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越南如何阻击比艾滋病更致命的疾病

更新时间:2016-3-30 10:20:36 来源:纽约时报中文网 作者:佚名

Vietnam’s Battle With Tuberculosis
越南如何阻击比艾滋病更致命的疾病

Dr. Bui Xuan Hiep, the head of tuberculosis control in this city’s Hoang Mai district, paged proudly through a large handwritten patient log.

在河内市黄梅区,主管结核病控制的裴春协医生(Dr.Bui Xuan Hiep)自豪地翻着一大本手写的患者名录。

“This district’s cure rate averages 90 percent,” he said. Still, Dr. Bui could see problems.

“本郡的治愈率平均达到90%,”他说。但他依然能看到存在的问题。

Seven patients had turned up with multidrug-resistant tuberculosis; four had been cured, two had died — and one had simply disappeared.

曾经有七名耐多药结核病患者,四人病愈,两人死亡,另一人则完全不见了踪影。

It’s a story repeated throughout Vietnam. The nation was once racked by a tuberculosis epidemic, one of the worst in which H.I.V. was not the driving force. But officials fought back fiercely.

这种情况在越南全国各地上演。这个国家曾深受结核病泛滥成灾之苦。在非艾滋病病毒造成的疾病中,结核病堪称危害最深的病种之一。但越南官方进行了有力的反击。

Twenty-five years ago, battered by the aftermath of a long war, chronic poverty and a heavy-handed government isolated from much of the world, Vietnam had nearly 600 cases of tuberculosis for every 100,000 residents. Today, it has less than 200.

25年前,受漫长的战争、长期的贫困和遭到世界很多国家孤立的强权政府的影响,越南每10万人中有近600例结核病病例。如今,这个数字已降至不到200.

The country boasts a 90 percent cure rate for uncomplicated tuberculosis and cures 75 percent of its drug-resistant cases, easily beating the global average, 50 percent.

该国不复杂的结核病病例治愈率高达90%,耐药病例的治愈率也达到75%,轻松超过了50%的全球平均水平。

Indeed, public health officials worldwide have made remarkable progress against tuberculosis. Deaths from the disease have fallen drastically since 2000, according to the World Health Organization. Tuberculosis has been halted or reversed in 16 of the 22 countries that account for the vast majority of cases.

的确,世界范围内的公共卫生机构在防治结核病方面取得了显著的进步。世界卫生组织(World Health Organization)称,自2000年以来,死于结核病的人已大幅减少。在绝大部分病例所在的22个国家中,已有16个国家阻止或扭转了结核病的蔓延趋势。

But Ban Ki-moon, secretary-general of the United Nations, last week warned that the fight was “only half won” and estimated that 1.5 million worldwide would die of the disease this year.

但联合国秘书长潘基文(Ban Ki-moon)上周警告称,这场斗争“只赢了一半”,并估计今年全世界会有150万人死于结核病。

There is no better example of how fragile this success may be than Vietnam. Hospital wards here are packed dangerously full, raising the risk that drug-resistant strains will spread.

越南比其他任何地方都能更好地表现这种成功的脆弱。医院病房里人满为患,增加了耐药菌株的扩散风险。

The easy-to-reach patients have been treated, and many of the rest are the hardest to help: heroin-addicted couriers and laborers from the poppy fields of the nearby Golden Triangle, and mountain villagers who do not speak Vietnamese and are barely connected to the health care system.

容易接触到的患者得到了治疗。而剩下的患者中,很多都属于最难帮助的群体:来自附近金三角地区罂粟田的沾染海洛因毒瘾的苦力和运毒者,以及山区那些不说越南语的村民,他们基本上未被医疗保健体系覆盖。

But the biggest threat is that the money is close to running out.

但现在,最大的威胁是资金接近枯竭。

To reach Vietnam’s ambitious goal of pushing prevalence rates down to 20 cases per 100,000 residents — essentially eliminating tuberculosis as a public health problem — its tuberculosis-control program needs to spend at least $66 million a year. It now spends about $26 million a year.

越南计划把每10万人中的患者人数降到20人以下,本质上就是让结核病不再是公共卫生问题。为了实现这个宏伟的目标,该国的结核病控制计划每年至少需要花费6600万美元。目前,该计划每年大约支出2600万美元。

About $19 million of that comes from foreign donors, with more than a third from the United States, Dr. Nguyen said. Evidence of donor help is everywhere.

一位阮姓医生称,这笔钱中约有1900万美元是来自外国的捐款,其中超过三分之一来自美国。而外国援助的证据随处可见。

The expensive diagnostic machines in hospital laboratories bear stickers from the United States Agency for International Development or from The Global Fund to Fight AIDS, Tuberculosis and Malaria, 30 percent of whose budget is paid by the United States. But The Global Fund, the chief support of the tuberculosis program here, is struggling and has promised support only through 2017. The White House, in its proposed budget for fiscal year 2016, reduced its contribution to the fund by 18 percent and to Usaid’s tuberculosis programs by 19 percent.

医院实验室里,昂贵的诊断机器上贴着来自美国国际开发署(United States Agency for International Development)或全球抗击艾滋病、结核病和疟疾基金(The Global Fund to Fight AIDS, Tuberculosis and Malaria,简称全球基金)的贴纸。这些机器的预算中,30%由美国支付。但作为越南结核病项目的主要支持者,全球基金自身举步维艰,只承诺在2017年结束前提供支持。在2016财年的预算提案中,白宫将对该基金和美国国际开发署结核病项目的捐款分别削减了18%和19%。

Officials here and at the W.H.O. fear that hard-won progress may soon be reversed and a remarkable success story may come apart, with deadly consequences.

越南和世卫组织的官员担心,来之不易的进步可能很快便会被逆转,非同反响的成功也可能会瓦解,造成致命的后果。

After years in the shadow of the AIDS epidemic, tuberculosis is regaining its notoriety as one of the world’s great killers: an airborne bacterium that spreads easily among people living crowded together — in jails, ships, mines, trenches or slums — and insinuates itself deep in the lungs and grows, slowly tearing apart the tissue until victims are coughing up blood.

在被艾滋病的阴影笼罩多年后,结核病正在重新成为全世界的主要杀手。结核病是一种通过空气传播的细菌引起的。这种细菌容易在生活在拥挤空间,如监狱、轮船、矿井、沟渠或贫民窟里的人之间扩散。细菌会进入肺部,在肺里生长,慢慢导致组织撕裂,直到患者咳血。

Tuberculosis now kills more people around the world than AIDS, according to the W.H.O.: 4,100 a day, compared with 3,300 dying of AIDS, making tuberculosis the leading infectious cause of death in the world.

据世卫组织称,现在全球死于结核病的人多过死于艾滋病的人:每天有4100人死于结核病,相比之下,有3300人死于艾滋病。这使结核病成了全世界头号传染性死因。

Mortality from both diseases is dropping, but tuberculosis deaths have fallen more slowly, especially in Asia.

死于这两种疾病的人都在减少,但死于结核病的人数减少得更慢一些,尤其是在亚洲。

Vietnam’s success where so many other nations have failed is not just because of donor money, said Dr. Mario C. Raviglione, the director of the W.H.O.’s global tuberculosis program.

世卫组织全球结核病项目主任马里奥·拉维格里奥尼(Mario Raviglione)称,在其他很多国家都失败了的情况下,越南能够取得成功不仅是因为获得了捐款。

“It succeeds because it’s a Communist country,” he said. “Socialist countries put a lot of resources into primary care: lots of doctors, lots of clinics. And once central government adopts a thing, they really do it. They give orders.”

“它取得成功是因为它是一个共产主义国家,”他说。“社会主义国家会把大量资源用于初级医疗护理,有着大批医生、众多诊所。一旦中央政府决定要做某件事,他们就真的会做。他们会下命令。”

Tuberculosis is an ideal disease for a regimented treatment approach.

结核病是一种典型的需要对治疗方法进行严格管理的疾病。

Almost all patients with “uncomplicated” tuberculosis — bacteria that are not drug-resistant — can be cured if they take a standard menu of four antibiotics every day for six months without fail.

如果遵照标准的治疗方案,每天服用四种抗生素,不间断地坚持半年,几乎所有“不复杂的”结核病,即致病细菌不耐药的患者都能被治愈。

In Vietnam, treatment standards set at the national level are followed by the entire public health network. The National Lung Disease Hospital in Hanoi oversees 64 provincial hospitals, which oversee 845 district hospitals, which oversee 11,065 neighborhood health clinics.

在越南,治疗标准由国家制定,整个公共卫生系统都要遵守。位于河内的国家肺病医院(National Lung Disease Hospital)管辖着64个省级医院,这些省级医院下面又管辖着845家地区医院,后者则负责管辖11065家社区卫生所。

The pharmaceutical-supply chain, the Achilles’ heel in many tuberculosis-ridden countries, is impressive. On a weeklong tour of urban and rural clinics, not one nurse or patient reported ever running out of drugs.

在很多结核病肆虐的国家,药物供应链是致命的弱点。但越南的药物供应链令人敬佩。在对城市和农村诊所的一周巡视之旅中,没有一个护士或患者反映没药了。

Those neighborhood clinics — usually just a few examining rooms, a small pharmacy and a parking lot — are as ubiquitous here as police stations and firehouses in the United States.

这些社区诊所通常就是几间问诊室、一个小药房和一个停车场。它们随处可见,就像美国的警察局和消防站一样。

They treat many illnesses, but their role in tuberculosis is simple: Every tuberculosis patient in the district reports once a day to take his or her pills in front of a nurse. Each dose taken is checked off on a yellow card.

虽然可以治疗很多疾病,但这些诊所在结核病防治中的作用很简单:所在区域的所有结核病患者每天都要来报道一次,当着护士的面服药。一个黄色的卡片上记录着患者每次服药后打的勾。

Patients with drug-resistant disease are especially hard to help. Their medicines, some of which are intravenous, must be taken for two years, and can cause deafness, psychosis and kidney failure. Patients must be hospitalized, their movements restricted to one or two corridors, sometimes for months until they are no longer coughing up live bacteria.

帮助耐药性患者非常难。他们必须坚持服药两年,有些药需采取静脉注射的方式。这些药物可能会造成耳聋、精神错乱和肾功能衰竭。此外,病人必须住院治疗,只能在一两个走廊里活动。有时候,这种情况要持续数月,直到他们不再咳出活的细菌。

If they become worse instead of better, the prognosis is usually grim. Extensively drug-resistant disease (XDR TB) requires even more toxic drugs costing 25 times as much. Most XDR TB patients here die.

如果病情并未好转,而是发生恶化,预后通常都很严峻。广泛耐药肺结核(Extensively drug-resistant disease,简称XDR TB)的治疗甚至需要用毒性更强的药物。它们的价格是一般药物的25倍。在越南,大部分XDR TB患者都会丧命。

There are many signs that the national tuberculosis program here survives on a shoestring budget.

很多迹象表明,越南全国性的结核病计划全靠有限的预算支撑着。

While its top laboratories have some modern equipment, the 64 provincial hospitals share only 60 rapid diagnostic machines, less than half the number they need, even though Vietnam pays only $17,000 for each, about a tenth of the American retail price.

尽管顶级实验室配备了一些现代设备,但全国64家省级医院只能共用60台快速诊断机器。这个数字不及需求的一半,尽管每台机器越南只用付1.7万美元。这大约是美国零售价格的十分之一。

More ominously, hospital wards are dangerously crowded. Seven patients a room, with beds only a foot apart, is not an uncommon sight. (That effectively means 14 inhabitants a room, as many patients have a relative sleeping on the floor or in a corridor to do nursing chores and bring food.)

更可怕的是,医院的病房非常拥挤。一间病房里住七个人,病床之间只有约30厘米距离的情况并不少见。(这实际上意味着一个房间住14个人,因为很多患者需要有一名亲属护理,为其打饭。这些人只能睡在地上或是走廊里。)

Geography presents the tuberculosis-control program with another kind of obstacle. In the Shangri La-like valleys of Son La province, a six-hour drive west of Hanoi, some inhabitants live in villages with thatched roofs and speak only Hmong, Meo or Thai.

地理环境给结核病控制计划造成了另一种障碍。在河内以西六小时车程的山罗省类似于香格里拉的谷地,一些村民家里的屋顶是用茅草盖的。他们只会说苗语或泰语。

Finding and keeping them in treatment is hard, said Dr. Tong Van Hieu, the director of the Quyet Thang neighborhood clinic in Son La. Some believe tuberculosis is caused by fog or dust or gold mine fumes, and turn first to folk remedies.

山罗省厥升社区诊所主任宋文孝(Tong Van Hieu)说,找到他们并让其接受治疗很难。一些人认为结核病是大雾、灰尘或金矿冒出的烟造成的。他们首先会求助于民间偏方。

In the cities, a new problem is on the rise.

在城市里,一个新问题正在加剧。

Vietnam’s growing prosperity lets some patients afford private doctors — who often ignore the official four-drug regimen and fail to insist their patients take every pill.

越南日渐繁荣,这让一些病人能负担得起私人医生。而私人医生往往会忽视官方规定的由四种药组成的治疗方案,并且做不到坚持让病人服用全部药物。

And sometimes, even when compliant patients play by the rules, treatment fails, anyway.

而且毕竟有时候,即便病人顺从地遵守规则,治疗也会失败。

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