我们能让下一代活到 150岁吗？

这几年，你想必已经听到过这样的说法：“第一个能活到150岁的孩子已经出生了。”这确实是一种令人兴奋的说法。不管这一论断是否属实，这都说明了全球人口的平均预期寿命在20世纪已经有了显著提升。据来自世界卫生组织的数据显示，光是从2000年到2015年，全球人口的平均预期寿命就增长了5岁。这种趋势在美国也不例外。就在上个月，美国疾病控制与预防中心发布报告称，从2000年到2014年，美国人口的总体预期寿命增长了2岁。这一增幅基本上与美国前几十年的增长情况保持了一致，呈稳步上升态势。在1900年时，美国人口的平均预期寿命约为47岁，目前已经接近79岁。以这样的增长速度看，我们的儿孙显然会比我们更加长寿，而且健康状况也会超越我们这一代人。但事实果真如此吗？

要回答这个问题，首先要看看历史上是哪些因素推动了居民预期寿命的增长。很多人可能立刻会想到医疗技术的进步。毕竟20世纪出现的医疗突破实在是不胜枚举——从乔纳斯·索尔克的小儿麻痹症疫苗，到艾滋病治疗技术的进步，再到心血管疾病与干细胞研究出现的新的曙光，无不大幅延长了相关患者的生命。然而，全球人口预期寿命的增长，从时间要早于其中许多医学成就的应用。以英国为例，该国人口预期寿命的增长始于19世纪的工业革命时期。历史学家托马斯·麦基翁认为，工业革命提高了人们的生活标准，尤其是人们的营养水平——而这也正是推动人口预期寿命的最主要的因素。此外，工业革命也为劳动力的普遍就业以及城镇化创造了条件。然而在城镇化的过程中，如果没有适当的卫生标准，城镇就会成为各种传染病的温床。为了控制传染病的传播，英国的改革派创立了一种综合性的公共卫生管理方法，即1848年的《公共卫生法案》。根据该法案，英国从中央到地方都建立了主管公共卫生事务的委员会，后续的许多公共卫生规定也相继出台。需要指出的是，《公共卫生法案》并不是一项医学上的创新，而是特定社会经济背景下的一种政治反应。它是在城镇化和工业革命的影响下，通过创造更加清洁的公共卫生环境，鼓励社会更加积极地捍卫自身健康，从而系统性地解决致病因素而设计的一种方案。

从很多方面看，我们这个时代正在经历的另一次工业革命——即数字革命，并非完全是为了提升我们的卫生和健康条件，更主要的是要发挥科学技术的潜能，解决我们生活中遇到的种种问题。在健康领域，我们将数额极为惊人的投资投向了一些成本越来越高昂的先进疗法，而不是用来解决社会、经济和环境领域的致病因素。在美国，高达90%的医疗卫生支出都投入到了疾病的治疗和护理上，对公共卫生建设的关注则退居末流。我们把大量资金投入到了如何治病而不是如何防病上，这种做法已经带来了现实的影响。虽然美国花在医疗卫生上的钱比任何国家都多，但这些医疗投资的规模与其成果却是不相称的。在总体健康水平上，美国仍然落后于许多同等发达程度的国家。虽然美国的总体国民预期寿命仍在提高，但提高的速度却比其他发达国家慢了不少。比如在1979年，美国的女性预期寿命还排在发达国家的中游，经历了这几十年，到了2006年，美国的女性预期寿命已经在发达国家里垫底了。

由于我们不愿意解决那些最基础的致病因素，导致整个社会都遭到了更深的影响。由于忽略了对社会、经济和环境等方面的致病因素的影响，美国已经成了一个连医疗卫生上都存在贫富差距的国家，一部分居民享受着比另一部分居民活得更加健康长寿的机会。由于选择了将重点放在“治病”而非“防病”上，我们纵容了这种医疗不公的恶化，扩大了医疗卫生上的贫富差距。从最近的人均预期寿命数据上尤其能看出这一点。在美国，如果你是个白人，你的预期寿命还有可能会继续增长，但其他族群就不一定了。比如2010年，美国男性黑人的平均预期寿命比白人整整低了5年。与此同时，部分白人群体也见证了医疗不公的影响。去年，《美国国家科学院院刊》上发表的一篇论文揭示，在1998年到2013年间，美国中年男性特别是拥有高中以下学历者的死亡率，平均每年都递增0.5%，原因包括自杀率升高、吸毒过量、酗酒等等。根据该研究的计算，如果在那段时间里，美国白人中年男性的死亡率能够与其他西方工业国家持平的话，那么足足有96,000人就不会中年早逝。在这种情形下，美国白人的平均预期寿命在2013年和2014年间实际上还下跌了0.1岁。

“医疗不公”反映的并非医学的失败，而反映了投资与政策的失败。在工业革命期间，英国的改革者们准确地发现，造就了庞大的工业和财富的那只经济上的“看不见的手”，也正是造就了不健康的城市环境的幕手黑手。工业时代的英国改革者们对疾病的了解或许是有限的，但他们出台的对环境的结构性整治政策，却有益于控制疾病的传播。然后他们才通过政治活动、公共宣传和基本的卫生规定来改善这些条件。如今这个时代，医疗卫生事业也同样受强大的结构性力量的影响。漫长的种族歧视历史影响了美国几十代黑人的健康水平；强大的经济力量导致了很多工人阶级陷入失业。可以说，我们的健康水平就反映了我们生活于其中的这个社会。

为了让我们的孩子们过上更加健康长寿的生活，我们必须解决根子上的原因。健康说到底是由生活环境中的政治、社会、文化和经济条件决定的。除非我们从根本上改善这些条件，否则我们的预期寿命水平必将撞上天花板。要解决这些根子上的问题，就得采用19世纪的英国人解决肮脏的街道的方法，因为健康问题是绝对值得我们的关注和投资的。在上述因素中有任何一点做得不够，都会影响我们所有人过上健康长寿的生活。 （财富中文网）

译者：朴成奎

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.