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2019年08月22日 13:26:43 | 作者:千龙报 | 来源:新华社
Historically, the science of epidemiology was directed toward identifying and controlling epidemics of infectious disease. In a study just published in the New England Journal of Medicine, my colleagues and I highlight another important job for epidemiologists: identifying and controlling epidemics of medical care.历史上,流行病学的研究方向是确诊和控制广泛传播的传染病。我和同事们在《新英格兰医学杂志》(New England Journal of Medicine)上刚刚发表的一篇研究论文中指出,流行病专家还有另外一项任务:识别和控制医疗界造成的流行病。The setting is South Korea, where, over the last two decades, the incidence of thyroid cancer has increased fifteenfold. Nowhere in the world is the rate of any cancer growing faster.研究的背景是韩国。在过去20年里,这里甲状腺癌的发病率提高到了最初的15倍。全世界任何地方都没有哪种癌症能如此之快地增长。We’ve all been taught to seek biological explanations for a significant rise in disease — perhaps a new infectious agent or environmental exposure. But in South Korea, we are seeing something different: an epidemic of diagnosis.我们受过的教育都是,为发病率的显著提高寻找生物学上的解释,或许是新的病原体,或许是环境暴露。然而在韩国,我们看到了不同的情况,这种流行病是因为诊断造成的。In 1999 the government initiated a national health-screening program focused on reducing cancer and other common diseases. Although thyroid cancer screening was not included in the program, all it requires is a simple test — an ultrasound of the neck. Hospitals have ultrasound machines and so do many doctors’ offices. Both promoted thyroid cancer screening as an inexpensive add-on to the government program. It was an easy sell, particularly with the government, the medical community, the news media and cancer “survivors” praising the virtue of early cancer detection.1999年,韩国政府启动了一项全国性的体检计划,主要目的是减少癌症和常见病。尽管其中并不包括甲状腺癌筛查,但它只需要一个简单的步骤:颈部超声波检查。医院里有超声波设备,很多医生的诊所里也有。医院和医生都认为,它是政府计划之外一项廉价的补充检查,因而鼓励患者检查。而患者也很乐于接受,尤其是因为政府、医疗界、新闻媒体和癌症“生还者”都称赞,及早发现癌症有好处。In doing so they inadvertently highlighted the major harm of early detection: What was a rare cancer is now the most common cancer in South Korea.但这样做也意外地突显了及早诊断的巨大危害:一种本来罕见的癌症,成为了韩国最常见的癌症。Where did all those new thyroid cancers come from? They were always there. As early as 1947 pathologists recognized that, although it was a very rare cause of death, thyroid cancer was a frequent finding during autopsies. Studies have since shown that over a third of adults have thyroid cancer. Virtually all of these cancers are small “papillary thyroid cancers,” many of which will never become evident during a person’s life.那些新增的甲状腺癌患者是从哪里来的呢?他们其实一直存在。早在1947年,病理学家就发现,尽管极少成为死因,但是在尸检中经常发现死者患有甲状腺癌的情况。从那时起,研究就发现,超过三分之一的成年人患有甲状腺癌。其中几乎所有人患的都是微小的“甲状腺乳头状癌”,许多人一生中症状都不明显。Unless that person receives a screening ultrasound. In fact, virtually all the newly identified thyroid cancers in Korea are papillary thyroid cancers. How do we know this is not a real epidemic of disease? Because the number of Koreans dying from thyroid cancer has not changed. If the screening were saving lives, the death rate would decline, or increase more slowly as the epidemic sp — but not stay perfectly flat.除非这个人接受了超声波检查。事实上在韩国,几乎所有新确诊的甲状腺癌都是乳头状癌。我们怎么才能知道这不是真正的流行病呢?因为在韩国,死于甲状腺癌的人数并没有变化。如果超声检查挽救了患者的生命,那么死亡率应该降低才对,而如果流行病蔓延开来,死亡率应该缓慢上升才对——然而数据却完全没有起伏。An epidemic of diagnosis is not good for anyone’s health. Resources are needlessly diverted; people are needlessly scared. But the biggest problem is that it begets an epidemic of treatment.诊断呈现的流行病对任何人的健康都没有好处,而且它毫无必要地转移了资源,也毫无必要地惊吓了患者。然而最大的问题是,它在医疗体系内催生了过度治疗。The majority of patients given diagnoses of thyroid cancer have their thyroid gland removed. The thyroid is an important gland — it produces the hormones that control metabolism. Without it, patients may need lifelong thyroid replacement therapy. And it can take doctors a while to find the right dose for each individual. In the meantime, patients suffer from the effects of too little or too much thyroid hormone, including energy and weight fluctuations.多数被诊断患有甲状腺癌的患者,被切除了甲状腺。然而甲状腺是一个重要的腺体,它能分泌控制新陈代谢的激素。如果切除了,患者就可能会终生需要甲状腺替代治疗,而且医生可能需要一段时间才能为每一位患者找到恰当的剂量。与此同时,患者还要承受甲状腺素水平过低或过高的后果,包括精力和体重的波动。The surgery has other less common complications. In South Korea and the ed States about 10 percent of patients have problems with calcium metabolism and about 2 percent experience vocal cord paralysis. And, as with any surgery, there can be life-threatening effects — blood clots in the lungs, heart attacks and strokes. In about two of every 1,000 thyroid cancer operations, the patient dies. It’s rare, but it happens.这种手术也会产生一些并不十分常见的并发症。在韩国和美国,大约10%的患者产生了钙质代谢问题,约有2%的患者发生了声带麻痹。此外,就像任何一种手术一样,它可能会产生威胁生命的后果,如肺部血凝块、心肌梗死和中风。每一千例甲状腺癌手术中,大约会有两名患者身亡。很罕见,但的确会发生。Could what happened in South Korea happen here? Absolutely. Even without a concerted effort to promote screening, thyroid cancer incidence in the ed States is up threefold since 1975. To reverse this trend, we need to actively discourage early thyroid cancer detection.在韩国发生的情况也会在美国发生吗?绝对会。尽管没有各方同心协力推动筛查,美国的甲状腺病例自1975年以来也已经提高到了最初的三倍。要想扭转这种趋势,我们需要积极地劝阻甲状腺癌的早期检查。The virtue of early detection is so ingrained and so appealing that many assume that screening can only be good for you. But that’s not true. The Korean experience illustrates the downside of trying to find cancer early: overdiagnosis and overtreatment. The problem is greatest for thyroid and prostate cancer, but also exists for cancers of the lung, breast, skin and kidney. And then there is all the angst surrounding screening — that can’t be good for anyone’s health.及早检查有好处的观念根深蒂固,而且也很吸引人,所以许多人都认为,做一下检查只会有好处。然而事实并非如此。韩国的经验显示出,试图早期诊断癌症的做法有负面的影响:过度诊断和过度治疗。甲状腺癌和前列腺癌的问题最为严重,然而对肺癌、乳腺癌、皮肤癌、肾癌也存在。当然还有对于检查的焦躁,这可是对任何人的健康都不会有好处的。Of course, screening makes sense in some situations: in particular for people who are at a genuinely high risk for the cancer — those with multiple cancer deaths in their family history. People at average risk who expect to live long enough to experience the potential benefit in the future — and who are willing to accept the chance of harm from unneeded treatment now — may also decide that the screening makes sense for them.当然,检查在一些情况下是有意义的,尤其是癌症真正的高危患者:家族内有多人死于癌症的患者。患病风险中等,但预期寿命足够长,未来可以体验到潜在收益的人——以及那些愿意接受现在并不需要的治疗带来的受到损害的可能性的人——或许也会认定接受检查是合理的。Nevertheless, those interested in early detection may want to concern themselves with the question of how early. Sure, we would rather diagnose cancer in a small breast lump than wait until it develops into a large breast mass. But it may be excessive to extrapolate from that to searching for microscopic cancers. Many of the thyroid cancers found in South Korea were less than a centimeter in size. If we look for earlier cancers, we will always find more. And, at some point, we identify too many things that are better off left unfound. In short, having doctors not look too hard for early cancer is in your interest.尽管如此,有兴趣及早检查的人们,也应该考虑一下多早算早的问题。当然,我们宁愿早些诊断微小的乳腺肿块是不是癌症,也不愿意坐视它发展成大肿块。但如果就此推论,应当寻找显微镜才能看到的微小肿块,恐怕就过头了。韩国发现的许多甲状腺癌变的尺寸不足一厘米。如果我们去寻找癌变的话,总能发现更多病例。但超过了一个限度,我们确诊出的问题就太多了,还不如让它们留在那里不被发现好。简而言之,让医生不要那么热衷于发现早期的癌变,符合患者的利益。That’s where epidemiology comes in. Too many epidemiologists concern themselves not with controlling infectious disease, but with hoping to find small health effects of environmental exposures — or worse, uncertain effects of minor genetic alterations. Perhaps they should instead monitor the more important risk to human health: epidemics of medical care.这正是流行病学的意义。太多的流行病专家不是关注于控制传染病,而是希望寻找环境暴露因素对健康产生的微小影响,更糟的是,寻找微小基因差异可能产生的影响。或许他们应该去关注人类健康更重要的风险:医疗界造成的流行病。 /201411/341588We all know what makes for good character in soldiers. We#39;ve seen the movies about heroes who display courage, loyalty and coolness under fire. But what about somebody who sits in front of a keyboard all day? Is it possible to display and cultivate character if you are just an information age office jockey, alone with a memo or your computer?我们都知道,对士兵而言,何为优秀品质的要义。我们看过的一些电影所刻画的英雄人物,在炮火中表现出了勇气、忠诚和冷静。但对一天到晚坐在键盘前的人而言,又是什么呢?如果你仅仅是信息时代里的一个写字楼职员,成天与备忘录或电脑相伴,那你还有机会展现和培养自己的品质吗?Of course it is. Even if you are alone in your office, you are thinking. Thinking well under a barrage of information may be a different sort of moral challenge than fighting well under a hail of bullets, but it#39;s a character challenge nonetheless.当然可以。即便是独自待在办公室里,你也在思考。和在林弹雨下好好战斗相比,面对大量信息时好好思考可能是一种截然不同的道德挑战,但它仍然不失为对品性的一种挑战。In their 2007 book, ;Intellectual Virtues,; Robert C. Roberts of Baylor University and W. Jay Wood of Wheaton College list some of the cerebral virtues. We can all grade ourselves on how good we are at each of them.贝勒大学(Baylor University)的罗伯特·C·罗伯茨(Robert C. Roberts)和威顿学院(Wheaton College)的W·杰伊·伍德(W. Jay Wood)在2007年出版的《智识美德》(Intellectual Virtues)一书中,列出了一些智识上的美德。我们可以逐项给自己打分,看看自己做得怎么样。First, there is love of learning. Some people are just more ardently curious than others, either by cultivation or by nature.第一条是爱学习。后天养成的也好,天生的也罢,有些人就是比另外一些人具有更强烈的好奇心。Second, there is courage. The obvious form of intellectual courage is the willingness to hold unpopular views. But the subtler form is knowing how much risk to take in jumping to conclusions. The reckless thinker takes a few pieces of information and leaps to some faraway conspiracy theory. The perfectionist, on the other hand, is unwilling to put anything out there except under ideal conditions for fear that she could be wrong. Intellectual courage is self-regulation, Roberts and Wood argue, knowing when to be daring and when to be cautious. The philosopher Thomas Kuhn pointed out that scientists often simply ignore facts that don#39;t fit with their existing paradigms, but an intellectually courageous person is willing to look at things that are surprisingly hard to look at.第二条是勇气。智识的勇气有一种明显的表现形式,即乐于持有不受欢迎的观点。但它还有一种更微妙的表现形式,那就是知道急于下结论会带来多大的风险。莽撞的思考者会撷取少量信息,迅速推导出虚无缥缈的阴谋论。完美主义者则与此相反,如果条件不完备,她是不愿意下任何定论的,因为担心自己可能出错。罗伯茨和伍德说,智识的勇气是一种自律,知道在什么时候该大胆、在什么时候该谨慎。哲学家托马斯·库恩曾指出,科学家们常常简单粗暴地忽略掉跟既有范式不相符的事实;但一个人如果具有智识的勇气,会乐于去研究那些异常难于接受的事情。Third, there is firmness. You don#39;t want to be a person who surrenders his beliefs at the slightest whiff of opposition. On the other hand, you don#39;t want to hold dogmatically to a belief against all evidence. The median point between flaccidity and rigidity is the virtue of firmness. The firm believer can build a steady worldview on solid timbers but still delight in new information. She can gracefully adjust the strength of her conviction to the strength of the evidence. Firmness is a quality of mental agility.第三条是坚定。你肯定不想做一个听到些许反对的声音就放弃自己观点的人。另一方面,你肯定也不愿罔顾所有据,死抱着一个观点不放。坚定这一美德就存在于软弱和顽固的中间点上。坚定地持有某些观念的人,可以用可靠的素材搭建起稳固的世界观,但仍然乐于接触新信息。她能够根据据的力度,优雅地调整自己对某个观点的相信程度。坚定也是一种机敏。Fourth, there is humility, which is not letting your own desire for status get in the way of accuracy. The humble person fights against vanity and self-importance. He#39;s not writing those sentences people write to make themselves seem smart; he#39;s not thinking of himself much at all. The humble researcher doesn#39;t become arrogant toward his subject, assuming he has mastered it. Such a person is open to learning from anyone at any stage in life.第四条是谦逊,有了它,你就不会让对地位的渴望妨碍自己做出准确的判断。谦逊的人会与虚荣和自大做斗争。他的笔下不会出现人们常写的那些让自己看起来很聪明的句子;他根本不是自视甚高的人。谦逊的研究人员不会在其研究领域妄自尊大,想当然地认为自己精通一切。无论处于人生的哪个阶段,这样的人都愿意向他人学习。Fifth, there is autonomy. You don#39;t want to be a person who slavishly adopts whatever opinion your teacher or some author gives you. On the other hand, you don#39;t want to reject all guidance from people who know what they are talking about. Autonomy is the median of knowing when to bow to authority and when not to, when to follow a role model and when not to, when to adhere to tradition and when not to.第五条是自主。你肯定不想盲从于导师或哪个作家表达的任何观点。另一当方面,你肯定也不愿将那些内行人士的所有指导拒之门外。自主的美德在于,知道在什么时候该从权威,什么时候该坚持己见;什么时候该向榜样学习,什么时候该摆脱榜样;什么时候该遵循传统,什么时候该予以摒弃。Finally, there is generosity. This virtue starts with the willingness to share knowledge and give others credit. But it also means hearing others as they would like to be heard, looking for what each person has to teach and not looking to triumphantly pounce upon their errors.最后一条是慷慨。这种美德的起点是愿意分享知识,并给予他人应有的承认。不过,慷慨也意味着,在别人希望发出声音时予以倾听,寻找每个人能为人师表之处,不去洋洋自得地在他人身上纠错。We all probably excel at some of these virtues and are deficient in others. But I#39;m struck by how much of the mainstream literature on decision-making treats the mind as some disembodied organ that can be programed like a computer.在这些美德中,我们可能都是在某些方面出色,在另一些方面有所欠缺。但让我感触的是,居然有那么多关于制定决策方面的主流文章将思想当成某种脱离个人的东西,能像台计算机那样按编好的程序操作。In fact, the mind is embedded in human nature, and very often thinking well means pushing against the grain of our nature — against vanity, against laziness, against the desire for certainty, against the desire to avoid painful truths. Good thinking isn#39;t just adopting the right technique. It#39;s a moral enterprise and requires good character, the ability to go against our lesser impulses for the sake of our higher ones.实际上,思想蕴含在人性之中,而在很多情况下,好好思考意味着战胜我们的本性——抗击虚荣、懒惰、对确定性的渴求、对避免痛苦事实的渴望。好的思维不仅仅是采用正确的技巧。它是一种道德勇气,需要良好的品性,是克低等冲动来获取更高尚目标的能力。Montaigne once wrote that ;We can be knowledgeable with other men#39;s knowledge, but we can#39;t be wise with other men#39;s wisdom.; That#39;s because wisdom isn#39;t a body of information. It#39;s the moral quality of knowing how to handle your own limitations. Warren Buffett made a similar point in his own sphere, ;Investing is not a game where the guy with the 160 I.Q. beats the guy with the 130 I.Q. Once you have ordinary intelligence, what you need is the temperament to control the urges that get other people into trouble.;蒙田曾写道,“即使我们可以凭借别人的知识成为学者,但要成为哲人,却只能靠我们自己的智慧。”这是因为,智慧并非大量信息的简单集合。它是一种知晓如何应对自身局限性的道德品质。沃伦·巴菲特(Warren Buffett)曾在其领域中发表过类似的见解,“投资不是智商160的家伙打败智商130的人。只要你智力正常,你只需要自己的性情能够控制住让别人陷入麻烦的冲动。”Character tests are pervasive even in modern everyday life. It#39;s possible to be heroic if you#39;re just sitting alone in your office. It just doesn#39;t make for a good movie.即便是在当代日常生活中,对个人品质的考验也无处不在。就算你只是独自坐在办公室里,也可能成为英雄。只不过,这拍不成一部劲爆的电影。 /201409/325534The modern maraschino cherry is “a real cherry with the cherry flavor removed,” explains Darcy O’Neil, a chemist and the author of “Fix the Pumps,” a history of the soda fountain. The original version, by contrast, was a marasca cherry — a sour, dark variety cultivated on the coast of Dalmatia (now part of Croatia) beginning in the mid-19th century. It was brined in ocean water, then preserved in a liqueur made from its own juices, as well as leaves and ground-up pits.现代的酒渍马拉斯奇诺樱桃(maraschino cherry,特指冰淇淋、鸡尾酒,奶油蛋糕等物上的装饰性红樱桃——译注)是一种“去掉了樱桃味的樱桃”,化学家达西·奥尼尔(Darcy O’Neil)说,他曾出版讲述冷饮机历史的《修好水泵》(Fix the Pumps)一书。马拉斯奇诺樱桃是用欧洲酸樱桃制成的,二者截然相反。欧洲酸樱桃又酸又黑,是19世纪中期在达尔马提亚(今克罗地亚境内)培育出来的。制作方法是将它用海水浸泡,之后用同一种樱桃的汁液、叶子和碾碎的籽制成的甜酒腌渍。The fruit first arrived on American shores as a luxury import around the turn of the century, along with a cheaper version made primarily in France using sugar and dyes. Large shipments of European cherries that had been preserved but not fully transformed into maraschinos were also sent to the ed States — American cherries were considered unacceptable because of their mushier texture — where they, too, were made into less rarefied versions of the Croatian original.在19世纪与20世纪之交,这种果子作为一种奢侈的进口物品来到美国大洋两岸,此外还有一种较为便宜的法国制造品种,用糖和颜料浸渍而成。美国樱桃被认为质地较软,无法用来制作马拉斯奇诺樱桃,于是大量欧洲半成品樱桃也被运往美国,在美国本土加工制作,但没有克罗地亚的原产品那么正宗。Americans happily gobbled up imitation marascas, usually flavored with vanilla or almond. But when information about how they were made was leaked, outraged articles followed. “Maraschino Cherries Violate Pure Food Law,” ran one 1907 headline. According to another report, the fruit was smoked in sulfur and packed in a noxious chemical brine before shipping; once in the factory, it was soaked in sugar syrup, flavored and dyed red with aniline, a toxic colorant made of coal-tar byproducts. So many maraschino impostors — some alcoholic and some not — hit the market that in 1912, the Food and Drug Administration issued an official statement on the difference between a real maraschino and an imitation.美国人开心地吃着这些仿制樱桃,通常是配香草和杏仁一起吃。但是当制作过程泄露后,开始出现愤怒的抨击文章,1907年,一篇文章题为“马拉斯奇诺樱桃触犯纯净食品法”。另一篇报道写道,这些樱桃经过硫磺烟熏,在运输前被浸泡在一种臭名昭著的化学制剂里。在工厂,它们被浸入糖浆,用苯胺调味和染上红色——苯胺是一种有毒的着色剂,由煤焦油的副产品制成。大量冒牌马拉斯奇诺樱桃涌入市场(有些是酒渍的,有些不是),1912年,美国食品和药物发表了一份官方声明,澄清真假马拉斯奇诺樱桃的不同之处。None of these alarming findings stopped people from eating the candied treats. It wasn’t long before American cherry growers, particularly in Oregon, where there were vast orchards, looked for ways to break into the market. Ernest Wiegand, a horticulturist at Oregon Agricultural College (now Oregon State University), focused on figuring out how best to preserve the shape and structure of local cherries to the standards Americans expected. “Preserving them with alcohol causes them to shrink,” O’Neil explains. “They become hard and wrinkled, and they don’t look like a plump, beautiful cherry.” In 1925, Wiegand discovered that adding calcium salts to the preserving brine firmed up the fruit. With a few modifications, this is still the method used to make maraschinos today. And while the maraschino we know has long been a kind of Frankenstein’s monster of the fruit world, in a Manhattan or on a sundae it offers a certain reliable comfort. “It’s got this burst of sweetness and sugar and childhood in it,” O’Neil says. “And those are good associations.”这些警告并没有阻止人们继续食用这种甜品。不久后,美国樱桃种植者,特别是拥有大片果园的俄勒冈州的种植者们找到办法打入这个市场。厄内斯特·维甘德是俄勒冈农业学院(今俄勒冈州立大学)的园艺学家,他致力于让本土樱桃的形状和质地在腌渍过程能够达到美国人期待的标准。“用酒精腌渍会让它们缩水,”奥尼尔说,“会让它们变硬起皱,看上去就不像美丽丰满的樱桃了。”1925年,维甘德发现,在腌渍液中加入钙盐,会让樱桃变得质地坚实。经过若干调整,这个方法如今仍应用在制作马拉斯奇诺樱桃的工序中。我们熟悉的马拉斯奇诺樱桃早已成为水果界的弗兰肯斯坦怪物,但当它随曼哈顿鸡尾酒和圣代冰淇淋一起端上来的时候,还是让人有种安心的舒适感。“它包含了关于甜蜜、糖果和童年的感觉,”奥尼尔说。“这些都是美妙的联想。” /201410/338308

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