most consistently marginalized groups: the transgender population. Transgender people are subject to frequent discrimination simply for being who they are; this can translate into lost jobs, lack of physical safety, and poor health, among other hardships. Transgender people live with HIV at about five times the US average rate, 15 percent report being harassed or attacked at work, and 40 percent have attempted suicide. Despite such challenges, we have been slow to extend to transgender people the same protections we have extended to other historically marginalized groups.

Meanwhile, the tentative gains that have been made are under imminent threat of being rolled back. In 2016, Massachusetts passed a law prohibiting discrimination against transgender people in places of public accommodation. This progress is now in danger—opponents of the law have placed on the November ballot an initiative calling for its repeal. In two months, the state’s voters will choose to either uphold the dignity, safety, and wellbeing of the state’s transgender population, or deny them their rights. In either case, politics will have played a key role in deciding how healthy transgender people will be able to be in Massachusetts.

While it is important that Massachusetts makes the right choice in November, it is equally important that we, collectively, choose health in all our political decisions. This means creating a demand for health in our system, so that political forces recognize that health has to be a priority in all we do. To achieve this, we must widen our gaze, to recognize that politics shapes health through medicine, yes, but, even more so, through the diverse array of conditions that determine whether we get sick or stay well.

The sheer variety of these social, economic, environmental, and legal forces echoes the ideas of none other than James Madison. In The Federalist Papers, Madison wrote that the strength of our politics would ultimately lie in its scope. To maintain a healthy body politic, he argued, we must “extend the sphere” of American political life. To ensure our politics truly promotes health, we must “extend the sphere” of what we talk about when we talk about health and politics, so that our conversation accounts for the full range of ways politics influences health.

Sandro Galea is a professor and Dean of Boston University School of Public Health. His book, Healthier: Fifty thoughts on the foundations of population health, was published in June 2017. This piece is part of an ongoing series by Boston University’s Dr. Sandro Galea on the intricacies of health care and public health.