宏观来看，医疗卫生即政治

我一提出医疗离不开政治，很多研究者很可能立刻想起十年来政界围绕奥巴马医改的来回纠结。奥巴马医改的设计初衷是为更多的美国人提供医疗服务，确实很重要。但我认为，这只是很小一个侧面，从宏观来看，医疗与政治之间其实关系密切。

我要向德国医生鲁道夫·魏尔肖借用“宏观”的概念。1848年，普鲁士政府任命年轻的病理学家魏尔肖调查上西里西亚地区的斑疹伤寒流行病，现在该地区已属于波兰。魏尔肖只去调查了三周，但他的观察结果却对人们对疾病的理解产生了持续影响。魏尔肖并没有写人们通常认为的致病原因，如细菌和感染模式等等，而是更关注社会和经济因素。他的报告着重介绍了贫困、内生障碍、教育机会缺乏导致的无知，以及社会经济领域的其他挑战。

魏尔肖在报告中指出：“毫无疑问，类似的伤寒疫情只在特定条件下才可能发生，而特定条件就是上里西亚地区贫穷和不够发达。我认为如果相关条件能改变，疫情就不会再出现。”为了防止预防此类流行病，上西里西亚要加强教育和就业，需要正常运行的地方政府，还有改进农业。简而言之要改革，而且只有政治层面参与才真正可行。

这也是为何魏尔肖留下一句名言：“医学是一门社会科学，政治只是宏观层面的医学。”我想稍稍修改下，我认为政治是宏观层面的医疗卫生。政治当然与医学密切相关。事实上，人们想到政治和医疗卫生时，要联系起来就得脑子转个弯。从关于奥巴马医改的争论，到政府管制药品的价格，要追踪政治决策与人们生病时依赖的药物和治疗关系相当容易。但政治与医学关系只是政治与医疗卫生关系一个相对次要的方面。正如魏尔肖观察到的，医疗卫生由生活条件决定。生活条件又受到法律、制度、经济和文化影响，所有条件都受到政治影响。

可以举个当代很多人习以为常的例子，即道路安全。1999年，行驶在道路上的美国人是1925年的六倍，驾驶汽车行驶的里程已达到10倍。然而，从上世纪20年代中到90年代末，每年汽车导致死亡数量减少约90%。为什么？因为上世纪制定了安全带法，为道路行驶和汽车制定了监管标准，还设立了国家公路交通安全管理局和国家交通安全委员会等公共机构。总之，种种法律和制度均为更安全驾驶创造了条件。

各种变化都是政治层面应医疗卫生的需求做出反应。美国人不能继续在危险道路上行驶，因而医疗卫生层面改进的需求刺激政界采取行动。政治行动也确实在医疗层面发挥了重要作用。历史过程中这种模式一再重演。举个例子，20世纪60年代，蕾切尔·卡逊的《寂静的春天》一书出版，揭露了农药对生态的破坏，协助环保运动推进，激励民众积极支持改革。最终政治层面出现风向变化，顺利成立环境保护局。

政治也通过政治人物影响医疗卫生，因为政客可影响公开讨论话题，以及由此产生的种种政策。政界高层可以让之前看似不相关的想法为众人接受。一旦接受，想法就可能变成政治政策，对医疗卫生产生实际影响。

该过程又称为调整奥弗顿之窗，由政治学家约瑟夫·奥弗顿提出。简单来说，奥弗顿之窗是指进入主流公开讨论范围的政治想法。窗外的想法只有两种，一种特别极端所以不用考虑，另一种则广为接受已成为政策。政治人物可利用高超的口才调整窗口方向，转向希望人们接受的想法。

事实证明唐纳德·特朗普特别擅长这一招。他对弱势群体，特别是穆斯林和移民的打击就令奥弗顿之窗发生巨大变化。因为他的所作所为，当前美国政府出台的政策有不少违反了美国核心价值，例如将移民儿童与家人隔离，还有禁止穆斯林国家游客入境等。

这些例子或许也解释了政治影响医疗卫生最重要的方式，即政治可以提升也可以破坏人们的尊严。如果人们的基本尊严遭到剥夺，也失去了尊严的政治表达权即公民权利，就容易陷入偏见和烦扰，感觉社会不关心他们，从而严重影响身心健康。

美国最边缘化群体之一——变性人一直如此。变性人经常因为身份受到歧视，可能会丢掉工作，人身安全受威胁，以及健康状况不佳等等。在美国携带HIV病毒的变性人比例约为普通美国人平均比例的五倍，15%的变性人表示工作中受过骚扰或攻击，40%尝试过自杀。尽管存在种种挑战，社会上对变性人的保护措施还是很难与历史上其他边缘化群体相比。

而且，偶有进展也面临倒退的威胁。2016年马萨诸塞州曾通过法律，禁止在公共场所歧视变性人。这一进展如今面临危险，反对者要求在11月就是否废除该法律举行投票。过两个月，马萨诸塞州选民将做出选择，可以继续维护变性人口的尊严、安全和幸福，也可以剥夺相关权利。不管如何选择，政治都将对马萨诸塞州变性人群的生活状况发挥关键作用。

11月马萨诸塞州做出正确选择固然重要，但人们在所有政治决策中共同重视医疗卫生同样重要。这意味着对医疗卫生提出系统性需求，如此一来政治力量才会认识到医疗卫生的关键作用。要切实做到，我们必须扩大视野，不仅要认识到政治可通过医学影响医疗卫生，但更重要的是，政治会影响决定人们生病还是健康的各种条件。

社会、经济、环境和法律的多样性与詹姆斯·麦迪逊的想法相呼应。麦迪逊在《联邦党人文集》中写道，政治的力量最终与其影响范围有关。他认为，要保持政体健康，就要尽可能“扩大美国政治生活的范围”。为了确保政治提升医疗卫生，讨论医疗卫生和政治时“要拓展范围”，这样讨论时才能完全覆盖政治影响医疗卫生的各种方式。（财富中文网）

桑德罗·加利是波士顿大学公共卫生学院的教授和院长。他著有《健康：关于人口健康基础的五十个想法》一书，于2017年6月出版。本文是他对医疗和公共健康复杂关系的系列研究之一。

译者：Pessy

审稿：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.