新一年馬上就要到來了，美國也將馬上迎來新一屆政府。我們也應(yīng)該認(rèn)真思考一下，我們應(yīng)該怎樣共同努力來提高所有人的福祉。比如我們是應(yīng)該減肥呢？還是應(yīng)該多鍛煉呢？

因此，我想從另一個角度為大家提出一系列新年目標(biāo)，這些目標(biāo)關(guān)系到我們所有人的根本健康。只有人人都樹立以下六個決心，才能真正提高全社會的健康水平。

縮小貧富差距

我們的收入水平?jīng)Q定了我們的食物質(zhì)量，決定了我們居住的小區(qū)的安全程度，決定了我們可以接受何等水平的教育，決定了我們的經(jīng)濟(jì)社會能否發(fā)展進(jìn)步。如果收入不足，甚至負(fù)債累累，就會對我們的健康產(chǎn)生嚴(yán)重影響。

然而如今被收入問題折磨的美國人變得越來越多了，換言之，這個國家的貧富差距正在拉大。據(jù)美國國會預(yù)算辦公室近期發(fā)布的報(bào)告顯示，2013年，美國所有居民家庭財(cái)富的76%集中在最富裕的10%的家庭手中。要解決貧富差距的問題，我們只能想方設(shè)法提高底層50%人民的收入水平。我們還是有很多方法能實(shí)現(xiàn)這個目標(biāo)的。比如我們可以擴(kuò)大低收入勞動所得稅收抵扣制（EITC）的覆蓋范疇，目前該政策主要覆蓋的是年收入在500美元到6.2萬美元之間的低收入勞動家庭，優(yōu)惠幅度也取決于具體收入水平和家庭成員的人數(shù)。另外，我們還可以提高遺產(chǎn)稅水平，并且彌補(bǔ)各種稅收漏洞，利用額外收來的稅金建設(shè)能提高公共福利的項(xiàng)目。

在美國以及全球推動男女平等

在包括美國在內(nèi)的許多國家，男女受教育和就業(yè)的機(jī)會都是不平等的，女性往往處于劣勢一方。這種性別上的不平等也給人類的總體健康水平造成了威脅。教育、就業(yè)和收入都是健康的決定因素，女性如果缺乏這些因素，也就無法享受到它們帶來的利益——比如權(quán)力、社會關(guān)系和政治代表性等。

此外，女性還要面對生殖健康方面的威脅。在美國，這種威脅包括對女性流產(chǎn)權(quán)的政策挑戰(zhàn)，以及健康的生殖保健服務(wù)等等。而在全球其他地區(qū)，女性割禮等殘害女性身體的行為，以及在婚姻和生子等方面禁錮在女性身上的文化枷鎖依然存在。解決這些問題不僅有益于提高女性的生活水平，同樣也有助于提高男性的生活水平。男女的不平等是具有代際效應(yīng)的，它會對家庭乃至社會產(chǎn)生深遠(yuǎn)的影響。只有為男女創(chuàng)造了公平競爭的舞臺，才能最終更進(jìn)一步地實(shí)現(xiàn)人人平等。

縮小社會分化

收入（財(cái)富）差異和性別差異只是社會分化的兩個比較有代表性的例子。社會分化嚴(yán)重影響了人類的總體健康水平，因此它也是決定公共健康的一個主因。社會分化為不同社會階層的人樹立了經(jīng)濟(jì)、社會和政治壁壘。比如種族就是社會分化的一個頑固標(biāo)記。在美國，黑人和白人的健康水平呈明顯差異，突顯了社會分化給社會帶來的許多健康挑戰(zhàn)。以肥胖癥為例，1976年至2004年間，患有肥胖癥的黑人女性的比例始終高于白人女性。另一個例子是艾滋病。

我們現(xiàn)在已經(jīng)可以通過一些非常有效的方法來預(yù)防或延緩艾滋病，比如使用安全套，或服用替諾福韋酯/恩曲他濱（舒發(fā)態(tài)）等藥物。隨著艾滋病的防治水平不斷提高，聯(lián)合國已經(jīng)將2030年定為“終結(jié)艾滋病”的目標(biāo)年份。然而受社會分化因素的影響，這很有可能將成為一個不切實(shí)際的目標(biāo)。比如社會上對艾滋病人的污名化貨幣等等。在一些嚴(yán)重男尊女卑的文化中，女性還會面臨更高的感染風(fēng)險。而縮小社會分化將大大有助于削弱這些風(fēng)險，從而有利于確保相關(guān)易感人群的健康。

提高所有階層的教育水平

教育可能是決定社會健康水平的最重要的因素了。缺乏高質(zhì)量的教育將導(dǎo)致不同社會群體間的健康水平差異增大，提高人們對疾病的易感性，縮短人們的預(yù)期壽命。而教育程度較高的人一般健康水平也比較好，這主要是由于教育水平與收入水平直接相關(guān)，收入越高，健康水平自然也就越好。教育也會讓人做出更明智的生活選擇，使人懂得避免危險行為。我們可以通過加大早期教育的投資來提高全社會的教育水平，這樣一來，我們就能拓寬人民獲得高質(zhì)量教育的渠道，加深教育對人的終身影響。目前少數(shù)族裔在教育資源上相比白人處于弱勢，因此我們的教育投資也是一項(xiàng)平權(quán)投資，它能夠最大激發(fā)教育對于提高人民整體健康水平的潛能。

預(yù)防槍支暴力并減輕其后果

2016年，美國又發(fā)生了多起震驚世界的特大兇殺案，正是因?yàn)檫@些極端暴力者持有槍支，大量無辜群眾才成為了槍下亡魂。除了這些世人皆知的大案，美國每年還會發(fā)生數(shù)千起涉槍事故，其中很多受害者是兒童。這也導(dǎo)致2016年美國的涉槍傷亡率達(dá)到了另人恐怖的水平。這些統(tǒng)計(jì)數(shù)據(jù)表明，美國要想終止暴力，就躲不開持槍與控槍的矛盾。美國的控槍政策可以說是失敗的，這一點(diǎn)從聯(lián)邦立法層面對控槍問題的無所作為就可以看出。此外，我們現(xiàn)在甚至沒有辦法去深入研究這個問題——因?yàn)檫B美國疾病控制與預(yù)防中心對控槍問題的研究經(jīng)費(fèi)都被砍了。如果我們真想提高人民的健康水平，我們就要從2017年開始，切實(shí)通過有效的立法手段，解決這個國家的槍支暴力問題。

預(yù)防藥物濫用

在全球尺度看，有5%的壽命減損都是由于酒精或服用違禁藥物導(dǎo)致的。光是美國從2000年到2014年死于藥物過量者就達(dá)到近50萬人，其中很多人死于我們最熟悉的鴉片類藥物。我舉個例子來說明一下這個問題的嚴(yán)重性：近10年來，濫用藥物導(dǎo)致的死亡人數(shù)已經(jīng)超過了車禍造成的死亡人數(shù)。要想解決濫用藥物的問題，我們有好幾種方法可以采用，比如加大教育力度，加大藥物濫用預(yù)防藥的普及程度，以及教育人們?nèi)绾问褂妙A(yù)防藥，等等。

此外我們還需要直面對藥物濫用者污名化的問題，污名化的后果是很嚴(yán)重的，它使許多藥物濫用者不愿于采用一些能救命的方法——比如已經(jīng)在北美一些城市建立的“毒品安全注射屋”等，這些措施在防止藥物成癮方面有可能發(fā)揮極大的作用。如果我們能下決心采用一些實(shí)際的、基于數(shù)據(jù)的解決方案來解決藥物濫用的問題，那么我們就能在阻止社會健康風(fēng)險蔓延的道路上取得真正的進(jìn)展。

有決心當(dāng)然是好的，然而2017年，我們能在以上這幾個方面都取得進(jìn)步嗎？在新總統(tǒng)的這段任期內(nèi)，我們能在這些問題上走多遠(yuǎn)，恐怕誰也說不準(zhǔn)。從他的言論立場看，這位當(dāng)選總統(tǒng)似乎也想對抗上面提出的許多問題。然而這并不意味著這些問題對我們來說就不重要了。在我看來，正是由于目前存在的不確定性，我們大家才更應(yīng)該共同肩負(fù)起社會責(zé)任，凝聚社會合力，打造一個更健康的世界。如果我們這樣做了，那么未來的每一年都將是更加健康的一年。祝大家新年快樂?。ㄘ?cái)富中文網(wǎng)）

作者：Sandro Galea

譯者：樸成奎

本文作者Sandro Galea是波士頓大學(xué)公共衛(wèi)生學(xué)院院長、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.