In the mid-'90s, the CDC and Kaiser Permanente discovered an exposure that dramatically increased the risk for seven out of 10 of the leading causes of death in the United States.

在90年代中期，CDC和Kaiser Permanente發現了一種暴露，它顯著增加了美國十大死因中七種的風險。

In high doses, it affects brain development, the immune system, hormonal systems, and even the way our DNA is read and transcribed.

在高劑量下，它影響大腦發育、免疫系統、荷爾蒙系統，甚至我們DNA的讀取和轉錄方式。

Folks who are exposed in very high doses have triple the lifetime risk of heart disease and lung cancer and a 20-year difference in life expectancy.

暴露在非常高劑量下的人，終生患心臟病和肺癌的風險是三倍，預期壽命相差20年。

And yet, doctors today are not trained in routine screening or treatment.

然而，今天的醫生沒有接受常規篩查或治療的培訓。

Now, the exposure I'm talking about is not a pesticide or a packaging chemical.

現在，我說的暴露不是殺蟲劑或包裝化學品。

Okay. What kind of trauma am I talking about here?

好的。我在這裡說的是什麼樣的創傷？

I'm not talking about failing a test or losing a basketball game.

我不是在說考試不及格或輸掉籃球比賽。

I am talking about threats that are so severe or pervasive that they literally get under our skin and change our physiology: things like abuse or neglect,

我說的是如此嚴重或普遍以至於它們真的深入我們的皮膚並改變我們生理的威脅：比如虐待或忽視，

or growing up with a parent who struggles with mental illness or substance dependence.

或與患有精神疾病或物質依賴的父母一起長大。

Now, for a long time, I viewed these things in the way I was trained to view them, either as a social problem -- refer to social services --

現在，很長一段時間，我以我被訓練的方式看待這些事情，要麼作為社會問題——轉介給社會服務——

or as a mental health problem -- refer to mental health services.

要麼作為心理健康問題——轉介給心理健康服務。

And then something happened to make me rethink my entire approach.

然後發生了一些事情讓我重新思考我的整個方法。

When I finished my residency, I wanted to go someplace where I felt really needed, someplace where I could make a difference.

當我完成住院醫師培訓時，我想去一個我真正需要的地方，一個我可以有所作為的地方。

So I came to work for California Pacific Medical Center, one of the best private hospitals in Northern California, and together, we opened a clinic in Bayview-Hunters Point,

所以我來為California Pacific Medical Center工作，這是北加州最好的私立醫院之一，我們一起在Bayview-Hunters Point開了一家診所，

one of the poorest, most underserved neighborhoods in San Francisco.

這是舊金山最貧窮、服務最不足的社區之一。

Now, prior to that point, there had been only one pediatrician in all of Bayview to serve more than 10,000 children, so we hung a shingle, and we were able to provide top-quality care

現在，在此之前，整個Bayview只有一名兒科醫生為超過10,000名兒童服務，所以我們掛牌開業，我們能夠提供優質護理

regardless of ability to pay.

無論支付能力如何。

It was so cool. We targeted the typical health disparities: access to care, immunization rates, asthma hospitalization rates, and we hit all of our numbers.

這太酷了。我們針對典型的健康差異：獲得護理、免疫接種率、哮喘住院率，我們達到了所有目標。

We felt very proud of ourselves.

我們為自己感到非常自豪。

But then I started noticing a disturbing trend.

但後來我開始注意到一個令人不安的趨勢。

A lot of kids were being referred to me for ADHD, or Attention Deficit Hyperactivity Disorder, but when I actually did a thorough history and physical,

很多孩子被轉介給我診斷ADHD，或注意力缺陷多動障礙，但當我真正做了詳細的病史和體檢時，

what I found was that for most of my patients, I couldn't make a diagnosis of ADHD.

我發現的是，對於我的大多數患者，我無法做出ADHD的診斷。

Most of the kids I was seeing had experienced such severe trauma that it felt like something else was going on.

我看到的大多數孩子都經歷過如此嚴重的創傷，感覺像是發生了別的事情。

Somehow I was missing something important.

不知何故，我錯過了一些重要的東西。

Now, before I did my residency, I did a master's degree in public health, and one of the things that they teach you in public health school

現在，在我做住院醫師之前，我獲得了公共衛生碩士學位，他們在公共衛生學校教你的其中一件事

is that if you're a doctor and you see 100 kids that all drink from the same well, and 98 of them develop diarrhea, you can go ahead and write that prescription

是如果你是一名醫生，你看到100個孩子都從同一口井喝水，其中98個出現腹瀉，你可以繼續開處方

for dose after dose after dose of antibiotics, or you can walk over and say, "What the hell is in this well?" So I began reading everything that I could get my hands on

一劑又一劑又一劑的抗生素，或者你可以走過去說：「這口井裡到底有什麼？」所以我開始閱讀我能拿到的一切

about how exposure to adversity affects the developing brains and bodies of children.

關於暴露於逆境如何影響兒童發育中的大腦和身體。

And then one day, my colleague walked into my office, and he said, "Dr. Burke, have you seen this?" In his hand was a copy of a research study

然後有一天，我的同事走進我的辦公室，他說：「Burke醫生，你看過這個嗎？」他手裡拿著一份研究報告的副本

called the Adverse Childhood Experiences Study.

叫做「不良童年經歷研究」。

That day changed my clinical practice and ultimately my career.

那天改變了我的臨床實踐，最終改變了我的職業生涯。

The Adverse Childhood Experiences Study is something that everybody needs to know about.

不良童年經歷研究是每個人都需要了解的。

It was done by Dr. Vince Felitti at Kaiser and Dr. Bob Anda at the CDC, and together, they asked 17,500 adults about their history of exposure

它是由Kaiser的Dr. Vince Felitti和CDC的Dr. Bob Anda完成的，他們一起詢問了17,500名成年人關於他們暴露的歷史

to what they called "adverse childhood experiences," or ACEs.

他們稱之為「不良童年經歷」，或ACEs。

Those include physical, emotional, or sexual abuse; physical or emotional neglect; parental mental illness, substance dependence, incarceration; parental separation or divorce; or domestic violence.

這些包括身體、情感或性虐待；身體或情感忽視；父母精神疾病、物質依賴、監禁；父母分離或離婚；或家庭暴力。

For every yes, you would get a point on your ACE score.

對於每個「是」，你會在ACE分數上得到一分。

And then what they did was they correlated these ACE scores against health outcomes.

然後他們做的是將這些ACE分數與健康結果相關聯。

What they found was striking.

他們的發現是驚人的。

Two things: Number one, ACEs are incredibly common.

兩件事：第一，ACEs非常普遍。

Sixty-seven percent of the population had at least one ACE, and 12.6 percent, one in eight, had four or more ACEs.

67%的人口至少有一個ACE，12.6%，即八分之一，有四個或更多ACEs。

The second thing that they found was that there was a dose-response relationship between ACEs and health outcomes: the higher your ACE score, the worse your health outcomes.

他們發現的第二件事是ACEs和健康結果之間存在劑量反應關係：你的ACE分數越高，你的健康結果越差。

For a person with an ACE score of four or more, their relative risk of chronic obstructive pulmonary disease was two and a half times that of someone with an ACE score of zero.

對於ACE分數為4或更高的人，他們患慢性阻塞性肺病的相對風險是ACE分數為0的人的2.5倍。

For hepatitis, it was also two and a half times.

對於肝炎，也是2.5倍。

For depression, it was four and a half times.

對於抑鬱症，是4.5倍。

For suicidality, it was 12 times.

對於自殺傾向，是12倍。

A person with an ACE score of seven or more had triple the lifetime risk of lung cancer and three and a half times the risk of ischemic heart disease,

ACE分數為7或更高的人，終生患肺癌的風險是三倍，患缺血性心臟病的風險是3.5倍，

the number one killer in the United States of America.

這是美國的頭號殺手。

Well, of course this makes sense.

當然，這是有道理的。

Some people looked at this data and they said, "Come on.

有些人看著這些數據，他們說：「得了吧。

You have a rough childhood, you're more likely to drink and smoke and do all these things that are going to ruin your health.

你有一個艱難的童年，你更可能喝酒和吸煙，做所有這些會毀掉你健康的事情。

This isn't science. This is just bad behavior." It turns out this is exactly where the science comes in.

這不是科學。這只是不良行為。」結果發現這正是科學的來源。

We now understand better than we ever have before how exposure to early adversity affects the developing brains and bodies of children.

我們現在比以往任何時候都更好地理解暴露於早期逆境如何影響兒童發育中的大腦和身體。

It affects areas like the nucleus accumbens, the pleasure and reward center of the brain that is implicated in substance dependence.

它影響像伏隔核這樣的區域，大腦的愉悅和獎勵中心，這與物質依賴有關。

It inhibits the prefrontal cortex, which is necessary for impulse control and executive function, a critical area for learning.

它抑制前額葉皮質，這是衝動控制和執行功能所必需的，是學習的關鍵區域。

And on MRI scans, we see measurable differences in the amygdala, the brain's fear response center.

在MRI掃描中，我們看到杏仁核（大腦的恐懼反應中心）的可測量差異。

So there are real neurologic reasons why folks exposed to high doses of adversity are more likely to engage in high-risk behavior, and that's important to know.

所以有真正的神經學原因，為什麼暴露於高劑量逆境的人更可能從事高風險行為，這很重要。

But it turns out that even if you don't engage in any high-risk behavior, you're still more likely to develop heart disease or cancer.

但結果發現，即使你不從事任何高風險行為，你仍然更可能患心臟病或癌症。

The reason for this has to do with the hypothalamic–pituitary–adrenal axis, the brain's and body's stress response system that governs our fight-or-flight response.

這樣做的原因與下丘腦-垂體-腎上腺軸有關，這是大腦和身體的壓力反應系統，控制我們的戰鬥或逃跑反應。

How does it work?

它是如何運作的？

Well, imagine you're walking in the forest and you see a bear.

想像你在森林裡走，看到一隻熊。

Immediately, your hypothalamus sends a signal to your pituitary, which sends a signal to your adrenal gland that says, "Release stress hormones! Adrenaline! Cortisol!" And so your heart starts to pound,

立即，你的下丘腦向你的垂體發送信號，垂體向你的腎上腺發送信號說：「釋放壓力荷爾蒙！腎上腺素！皮質醇！」所以你的心臟開始跳動，

Your pupils dilate, your airways open up, and you are ready to either fight that bear or run from the bear.

你的瞳孔擴張，你的氣道打開，你準備好要麼與那隻熊戰鬥，要麼從那隻熊逃跑。

And that is wonderful if you're in a forest and there's a bear.

如果你在森林裡，有一隻熊，這很棒。

But the problem is what happens when the bear comes home every night, and this system is activated over and over and over again, and it goes from being adaptive, or life-saving,

但問題是當熊每晚回家時會發生什麼，這個系統一次又一次又一次地被激活，它從適應性的，或救命的，

to maladaptive, or health-damaging.

變成不適應的，或損害健康的。

Children are especially sensitive to this repeated stress activation, because their brains and bodies are just developing.

兒童對這種重複的壓力激活特別敏感，因為他們的大腦和身體正在發育。

High doses of adversity not only affect brain structure and function, they affect the developing immune system, developing hormonal systems, and even the way our DNA is read and transcribed.

高劑量的逆境不僅影響大腦結構和功能，它們還影響發育中的免疫系統、發育中的荷爾蒙系統，甚至我們DNA的讀取和轉錄方式。

So for me, this information threw my old training out the window, because when we understand the mechanism of a disease, when we know not only which pathways are disrupted, but how,

所以對我來說，這些信息把我舊的培訓扔出了窗外，因為當我們理解疾病的機制時，當我們不僅知道哪些途徑被破壞，而且知道如何被破壞時，

then as doctors, it is our job to use this science for prevention and treatment.

那麼作為醫生，我們的工作是使用這門科學進行預防和治療。

That's what we do.

這就是我們所做的。

So in San Francisco, we created the Center for Youth Wellness to prevent, screen and heal the impacts of ACEs and toxic stress.

所以在舊金山，我們創建了青年健康中心，以預防、篩查和治癒ACEs和毒性壓力的影響。

We started simply with routine screening of every one of our kids at their regular physical, because I know that if my patient has an ACE score of 4,

我們簡單地從在每個孩子的常規體檢中進行常規篩查開始，因為我知道如果我的患者ACE分數為4，

as my patient with zero ACEs.

就像我的ACE分數為0的患者一樣。

I know that when she's in my exam room.

我知道當她在我的檢查室時。

For our patients who do screen positive, we have a multidisciplinary treatment team that works to reduce the dose of adversity and treat symptoms using best practices, including home visits, care coordination,

對於我們確實篩查呈陽性的患者，我們有一個多學科治療團隊，致力於減少逆境劑量並使用最佳實踐治療症狀，包括家訪、護理協調、

mental health care, nutrition, holistic interventions, and yes, medication when necessary.

心理健康護理、營養、整體乾預，是的，必要時使用藥物。

in a way that recognizes that they may need more aggressive treatment, given the changes to their hormonal and immune systems.

以一種認識到他們可能需要更積極治療的方式，考慮到他們荷爾蒙和免疫系統的變化。

So the other thing that happens when you understand this science is that you want to shout it from the rooftops, because this isn't just an issue for kids in Bayview.

所以當你理解這門科學時發生的另一件事是，你想從屋頂上大聲喊出來，因為這不僅僅是Bayview孩子們的問題。

I figured the minute that everybody else heard about this, it would be routine screening, multi-disciplinary treatment teams, and it would be a race to the most effective clinical treatment protocols.

我以為其他人一聽到這個，就會是常規篩查、多學科治療團隊，這將是一場競賽，看誰有最有效的臨床治療方案。

Yeah. That did not happen.

是的。那沒有發生。

And that was a huge learning for me.

這對我來說是一個巨大的學習。

What I had thought of as simply best clinical practice I now understand to be a movement.

我曾經認為只是最佳臨床實踐的東西，我現在理解為一場運動。

In the words of Dr. Robert Block, the former President of the American Academy of Pediatrics, "Adverse childhood experiences are the single greatest unaddressed public health threat

用Dr. Robert Block的話說，他是美國兒科學會的前主席，「不良童年經歷是我們國家今天面臨的單一最大的未解決的公共衛生威脅

facing our nation today." And for a lot of people, that's a terrifying prospect.

面對我們國家今天。」對許多人來說，這是一個可怕的前景。

The scope and scale of the problem seems so large that it feels overwhelming to think about how we might approach it.

問題的範圍和規模似乎如此之大，以至於思考我們如何可能解決它感覺令人不知所措。

But for me, that's actually where the hopes lies, because when we have the right framework, when we recognize this to be a public health crisis,

但對我來說，這實際上是希望所在，因為當我們有正確的框架時，當我們認識到這是一場公共衛生危機時，

then we can begin to use the right tool kit to come up with solutions.

那麼我們可以開始使用正確的工具包來提出解決方案。

From tobacco to lead poisoning to HIV/AIDS, the United States actually has quite a strong track record with addressing public health problems, but replicating those successes with ACEs and toxic stress

從煙草到鉛中毒到HIV/AIDS，美國實際上在解決公共衛生問題方面有相當強的成功記錄，但用ACEs和毒性壓力複製這些成功

is going to take determination and commitment, and when I look at what our nation's response has been so far, I wonder, why haven't we taken this more seriously?

將需要決心和承諾，當我看看我們國家迄今為止的反應時，我想知道，為什麼我們沒有更認真地對待這個問題？

You know, at first I thought that we marginalized the issue because it doesn't apply to us.

你知道，一開始我認為我們邊緣化了這個問題，因為它不適用於我們。

That's an issue for those kids in those neighborhoods.

那是那些社區裡那些孩子的問題。

Which is weird, because the data doesn't bear that out.

這很奇怪，因為數據不支持這一點。

The original ACEs study was done in a population that was 70 percent Caucasian, 70 percent college-educated.

最初的ACEs研究是在70%是白種人、70%受過大學教育的人群中進行的。

But then, the more I talked to folks, I'm beginning to think that maybe I had it completely backwards.

但後來，我與人們交談得越多，我開始認為也許我完全搞反了。

If I were to ask how many people in this room grew up with a family member who suffered from mental illness, I bet a few hands would go up.

如果我問這個房間裡有多少人與患有精神疾病的家庭成員一起長大，我打賭會有幾隻手舉起來。

And then if I were to ask how many folks had a parent who maybe drank too much, or who really believed that if you spare the rod, you spoil the child,

然後如果我問有多少人的父母可能喝得太多，或者真的相信如果你省了棍子，你就會寵壞孩子，

I bet a few more hands would go up.

我打賭會有更多的手舉起來。

Even in this room, this is an issue that touches many of us, and I am beginning to believe that we marginalize the issue because it does apply to us.

即使在這個房間裡，這是一個觸及我們許多人的問題，我開始相信我們邊緣化了這個問題，因為它確實適用於我們。

Maybe it's easier to see in other zip codes because we don't want to look at it.

也許在其他郵政編碼中更容易看到，因為我們不想看它。

We'd rather be sick.

我們寧願生病。

Fortunately, scientific advances and, frankly, economic realities make that option less viable every day.

幸運的是，科學進步，坦率地說，經濟現實使這個選擇每天都變得不那麼可行。

The science is clear: Early adversity dramatically affects health across a lifetime.

科學很清楚：早期逆境在一生中顯著影響健康。

Today, we are beginning to understand how to interrupt the progression from early adversity to disease and early death, and 30 years from now, the child who has a high ACE score

今天，我們開始理解如何中斷從早期逆境到疾病和早逝的進程，30年後，ACE分數高的孩子

and whose behavioral symptoms go unrecognized, whose asthma management is not connected, and who goes on to develop high blood pressure and early heart disease or cancer

其行為症狀未被識別，其哮喘管理未連接，並且繼續發展高血壓和早期心臟病或癌症

will be just as anomalous as a six-month mortality from HIV/AIDS.

將像HIV/AIDS的六個月死亡率一樣異常。

People will look at that situation and say, "What the heck happened there?" This is treatable.

人們會看著那種情況說：「那裡到底發生了什麼？」這是可以治療的。

The single most important thing that we need today is the courage to look this problem in the face and say, this is real and this is all of us.

我們今天最需要的單一最重要的事情是面對這個問題並說，這是真實的，這是我們所有人的勇氣。

I believe that we are the movement.

我相信我們就是這場運動。