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本文是波士頓大學(xué)桑德羅·加利亞博士分析錯(cuò)綜復(fù)雜的醫(yī)療和公共衛(wèi)生問(wèn)題的系列文章之一。

人們的健康是一種公共產(chǎn)品,。

估計(jì)該說(shuō)法與大多數(shù)讀者與健康的看法并不一致,。畢竟，健康難道不是由行為,、飲食和運(yùn)動(dòng)量決定的嗎,？雖然事實(shí)確實(shí)如此，但從根本上講,，行為不可避免地由周?chē)氖澜鐩Q定,。我來(lái)詳細(xì)解釋下。

公共產(chǎn)品是需要集體投資支持的公共資源,。像圖書(shū)館,、公園,、高速公路、國(guó)家安全之類(lèi),，都屬于公共產(chǎn)品,。全民支持，供全民使用,。這些之所以是公共產(chǎn)品而非個(gè)人商品,，是因?yàn)槿藗冋J(rèn)為相關(guān)產(chǎn)品對(duì)全民福利非常重要，不應(yīng)該完全由私人投資,，也不應(yīng)受市場(chǎng)力量左右,。例如，教育可造福所有人,，可以改善每個(gè)人的生活,。因此，教育作為公共產(chǎn)品得到全民支持,。

健康也屬于同一類(lèi),。每個(gè)人都看重健康，也渴望健康,，不管是為了自己還是為了關(guān)心的人,。不管政治立場(chǎng)如何，我還沒(méi)有發(fā)現(xiàn)不希望孩子盡可能健康的人,。

健康也得到了真金白銀的支持,。每年醫(yī)療保健方面耗資巨大,。然而,，正如我經(jīng)常寫(xiě)到，絕大多數(shù)投資都用于開(kāi)發(fā)藥物和醫(yī)療技術(shù),，并未用于推動(dòng)核心的社會(huì),、經(jīng)濟(jì)和環(huán)境力量，影響周?chē)氖澜鐝亩绊懭藗兊男袨?。如果相關(guān)努力缺失,，就很難真正實(shí)現(xiàn)全民健康。

當(dāng)然,，人們很容易想到,，健康不依賴集體投資，個(gè)體同樣可以為健康支出,。人們可能相信,，如果能夠請(qǐng)最好的醫(yī)生、買(mǎi)最好的藥品,，健康就可以得到保障,。

但這真有可能嗎？畢竟，如果沒(méi)有干凈的空氣和水,、沒(méi)有安全的社區(qū),、沒(méi)有公平經(jīng)濟(jì)和提供支持的社區(qū)網(wǎng)絡(luò)，很難保持健康,。以上列出的條件全部都是公共產(chǎn)品,，依賴集體投資才能發(fā)展。健康可以說(shuō)是一種典型的公共產(chǎn)品,，因?yàn)樗蕾囈幌盗杏晒餐顿Y的組合產(chǎn)品,。

可惜的是，過(guò)去30年里美國(guó)的公共產(chǎn)品投資不斷衰退,。投資不力的根源在于政治理念,，主要由里根政府時(shí)期的思路主導(dǎo)，將個(gè)人自由置于其他自由之上,，并將任何形式的公共投資視為對(duì)自由的潛在威脅,。

然而，該理念的失誤在于,，世上有不同類(lèi)型的自由,。有“主動(dòng)的自由”，例如言論自由,、機(jī)會(huì)自由,，自由選擇想做的事以及做的時(shí)間，符合當(dāng)前政治對(duì)自由的定義,。但還有另一種自由,，即“遠(yuǎn)離的自由”，指遠(yuǎn)離傷害和疾病,、遠(yuǎn)離無(wú)知,、遠(yuǎn)離可預(yù)防的損害健康的危險(xiǎn)。

維護(hù)“遠(yuǎn)離的自由”就要投資公共產(chǎn)品,。雖然過(guò)去35年里政治可能忽視了這一目標(biāo),，但以前曾采取能引起共鳴的愿景努力實(shí)現(xiàn)。該愿景是雄心勃勃的羅斯福新政核心,，在通過(guò)政府大規(guī)模干預(yù)改善美國(guó)社會(huì)各階層的生活,。

新政期間，富蘭克林·羅斯?？偨y(tǒng)曾經(jīng)表示,，所有人都有四種基本自由：言論自由,、宗教信仰自由,、免于匱乏的自由和免于恐懼的自由,。他倡導(dǎo)的理念在“主動(dòng)的自由”和“遠(yuǎn)離的自由”之間取得了平衡，然而當(dāng)前人們過(guò)于關(guān)注主動(dòng)的自由,，卻失去平衡,，忽視了遠(yuǎn)離的自由。

同時(shí),，如果沒(méi)有集體投資創(chuàng)造條件推動(dòng)自由,，人們既不可能免于匱乏，也不可能免于恐懼,。為了最大限度實(shí)現(xiàn)自由,，就要恢復(fù)歷史上國(guó)家對(duì)公共產(chǎn)品的尊重。

盡管政治上面臨挑戰(zhàn),，但公共產(chǎn)品在美國(guó)仍然可行,，因?yàn)閷?duì)人們的安全和健康來(lái)說(shuō)，它非常必要,。以道路安全為例,。世紀(jì)之交，美國(guó)人開(kāi)車(chē)的人數(shù)是1925年的6倍,，路上的機(jī)動(dòng)車(chē)數(shù)增加了11倍,。然而在1925年至1997年期間，每年機(jī)動(dòng)車(chē)導(dǎo)致死亡率下降了90%,。為什么,？是因?yàn)槊绹?guó)人駕駛技術(shù)提升了嗎？

不完全如此,。事實(shí)上,，死亡率下降是因?yàn)槲覀冞x擇將道路安全作為公共產(chǎn)品進(jìn)行投資。通過(guò)法律,，設(shè)立機(jī)構(gòu),，向人們提供培訓(xùn),，建立健全的規(guī)則和安全流程以確保道路安全,。確實(shí)很奏效。更重要的是,，該體系一直在運(yùn)轉(zhuǎn),，基本上沒(méi)有政治干預(yù)。很少有政客拿道路安全法規(guī)說(shuō)事,，攻擊政府權(quán)力過(guò)度擴(kuò)張,。原因就在于道路安全法與人們的健康息息相關(guān)。

在道路上保護(hù)人們的法律法規(guī)與其他保護(hù)健康的法律差別能有多大,？當(dāng)缺乏教育縮短壽命,，當(dāng)污濁的空氣導(dǎo)致疾病和死亡,，當(dāng)經(jīng)濟(jì)不公平擴(kuò)大貧富之間健康差距，我們有充分的理由像對(duì)待危險(xiǎn)道路一樣,，通過(guò)投資公共產(chǎn)品來(lái)解決影響健康的問(wèn)題,。

必須理清公共物品和健康之間的聯(lián)系，要達(dá)到對(duì)安全帶和安全關(guān)系的認(rèn)識(shí)水平,。此舉對(duì)考慮全民醫(yī)療保健,，對(duì)基礎(chǔ)設(shè)施、住房,、教育,、交通和環(huán)境的投資選擇影響深遠(yuǎn)。我們也從中明白,，如果真想實(shí)現(xiàn)健康,，一定要意識(shí)到公共產(chǎn)品是集體健康的關(guān)鍵。（財(cái)富中文網(wǎng)）

桑德羅·加利亞,，醫(yī)學(xué)博士,，波士頓大學(xué)公共衛(wèi)生學(xué)院教授和院長(zhǎng)。他的最新著作是《談起健康應(yīng)該討論什么》,。

譯者：馮豐

審校：夏林

This piece is part of an ongoing series by Boston University’s Dr. Sandro Galea on the intricacies of health care and public health.

Our health is a public good.

I suspect that statement runs at odds with how most readers think about their health. Is our health not, after all, determined by what we do, what we eat, and how much we exercise? While that is indeed the case, fundamentally, our behaviors are shaped by the world around us, inescapably so. Let me explain.

Public goods are common resources that need to be supported by collective investment. Libraries, parks, highways, national security—these are all examples of public goods, supported by all and accessible to all. The reason they are public goods, rather than individual commodities, is we have decided that they are so fundamental to our wellbeing that they should not be entirely the province of private investment or market forces. Education, for example, benefits everyone—there is no one whose life it does not stand to improve. It is therefore supported by everyone, as a public good.

Health falls in the same category. It is something everyone values—we all desire health, both for ourselves and for those we care about. I have yet to meet anyone, regardless of their political affiliation, who does not want their children to be as healthy as possible.

And we back up this with our money. We spend vast sums on health care each year. Yet, as I have often written, the overwhelming majority of this investment goes to developing drugs and medical technologies, rather than to the core social, economic, and environmental forces that shape health—the world around us that shapes our behavior, and without which our health cannot possibly flourish.

It is, of course, tempting to think that health does not depend on our collective investment, that we can, as individuals, simply buy health for ourselves. We may believe that, if we can just secure access to the best doctors and medicines, our health will be assured.

But is this really possible? After all, we cannot be healthy without clean air and water, safe neighborhoods, a fair economy, and supportive community networks. All of these conditions are themselves public goods, relying on our collective buy-in to thrive. Health is arguably the quintessential public good, depending as it does on a range of component goods, all of which are shaped by common investment.

Unfortunately, over the last 30 years, we in the US have allowed this investment to lapse. The roots of this disinvestment lie in a political philosophy, dominant since roughly the Reagan administration, that prioritizes individual freedom above practically all else, and sees any form of public investment as a potential threat to liberty.

What this philosophy misses, however, is that there are different kinds of freedom. There is “freedom to,” i. e. freedom to speak, to assemble, to do what we wish, when we wish. This form of freedom fits with how our current politics often defines the word. But there is another kind of freedom: “freedom from.” “Freedom from” means freedom from injury and disease, from ignorance, from the preventable hazards that undermine health.

Upholding “freedom from” means investing in public goods. While our politics may have neglected this goal over the last 35 years, our politics once embraced it with a vision that still resonates. This vision was at the heart of the New Deal, an ambitious suite of policies aimed at improving American life at all levels of society, through large-scale government effort.

Around the time of the New Deal, President Franklin Roosevelt said that all people are entitled to four basic freedoms: freedom of speech, freedom of worship, freedom from want, and freedom from fear. His freedoms strike a balance between “freedom to” and “freedom from,” a balance we have lost in our overwhelming focus on the former at the expense of the latter.

At the same time, neither freedom from want nor freedom from fear are possible without some measure of collective investment in creating the conditions for these freedoms to flourish. To maximize freedom, then, we must revive the country’s historic respect for public goods.

Despite political challenges, public goods remain viable in the US precisely because they are necessary for our safety and health. Take road safety. At the turn of the last century, there were six times as many Americans driving as there were in 1925, with an 11-fold increase in the number of motor vehicles on the road. Yet, between 1925 and 1997, the annual motor vehicle death rate fell by 90 percent. Why? Did Americans simply become better drivers?

Not quite. In fact, the death rate fell because we chose to invest in road safety as a public good. We passed laws, created agencies, and educated people, with the goal of creating a robust network of rules and safety procedures to keep our roads safe. And it worked. What is more, it keeps working, largely free of political meddling. It would be difficult to find the politician who attacks road safety as an example of government overreach. This is because road safety laws are so clearly tied to our health.

Are the laws that protect us on the road really so different from the laws that keep us healthy in other areas? When lack of education shortens lives, when dirty air causes disease and death, when economic unfairness widens health gaps between the wealthy and those with less, there is no reason why we should not treat these problems the same way we treat dangerous roads, by tackling them through investment in public goods.

We must make the link between public goods and health as clear as the link between seatbelts and safety. This has profound implications for our thinking about guaranteeing universal access to healthcare, about how we feel about selective investments in infrastructure, in housing, in education, in transportation, in the environment. And it teaches us that if we truly want to be healthy, we have no choice but to embrace public goods as the key to our collective health.

Sandro Galea, MD, DrPH, is Professor and Dean at the Boston University School of Public Health. His latest book is, Well: What we need to talk about when we talk about health.