Global Citizen, Global Nursing: Reshaping Nursing for the Future Needs of Citizens

全球公民，全球护理：为公民未来的需求重塑护理

– Keynote Address at the International Council of Nurses Conference

——在国际护士会的主旨讲话

Dr Margaret Chan, Director-General of the World Health Organization

世界卫生组织总干事 陈冯富珍博士

Seoul, Republic of Korea

韩国 首尔

20 June 2015

2015年6月20日

Excellencies, members and executives of the International Council of Nurses, ladies and gentlemen,

诸位阁下、国际护士会成员和高管、女士们、先生们：

It is said that a person who saves a life is a hero. A person who saves hundreds of lives is obviously a nurse.

人们说，挽救一个人生命的人是英雄。挽救成百上千人生命的人显然是护士。

That person is likely to be overworked, underpaid, and vastly under-appreciated, especially at the policy-making level. Yet that person is saving lives, all the same.

这样一个人往往工作时间过长、获得的报酬过低，而且人们通常认识不到其工作的重要性，特别是决策层。但这样一个人仍然是在挽救生命。

Through the auspices of a unifying federation like ICN, millions of nurses around the world speak with a single compelling voice. You are united by a shared vision, and guided by an international code of ethics that has been in place since 1953.

通过国际护士会这一统一组织，全世界数以百万计的护士能够以同一个有说服力的声音说话。你们团结在共同愿景下，并共同遵循1953年确定的国际伦理准则。

ICN has a much longer history than WHO, but has been in official relations with this Organization since 1948, when WHO was founded.

国际护士会比世卫组织的历史要长得多，但自1948年本组织建立以来你们就与本组织建立了正式关系。

We have been close allies in the best of times, like during the health for all movement and the expansion of childhood immunization, but also in the worst of times, including the darkest years of the AIDS epidemic and during countless emergencies and humanitarian disasters.

在最好的时代，我们是密切盟友，比如在人人享有卫生保健运动和扩大儿童免疫工作期间；在最坏的时代，我们也是密切盟友，包括在艾滋病流行的最黑暗年代以及无数次突发事件和人道主义灾难期间。

I thank ICN and its members for their passionate commitment to the right to health, and to the provision of patient-centred, family-centred, and evidence-based primary health care. I appreciate the recent endorsement of universal health coverage as a route to achieving better health outcomes for all people.

我感谢国际护士会及其成员满怀热情地致力于健康权、致力于提供以患者为本、以家庭为中心的循证初级卫生保健。我赞赏你们最近支持通过全民健康覆盖使所有人获得更好的健康结果。

The documentation prepared to commemorate this year’s International Nurses Day includes a number of insightful observations. Let me mention just one. “The international community has given too little attention to investments in health services in general and to the health workforce in particular.”

为纪念今年的国际护士节准备的文件内容包括一些很有见地的观点。在此，我谨举一个例子。“对于在整体卫生服务方面进行投资以及更具体而言对卫生人力进行投资，国际社会关注得太少。”

I could not agree more.

对这种说法，我再同意不过。

Prior to the outbreak of Ebola virus disease in West Africa, Guinea, Liberia, and Sierra Leone had only one to two physicians available per 100,000 population. WHO does not have estimates for the number of nurses working in any of these countries. But we do know how many nurses were infected, and how many died.

西非埃博拉病毒病疫情暴发前，几内亚、利比里亚和塞拉利昂平均每10万人只有一到两位医生。世卫组织没有这些国家有多少护士的估计数字。但我们确实知道有多少护士被感染，又有多少死亡。

Last month, WHO issued its first report on Ebola infections in health care workers, including doctors and nurses, but also laboratory staff, ambulance drivers, burial teams, cleaners, and community-based workers. More than 800 healthcare workers have been infected and more than 500 of them died.

上个月，世卫组织发表了有关医务工作者感染埃博拉病毒情况的报告，其中包含医生和护士，也包括实验室工作人员、救护车司机、埋葬团队、清洁工和社区工作人员。总共有八百多名医务工作者感染，其中五百余人死亡。

The report contains a startling statistic. Well over half of all those infected with Ebola were employed as nurses. Two-thirds of them died.

报告包括一个令人震惊的统计数据。半数以上被感染医务人员是护士，其中三分之二死亡。

We also know that many of these nurses were not paid their salaries or promised hazard pay, sometime for months. Early on in the outbreak, when not enough personal protective equipment was available, nurses used plastic trash bags to fashion aprons and protect their hands and feet.

我们还知道，这些护士中的许多人没有拿到工资或是许诺的危害岗位津贴，有时拿不到报酬的时间长达数月。疫情初期，个体防护装备不够用，护士们就用塑料垃圾袋围裹身体、保护手脚。

Yet despite no pay and no protection, they kept on working, kept on managing patients, putting their own lives at risk.

但是，虽然没有报酬也没有保护，他们还是冒着生命危险继续工作，继续管理病人。

We must praise their courage and dedication. I doubt that any other statistics portray so dramatically the role of the nursing profession in providing front-line care. I can think of no other recent outbreak that portrays so dramatically the consequences of failing to invest in health services and the health workforce for so many decades.

我们必须赞扬他们的勇气和奉献。我怀疑，是否有任何其它统计数字能够如此引人注目地展示一线护士所发挥的作用。我也想不出其它任何一次最近的疫情能够如此引人注目地展示数十年来未能充分投资于卫生服务和卫生人力所产生的后果。#p#副标题#e#

Ladies and gentlemen,

女士们、先生们，

We are global citizens in a world that has changed dramatically since the start of this century, when the Millennium Development Goals were put forward as an overarching framework for international cooperation.

本世纪初，千年发展目标成为国际合作的总框架。自那以来，全世界已经发生巨大变化。而我们是这个世界上的全球公民。

These changes reveal the consequences of living in a world of radically increased interdependence. National affairs are intertwined as never before by the international systems that govern economies, financial markets, business relations, and trade.

这些变化揭示出生活在日益相互依存世界的后果。经济、金融市场、商业关系和贸易方面的国际制度以前所未有的方式将国家事务交织在一起。

Given the phenomenal increases in the volume and speed of international travel, there is no such thing as a local outbreak anymore. The definition of sovereign national autonomy no longer holds true.

考虑到国际旅行的数量和速度大大增加，这世界上再也不存在本地疫情。传统的主权国家自主权定义也不再适用。

Drug-resistant bacteria easily cross borders. Pollution is trans-national. Climate change is universal. The advertising of unhealthy products is beamed across borders by satellite. Social media propagate rumours like they were facts, clouding medical advice and sometimes undermining policies, like those for childhood immunization.

耐药细菌可以轻易跨越边境。污染不分国界。气候变化普遍影响所有人。不健康产品的广告通过卫星广播到不同国家。社交媒体把谣言当做事实传播，给医疗建议蒙上阴云，有时还会削弱政策，例如有关儿童期免疫的政策。

The distinctions between policy spheres have likewise become blurred. What looks like a good policy for one sector of government can be disastrous for another.

各个政策领域之间的区分也变得模糊。某个政府部门的好政策可能给另外一个领域造成灾难性影响。

Biofuels can reduce the environmental damage caused by reliance on fossil fuels, but they can also endanger food security for millions. Trade agreements can open markets, but they can also shut down local livelihoods when heavily subsidized imports flood in.

生物燃料可以减少依赖化石燃料造成的环境破坏，但也会威胁到数百万人的粮食安全。贸易协议可以打开市场大门，但当获得大量补贴的进口产品涌入，当地人也会发现自己生计维艰。

All around the world, health is being shaped by the same powerful forces, like population ageing, rapid urbanization, and the globalized marketing of unhealthy products.

在全世界，健康都被同样的巨大力量所塑造，例如人口老龄化、快速城市化以及不健康产品的全球化营销。

These universal trends have given the world a number of “firsts”.

这些普遍趋势给世界许多“第一次”。

For the first time in history, the population of people aged 60 years and older outnumbers the population of children under the age of five. In other words, being in the older age group has become the “new normal” in the world’s demographic profile.

历史上第一次，60岁及以上人口数量超过了5岁以下儿童数量。换言之，全世界人口构成的“新常态”就是老龄人口增多。

The implications of this shift, in terms of the demands and costs of health care, are immense. The health workforce is also getting old.

这种转变对于卫生保健需求和费用的影响是巨大的。卫生人力队伍也在变老。

For the first time in history, more than half of humanity lives in an urban setting. Living in a city brings many benefits, like more opportunities for employment, improved food security, educational and cultural advantages, and better access to better health care.

历史上第一次，半数以上人类生活在城市。生活在城市有许多好处，例如更多就业机会、粮食安全更有保障、教育和文化优势以及更有机会获得更好的卫生保健服务。

But not for everyone. WHO estimates that nearly a billion people live in urban slums, shantytowns, on sidewalks, under bridges, or along the railroad tracks. As this year’s State of the World’s Mothers, issued by Save the Children, shows, one of the worst places in the world to be a mother is in an urban slum.

但并非对所有人都是如此。根据世卫组织估计，全世界近10亿人生活在城市贫民窟和棚户区或者是城市便道、桥下或铁道旁。根据救助儿童会今年发布的《世界母亲状况报告》，全世界最糟糕的做母亲的地点就是城市贫民窟。

For the first time in history, chronic noncommunicable diseases have overtaken infectious diseases as the leading cause of mortality worldwide. The burden of these diseases, long associated with affluent societies, has changed places.

历史上第一次，慢性非传染性疾病超过传染病成为全世界造成死亡的首要原因。这些疾病负担长期以来都和富裕社会密切相关，现在则改变了发生地点。

Today, 80% of premature mortality caused by heart disease, cancer, diabetes, and chronic lung disease is concentrated in low- and middle-income countries, which have the least capacity to cope.

今天，80%的心脏病、癌症和慢性肺病导致的过早死亡发生在应对能力最差的低收入和中等收入国家。

Most health systems in the developing world were built to manage brief episodes of acute infections, in which the patient either survives or dies. These systems are ill-prepared to manage diseases requiring long-term if not life-long care.

大部分发展中国家的卫生系统旨在管理急性感染的简短发作，患者要么活下来要么死去。这些系统没有做好管理需要长期乃至终生护理的疾病的准备。

For NCDs, all agree that prevention must be the cornerstone of the global response. Yet prevention is problematic, as the root causes of these diseases lie in non-health sectors.

对于非传染性疾病，所有人都同意，必须以预防作为全球应对工作的基石。但是，预防也面临诸多问题，因为这些疾病的根源在卫生部门以外。

Many of the risk factors for NCDs are amplified by the products and practices of corporations that are powerful economic operators, namely the tobacco, food, beverage, and alcohol industries. Market power readily translates into political power.

非传染性疾病的许多危险因素被身为强大经济运营者的烟草、食品、饮料和酒精业公司的产品和做法放大了。市场力量轻而易举地变成了政治力量。

These corporations seldom interfered with efforts to reach the health-related Millennium Development Goals. No PR firms were hired to portray the delivery of medicines for HIV and TB as interference with personal liberties by the Nanny State, with WHO depicted as the Mother Superior of all Nannies.

这些公司很少为实现卫生相关千年发展目标做出干预努力。并没有公关公司受雇于人，说提供抗艾滋病毒和结核病药物是保姆式国家干扰个人自由，或者世卫组织是所有嬷嬷背后的女修道院院长。

No lawsuits were filed to stop countries from reducing the risks for child mortality. No research was funded by industry to cast doubt on the causes of maternal mortality. Mosquitoes do not have front groups, and mosquitoes do not have lobbies.

没有人提起诉讼阻止各国减少儿童死亡风险。没有企业赞助质疑孕产妇死亡原因的研究。蚊子没有幌子公司，也不进行游说。

But the industries that contribute to the rise of NCDs do. When public health policies cross purposes with vested economic interests, we will face opposition, well-orchestrated opposition, and very well-funded opposition.

但是，助长非传染性疾病增加的企业却这样做了。当公共卫生政策与既得经济利益相冲突，我们将会遭到反对，而且是精心策划而且资金雄厚的反对。

Taken together, these trends give us yet another “first” that calls into question the very way the world defines human progress.

这些趋势也是“第一次”出现，并使全世界对人类进步的定义成为问题。

Beginning in the 19th century, improvements in hygiene and living conditions were followed by vast improvements in health status and life-expectancy. These environmental improvements aided the control of infectious diseases, totally vanquishing many major killers from modern societies.

从19世纪开始，卫生和生活条件的改善使人类健康状况大为改善、预期寿命大为延长。这些环境上的改善有助于控制传染病，使诸多主要死因从现代社会消失。

Today, the tables are turned. Instead of diseases vanishing as living conditions improve, socioeconomic progress is actually creating the conditions that favour the rise of NCDs. Economic growth, modernization, and urbanization have opened wide the entry point for the spread of unhealthy lifestyles.

今天，形势发生了一百八十度大转弯。从生活条件改善使疾病消失变成社会经济进步创造了助长非传染性疾病增加的条件。经济增长、现代化和城市化为不健康生活方式的蔓延大开其门。

This is a unique time in history where economic progress is actually increasing threats to health instead of reducing them.

这是历史上的独特时刻：经济进步没有减少而是在增加对健康的威胁。

In recent decades, China and India have lifted millions of their people out of poverty. This is one of the great achievements of economic development. But it has a clear down-side as well.

最近几十年，中国和印度有数千万人摆脱贫困。这是经济发展的伟大成就之一，但它也有明显的负面效应。

Two years ago, Chinese scientists published the results of a large national survey of diabetes prevalence. The authors estimated that China now has 114 million adults living with diabetes, representing a prevalence in the adult Chinese population of nearly 12%.

两年前，中国科学家发表全国糖尿病流行率大规模调查结果。据作者估计，中国现在有1.14亿成年人患糖尿病，占成人人口近12%。

Less than a third of those surveyed were aware of their condition and only a quarter reported receiving treatment.

只有不到三分之一被调查者了解自己的状况，只有四分之一在接受治疗。

Think about what this debilitating disease, with all its costly complications, means in the world’s second largest economy.

想想这种令人虚弱的疾病及其治疗费用昂贵的并发症对世界第二大经济体意味着什么。

Will the rising incidence and costs of NCDs devour the benefits of economic gain? The demography of poverty has also shifted. Today, more than 70% of the poor live in middle-income countries.

非传染性疾病患病率和费用上升是否会吞噬经济发展的好处？贫困的人口构成也发生了变化。现在，70%以上贫困人口生活在中等收入国家。

If the economy is going well, what pressure will be placed on governments to take care of the poor? The world does not need any more rich countries full of poor people.

如果经济发展良好，政府在照顾穷人方面会面临哪些压力？我们不需要更多到处都是穷人的富国。

There is a final global trend that shapes the challenges ahead as health professionals, and most especially nurses, transition to the post-2015 development era.

随着卫生工作者特别是护士步入2015年以后的发展时代，还有一个全球趋势影响着未来的挑战。

This is the world’s growing inequalities.

这就是全世界日益增加的不平等。

According to the Organization for Economic Cooperation and Development, or OECD, inequalities, in income levels and opportunities, have reached their most extreme levels seen in more than half a century.

根据经济合作与发展组织的研究，收入水平和机会方面的不平等已经达到半个多世纪以来最极端的程度。

Put another way, the Swiss bank, Credit Suisse, estimated last year that the combined wealth of the world’s richest 85 people equals the combined wealth of the world’s poorest 3.5 billion people.

此外，瑞士信贷集团去年估计，全世界最富有85人的财富加起来相当于全世界最贫穷35亿人的财富之和。

A world that is so badly out of balance is neither stable nor secure.

如此失衡的世界既不稳定也不安全。

I recall the statement from your ethical code: “The nurse advocates for equity and social justice in resource allocation, access to health care and other social and economic services.”

我记得你们的《伦理准则》中有这样一句话：“在资源分配、获取卫生保健及其它社会和经济服务方面，护士推动公平和社会正义。”

Again, I thank ICN for its commitment to universal health coverage. UHC is one of the most powerful social equalizers among all policy options.

我要再次感谢国际护士会致力于全民健康覆盖。这是所有政策方案中实现社会平等最有力的工具之一。#p#副标题#e#

Ladies and gentlemen,

女士们、先生们，

The nursing profession is acutely aware of what these trends mean for health care, the costs, and the added demands on the daily practice of your work. The level of awareness is readily apparent in the agenda for this event.

护理行业已经敏锐地注意到这些趋势对于卫生保健、相关费用以及对你们日程工作的更多要求意味着什么。这种认识也明显反映在本次大会的议程上。

The nursing profession, that so-called “sleeping giant”, is actually wide awake and ready to race ahead in clearly defined strategic directions. You are waiting for the starting gun.

护理行业这个所谓的“沉睡的巨人”其实早已醒来，并准备好朝着明确界定的战略方向全力奔跑。你们正在等待发令枪响。

Even more so, you are waiting for someone to let up on the reins that hold you back, the constraints that keep you from performing with the full set of competencies for which you were educated, trained, and licensed.

甚至，你们正在等待有人来放松束缚着你们的缰绳，使你们摆脱限制，从而发挥出你们通过教育、培训获得并因而拥有从业资格的全部能力。

Some constraints have historical roots, often in legislation. As far back as 1986, experts convened by WHO concluded that national and subnational regulations often prevent nurses from exercising their full knowledge and skills.

一些限制有其历史渊源，往往存在于立法中。早在1986年，世卫组织召集的专家就得出结论：国家和地方法规常使护士无法运用他们的全部知识和技能。

The report set out a strategy for strengthening the contribution of nurses to primary health care based on a reorientation of legislation.

该报告阐述了通过调整立法加强护士对初级卫生保健的贡献的战略。

The impact of that strategy has been disappointing. Much more recently the US Institute of Medicine’s 2010 report on “The future of nursing: leading change, advancing health” reached much the same conclusion.

该战略的影响令人失望。美国医学研究所2010年报告《护理的未来：引领变革、推动健康》得出了基本一样的结论。

Again, that report argued that nurses should be able to practice to the full extent of their education and training.

报告再次指出，应该让护士充分实践他们所受到的教育和培训。

The conclusion is similar to the one made 24 years ago: regulatory and institutional obstacles, including limits on nurses’ scope of practice, should be removed so that health systems can reap the full benefit of their training, skills, and knowledge.

其结论与24年前的结论类似：应消除监管和体制障碍，包括对护士执业范围的限制，使卫生系统能够充分利用他们的培训、技能和知识。

Other constraints are attitudinal, often entrenched in the views and policies of national medical associations. As bluntly stated by the IOM report, physicians are unwilling to embrace policy that expands the supply and roles of nurses.

其它限制则是态度上的，根深蒂固地存在于国家医学协会的观点和政策中。正如美国医学研究所报告所直率指出的那样，医生不愿意接受扩大护士供应和职能的政策。

My own view is this. Given the enormous complexity of health challenges faced as the world transitions to the post-2015 era, no one, including WHO, dares to ignore the full contribution that the nursing profession can make.

我个人的看法是这样的：随着全世界进入2015年以后阶段，鉴于卫生挑战极为复杂，没有人，包括世卫组织，敢忽视护理专业人员所能做出的全部贡献。

If for no other reason, we cannot afford to ignore you.

即使没有其它原因，我们也负担不起忽视你们的后果。

A recent study conducted in the US found that the majority of clinicians have no idea about the costs of the interventions they order or the procedures they perform. In contrast, nurses are trained to work in a context of cost constraints, especially when their job involves procurement of medicines and hospital supplies.

美国最近一项研究发现，大部分临床医生对于自己所要求采取的干预措施或是开展的医学程序的费用一无所知。与此相反，护士接受的培训就包括在费用受限情况下开展工作，特别是在其工作涉及采购药品和医院物资的情况下。

Nurses need to have a much more active role in the policy process, especially in decisions that influence the financing of health services.

护士需要在决策进程中发挥更为积极的作用，特别是对影响卫生服务供资的决定。

For NCDs, we cannot afford to miss opportunities for prevention, for early diagnosis, for counselling aimed at behavioural change, or for community-based approaches that improve health literacy.

面对非传染性疾病，我们负担不起失去预防、早期诊断、提供咨询以促进行为变化或是以社区为基础提高健康意识机会的后果。

As I speak, many health systems are at a critical juncture in planning their health workforces. For several reasons, the supply of primary health care physicians is dwindling, precisely at a time when the need for primary care has never been greater.

目前，许多卫生系统都处于规划卫生人力的关键时刻。由于种种原因，初级卫生保健医生的供应正在萎缩，而初级保健需求却比历史上任何时候都多。

In countries facing a shortage of primary care physicians, one way to fill the gap is to permit nurses with advanced degrees to practice without a doctor’s oversight, order and interpret diagnostic tests, prescribe medicines, and administer treatment. Yet this obvious solution still faces opposition from the medical profession.

在缺乏初级保健医生的国家，填补空白的一个办法是允许具有高级学位的护士在没有医生监督的情况下执业，包括开化验单和解读化验结果、开药以及管理治疗。但是，这一明显的解决方案仍面临来自医生的反对意见。

Physicians who continue to believe that expanding the scope of nursing practice will have an adverse effect on the quality of patient care have not looked at the evidence. Mounting evidence shows that this opposition is more about competition than competence.

仍然认为扩大护士执业范围对患者护理质量有不良影响的医生是没有研究证据。越来越多证据表明，这种反对意见更多是出于竞争而不是能力考虑。

Nor can we afford to ignore other lines of evidence. Hospitals with a higher ratio of nurses to patient have lower mortality rates.

我们也负担不起忽视其它证据的后果。护士与患者比例更高的医院死亡率更低。

Studies underscore the quality of care provided by nurses, including preventing medical errors and medication mistakes, reducing or eliminating infections, shortening hospital stays, and easing the transition of patients from hospital to home.

多项研究显示，护士可以提供高质量护理，包括防止医疗和用药错误、减少或消除感染、缩短住院时间、使患者从医院到家里的过渡更为容易。

Nurses using new technologies to care for patients, including the elderly, in their homes have been shown to reduce the number of hospital readmissions and visits to emergency wards. All of this cuts costs, of course, but it also improves the quality of life for patients.

有证据显示，护士使用新技术在患者（包括老年人）家里提供护理有助于减少重新住院和进入急诊病房的次数。所有这些当然都会降低费用，但也会提高患者的生活质量。

What is needed is a less rigid dichotomy between the autonomy of nurses and doctors, and more collaborative teamwork.

需要减少护士和医生之间僵化的二分法，并进行更多团队合作。

This emphasis is thought to be one reason for the effectiveness of the WHO Surgical Safety Checklist, which gives all members of the team, and most especially nurses, an equal voice in decisions about surgical care.

强调这一点被认为是世卫组织手术安全检查表有实效的原因之一。该检查表使所有团队成员，特别是护士，在有关手术护理的决定中有平等发言权。

Studies conducted in eight countries showed that use of this simple 19-item checklist reduced the rate of deaths and surgical complications by more than one third.

在八个国家进行的研究表明，这一简单的包含19项内容的检查表使死亡和手术并发症率降低了三分之一还多。

Other studies have noted an increased likelihood of staff speaking up when a problem is noticed. In fact, WHO recommends that a nurse be put in charge of running the checklist.

其它研究还注意到，工作人员更愿意在注意到问题时把问题提出来。事实上，世卫组织建议由护士负责根据检查表核对各项内容。

Ladies and gentlemen,

女士们、先生们，

The nursing profession can transform the way health services are organized and how health care is delivered.

护理专业可以改变卫生服务的组织和提供方式。

The sleeping giant is wide awake. With health challenged by so many first-time events, the starting gun has sounded.

沉睡的巨人早已醒来。面对如此之多“第一次”事件带来的挑战，发令枪已经打响。

You know where the health of this world needs you to run, and you are fully competent to move in those directions.

你们知道这个世界的卫生事业需要你们往哪个方向奔跑，而且你们也完全有能力朝那个方向前进。

As I said, no one can afford to ignore your potential to change things for the better.

如我所言，没有人负担得起忽视你们改变形势使之朝好的方向发展的潜力所产生的后果。

More cost-effective and more care-effective services will be the result.

而你们的努力将带来更有成本效益、更见护理效果的服务。

Thank you.

谢谢大家。

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