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某天,我在手术室里做手术。站在我旁边的是麻醉组的成员马克·西蒙,他29岁,是医院的实习医生。手术并不复杂,所以我们开始聊天。我提到自己一直在思考的囊肿性纤维化治疗体系,结果没想到,这个话题正好触及他的痛处,因为马克本人就患有这种疾病。我事先一点也不知道他的病,尽管我们已经合作过很多次,而且他身材矮小,经常发出刺耳的咳嗽声,这些正是这种病患者的常见症状。他告诉我,疾病使他经历了极度痛苦的煎熬。在医学院学习的前三年,他还能保持健康。但是到了第四年,他的病情恶化了,必须住院四周。接下来的一年在波士顿实习,他也耽误了六周。现在是他实习的第二年,才刚过一半,他已经又住了一个月院。29岁的他心里再清楚不过了,这种病的患者平均寿命只有33岁。所以我们集中讨论的问题是:哪种方式更有可能挽救他的生命——投资试验室科学,还是努力提高现有医疗方法的功效?
大多数人想到的答案一定是投资实验室科学,找到治愈疾病的方法。1989年,科学家发现了囊肿性纤维化的致病基因,在当时看来,投资实验室科学的确是个明智的选择,人们相信只需几年就能够找出治愈疾病的方法。然而,期盼的进展并没有出现。马克没有放弃希望,他相信这种病终有一天会有办法治愈的,但是否来得及挽救他的生命呢?他并没有把所有希望都寄托在这上面。他说,相反的,运用已有的知识技术,提高和改善临床疗效,这才是他的希望所在。他认为,相比之下,这个方式能够挽救更多的生命。我也赞同他的观点。
当然,不管是囊肿性纤维化、儿童淋巴瘤、心脏病,或是其他任何损害人类健康的疾病,我们都需要不断创新,拓宽知识,发展新的治疗方法。但现实情况是,我们并没有有效地运用科学已经赋予我们的能力,我们也没有付出多少努力去改变这个现状。而另一方面,当我们把成效作为一门科学,如医护人员在洗手、医治战场伤员和接生婴儿等方面所做的那样,成千上万的生命得到了挽救。事实上,为了提高医疗成效而进行的科学投入——眼前看来虽然只占科研预算的极小部分——到了下一个十年,将会比实验室科学挽救更多人的生命,比起基因破译、干细胞疗法、癌症疫苗,以及其他我们在新闻里听过的一切实验研究,它能够救活更多人。再也不会有比这更丰厚的回报了。
以乳腺癌为例。1990年以后,在工业化国家里,乳腺癌的死亡率已经下降到大约25%。最近,对美国乳腺癌档案数据的研究表明,死亡率下降的原因,至少有四分之一、甚至可能超过一半要归功于女性更多地采用了乳房X光片检查。乳房X光片能够及时发现体积尚小、还无法触摸到的乳腺癌肿瘤,让患者在癌细胞扩散之前及早得到治疗,从而挽救患者生命。但这种方法要想发挥作用,关键是女性必须每年一次、按时进行乳房X光片检查。如果间隔时间超过一年,乳腺癌肿瘤就有可能在患者毫无察觉的情况下形成、生长并扩散。
那么,有多少女性每年做一次乳房X光片检查?7名女性中,有1名能连续坚持5年;16名女性中,只有1名能坚持10年。没做检查的原因五花八门。责任当然往往在女性自身,但她们之所以不坚持做检查,有几种潜在的主要原因,包括做检查耗费时间、令人不适、很麻烦,有这种设施的医院不多,对于没有医疗保险的人来说价格太昂贵,而且做完检查后很少能得到相关结果和提示。美国政府和私人基金会每年花费近十亿美元研究乳腺癌的新疗法,却极少有人想到投资改善乳房X光片检查的舒适度和方便性,尽管研究结果一致表明,单单更规律、更合理地运用这一项技术,就能将乳腺癌的死亡率减少三分之一。这只是其中一个例子而已,能够说明提高医疗实践的成效会获得的巨大成果。
然而,直到我留意观察了世界上其他大多数地方的医疗实践之后,才算是彻底、深刻领悟了提高医疗成效所带来的巨大潜在价值。在那些地方,挽救人们生命的最大希望就在于提高医疗成效,而不是什么遗传学研究。
* * * *
2003年,我终于完成了外科训练。在开始正式执业之前,我决定先以访问医生的身份前往印度考察,那里是我的祖籍。在两个月的旅程中,我先后在印度境内的六家公立医院工作,有安置了2 000张病床的定点医疗中心,也有乡村农舍医院以及普通的全科医院,平均每个地方我都逗留了一两周时间。
其中一家是地区医院,为包括乌提村(我父亲的故乡)在内的一些地区提供医疗服务。乌提村隶属马哈拉施特拉邦,位于孟买以东约650公里处,在卡纳塔克邦(也就是我见证脊髓灰质炎扫荡行动的地方)的正北面。我父亲家族的大部分亲戚都还在那里生活,他有12个兄弟姐妹,都是农民,种植甘蔗、棉花,还有一种叫做高粱的农作物,这些就是他们的经济作物。有了滴灌设备,他们一年能有两次收成,再加上父亲寄来的钱,足够他们维持殷实的生活。乌提有公路和电力,一些家庭还有自来水。营养不良不再是困扰人们的问题。如果村民病了或者需要体检,那儿有一个初级卫生所,里面有一个医生,大概每周来一次。要是村民得了疟疾或腹泻方面的疾病,卫生所的医生会把病人送到附近小镇乌马克海德的农舍医院。倘若是更严重的疾病,他会把他们送到110公里远的南戴德地区医院。我的堂兄之前患肾结石就是在那里治疗的。
不过,南戴德地区医院是那里唯一的一所公立医院,要负责为1 400个像乌提这样的村庄、总计大约230万人口提供医疗服务。医院有500张病床,3个主要的手术室。我到访的时候,发现这里只有九名外科医生。(想象一下整个堪萨斯州只有九名外科医生的情形!)医院的两栋主楼都是四层高,用水泥砌成,外墙粉刷着浅褐色的灰泥涂层。外科医生们每天早晨一到医院,就会看到几百号人水泄不通地围在那里,拼命地往门诊部里面挤。其中至少有两百人是来看外科门诊的。外科住院部也总是人满为患,请他们去给其他科的患者会诊的电话也总是接连不断。令我疑惑不解的是,他们是怎么完成工作的?外科医生们要做那么多疝气手术、肿瘤切除手术、阑尾手术,还有肾结石手术,自己还要睡觉、生活,他们是怎么办到的?