发布者: Candy_hao | 发布时间: 2020-8-31 21:21| 查看数: 150| 评论数: 0|

In the mid-'90s, the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for seven out of 10 of the leading causes of death in the United States.

90 年代中期, CDC 和 Kaiser Permanente 发现: 暴露于某种事物中 会极大增加死亡风险, 七成美国民众的首要死因皆由此引起。

In high doses, it affects brain development, the immune system, hormonal systems, and even the way our DNA is read and transcribed. Folks who are exposed in very high doses have triple the lifetime risk of heart disease and lung cancer and a 20-year difference in life expectancy.

暴露剂量较高时,会影响大脑发育, 免疫系统,内分泌系统, 甚至影响到基因的读取及转录方式。暴露在极高剂量下的人群, 有 3 倍的风险患上心脏病和肺癌, 预期寿命缩短 20 年。

And yet, doctors today are not trained in routine screening or treatment. Now, the exposure I'm talking about is not a pesticide or a packaging chemical. It's childhood trauma. Okay. What kind of trauma am I talking about here? I'm not talking about failing a test or losing a basketball game.

然而,目前医生们还未被培训以常规筛查和治疗的手段来应对这种风险。我所说的暴露危害并不针对某种农药 或包装上的化学物质。而是儿童期创伤。那么,我要说的是哪种创伤呢?我要说的可不是 考试不及格或输掉篮球比赛。

I am talking about threats that are so severe or pervasive that they literally get under our skin and change our physiology: things like abuse or neglect, or growing up with a parent who struggles with mental illness or substance dependence.

我要说的是那种如此严重而又无处不在的威胁, 以致于它让我们毛骨悚然, 并从生理上改变了我们:比如,受虐待或被忽视, 又或者,抚养我们的父母, 本身就深受精神疾病之苦, 或是深陷于"物质依赖"疾病。

Now, for a long time, I viewed these things in the way I was trained to view them, either as a social problem -- refer to social services -- or as a mental health problem -- refer to mental health services. And then something happened to make me rethink my entire approach.

一直以来, 我都按照所教导的方式来看待这些事情。要么把它当成一个社会问题-- 交给社会服务去处理, 要么把它当成一个心理健康问题-- 交给心理健康咨询来解决。后来发生了一些事情, 使我反思我的整个思维方式。

When I finished my residency, I wanted to go someplace where I felt really needed, someplace where I could make a difference. So I came to work for California Pacific Medical Center, one of the best private hospitals in Northern California,

在医院实习结束后, 我想去个我觉得真正需要我的地方, 去个我可以有所作为的地方。因此,我选择为加利利福尼亚太平洋医疗中心(CPMC)工作, 这是加利福尼亚北部最优秀的私立医院之一,

and together, we opened a clinic in Bayview-Hunters Point, one of the poorest, most underserved neighborhoods in San Francisco. Now, prior to that point, there had been only one pediatrician in all of Bayview to serve more than 10,000 children, so we hung a shingle, and we were able to provide top-quality care regardless of ability to pay.

我与该医院合作,在旧金山最穷、 社区服务最差的居民区-- 湾景区猎人角(Bayview-Hunters Point)开了一家诊所。在此之前, 整个湾景区(Bayview)社区仅有一名儿科医生, 为一万多名儿童服务, 因此,我们开始挂招牌 营业, 提供最优质的医疗服务, 不论是否有能力支付医疗费用。

It was so cool. We targeted the typical health disparities: access to care, immunization rates, asthma hospitalization rates, and we hit all of our numbers. We felt very proud of ourselves.

这种感觉很棒。我们找出了在医疗服务上现状与标准的差距:普及医疗保健, 免疫接种率、哮喘住院率等, 我们都完成了达标。我们为自己感到骄傲。

But then I started noticing a disturbing trend. A lot of kids were being referred to me for ADHD, or Attention Deficit Hyperactivity Disorder, but when I actually did a thorough history and physical,

但就在那时,我开始注意到 一种令人忧心的趋势。很多孩子因为多动症(简称 ADHD), 被送到我这里进行医治, 可是,当我对孩子们的病史和身体状况进行彻查时,

what I found was that for most of my patients, I couldn't make a diagnosis of ADHD.  Most of the kids I was seeing had experienced such severe trauma that it felt like something else was going on. Somehow I was missing something important.

却发现大多数患儿的情况, 我无法下"多动症"(ADHD)的诊断。多数来就诊的孩子都经历过如此严重的创伤, 让人觉得似乎事情并不简单。不知怎的,我漏查了某个重要的因素。

Now, before I did my residency, I did a master's degree in public health, and one of the things that they teach you in public health school is that if you're a doctor and you see 100 kids that all drink from the same well, and 98 of them develop diarrhea, you can go ahead and write that prescription for dose after dose after dose of antibiotics,

在实习之前,我曾攻读公共健康硕士学位, 在公共健康学校里, 我们曾学过这样的一课, 如果你是一名医生, 当你知道有 100 个孩子从同一口井中饮水, 其中 98 人患了腹泻, 你可以着手治疗, 给每个病人都开抗生素, 一剂,一剂,又一剂的开。

or you can walk over and say, "What the hell is in this well?" So I began reading everything that I could get my hands on about how exposure to adversity affects the developing brains and bodies of children.

可是你也可以走去井边, 问声,"井里到底有什么鬼东西?" 所以,我开始查阅手头所有的相关资料, 了解暴露在不幸中, 是如何影响儿童的大脑和身体发育的。

And then one day, my colleague walked into my office, and he said, "Dr. Burke, have you seen this?" In his hand was a copy of a research study called the Adverse Childhood Experiences Study. That day changed my clinical practice and ultimately my career.

然后有一天, 一个同事走进我的办公室, 他问我,"伯克医生,你看过这个吗?" 在他手里的是一份调查研究的复印件, 题目是"童年不良经历(ACE)研究"。那一天,改变了我的临床实践, 也最终改变了我的职业生涯。

The Adverse Childhood Experiences Study is something that everybody needs to know about. It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC, and together, they asked 17,500 adults about their history of exposure to what they called "adverse childhood experiences," or ACEs.

童年不良经历(ACE)的研究 是每一个人都应该要了解的。Vince Felitti博士和Bob Anda博士 分别在 Kaiser和 CDC 进行了这项研究, 他们两人一起询问了 17,500 成年人, 了解他们的"童年不良经历",又称 ACE。

Those include physical, emotional, or sexual abuse; physical or emotional neglect; parental mental illness, substance dependence, incarceration; parental separation or divorce; or domestic violence.


For every yes, you would get a point on your ACE score. And then what they did was they correlated these ACE scores against health outcomes. What they found was striking. Two things: Number one, ACEs are incredibly common. Sixty-seven percent of the population had at least one ACE, and 12.6 percent, one in eight, had four or more ACEs.

每个问题只要回答"是", ACE 分数就增加一分。接下来, 他们将 ACE 分数与健康状况关联起来, 得出的结果是令人震惊的。结论有两点:第一点,ACE 十分普遍, 简直令人不可思议。67%的人曾至少有一个 ACE 得分, 有12.6%(八分之一)的人有四或四以上的 ACE 得分。

The second thing that they found was that there was a dose-response relationship between ACEs and health outcomes: the higher your ACE score, the worse your health outcomes. For a person with an ACE score of four or more, their relative risk of chronic obstructive pulmonary disease was two and a half times that of someone with an ACE score of zero.

研究发现的第二点, 是 ACE 与健康状况之间存在着一种剂量反应关系:ACE 得分越高,健康状况越糟糕。如果一个人的 ACE 分数大于等于 4 分, 他患慢性阻塞性肺病的相对风险是 ACE 分数为 0 时的 2.5 倍。

For hepatitis, it was also two and a half times. For depression, it was four and a half times. For suicidality, it was 12 times. A person with an ACE score of seven or more had triple the lifetime risk of lung cancer and three and a half times the risk of ischemic heart disease, the number one killer in the United States of America.

患上肝炎的风险是 2.5 倍。而患上抑郁症的风险是 4.5 倍。自杀风险是 12 倍。ACE 分数大于等于 7 的人 终身都有 3 倍的风险患上肺癌, 和 3.5 倍的风险患上冠心病-- 这种目前在美国当属头号杀手的疾病。

Well, of course this makes sense. Some people looked at this data and they said, "Come on. You have a rough childhood, you're more likely to drink and smoke and do all these things that are going to ruin your health. This isn't science. This is just bad behavior."

当然,这其实挺有道理。有些人看了这些数据之后会说, "好啦,你有个糟糕的童年, 你更容易酗酒和抽烟, 还去做一切会毁掉你健康的事情。这又不是科学,这只是坏的行为而已."

It turns out this is exactly where the science comes in. We now understand better than we ever have before how exposure to early adversity affects the developing brains and bodies of children. It affects areas like the nucleus accumbens, the pleasure and reward center of the brain that is implicated in substance dependence.

然而,事实证明我们恰恰要用科学来分析它。目前,我们前所未有的更加理解 早年遭受的不幸 会怎样影响儿童大脑和身体的发育。早年遭受的不幸会影响大脑的伏隔核 (nucleus accumbens)-- 人脑中与快乐和奖赏相关的处理中心, 它与"物质依赖"疾病相关。

It inhibits the prefrontal cortex, which is necessary for impulse control and executive function, a critical area for learning. And on MRI scans, we see measurable differences in the amygdala, the brain's fear response center.

早年遭受的不幸还会抑制大脑的前额叶皮质(Prefrontal cortex), 而前额皮质对神经冲动 控制与执行功能是必不可少的, 这个区域对于学习能力非常关键。在核磁共振成像扫描(MRI)上, 我们观察到大脑的恐惧反应中枢 - 杏仁核(amygdala)中, 存在可以测量的差异。

So there are real neurologic reasons why folks exposed to high doses of adversity are more likely to engage in high-risk behavior, and that's important to know. But it turns out that even if you don't engage in any high-risk behavior, you're still more likely to develop heart disease or cancer.

因此,这便可以从神经学角度诠释:为什么人们一旦遭受大量不幸, 则更容易出现高风险行为。了解了这点十分重要。但事实证明, 即使你不从事任何高风险的行为, 你仍然更容易患上 心脏疾病或癌症。

The reason for this has to do with the hypothalamic–pituitary– adrenal axis, the brain's and body's stress response system that governs our fight-or-flight response. How does it work? Well, imagine you're walking in the forest and you see a bear.

因为这与"下丘脑-垂体-肾上腺轴"有关-- 它是大脑和身体的应激反应系统, 支配我们做出"或战或逃反应"。(fight-or-flight response)。这一系统是如何运行的呢?想象你漫步在森林里, 突然看到一头熊。

Immediately, your hypothalamus sends a signal to your pituitary, which sends a signal to your adrenal gland that says, "Release stress hormones! Adrenaline! Cortisol!" And so your heart starts to pound, Your pupils dilate, your airways open up, and you are ready to either fight that bear or run from the bear.

你的下丘脑会立即 向你的垂体发送信号, 垂体再向你的肾上腺发送信号:"释放应激激素! 肾上腺素! 皮质醇 !" 你的心脏因而开始快速跳动, 瞳孔扩张,呼吸道打开, 这时你已准备好:要么就和熊战斗,要么就逃跑。

And that is wonderful if you're in a forest and there's a bear. But the problem is what happens when the bear comes home every night, and this system is activated over and over and over again, and it goes from being adaptive, or life-saving, to maladaptive, or health-damaging.

这个反应很棒-- 如果你在森林里, 那还有一只熊。可问题是,假如每个晚上熊都回家来该怎么办, 这套系统将一遍又一遍地被激活, 它就会从适应到不适应, 从救你的命到损害你的健康。

Children are especially sensitive to this repeated stress activation, because their brains and bodies are just developing. High doses of adversity not only affect brain structure and function, they affect the developing immune system, developing hormonal systems, and even the way our DNA is read and transcribed.

儿童对这种反复的应激激活尤其敏感, 因为他们的大脑和身体正处在发育阶段。高剂量的不良经历不仅会影响大脑结构和功能, 还会影响正在发育的免疫系统, 以及正在发育的内分泌系统, 甚至还会影响 我们的 DNA 读取和转录方式。

So for me, this information threw my old training out the window, because when we understand the mechanism of a disease, when we know not only which pathways are disrupted, but how, then as doctors, it is our job to use this science for prevention and treatment. That's what we do.

这些知识让我彻底抛弃了以前所受训的那一套, 因为,当我们了解疾病机制时, 当我们不仅知道哪些路径被干扰, 而且知道它们是怎样被干扰时, 作为医生,我们的职责, 就是使用这门科学去做疾病的防治工作。那就是我们要做的。

So in San Francisco, we created the Center for Youth Wellness to prevent, screen and heal the impacts of ACEs and toxic stress. We started simply with routine screening of every one of our kids at their regular physical,

因此,我们在旧金山创办了 青少年健康中心, 目的是预防、筛查和治愈 ACE 和毒性应激的影响。我们开始在孩子们的定期体检中, 对每个孩子进行例行检查,

because I know that if my patient has an ACE score of 4, she's two and a half times as likely to develop hepatitis or COPD, she's four and half times as likely to become depressed, and she's 12 times as likely to attempt to take her own life as my patient with zero ACEs.

因为我知道,如果我的病人 ACE 得分为 4 分, 她患上肝炎或慢性阻塞性肺病(COPD) 的概率是 1.5 倍, 患上抑郁症的概率是 4.5 倍, 她自杀的几率是 ACE 得分为 0 的病人的 12 倍。

I know that when she's in my exam room. For our patients who do screen positive, we have a multidisciplinary treatment team that works to reduce the dose of adversity and treat symptoms using best practices, including home visits, care coordination, mental health care, nutrition, holistic interventions, and yes, medication when necessary.

她在我的检查室里, 我就已经知道这一切了。对于检查结果为阳性的病人, 我们有一支多学科 综合治疗团队,致力于减少不良经历造成的影响, 并使用最佳疗法治疗病症, 包括家庭访视、护理协调、 心理保健、营养、 综合干预 措施, 以及必要时结合药物治疗。

But we also educate parents about the impacts of ACEs and toxic stress the same way you would for covering electrical outlets, or lead poisoning, and we tailor the care of our asthmatics and our diabetics in a way that recognizes that they may need more aggressive treatment, given the changes to their hormonal and immune systems.

但我们也教家长们了解 ACE 和毒性应激造成的影响, 这种影响与电源插座或铅中毒的危险性可以相提并论, 我们调整了哮喘 及糖尿病患儿的护理服务, 意识到他们可能需要更积极主动的治疗, 以作用于他们的内分泌和免疫系统。

So the other thing that happens when you understand this science is that you want to shout it from the rooftops, because this isn't just an issue for kids in Bayview. I figured the minute that everybody else heard about this, it would be routine screening, multi-disciplinary treatment teams, and it would be a race to the most effective clinical treatment protocols. Yeah. That did not happen.

当你理解了这门科学时, 你会想要把它广而告之, 因为这不仅仅是湾景区(Bayview)孩子的问题。我本来以为其他人一旦了解到这一点, 就会着手例行检查、 组建多学科治疗团队, 甚至大家争先恐后 想找到最有效的治疗方案。可这些都没有发生。

And that was a huge learning for me. What I had thought of as simply best clinical practice I now understand to be a movement. In the words of Dr. Robert Block, the former President of the American Academy of Pediatrics, "Adverse childhood experiences are the single greatest unaddressed public health threat facing our nation today."

这可是给了我一个很大的教训。我原以为简单的找到最好的临床手段来治疗就行了, 现在我明白了,这是一场运动。正如 Robert Block 博士, 这位前美国儿科学会会长所言, "童年不良经历(ACE)是今天我们国家所面临的,唯一,最大的, 未能解决的公共健康威胁."

And for a lot of people, that's a terrifying prospect. The scope and scale of the problem seems so large that it feels overwhelming to think about how we might approach it.

对于很多人来说, 这个前景可不容乐观。这个问题的范围之广,规模之大 使我们不得不考虑应对之策。

But for me, that's actually where the hopes lies, because when we have the right framework, when we recognize this to be a public health crisis, then we can begin to use the right tool kit to come up with solutions.

但在我看来,危机即是转机, 当我们确立正确框架时, 当我们意识到 这是公共健康危机时, 我们才能开始使用正确的方法来求得解决方案。

From tobacco to lead poisoning to HIV/AIDS, the United States actually has quite a strong track record with addressing public health problems, but replicating those successes with ACEs and toxic stress is going to take determination and commitment, and when I look at what our nation's response has been so far, I wonder, why haven't we taken this more seriously?

从烟草到铅中毒,再到艾滋病, 在解决公共健康问题方面, 美国实际上保持着良好记录, 但要,在 ACE 和毒性应激方面取得同样成功, 则需要下定决心、履行承诺, 当我看到,我们国家对这一问题至今的反应时, 我想知道, 为什么我们没有更认真的对待这个问题?

You know, at first I thought that we marginalized the issue because it doesn't apply to us. That's an issue for those kids in those neighborhoods. Which is weird, because the data doesn't bear that out.

要知道,一开始我还想, 这是因为我们漠视 了这个问题, 以为它跟我们无关。以为只有别的小孩, 邻居家的小孩才有这问题。但很奇怪,数据可不是这么说的。

The original ACEs study was done in a population that was 70 percent Caucasian, 70 percent college-educated. But then, the more I talked to folks, I'm beginning to think that maybe I had it completely backwards.

初始 ACE 的研究样本群体为:白人占 70%, 大学毕业占70%。后来,我和大家谈得多了, 我便开始想,也许 我把这个问题完全本末倒置了。

If I were to ask how many people in this room grew up with a family member who suffered from mental illness, I bet a few hands would go up. And then if I were to ask how many folks had a parent who maybe drank too much, or who really believed that if you spare the rod, you spoil the child, I bet a few more hands would go up.

如果我问现场这个房间内有多少人在成长过程中 有家庭成员患有精神疾病, 我相信,会有几个人举手。如果我再问,有多少人父亲或母亲酗酒, 或者是坚信:孩子要打,惯不得。我敢打赌会有更多的人举手。

Even in this room, this is an issue that touches many of us, and I am beginning to believe that we marginalize the issue because it does apply to us. Maybe it's easier to see in other zip codes because we don't want to look at it. We'd rather be sick.

即使只是在我们的会场, 这也是一个影响到了很多人的问题。我开始相信我们漠视这个问题 是因为,它与我们息息相关。也许把它说成别的地区的事, 我们才能更容易的看清楚, 因为我们自己情愿生病, 也不愿意正视这个问题。

Fortunately, scientific advances and, frankly, economic realities make that option less viable every day. The science is clear: Early adversity dramatically affects health across a lifetime. Today, we are beginning to understand how to interrupt the progression from early adversity to disease and early death,

幸运的是,科学进步, 坦率地说,还有经济现实逐渐使我们无法再继续漠视下去了。科学研究清楚显示:早期不良经历对人的一生的健康影响巨大。今天,我们开始了解如何中断 从早期不良经历发展至 疾病和过早死亡这一进程,

and 30 years from now, the child who has a high ACE score and whose behavioral symptoms go unrecognized, whose asthma management is not connected, and who goes on to develop high blood pressure and early heart disease or cancer will be just as anomalous as a six-month mortality from HIV/AIDS.

从现在算起,30 年后, 高 ACE 分数的儿童, 如果其行为症状未被识别, 哮喘诊疗未与 ACE 相关联,持续发展为高血压, 并患上早期心脏病或癌症, 那么这就象 6 个月的婴儿患艾滋病一样, 都是异常的。

People will look at that situation and say, "What the heck happened there?" This is treatable. This is beatable. The single most important thing that we need today is the courage to look this problem in the face and say, this is real and this is all of us. I believe that we are the movement.

人们看到这种情况都会说:"这究竟发生的是什么鬼事?" 这种病症是可以治疗的, 也是可以战胜的。我们今天最需要的是 直面这个问题的勇气, 并且承认,这个问题确实存在, 与我们息息相关。我相信我们将实现这一变革运动。

Thank you.



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