汤姆·弗里登与埃里克·托波尔 - 探讨《更佳健康之道》一书

我们正在直播。观众朋友们正在加入我们，我对此感到非常兴奋，因为今天请到了我的好朋友汤姆·弗里登博士，他曾任美国疾控中心主任。他有一本新书，名为《公式》。《健康公式》。这不仅是单一层面的，而是包含两个层面——个人层面和群体层面。

We are live. And folks are joining us, and I'm excited about that because I've got a great friend here today, doctor Tom Frieden, who was the former director of the CDC. And he has a new book, and it's called The Formula. The Formula for Better Health. And that's not at one level, it's at two levels, both at the individual and the population level.

汤姆，我们有很多内容要讨论。恭喜你。我知道这本书昨天正式出版了对吗？

So there's a lot to discuss here, Tom. Congratulations. I know the book was formally published yesterday. Is that right?

完全正确。谢谢你，埃里克。

Absolutely. Thank you, Eric.

是的。这本书确实非常深刻。我们将探讨其中一些精彩观点，因为你精准指出了我们面临的问题——无论是作为美国人还是全球公民，或是个人健康层面——如何达到更健康的状态。你深入探讨的卡珊德拉诅咒这一概念简直太精妙了，这可以说是本书的基石，你也进行了充分阐述。

Yeah. No, it's really very thoughtful. And we're going to go through some of the really great, points in it because you, have nailed some of the issues that we are confronting to get us to a much healthier state, both as Americans or globally and also, as a personal health story. Now one of the things that I thought was so perfect that you delved into was the Cassandra curse. This is kind of a cornerstone of the book, and you take it to great extent.

或许你可以从希腊神话中的这个诅咒开始，讲讲它如何帮助我们变得更健康。

So maybe you can start with that about the Greek mythology, this curse, and how it all applies to getting us healthier.

非常感谢你，埃里克。实际上《破解公共卫生的卡珊德拉诅咒》是这个项目的暂定名，我断断续续筹备了十年。后来发现大多数人没听说过卡珊德拉，所以这个书名效果可能不好。卡珊德拉是希腊神话中的女祭司，她被赋予预知未来的能力。

Thanks so much, Eric. The Cassandra Curse, actually, the working title for the book, which I've worked on on and off for ten years, was How to Break Public Health's Cassandra Curse. And then I found out that most people hadn't heard of Cassandra. So that wasn't going to be a very effective book title. Cassandra was a priestess in Greek mythology, and she was blessed with foresight.

她能预见未来将发生的悲剧，但被诅咒的是——当她预言这些未来灾难时没人相信她，于是所有预言都成真了。这正是我们在公共卫生领域甚至个人健康方面的处境。破解卡珊德拉诅咒正是这个健康公式的一部分。这是个经过验证的方法，实际上已经拯救了数亿生命，还能再拯救数亿人。它对个人健康同样具有重要意义。

She could foresee the future and future tragedies that were going to strike, but she was cursed that nobody believed her when she prophesied those future tragedies, and so they all came to pass. And that's been what we've been like in public health and actually as individuals also. And breaking the Cassandra curse is part of the formula. It is really an approach that's been proven that has saved millions, actually literally hundreds of millions of lives, and can save hundreds of millions more. And it's really relevant for individual health as well.

这种方法的核心公式是：观察、相信、创造。分为三个阶段。卡珊德拉诅咒实际上属于‘创造’阶段。我们必须看清那些即将致我们于死地的无形威胁，还要识别环境中那些可能正在毒害我们却看不见的毒素。

And the approach, the formula is see, believe, create. Three phases. And the Cassandra curse is really part of the C phase. We have to see the invisible threats that are coming at us that are going to kill us. We also have to see the toxins that we can't see in our environment that may be poisoning us.

没错。我们还必须看清趋势，比如埃博拉疫情。我在CDC工作时，埃博拉正在西非爆发，却无人关注。直到建模师马丁·梅尔特展示了指数级增长曲线，人们才恍然大悟。所以识别趋势至关重要。

Right. And we also have to see the trends of, you know, like Ebola, when I was running CDC, Ebola was exploding with West Africa. We couldn't get anyone to pay attention. And then a modeler, Martin Melter, showed this exponential increase, and then people got it. So you have to see trends.

必须看清项目是成功还是失败。稍后我们会讨论的一点是：既要看清技术严谨的进步路径，也要明白为何我们会对这些警告视而不见。卡珊德拉诅咒正揭示了这种矛盾——我们预知灾祸却无动于衷。在书中第二章，我阐述了造成这种现象的六大驱动因素。

You have to see whether programs are succeeding or failing. And one thing I'm sure we'll talk about in a bit is you have to see the path to progress, the technically rigorous path. But you also have to see why we're blind, why we don't pay attention to those warnings. And the Cassandra curse really indicates that we may know something bad is going to happen, but we don't act on it and why. And in chapter two of the book, I talk about six of the drivers for the Cassandra Cursed.

深层问题在于我们的认知存在偏差。我们对自己、世界和未来的判断都与现实脱节，导致行动缺失。举个卡珊德拉诅咒的驱动因素例子：夸张贴现效应。简单说就是我们总是低估未来。

The underlying theme there is that our perceptions are wrong. Our perceptions are inaccurate. We think things about ourselves, about the world, and about the future that aren't really aligned with reality, and therefore we don't act. I'll give you just one of these six drivers of the Cassandra curse, which is a fancy term called hyperbolic discounting. What it basically says is we shortchange the future.

如果每个吸烟者都知道下一支烟有50%的致死率，大多数人都会戒烟。但事实上半数吸烟者终将死于烟草。那么如何破除卡珊德拉诅咒？针对六大因素我都提出了解决方案。对于夸张贴现效应，有个很妙的方法——

If every smoker knew that they had a fiftyfifty chance of dropping dead after the next cigarette, not a whole lot of people will keep smoking. But fifty percent of smokers, unless they quit, are going get killed by tobacco. So how then do we break the Cassandra curse? And for each of the six drivers, I go through a way to break it. In terms of the shortchanging the future, the hyperbolic discounting, it's kind of cool.

可以做两件事：一是用情感和理性把远期目标当作明日之事；二是用短期收益补偿长期投入。比如在时间管理上，当我接到演讲邀约时，现在会自问：如果是明天，我会答应吗？

You can do two things. One, you can use emotion and rationality to think of something far in the future as tomorrow. And two, you can reward yourself or society with short term gains that compensate for that longer term. So, to give you one example of each, in the time management field, if I get a request for something, go to a meeting, give a talk, I used to show up at these talks and think, why did I agree to this? And I realized, well, I agreed to it six or twelve months ago when it seemed like it was never going to happen.

所以现在收到邀请时我会问：若在明天，我愿意做吗？像这次精彩的播客我就答应了。但往往答案是否定的——如果没有这个自问环节，我可能就草率答应了。健康决策也是同理。

So now when I get an invitation, I say, if it were tomorrow, would I do it? And if the answer is yes, then I do it, like this wonderful podcast. But often, the answer is no. If it were tomorrow, I wouldn't want to do it, but I would have said yes if I hadn't asked myself that question. The same is true for health.

如果我们能运用理性思维或情感去感知眼前的事物。以公共政策为例，费城通过将汽水税收入用于早期儿童教育，成功推动了该税种的通过。这样既获得了短期利益，又兼顾了长远效益。所以，这是一个简短问题的冗长回答。

If we can use our rational brains or use our emotions to think of something as right here before us. On a public policy, to give you an example of this, Philadelphia got a soda tax passed by including the revenue going for early childhood education. So, you give a short term benefit in addition to the long term benefit. So, long answer to a short question.

不，这很棒。我是说，我想给大家看这张图表，就是图1.1。看到了吗？就是这张图，看这里。注意到曲棍球杆曲线从这里突然飙升了吗？

Well, no, that's great. I mean, what I want to do is I wanna show this graph to everybody, this figure 1.1. Okay? This graph, here we go. You see how that hockey stick takes off right there?

干预与否。这是那本名著里的经典场景——你们身处战情室，正试图用卡珊德拉诅咒说服众人。时间是2014年。

No intervention or intervention. This is a famous from the book, You're in the situation room. Are now trying to convince talk about a Cassandra curse. Right? You're trying to convince it's 2014.

埃博拉疫情正在升温。人们不断死亡，却无人采取行动。疫情被完全忽视。你们亲眼所见，也深信不疑。

Ebola is warming up. People are dying, and nothing is being done. It's being ignored. You can see it. You believe it.

你们想制定应对计划。现在展示这张图表，请谈谈那次经历。

You wanna create a plan. And you show this figure. Tell us about that experience.

是的，那确实像是卡珊德拉时刻。我们无法说服人们投资，也无法解释事态有多严重。我当时要去西非，必须告诉当地民众：援助无法及时到达。

Yeah. So it really felt like the Cassandra moment. We couldn't convince people to invest. We couldn't explain how bad it was. I had gone to West Africa or was going in West Africa, I had to meet with folks and say, We're not going to get aid here in time.

病例每三周就翻一番。我们当时预测到年底可能会有百万病例——那时是五六月，而到次年一月就会达到百万。有趣的是，这个预测确实促成了行动。萨曼莎·鲍尔在她的书里也提到过，战情室里那张震撼的表格。

Cases are doubling every three weeks. And it was really the explanation that there could be a million cases by the end of the year. This was May, June, and by January, there would be a million cases. And what's interesting is that did galvanize action. Samantha Power talks about that in her book as well, this dramatic table drop in the situation room.

但这位建模师马丁·梅尔策的贡献远不止于此，他还做了一件非常有趣的事。他向我们指明了前进的道路。他证明只要实现至少70%的安全护理和70%的安全殡葬，病例数就会迅速下降。这个公式'看见-相信-创造'的核心，就是要看清技术驱动的进步路径。虽然有人批评马丁的模型，认为如果病例每三周翻一番，模型可能就需要调整。

But there's more to this modeler, Martin Meltzer, had done something also very interesting. He had shown us the route to progress. He showed that if we got to at least 70% safe care and at least 70% safe burial, cases would drop just as rapidly. And so part of the formula, see, believe, create, is to see the technically rigorous path to progress. And some people criticized Martin's model because you probably would have changed if things had kept doubling every three weeks.

但关键在于，若不做出改变，那种情况确实会发生。我想展示图1.2——这非常有意思——数据证明他完全正确。将他预测的曲线与实际数据叠加，结果分毫不差。所以我认为技术严谨性的一部分，就在于看清进步的道路。

But the point was without change, that would have happened. But, you know, I'm just gonna show figure That 1.2, which is really interesting. What this showed was he was exactly right. If you superimpose what happened on what he said would happen, that's exactly what happened. So I think part of technical rigor is seeing the pathway to progress.

这不仅包括随机对照试验（RCT），还包括实践证据。它包含实际经验。作为结核病专家，我深知随机对照研究始于结核病治疗，我们由此学会了诊疗方法。这些研究很棒，但它们只是证据的一种形式，并非在所有情况下都是最佳选择。

That includes not just RCTs, randomized controlled trials, but includes practice based evidence. It includes practical experiences. I think often, look, by training a tuberculosis specialist, randomized control studies started with tuberculosis, and we learned how to treat. So I think they're fantastic, but they're just one form of evidence. And they're not necessarily the best form of evidence for everything, only for some things.

因此当我们讨论看清进步道路时，这对个人健康也极具参考价值。我们必须坦诚区分'几乎确定'、'很可能'、'有可能'和'仅是猜测'。对于关乎个人或社会健康的诸多事项，必须明确其所属类别，才能看清进步路径，进而相信可以取得更大进展并系统性地扩大成果。

So when we talk about seeing the pathway to progress, we also have and this is very relevant for personal health. I think we have to be really frank about almost certain, likely, possible, or just a guess. For a lot of things that are relevant for personal or societal health, you really have to think of which of those categories it fits into if you're going to see the pathway to progress and then figure out how to believe you can make more progress and systematically scale up.

是的。你列举了这么多精彩案例，尤其强调了这个观点：必须预见未来，正视那些隐形特征。比如回顾1925年爱丽丝·汉密尔顿关于汽油加铅的研究，我们花了五十年时间才认识到这不仅导致儿童智力发育问题，还引发成人心脏疾病。

Yes. Well, you show so many great examples, and you really hit hard on this scene. You have to see. You have to acknowledge the the future, the invisibility feature. Like, for example, you go back to 1925 with putting lead in gasoline with Alice Hamilton and how we went fifty years, fifty years before not only were children having, you know, mental development issues, adults with heart disease.

我之前和布鲁斯·兰菲尔讨论过这个问题。

I did discuss this with Bruce Lamphere in a prior Yeah.

我读过/听过那段讨论。

I read I listened to that.

肾脏病、中风等等这些疾病。卡珊德拉诅咒被打破花了那么长时间，真是令人惊叹。当然，你还带我们回顾了九十年代初纽约市抗药性结核病的情况。这么多精彩的案例。

Kidney, stroke, and all this stuff. And it took all that time for the Cassandra curse to be broken. It's amazing. And of course, you you take us through the TB, in New York City, the TB resistant in the early nineteen nineties. So many great examples.

正如你所说，这不仅仅是随机试验和建模，还有自然实验。我的意思是，至今仍有很多人不愿接种带状疱疹疫苗。而我们从威尔士、美国和澳大利亚的三项大型自然实验数据中看到，阿尔茨海默症和痴呆症发病率降低了约20%，这本该是一种惊人的药物效果，但他们却看不到益处。这确实是我们健康问题的一部分，对吧？

And as you said, it's not just randomized trials and modeling, natural experiments. I mean, still so many people won't get a shingles vaccine. And we see the data consistent three big natural experiments in Wales, The US, and Australia that shows like twenty some percent reduction of Alzheimer's and dementia, which would be a phenomenal drug, but they don't see the benefit. I mean, this is part of our health problem. Is true?

是的。坦白说，我认为个人健康领域充斥着太多炒作、草率思考和欺诈行为，以至于那些简单有效的方法反而被忽视了。部分原因在于改变本身就足够困难，让人们相信看似不可避免的事情可以改变也很难，但我们已经取得了很大进展。我们可以逐步取得更多进展，培养乐观态度。

Yeah. I think there's frankly so much hype, so much sloppy thinking, and so much grifting in the personal wellness space that the simple stuff gets lost. And part of the C is hard enough, believing things that may seem inevitable can be changed is also hard, but we've made a lot of progress. We can make phased further progress. We can cultivate optimism.

但这个公式中最困难的部分是创造一个更健康的未来，因为挑战永远存在。你必须分清轻重缓急，必须组织有序。我在‘决心拯救生命’组织的工作中经常处理这个问题。我们在全球各国开展工作。

But the hardest part of the formula is to create a healthier future because there are always going to be challenges. You have to prioritize. You have to organize. We deal with this a lot in our work at my organization Resolve to Save Lives. We work in countries around the world.

人们总想为所有人做所有事，结果却没能为最需要帮助的人群提供最重要的服务。渐进式普遍主义理念主张：从对最需要人群最具影响力的服务开始，然后随着资源和人力允许逐步扩展——保持简单、有效沟通、克服障碍。我认为要突破个人健康建议中的炒作迷雾，技术严谨性的工具之一就是理解我所说的‘负担乘以可改善性’：问题有多大？我们能解决多少？

And people want to do everything for everyone, but you end up not doing the most important things for the people who can benefit the most. And this concept of progressive universalism, that we're going to start with the highest impact services for the people most in need, will benefit most, and then we're going to expand as resources, financial and human allow, keeping it simple, communicating well, overcoming barriers. But I think this issue of getting past the hype in personal health advice. One of the tools of technical rigor is understanding what I call burden times amenability. How big is the problem and how much can we do about it?

关于带状疱疹疫苗预防痴呆的效果，我在书中讨论过。虽然存在一些证据，但可能仍有残留混杂因素或方法论问题。不过最新研究非常可靠，因为它是自然实验。实际上这是我们最后引用的文献——这本书有500多处参考文献。

So I would say shingles vaccine for dementia prevention, I discuss it in the book. There is some evidence. It may still be residual confounding or methodological problems, but the most recent study is really good because it's an experiment of nature. And we actually this was the last reference. There are more than 500 references in the book.

之所以作为最后一条引用，是因为它当时还是预印本。

It was the last reference because it was just a preprint.

而且

And

所以在校样的最后一天，他们更改了标题和其他几处内容。我们修正了参考文献。但确实，我认为你需要看清什么是没有过度宣传的，当然，有些未经证实的事情你可能想尝试，因为你想这么做。但我们要明确一点。血压可能是任何非吸烟者能控制的最重要因素。

so on the last day of the galley proofs, they changed the title and a couple other things. We got the reference right. But, yeah, I think you have to look at what's a hype free and sure, there are things that are unproven that maybe you want to try because you want to do that. But let's be clear. Blood pressure is probably the single most important thing that any nonsmoker can do.

如果你吸烟，最重要的事情就是戒烟。但对于血压，证据非常明确，从115/75开始，每增加20个单位，你心脏病发作、中风或死亡的风险就会翻倍。自从SPRINT试验（一项出色的随机对照试验）以来，我们发现将血压降至120能使心脏病发作、中风或死亡的风险降低四分之一，即27%。而且这些都是极好的通用药物。在全球范围内，各国用每年5美元的成本就能用最好的药物治疗高血压。

If you smoke cigarettes, the most important thing you can do is to quit. But for blood pressure, the evidence is so strong that starting at 115 over 75, your risk of a heart attack, stroke, or death doubles with every 20 increase. And since the SPRINT trial, great RCT, we've seen that down to 120 knocks down your risk of heart attack, stroke, or death by a quarter, twenty seven percent. If we And they're all great generic medications. Globally, countries treat hypertension for $5 a year with the best medicines there are.

还有他汀类药物，非常非常有效。体育活动，我知道你是大力倡导者。这是最接近神奇药物的东西。可能没有任何药片或注射剂能像定期体育活动那样显著改善你的健康。

And statins, very, very effective. Physical activity, I know you're a big proponent. The closest thing there is to a wonder drug. There's probably no pill or injection that can improve your health as much as regular physical activity.

对。嗯，你知道，提问者之一史蒂文·汤普森，应该是这个名字。顺便说，如果你们有问题想问汤姆或我们，请随时在留言中提出。但他问：'未来属于谁？'正如我介绍时所说，我们讨论的是你那本涉及两个层面——人口和个人未来——的书。

Right. Well, you know, one of the people questioned, Steven Thompson, think his name. And by the way, if you have questions for Tom or us, don't hesitate to put it in the message. But he said, future for whom? And we are, as I introduced, talking about your book that gets at both levels, the population and individual future.

正如你提到的，对个人而言，不仅是吸烟、血压、低钠，120/80的血压值在临床上仍未得到普遍认可。大多数基层医生甚至心脏病专家仍会接受更高的血压值。

And as you mentioned, for the individual, not only smoking, blood pressure, low sodium, that blood pressure of 120 over 80 still is not clinically accepted. That's still most primary care docs, cardiologists even, will accept much higher blood pressures.

他们甚至达不到140的标准。知道吗，埃里克？我们在美国每年花费4.5万亿美元用于医疗保健。我们能做的最重要的事情就是把血压控制在140以内。而我们连一半时间都做不到这一点。

And they don't even hit 140. Know what, Eric? We spend $4,500,000,000,000 on healthcare in The US. The single most important thing we could get right is to control blood pressure even to 140. And we don't do that even half the time.

不。然后，当然还有运动。这就引出了我今天想请你和我们一起探讨的另一个概念——预防悖论。请告诉我们，个人利益与群体利益之间究竟存在怎样的冲突。

No. And then, of course, the exercise. So that's but that brings up this other concept that I wanted you to develop with us today, the prevention paradox. Tell us about how we are really, the conflict between a personal benefit versus a population level benefit.

预防悖论是一个非常重要的概念，由杰弗里·罗斯提出。其核心理念是：大规模人群中微小改变产生的整体影响，远胜于小范围人群中的重大改变。这种效应可能带来微小益处，也可能造成微小危害。我将举两个例子说明。

The prevention paradox is a really important concept. Jeffrey Rose came up with it. The idea is that small changes across large populations make a bigger difference than big changes across small populations. And that can go in either direction, small benefits or small harms. I'll mention two.

我们讨论过铅的问题。全社会每人减少一点点铅暴露，就能带来巨大的经济、教育、心血管和肾脏方面的收益。但没有任何个人能感知到这种受益。然而，需要除铅的行业可能会游说阻止这些改变。同理，减少钾或钠的摄入也是如此。

We talked about lead. Just a little bit of lead less throughout all of society creates massive benefits, economic, educational, cardiovascular, kidney. But no one person may know that they've been benefited. However, the industry that had to get the lead out may lobby and block those changes. Similarly, decreasing potassium or decreasing sodium.

如果我们在全社会范围内稍微调整这些指标，没有人会察觉，但可能预防成千上万例心脏病发作和中风。但需要改变的企业必定会反对。预防悖论之所以重要有两个原因：首先它揭示了为何我们难以有效准确地认知现实——我们看不到真正影响健康的因素，因为它们是通过对多数人产生微小影响来实现整体重大改变的。

If we just do that a little bit across all of society, no one's gonna notice, but it may prevent thousands or hundreds of thousands of heart attacks and strokes. But the companies that have to change are gonna oppose. So this prevention paradox is really important for two reasons. One, it's an example of why we don't see reality so effectively, so accurately. We don't see what's really driving health because we can't see the things that are making a big difference because they're making a little difference for a lot of people.

但这存在政治推论：烟草、铅、食品、酒精等污染行业会形成集中而强大的反对力量，阻挠那些惠及全民的分散化益处。因此公共卫生总是处于劣势，我们必须逆势而上，不断申明：这对每个人都有微小的好处，却会对少数群体造成重大损失。我们需要安抚这些少数群体，并组织受益者形成合力。

But that has a political corollary, which means basically you're going to have tobacco, lead, food, alcohol, the polluting industries, a very concentrated and powerful opposition to benefits that will be for everyone diffusely. So public health has the odds stacked against it. We're always going to have to fight uphill. We're always going to have to say, Listen, this is good for everyone, a little bit, and bad for a few groups, a lot. And we're going to have to mitigate those few groups and organize the people who benefit from it.

因为预防悖论是个至关重要的概念——那些最能改善健康的措施，我们可能永远无法直观看到其效果。

Because the prevention paradox is a very important concept. The things that will improve health most, we may never see.

没错。这种情况也适用于医生群体，他们会说'我在临床实践中看不到这种效果'，但他们的接诊量可能只有几千人。而通过其他方式已证实了这些预防措施的有效性。这种预防治疗悖论就在于：你无法感知更大的样本基数。现在我想探讨的是，因为当前这种'眼见为实'的思维模式恰恰与之相反。

Right. Well, you know, and it also applies at the physician side because physicians will say, well, I don't see this in my practice, but their practice may be a couple thousand patients. And it's been proven through other means. And so the same prevention treatment paradox is you just don't have a feel for the bigger picture, the bigger denominator. Now one of the things I wanna get to, because this see, believe, create formula is what have the antithesis of that right now.

我们什么都没看到。我们否认一切。如果连第一步或基本方案都没达成，就更谈不上相信、制定计划或采取行动了。那么你对当前这个烂摊子怎么看？你有什么评论吗？

We're not seeing anything. We're denying everything. And then we can't even get to the believe or create a plan or, you know, try to do something about it if you don't even get to the first part or the formula. So what what are you seeing about the mess that we're in right now? What what comments do you have about that?

确实如此，目前最大的风险之一是我们正在削弱识别健康威胁的能力——这些威胁危及生命、生计和家庭。举一个典型例子：由于预算削减、人员裁减以及CDC（疾控中心）遭受重创，公共卫生正遭受双重打击——字面意义上的枪击（一名枪手向CDC园区发射了近500发子弹），以及象征性的大规模预算削减、数千名员工被解雇、半数国家中心关闭。甚至连追踪食源性疾病的FoodNet和PulseNet系统也将停止监测李斯特菌和弯曲杆菌这两种严重传染病。

Well, it's absolutely the case that the the one of the biggest risks here is that we are undermining our ability to see the health threats, threats to our lives, our livelihoods, our families. Take one example from many. Apparently, of budget cuts and staffing cuts and the devastation of the CDC, public health is under assault right now, literal assault, as a gunman opened fire and fired close to 500 rounds into the CDC campus, but also figuratively with massive budget cuts, thousands of staff laid off, half of the national centers closed. And FoodNet, PulseNet, one of the things that tracks foodborne illnesses, is going to stop tracking Listeria and Campylobacter. These are two serious infections.

顺便说一句，这些病菌主要通过生乳等途径传播。CDC现在无力应对，又遇上政府停摆。如果CDC无法追踪疫情，当你在超市随手拿起冷冻豌豆、速食餐或其他商品时，里面可能含有致病细菌。我们正在亲手瓦解自己的防护体系。

They're spread, by the way, by raw milk, among other things. CDC isn't able Now we have government shutdown. If CDC isn't able to track things, you go to the supermarket and pick up whatever it is, a package of frozen peas or a TV dinner or something else. It may have bacteria in it that make you sick. So we are undermining our protections.

我们正对微生物和有毒威胁视而不见。同时还在开倒车——撤销针对PM2.5（每年导致十万美国人死亡）、汞、砷、PFAS等永久性化学物的防护措施，令人震惊的是这些物质污染了美国一半的水源。某些不愿采取公益措施的企业现在掌权了，本质上你的肺部成了它们的排污场——它们可以随心所欲地向你的肺部排放污染物。

We are leaving ourselves blind to the microbial and toxic threats. We're also turning back the clock on protections against PM two point five that already kills one hundred thousand Americans every year, mercury and arsenic and PFAS and other forever chemicals, which astonishing to me contaminate half of the water in America. And they've rolled back the protections there. So what you have here is kind of that that those concentrated costs, those companies that don't want to do things that will benefit everyone, they're in control now. And basically, it's open season on your lungs because they can pollute all they want into your lungs.

这与预防悖论完全相反，形成了一种危害悖论：放任少数利己行业污染环境、销售有毒产品，最终危害将广泛蔓延。但仍有出路，我认为...

And this is the opposite of the prevention paradox, the harm paradox that basically you're allowing a few self interested industries to pollute, to contaminate, to sell toxic things, and the harms will be very widespread. But there is a way forward. Think I hope

目前看来形势相当黯淡，汤姆。

it's looking pretty bleak right now, Tom.

确实如此。我们必须睁大眼睛认清现实。事实是顽固的——即使被否认、压制、滥用或曲解，它们依然是事实。

It is. It is. And I don't think we should be anything other but eyes wide open about this. But facts are stubborn things. And even if they're denied, suppressed, misused, misquoted, they're still facts.

这些现象依然存在。人们渴望健康。当你观察'让美国健康'MAHA运动时，会发现它触及了一个关键问题——人们对医疗体系深感沮丧，这个体系无法提供良好护理，却过度强调某些药物治疗。我认为这造成了混乱。有时我们对某些病症过度治疗，而对其他病症又治疗不足。

And they're still the reality out there. And people want to be healthy. When you look at the Make America Healthy MAHA movement, it's tapping into something very important, that people are so frustrated with our health care system where you can't get good care, with inappropriate overemphasis on some pharmaceutical treatments. I think that gets confused. Sometimes we overtreat some things and undertreat some things.

但存在不容忽视的事实和坚定的人们。我认为我们将越来越多地看到各州、组织和地方不是重建，而是向前推进，构建一个更互联的卫生体系——涵盖医疗保健和公共卫生，这个体系沟通顺畅、优先级明确，能建立联盟与韧性，提供对民众真正重要的成果：更长久的健康寿命，同时摆脱那些问题严重的利益冲突——我们为药物和疫苗支付过高费用，却获得远不足以挽救众多生命的基础护理。

But there are stubborn facts and committed people. And I think what we'll see increasingly is states, organizations, localities building forward, not building back, building forward to a health system, including both health care and public health, that's more connected, that communicates well, that prioritizes well, that creates alliances and resilience, that delivers results that matter to people, longer, healthier lives, that gets away from some of the really problematic conflicts of interest where we're paying way too much for medicines and vaccines and getting far too little of the basic care that can save lots of lives.

是的。你再次提到了我们环境毒素中的可见部分，不仅是空气污染。你谈到PM2.5颗粒物，还有微塑料和纳米塑料。我们知道这些物质正在造成伤害。已有研究涉及血管、大脑等多个方面。

Yeah. Well, you touched on, again, the seeing part of our environmental toxins, not just air pollution. You mentioned the particulate matter 2.5, but also microplastics, nanoplastics. We know they are causing harm. You already have studies in blood vessels, the brain, and whatnot.

生殖健康可能也是问题的一部分。但与'让美国更健康'的运动背道而驰，我们正走向错误方向。甚至否认气候变化及其与另一场流行病的关联，也是问题所在。从很多方面看，我们都在倒退。而你为我们指明了一条合理的前进道路。

Reproductive health as well may be accounting for part of that issue. But instead of this movement to try to have a healthier America, we're going in the wrong direction. And of course, denying even climate change and its intersection with another pandemic, is also, you know, part of the story. So in so many ways, we're we're going backwards. And you have provided us, you know, a way forward, which is sensible.

这很简单。它的可贵之处在于预防知识。重点在于此，而非忽视或否认。

It's pretty simple. You know? That's what's good about it is, you know, the knowledge to prevent. It's all about that. It's not about it's about ignoring or denying.

我们面临的'卡珊德拉诅咒'充斥着大量否认主义，这非常不幸。我欣赏你对未来方向的乐观态度，但我看不到任何进展。比如昨天刚发表一篇关于儿童青少年新冠的重要论文：二次感染会导致长期新冠症状翻倍，伴随多种其他不良症状和后果。而我们现在的新冠疫苗仅限65岁以上人群接种。

I mean, what we have with this Cassandra's curse is a lot of denialism, and this is really unfortunate. I like your optimism about where we can head, but I don't see any of it. Like, for example, yesterday was published an important paper about COVID in children and teens. With a second infection, there was a doubling of long COVID with lots of other symptoms and outcomes that were adverse. And here we are, the COVID vaccines are only for people 65.

我们仍然——

We still-

我是说，埃里克，甚至CDC的免疫实践咨询委员会基本上都被那些没有疫苗专业知识的非科学意识形态者接管了。而我曾监督该委员会长达八年。它本应基于严谨的事实科学，完全透明，所有报告都公开在网上。我认为它在沟通上可以做得更好。但其中一项举措是将65岁以上人群的新冠疫苗接种改为所谓的'共享临床决策'。

Even that, I mean, Eric, even that the Advisory Committee on Immunization Practices at the CDC was basically taken over by unscientific ideologues who don't have expertise in vaccine. And I oversaw that committee for eight years. It used rigorous, fact based science, complete transparency, every presentation on the web. I think it could have communicated better. But one of the things it did is to change vaccination against COVID, even for people over the age of 65, to what's called shared clinical decision making.

这只有在证据平衡且无明确益处时才会采用。这简直荒谬。65岁以上接种疫苗者重症和死亡率显著降低。这是政府在推卸责任。我认为简洁性很重要，希望人们从书中不仅获得希望的信息——虽然此刻我们确实需要——更因为我们已取得巨大进展且能做得更好。

That's only used if we're at equipoise and there is no evidence that it helps. That's nonsense. There's a dramatic reduction in severe illness or death among people who get vaccinated and are 65. So that's an abdication of the government responsibility. Again, I think simplicity is important, and what I hope people get from the book is not just a message of hope, though I know we need that in this time, and it is that because we've made a lot of progress and we can make a lot more.

这同样是一份关于方法的启示：如何取得更多进展，洞察无形使之显现，相信我们能逐步推进。通过一步步建立信心、培养乐观，用优先、简明、有效沟通的举措创造更健康未来，突破那些始终存在的障碍。总会有既得利益集团阻挠公共卫生进步，但数百年来我们一直在前进。埃里克，这方面你比我更了解。

It's also a message of how, how to make more progress, seeing the invisible and making it apparent, believing we can make progress, including making phased progress. So step by step, you can build that confidence and cultivate optimism, and then creating a healthier future with prioritized, simple, well communicated initiatives, solutions that overcome the barriers that are always going to be there. There are always going to be self interested groups that block public health progress. But for hundreds of years, we've been making progress. And really, I mean, you know this so much better than I do, Eric.

如今我们拥有惊人的工具：人类史上最精良的诊断技术、药物和疫苗。某些人工智能工具让工作更高效，令我印象深刻。我们完全有潜力延长健康寿命，预防现今多数心梗中风，避免现代环境中无处不在的有害暴露。

We have amazing tools today. We have the best diagnostics, the best medications, the best vaccines that humanity has ever had. I'm pretty impressed with some of the artificial intelligence tools of making our work better, faster, and we have such potential to live long, healthy lives to prevent most of the heart attacks and strokes that happen today, to avoid the toxic exposures that we're bathed in in our modern environment.

是的，这正好引向我想讨论的最后一个话题。当苏珊·梅内雷斯突然离开CDC前，我们曾就预防（Prevention）达成共识——这方面一直做得不够。现在这个时代，你能够预见未来——比如德国那篇精准预测未来二十年健康事件的《自然》论文，连具体时间都能判定。

Yeah. Well, that gets us to the last topic I wanted to run by you. When I talked to Susan Meneres before she suddenly was no longer at CDC, she and I were in alignment about the P, CDC p for prevention, which, you know, there hasn't been enough of that. And we're at a time right now where if you can see your future you know, as you know, there was a recent nature paper actually from Germany, which predicts your future events and health for the next twenty years remarkably accurately. And not just the events, but when.

正如你刚才提到的，汤姆，现在还有所有这些诊断工具：多基因风险评分、蛋白质器官时钟等数据层。我们已经能识别高风险人群，并掌握预防这些疾病的方法。

And then added to that, as you just mentioned, Tom, there's all these diagnostics. Like, example, you know, it could be a polygenic risk score. It could be your protein organ clocks, all these other layers of data. We can do this now. We can say who's at high risk, and we have we know the ways to prevent these diseases.

在我看来，医学正处在一个被忽视的激动时刻——预防能力的提升本应带来变革。我知道你深有共鸣，因为这始于预见未来。对于未来几年将初级预防（从不患病开始）提升到新高度，你有何见解？

It seems to me that it's a really exciting time in medicine, is being missed because of this enhanced capability for prevention, which I know you're into that, because it starts with seeing, seeing the future. What are your thoughts about taking prevention, primary prevention, never getting the disease in the first place, to a new level in the years ahead?

我认为，社会层面和个人层面都有一些措施可以显著降低我们的主要死因——心脏病发作和中风的发生率。比如对烟草、酒精、含糖饮料和垃圾食品征收健康税；实施烟草监管，包括FDA有权进行的烟草去尼古丁化；酒精预防措施，如加强警示标识、降低酒精浓度、限制销售时间和地点；以及在包装正面添加警示标签。

Well, I think there are probably a handful of things that we could do as society and a handful of things that we can do as individuals that would really bring our leading cause of death, heart attacks and strokes, down to much, much lower levels. Health taxes on tobacco, alcohol, sugary drinks, junk food. Tobacco regulation, including denicotinizing tobacco, which the FDA has the authority to do. Alcohol prevention, including strong warnings, reductions of alcohol density, and sales of alcohol hours and places of sale. Front of pack warning labels.

智利这个国家已经实施了这些措施，在改善营养方面取得了巨大成功。包括减少钠摄入、推广富钾低钠盐、管控PM2.5、实施枪支安全法规。枪支暴力是美国人平均寿命低于欧洲人的主要原因之一。在医疗体系方面，我们需要改变支付方式，让医疗机构通过保持民众健康来获得更多收益。

Chile, the country of Chile, did this, and it's a hugely successful way of improving nutrition. Reducing sodium and promoting potassium enriched low sodium salts. Regulating PM 2.5, having gun safety regulations. Gun violence is one of the major reasons Americans live shorter lives on average than Europeans. In medical care, change the way we pay so the healthcare system will make more money if they keep people healthy.

现行医疗体系反而从民众患病中获利。在公共卫生领域，我们需要建立更好的数据系统、采取更快速行动、更贴近现实情况、确保充足资金支持，并回归科学独立性。

Right now, the health care system makes more money if people get sick. And in public health, we need better data systems, faster action, closer alignment with realities, enough funding, and getting back to scientific independence.

我赞同你的观点，但你提到的都是群体层面的措施。当实施这些政策时——比如疫苗强制接种就是个例子——我们看到很多人会产生抵触情绪，他们会说'我不想被征收垃圾食品税'。

I'm with you, but all the things you outlined were at the population level. And what we saw when that is being done, like, for example, vaccine mandates, as an example. There are many others. They get people bristled that, oh, I don't want to do this. I don't want to have my junk food tax.

我的生活离不开垃圾食品。谁知道会有什么反弹呢？不过回到个人层面——因为你的书涉及了两个层面——是的，在个人层面，如果人们想了解风险并专注于如何预防疾病，我们过去确实缺乏这样的认知途径。

I live on junk food. Who knows what the comeback could be? However, at the individual level, again, because your book gets into both levels. Yes. And at the individual level, there's so much if people want to know the risk and they zoom in on how they can prevent that condition, That is something that we we didn't have that.

过去人们常说'卡珊德拉诅咒'：我不想检测APOE4基因状态，因为不想知道自己是否有阿尔茨海默病高风险。但现在我们已经到了可以通过干预预防阿尔茨海默病的时代。事实上，你知道的，未来几周将有几项关于GLP-1类药物（如Ozempic）的临床试验结果即将公布。

It used to be the Cassandra curse was, I don't wanna know APOE four status because I don't wanna know if I'm a high risk for Alzheimer's. Now we're at a time where we should be able to prevent Alzheimer's if we go after this. In fact, as you know, there's a couple of trials that are gonna be out soon in the weeks ahead that are testing GLP-one drug, Ozempic.

是的。

Yeah.

两项针对阿尔茨海默病的大型试验——EVOQUE和EVOQUE Plus。这些是轻度阿尔茨海默病患者。他们一开始甚至没有预防阿尔茨海默病。如果那成真了，天啊。但我认为我们都对预防感到兴奋，不过我想在个人层面上和你确认清楚。

Two big trials, EVOQUE and EVOQUE Plus against Alzheimer's. These are people with mild Alzheimer's. They're not even preventing Alzheimer's in the first place. If that hits, oh my gosh. But I think we share the prevention's excitement, but I want to nail you down on at the personal level.

是的，这也是我想谈的。关于强制令的一点看法：对个人实施强制是一回事，监管公司则是另一回事。

Yeah. That's what I want to get to also. Just one point about mandates. It's one thing to mandate individuals. It's another to regulate companies.

我认为对个人的强制令应该极其罕见。比如我不认为在新冠期间我们应该强制接种疫苗。但强制或监管公司以避免伤害民众，这不是剥夺个人自由，而是增进个人自由。明白吗？

And I think mandates on individuals should be awfully rare. I don't think we should have been mandating vaccination, for example, during COVID. But mandating or regulating companies so they don't hurt people, that's not about taking away personal liberty. That's about increasing personal liberty. Okay.

第六点。我认为真正影响个人健康的六件事：将血压控制在120以下。

Six. There's six things that I think really make a difference for personal health. Get your blood pressure under 120.

对。

Right.

保持血脂健康，这可能需要将LDL控制在70以下，ApoB也控制在70以下。

Get your lipids healthy, and that's probably your LDL under 70 and your ApoB under 70.

没错，这样你的LPA也会降低。

Yeah. And so it'll get your LPA low too.

是的，等我们想好怎么处理那件事。

Yep. Once we figure out what to do with that.

你已经有一种药可以治那个了。

You got a drug coming for that one.

没错。体育锻炼是最接近灵丹妙药的存在，每周至少四天，每天至少三十分钟适度快节奏的运动。要知道，它对健康的益处胜过任何药片，对各方面都有好处。它能改善情绪，缓解抑郁。

Yeah. Physical activity, the closest thing to a wonder drug, at least four days a week, at least thirty minutes per day of moderately brisk activity. You know, it'll do more for your health than any pill, and it's just great for everything. It's great for mood. It's great for depression.

它对糖尿病、肥胖症、癌症和血压都有益——即使你体重一斤都没减。睡眠方面，正如你在Substack上强调的Eric，至少要保证七到九小时的睡眠。

It's great for diabetes. It's great for obesity. It's great for cancer. It's great for blood pressure, even if you don't lose one ounce of weight. Sleep, as you've emphasized in your sub stack, Eric, at least seven hours, seven to nine hours of sleep.

说来容易做来难，但确实有些可行措施。感谢你提到新型助眠药物，部分人群可能会受益。营养方面确实复杂，但有些原则非常明确：多摄入钾、少钠，多膳食纤维、少加工肉，少糖。

Easier said than done, but there are things that can be done. Thank you for pointing out the new class of sleep meds that some people may benefit from. Nutrition. Nutrition is really complicated, but there's some things that are really clear. More potassium, less sodium, more fiber, less processed meat, less sugar.

再深入就非常复杂了，但从流行病学技术严谨性角度，我确信这些措施会产生重大影响。最后第六点是远离毒素：烟草、酒精、PM2.5，以及新晋三大危害——纳米颗粒、微塑料和内分泌干扰物。我们尚未完全理解其危害程度，但它们绝非环境中的有益物质。

It gets really complicated past that, but those things from an epidemiologic technical rigor standpoint, I'm really certain will make a really big difference. And then finally, the sixth is avoid toxins, tobacco, alcohol, PM two point five, and the new ones, the big three, nanoparticles, microplastics, and endocrine disruptors. We don't fully understand what harms they're creating and how much, but they are not good things to have in your environment.

确实。而且这些毒素很难根除或减少，因为需要健康政策变革。这要么直接指向企业责任，要么需要政府监管和执法介入。

Yeah. And they're tough to eradicate or diminish because we need health policy changes. They either go right back to the companies and the need for governmental regulation and enforcement.

总之——我想告诉你写完这本书后，我在个人健康习惯上做的两个小改变。我吃了更多的红薯，因为我之前完全不知道它们这么健康又美味。我还买了一台反渗透净水机，这是避免塑料微粒的方法，要知道50%的水里都含有这些物质。

Anyway- I'll tell you two little things I changed in my personal health regime after writing this book. I eat a lot more sweet potatoes because I had no idea they were so healthy and they're delicious. And I bought a reverse osmosis machine for my water because that's a way of avoiding plastics, microplastics, and you know, 50% of our water has stuff in it.

哦，哦，这主意不错。用过滤器或其他技术来减少微塑料摄入，你知道的，它们会直接进入你的配方里。你看不见，但你知道它们就在那里。正如你所说，这是个大问题，我们不能再忽视了。

Oh, oh, that is a good idea. Having filters or whatever technique to to reduce the microplastic exposure, you know, it's it goes right into your formula. See. You can't see it, but you know it's in there. As you say, it's a big deal, and we can't ignore it anymore.

是的。谢谢你，埃里克，感谢你所做的一切。你一直是科学界的杰出声音。你总是站在最前沿，告诉我们即将发生什么、现在什么重要。

Yeah. Thank you, Eric, for what you do. You've been such a great voice of science. You are always at the cutting edge. You're always telling us what's around the corner, what's now, what's important.

我很喜欢你的书《长寿》。令我着迷的是，你从基础科学研究者的角度，而我从流行病学分析师的角度，得出了几乎相同的个人健康配方。

And I loved your book, Longevity. And I was fascinated by that you, from a very basic science science researcher standpoint, and I, from an epidemiologic analyst standpoint, come up with pretty much the same formula for personal health.

嗯。有个问题是你买了哪种反渗透净水机？

Yeah. One of the questions was what reverse osmosis machine did you get?

我不会——我从不接受公司赞助，所以不会透露品牌。但你可以参考《消费者报告》、Wirecutter和其他独立测评，看看哪些产品评价好。

I'm not gonna I've never taken money from a company, so I'm not gonna say what brand I use. But get on to Consumer Reports and Wirecutter and Independent Assessments and see which have a good assessment.

好的。这本书《健康配方》就在这里，我想你会得到好评的。

All right. Well, the book is here, The Formula for Better Health. Think you're in good review.

我想特别说明，这本书的所有收益都将用于支持全球健康项目。这些资金会流向致力于拯救生命的组织和项目，也就是我所领导的机构合作的伙伴。我个人不会从中获取任何利润。

And I do want to say that all proceeds from this book go to programs to support health around the world. They go to organizations and programs that resolve to save lives, the organization I lead work with. I don't get any of the profits of this.

这真是太棒了，尤其是在我们看到美国国际开发署的资金被削减、对外援助被掏空的情况下。汤姆，你做得太出色了。非常感谢你今天参与节目，感谢你在Resolve所做的一切工作，请继续保持。我们会持续关注。

Well, that's fantastic, especially when we've seen the USAID money taken and gutted and everything else of foreign aid. So you're phenomenal, Tom. Thanks so much for joining today and all the work you're doing with Resolve, and keep up the great stuff. We'll be following it. That's

埃里克，同样祝福你。非常感谢。很高兴能与你交谈。

for Same to you, Eric. Thank you so much. Great speaking And with

感谢大家今天的参与。真的——

thanks everybody for joining today. Really-

谢谢大家。

Thank you all.

非常精彩的对话、问题和信息。谢谢。再见。

Terrific conversation and questions and messages. Thanks. Bye bye.