想让2017年的世界变得更健康？应从这6个方面入手

新一年马上就要到来了，美国也将马上迎来新一届政府。我们也应该认真思考一下，我们应该怎样共同努力来提高所有人的福祉。比如我们是应该减肥呢？还是应该多锻炼呢？

因此，我想从另一个角度为大家提出一系列新年目标，这些目标关系到我们所有人的根本健康。只有人人都树立以下六个决心，才能真正提高全社会的健康水平。

缩小贫富差距

我们的收入水平决定了我们的食物质量，决定了我们居住的小区的安全程度，决定了我们可以接受何等水平的教育，决定了我们的经济社会能否发展进步。如果收入不足，甚至负债累累，就会对我们的健康产生严重影响。

然而如今被收入问题折磨的美国人变得越来越多了，换言之，这个国家的贫富差距正在拉大。据美国国会预算办公室近期发布的报告显示，2013年，美国所有居民家庭财富的76%集中在最富裕的10%的家庭手中。要解决贫富差距的问题，我们只能想方设法提高底层50%人民的收入水平。我们还是有很多方法能实现这个目标的。比如我们可以扩大低收入劳动所得税收抵扣制（EITC）的覆盖范畴，目前该政策主要覆盖的是年收入在500美元到6.2万美元之间的低收入劳动家庭，优惠幅度也取决于具体收入水平和家庭成员的人数。另外，我们还可以提高遗产税水平，并且弥补各种税收漏洞，利用额外收来的税金建设能提高公共福利的项目。

在美国以及全球推动男女平等

在包括美国在内的许多国家，男女受教育和就业的机会都是不平等的，女性往往处于劣势一方。这种性别上的不平等也给人类的总体健康水平造成了威胁。教育、就业和收入都是健康的决定因素，女性如果缺乏这些因素，也就无法享受到它们带来的利益——比如权力、社会关系和政治代表性等。

此外，女性还要面对生殖健康方面的威胁。在美国，这种威胁包括对女性流产权的政策挑战，以及健康的生殖保健服务等等。而在全球其他地区，女性割礼等残害女性身体的行为，以及在婚姻和生子等方面禁锢在女性身上的文化枷锁依然存在。解决这些问题不仅有益于提高女性的生活水平，同样也有助于提高男性的生活水平。男女的不平等是具有代际效应的，它会对家庭乃至社会产生深远的影响。只有为男女创造了公平竞争的舞台，才能最终更进一步地实现人人平等。

缩小社会分化

收入（财富）差异和性别差异只是社会分化的两个比较有代表性的例子。社会分化严重影响了人类的总体健康水平，因此它也是决定公共健康的一个主因。社会分化为不同社会阶层的人树立了经济、社会和政治壁垒。比如种族就是社会分化的一个顽固标记。在美国，黑人和白人的健康水平呈明显差异，突显了社会分化给社会带来的许多健康挑战。以肥胖症为例，1976年至2004年间，患有肥胖症的黑人女性的比例始终高于白人女性。另一个例子是艾滋病。

我们现在已经可以通过一些非常有效的方法来预防或延缓艾滋病，比如使用安全套，或服用替诺福韦酯/恩曲他滨（舒发态）等药物。随着艾滋病的防治水平不断提高，联合国已经将2030年定为“终结艾滋病”的目标年份。然而受社会分化因素的影响，这很有可能将成为一个不切实际的目标。比如社会上对艾滋病人的污名化货币等等。在一些严重男尊女卑的文化中，女性还会面临更高的感染风险。而缩小社会分化将大大有助于削弱这些风险，从而有利于确保相关易感人群的健康。

提高所有阶层的教育水平

教育可能是决定社会健康水平的最重要的因素了。缺乏高质量的教育将导致不同社会群体间的健康水平差异增大，提高人们对疾病的易感性，缩短人们的预期寿命。而教育程度较高的人一般健康水平也比较好，这主要是由于教育水平与收入水平直接相关，收入越高，健康水平自然也就越好。教育也会让人做出更明智的生活选择，使人懂得避免危险行为。我们可以通过加大早期教育的投资来提高全社会的教育水平，这样一来，我们就能拓宽人民获得高质量教育的渠道，加深教育对人的终身影响。目前少数族裔在教育资源上相比白人处于弱势，因此我们的教育投资也是一项平权投资，它能够最大激发教育对于提高人民整体健康水平的潜能。

预防枪支暴力并减轻其后果

2016年，美国又发生了多起震惊世界的特大凶杀案，正是因为这些极端暴力者持有枪支，大量无辜群众才成为了枪下亡魂。除了这些世人皆知的大案，美国每年还会发生数千起涉枪事故，其中很多受害者是儿童。这也导致2016年美国的涉枪伤亡率达到了另人恐怖的水平。这些统计数据表明，美国要想终止暴力，就躲不开持枪与控枪的矛盾。美国的控枪政策可以说是失败的，这一点从联邦立法层面对控枪问题的无所作为就可以看出。此外，我们现在甚至没有办法去深入研究这个问题——因为连美国疾病控制与预防中心对控枪问题的研究经费都被砍了。如果我们真想提高人民的健康水平，我们就要从2017年开始，切实通过有效的立法手段，解决这个国家的枪支暴力问题。

预防药物滥用

在全球尺度看，有5%的寿命减损都是由于酒精或服用违禁药物导致的。光是美国从2000年到2014年死于药物过量者就达到近50万人，其中很多人死于我们最熟悉的鸦片类药物。我举个例子来说明一下这个问题的严重性：近10年来，滥用药物导致的死亡人数已经超过了车祸造成的死亡人数。要想解决滥用药物的问题，我们有好几种方法可以采用，比如加大教育力度，加大药物滥用预防药的普及程度，以及教育人们如何使用预防药，等等。

此外我们还需要直面对药物滥用者污名化的问题，污名化的后果是很严重的，它使许多药物滥用者不愿于采用一些能救命的方法——比如已经在北美一些城市建立的“毒品安全注射屋”等，这些措施在防止药物成瘾方面有可能发挥极大的作用。如果我们能下决心采用一些实际的、基于数据的解决方案来解决药物滥用的问题，那么我们就能在阻止社会健康风险蔓延的道路上取得真正的进展。

有决心当然是好的，然而2017年，我们能在以上这几个方面都取得进步吗？在新总统的这段任期内，我们能在这些问题上走多远，恐怕谁也说不准。从他的言论立场看，这位当选总统似乎也想对抗上面提出的许多问题。然而这并不意味着这些问题对我们来说就不重要了。在我看来，正是由于目前存在的不确定性，我们大家才更应该共同肩负起社会责任，凝聚社会合力，打造一个更健康的世界。如果我们这样做了，那么未来的每一年都将是更加健康的一年。祝大家新年快乐！（财富中文网）

作者：Sandro Galea

译者：朴成奎

本文作者Sandro Galea是波士顿大学公共卫生学院院长、教授。

As we look at a new year ahead with a new administration, it’s time to ask, what should we collectively be doing to improve our overall well-being. Should we decide to lose weight? Or to exercise more?

With this in mind, I would like to suggest an alternative focus for our New Year’s goals, one that engages with the core causes of health, taking the form of the following six resolutions, to truly improve the health of all.

Narrow income and wealth gaps

Income determines the quality of our food, the safety of our neighborhood, the level of education we can afford to access, and our opportunities for economic and social advancement. The extent of its influence taans that the lack of income, or, worse, the accumulation of debt, can seriously undermine health.

Increasingly, more and more Americans are experiencing this disadvantage, a problem best characterized by the growing income inequality in this country. The Congressional Budget Office recently reported that, in 2013, 76% of all family wealth was concentrated among families in the top 10% of the wealth distribution. To tackle this problem, we have no choice but to focus on improving incomes for those in the lower fiftieth percentile. There are many ways we could do this. For example, we could do this by extending coverage of the Earned Income Tax Credit (EITC), a cash-transfer benefit for the working poor that ranges from approximately $500 to $6,2000 annually, depending on income and family size. We could also address this challenge by updating our estate tax, minimizing loopholes to ensure that all pay their fair share, and using the extra funds for projects that benefit the public good.

Work towards gender equity, both in the United States and abroad

In many countries, including the US, education and employment opportunities are unequally distributed between women and men, with women often at a disadvantage. These imbalances in gender equity are a threat to the health of populations. Education, employment, and income are all key determinants of health. Lack of access to these assets also means lack of access to the benefits that they can confer — benefits like power, social connections, and political agency.

Women must also contend with threats to their reproductive health. In the US, these threats include policy challenges to women’s right to abortions and safe reproductive care. Globally, women face difficulties like female genital mutilation and the cultural enforcement of rules governing marriage and childbearing. Resolving to improve these conditions means improving not only the lives of women, but of men, too. Gender inequity has intergenerational effects that shape the lives of families and communities. Leveling the gender playing field therefore means, ultimately, creating greater equity for everyone.

Narrow social divides

Income/wealth and gender equity gaps are both examples of the broader problem of social divides that undermine the health of populations, a central concern of public health. These divides shape health by creating barriers to the economic, social, and political resources that promote well-being. Race, for example, is a stubbornly persistent marker of social divides. In the US, black-white health disparities characterize a number of health challenges. Take obesity. Between 1976 and 2004, black women had a consistently higher obesity rate than white women. The challenge of HIV/AIDS provides another example.

We can now mitigate HIV through the use of several highly effective measures, from condoms to Tenofovir disoproxil/emtricitabine (Truvada). Within the context of these advances, the UN has set 2030 as a target date for “the end of AIDS.” Yet this may prove unrealistic, due to challenges to prevention posed by social divides. These challenges include stigma, as well as, in some cultures, a power imbalance between men and women, which can put women at greater risk of infection. Narrowing social divides would go far towards reducing these risks and safeguarding the health of vulnerable populations.

Improve education at all levels.

Education is perhaps the single most important determinant of population health. Lack of quality education can widen health disparities between groups, increase vulnerability to diseases, and shorten life expectancy. The better-educated enjoy better health for a number of reasons, chiefly due to education’s link to income, with all the attendant health advantages of earning more money. Education may also be associated with better life choices, and the avoidance of risky behavior. We can promote education through a broader investment in early education, which represents a chance to both widen access to quality schooling and deepen its influence throughout the lifecourse. With minority students often at a disadvantage compared to white students, an investment in education also means an investment in equity, maximizing the potential of education to create healthier populations.

Prevent gun violence and mitigate its consequences

In the US, 2016 was characterized by a number of high-profile acts of mass murder, where guns enabled hate-filled individuals to carry out attacks on populations. In addition to these well-publicized crimes, many thousands of gun-related incidents—often involving children—have led to an annual injury and death rate that is truly horrific. These statistics make it clear that any discussion about ending violence must engage with the challenge of guns, and their proliferation in this country. Our failure to do so is reflected by legislative inaction on this issue at the federal level. This failure is compounded by our inability to even study the problem—as a result of the current ban on Centers for Disease Control and Prevention gun research funding. Gun violence is a clear threat to the health and well-being of all Americans. If we are serious about promoting health, we should begin 2017 by addressing the problem of gun violence in this country through meaningful legislative action.

Invest in substance abuse prevention

Globally, close to 5% of total years of life lost have been attributed to alcohol and illicit drug use. In the US, nearly half a million Americans died from drug overdoses between 2000 and 2014, with the opioid crisis, in particular, an all-too familiar driver of this mortality burden. The scope of this problem is perhaps best illustrated by the fact that, for close to a decade, drug-related deaths have exceeded motor vehicle deaths in the US. There are several solutions that could be applied towards mitigating the problem of substance abuse—from education campaigns, to making overdose prevention medication more widely available and teaching people how to effectively use it.

We must also confront the stigma that has thus far prevented us from embracing lifesaving measures, like safe injection sites, which could potentially make a dramatic difference in efforts to prevent addiction. By resolving to apply practical, data-based solutions to the challenge of substance abuse, we could generate real progress towards minimizing preventable health hazards in our society.

Resolutions are, of course, aspirational. Will we achieve progress on all of these in 2017? The recent election casts real doubt on how far we will get on these issues during the coming presidential term. The President-elect’s stated positions seem to be in opposition to many of the issues discussed here. But that does not make them any less important. It seems to me that the present uncertainty means that it is truly up to all of us to hold ourselves as a society accountable for what actually needs to happen to create a healthier world. If we can do so, we have a chance to build a future where each year is healthier than the last. Happy New Year.