怎样活得更久更健康

1947年，狄兰·托马斯创作了自己最著名的诗篇《不要温柔走进那良宵》，劝诫读者拒绝生命的尽头。诗中写道：“怒斥吧，怒斥光的消逝。”70年后，这种情绪在很大程度上激发了美国的医药投资。和其他经济水平相当的国家相比，美国的健康开支要高得多，而且其中很大一部分都用在了老年人医疗保健上。2012年，年逾65岁的美国人的平均医疗保健支出为18988美元，是儿童平均开支的5倍，适龄劳动人口平均支出的3倍左右。这些资金成了美国健康花费整体趋势的组成部分。2015年，美国健康总支出增长了5.8%，达到3.2万亿美元。

在如此巨大的投入之下，延长美国人寿命的手段层出不穷，而且往往为此利用基因和药物创新。举例来说，硅谷科技龙头企业已经表露了“解决老化问题”和“改写生命密码”的意愿。吸引它们的是这样一种可能性，即在恰当技术的帮助下，人类也许能获得无限的寿命。

在本周的《财富》健康头脑风暴大会上，我将从人口健康角度探讨人们的长寿诉求，以下则是其中将要谈到的一些想法。

100年来，人口预期寿命大大延长。1900年，美国的人口平均预期寿命约为47岁，如今则在79岁上下。但这样的增长主要来自工业革命后公众营养和生活水平的提升，以及公共健康领域的成就。虽然有了长足进步，但我们发现它们给人口预期寿命带来的回报正在下降。无论我们多么渴望，人都无法永生。实际上，88%的美国人都活不到94岁，活不到100岁的占98%。新医疗手段确实有助于延长寿命，但作用有限。最近对健康技术评估报告的分析表明，2003-2013年，能延长整体存活期的癌症治疗新药平均只能让患者多活3.43个月。同时，在所有癌症新药中，已经证明可以延长存活期的不足20%。总的来说，基因或药物创新对人类寿命的潜在提升幅度在100岁左右见顶，随后迅速下滑，到115岁就不再起作用，这进一步证实人的寿命是有限的。

面对这样的现实，我们怎样才能在自己拥有的这段时间里提高生命质量呢？就像20世纪我们周围的变化延长了人口预期寿命一样，社会、经济和环境条件的改善同样能造就21世纪的幸福生活。举例来说，在100万人口的城市，如果交通系统扩张40%，健康成本就可下降2.16亿美元。通过按环保标准改造住房，改善通风并减少对有害化学品的接触，当地居民的生活质量就有望成倍提高。儿童早期教育的成本收益比为1比5。也就是说，在这方面花1美元带来的益处，比如减少犯罪和少女怀孕，可节省5美元的支出。我们还可以通过渐进式税制改革，特别是通过调整劳动所得税抵扣幅度来大大造福人群。这个抵扣幅度每上调10%，美国每10万名婴儿的死亡率就会下降23.2名。

这些措施能让我们朝着建设健康社会的方向大举迈进。此前我们已经欣然接受了类似的做法，而且效果显著。如今美国人的道路行程超过以往任何时候，但1925-1997年，美国的机动车交通事故死亡人数从每1亿车英里18人降至1.7人。降低交通事故死亡人数的途径是通过法律手段来阻止不安全驾驶行为，促进安全带的使用以及修筑更安全的道路。简而言之，我们已经通过改变驾驶环境和尽量减少危险提高了人们的健康水平。值得注意的是，我们在提高司机素质方面所做的少之又少，相反，我们改变了他们周围的环境，从而让所有人都更加安全。

这对我们建立更美好社会的思路格外重要。如果社会无视人们身边决定幸福水平的因素，就算幸运到有钱和有资源的人也无法买到更健康的生活和更长的寿命。2010年以来，最多有5.6万人死于流感，而这种疾病基本可以通过接种疫苗来预防。就是否患上流感而言，旁人的行为和我们自己的行为同样重要。

在牙齿健康领域，如果不饮用添加氟化物的水，每1亿美国人发生龋齿的风险就会上升15%。我们中间有多少人知道自己是否饮用了足够的添加氟化物的水呢？超重人士的朋友变得超重的风险比其他人高57%。我们中间有多少人会根据对方是否超重来选择朋友呢？无论是否喜欢，我们周围的世界都在影响我们的健康。我们绝不可能通过花钱来摆脱社交网络和政府政策，而后者决定着我们的幸福和寿命，因此这是我们共同的问题。

托马斯在他的诗中描述了生命走到尽头时的遗憾之情和错失的良机。诗中所说的“日暮时咆哮”的人看到的并非不确定的未来，而是以往未能实现的承诺，或者说自己人生的质量。最终，起决定作用的是我们生命的丰富程度，是从幼到老的健康水平以及和周边社区的联系。要让所有人都过上这样的生活，我们就不能错过对始终都在促进健康的文化进行投资的机会。（财富中文网）

译者：Charlie

审稿：夏林

本文作者桑德罗·加利亚是波士顿大学公共卫生学院院长、Robert A. Knox讲席教授。他的新书《更健康：关于人口健康基石的50个想法》（Healthier: Fifty thoughts on the foundations of population health）将于今年6月出版。

In 1947, Dylan Thomas composed his most famous poem, “Do not go gentle into that good night,” exhorting the reader to resist the end of life. “Rage, rage against the dying of the light,” Thomas wrote. Seventy years later, this sentiment infuses much of America’s investments in medicine. The US spends far more on health than any economically comparable country, with much of that money going towards healthcare for older Americans. In 2012, those over 65 years old spent an average of $18,988, which is more than five times the expenditure per child, and about three times the expenditure per working-age individual. This investment feeds into the broader trend of US health spending, which, in 2015, grew 5.8%, amounting to $3.2 trillion total.

Within the context of this enormous investment, we have seen the rise of a number of initiatives geared towards adding years to our lifespan, often leveraging genomics and pharmaceutical innovations toward this goal. Silicon Valley tech leaders, for example, have expressed a desire to “solve aging” and “hack the code of life,” enthralled by the possibility that, with the right technology, there may be no limit to how long we can live.

This week at Fortune’s Brainstorm Health conference, I will talk about the human quest for longevity viewed through the lens of population health. What follows is a preview, of sorts, of the thoughts I will be presenting there.

Life expectancy has increased significantly in the last century. In 1900, US life expectancy was about 47. It is now about 79. However, these gains were largely due to public improvements in nutrition and living standards precipitated by the Industrial Revolution, as well as to achievements in public health. Despite this remarkable progress, we are in the midst of seeing diminishing returns with respect to life expectancy. However much we might wish it were otherwise, we cannot live forever. Indeed, 88% of Americans will die before the age of 94, and 98% of Americans will die before the age of 100. It is true that new treatments can help prolong your life, but only to a limited degree. A recent analysis of health technology assessment reports found new cancer drugs to be associated with increased overall survival by an average of just 3.43 months between 2003 and 2013. Further, less than 20% of new cancer drugs have been proven to contribute to a survival increase. Overall, potential survival gains due to genetic or pharmaceutical innovation peak at about age 100, then quickly decline until the age of 115, adding more weight to the conclusion that the human lifespan is fixed.

Given this reality, how can we make life better during the time we have? Just as changes in the world around us contributed to rising life expectancy in the 20th century, improvement of these same social, economic, and environmental conditions can contribute to wellbeing in the 21stcentury. In a city of a million residents, for example, we could save $216 million in health costs through a 40% expansion of transit developments. We could double the quality of life for those living there by renovating housing according to green standards, improving ventilation, and reducing exposure to harmful chemicals. Early childhood education programs are associated with a benefit-cost ratio of 5:1, which means that for every dollar we spend on them we save five due to reductions in crime and teen pregnancy, among many other benefits. We could also do much good through progressive tax reform, especially by modifying the Earned Income Tax Credit (EITC). Each time the EITC has been raised by 10%, infant morality in the US dropped by 23.2 per 100,000 children.

Taking these steps would go far towards building a world that generates health. We have embraced similar measures in the past, to significant effect. In the US, we now travel more miles by road than ever before, yet in the years between 1925 and 1997, the nation decreased the number of motor vehicle deaths from a rate of 18 deaths per 100 million vehicle miles traveled to 1.7 deaths per 100 million miles traveled. The U.S. achieved this reduction by introducing legal disincentives for unsafe driving, promoting seatbelt use, and building safer roads. In short, we have improved health by changing the context around driving, minimizing hazard. It is worth noting that we did very little to improve the actual driver himself — rather, we changed the world around him, making us all safer.

This has particular importance for how we think of creating a better world. Even those of us who are lucky enough to have money and resources cannot buy ever-greater health and longer life in a society that neglects the conditions around us that determine wellbeing. Up to 56,000 people have died from the flu since 2010, a disease that is largely preventable through vaccines. Whether or not we get the flu depends as much on what those around us do as it does on our own actions.

In the area of dental health, risk of cavities increases by 15% for the 100 million Americans who do not drink fluoridated water. How many of us know whether we are drinking sufficiently fluoridated water? And our risk of becoming obese increases by 57% if we have a friend who becomes obese. How many of us choose our friends based on whether or not they are obese? The world around us therefore affects our health, whether we like it or not. It is simply not possible to buy our way out of the social networks and political policies that shape our wellbeing and our longevity, making this our shared issue.

In his poem, Thomas writes of the sense of regret and missed opportunities that can accompany the end of life. It is not to the uncertain future that his characters who “rave at close of day” look, but to the unfulfilled promise of the past — the quality of their years. What counts, in the end, is the richness of our lives, and the extent to which our time was healthy, and linked—from childhood to old age—to the community around us. To make this kind of life accessible to all, we must not miss our chance to invest in a culture that facilitates health throughout life.

Sandro Galea is the Robert A. Knox Professor and Dean of Boston University School of Public Health. His also author of the forthcoming book, Healthier: Fifty thoughts on the foundations of population health, which will publish in June.