That's what spreads HIV."

「人們會做蠢事，

This was a headline in a U.K. newspaper,

愛滋病就這樣傳播開來。」

The Guardian, not that long ago.

這是不久前英國報紙

I'm curious, show of hands, who agrees with it?

《衛報》的頭條標題。

Well, one or two brave souls.

我很好奇，有誰同意這句話? 舉個手吧!

This is actually a direct quote from an epidemiologist

嗯，有一兩位，真是勇敢。

who's been in field of HIV for 15 years,

這句話出自一位流行病學家，

worked on four continents,

她研究HIV已有15年，

and you're looking at her.

足跡遍及四大洲，

And I am now going to argue

這個人就是我

that this is only half true.

我想說的是，

People do get HIV because they do stupid things,

這句話只有一半是真的。

but most of them are doing stupid things

有些人的確是因為做了蠢事而感染HIV，

for perfectly rational reasons.

但其中大部分的人做出這些蠢事

Now, "rational" is the dominant paradigm

是有完全合乎理性的原因

in public health,

現在，理性在公共衛生上

and if you put your public health nerd glasses on,

是首要的準則。

you'll see that if we give people the information that they need

如果你戴上了愚蠢的公共衛生檢視鏡，

about what's good for them and what's bad for them,

你將會看到若我們提供人們所需的資訊，

if you give them the services

告訴他們什麼對他們是好的，什麼是不好的，

that they can use to act on that information,

或是我們提供服務，

and a little bit of motivation,

讓他們可以根據所得的資訊來行動

people will make rational decisions

加上一點點動機，

and live long and healthy lives.

人們將可以做出理性的決定，

Wonderful.

並過著健康長壽的生活

That's slightly problematic for me because I work in HIV,

棒極了!

and although I'm sure you all know

這對我來講是有點問題的，因為我在愛滋病領域工作，

that HIV is about poverty and gender inequality,

雖然我很確定你們都知道

and if you were at TED '07

HIV關乎著貧窮還有性別不平等，

it's about coffee prices ...

如果你有參加2007年的TED，

Actually, HIV's about sex and drugs,

就會知道愛滋病也和咖啡的價格息息相關。

and if there are two things that make

事實上，HIV和性交、毒品脫不了關係。€

human beings a little bit irrational,

若有兩樣東西

they are erections and addiction.

能讓人類喪失理智，

(Laughter)

那就是勃起跟上癮。

So, let's start with what's rational for an addict.

(笑聲)

Now, I remember speaking to an Indonesian friend of mine, Frankie.

我們先看看對於一個癮君子來說，什麼是不合理的。

We were having lunch and he was telling me

我記得我跟一個印尼籍的朋友聊天，他叫做法蘭克。

about when he was in jail in Bali for a drug injection.

我們當時正在吃午餐，他正在跟我分享

It was someone's birthday, and they had very kindly

在巴里島獄中注射毒品的經驗。

smuggled some heroin into jail,

那一天是某個人的生日，他們很體貼地

and he was very generously sharing it out

走私了一些海洛因到獄中。

with all of his colleagues.

他非常大方地跟獄中好友

And so everyone lined up,

分享這些海洛因。

all the smackheads in a row,

於是每個人排成一排，

and the guy whose birthday it was

所有的癮君子排成一排。

filled up the fit,

而過生日的壽星

and he went down and started injecting people.

把注射器裝滿海洛因，

So he injects the first guy,

然後他走過來開始為大家注射。

and then he's wiping the needle on his shirt,

他替第一個傢伙注射，

and he injects the next guy.

接著他將針頭往襯衫上擦一擦，

And Frankie says, "I'm number 22 in line,

繼續幫下一個傢伙注射。

and I can see the needle coming down towards me,

法蘭克說「我排在第22個，

and there is blood all over the place.

我可以看到朝著我前進的針頭，

It's getting blunter and blunter.

到處都有血跡，

And a small part of my brain is thinking,

針頭變得越來越鈍，

'That is so gross

然後我大腦的一部分開始思考，

and really dangerous,'

「這真的很令人作嘔，

but most of my brain is thinking,

真的很危險。」

'Please let there be some smack left

但我大部份的腦子想的卻是

by the time it gets to me.

「輪到我的時候

Please let there be some left.'"

請留一點點給我。

And then, telling me this story,

拜託留下一些海洛因給我。」

Frankie said,

接著，故事說完後，

"You know ... God,

法蘭克說，

drugs really make you stupid."

「天啊!你知道嗎?

And, you know, you can't fault him for accuracy.

毒品真的會讓你變得很蠢。」

But, actually, Frankie, at that time,

你也知道，你無法反駁他說的，

was a heroin addict and he was in jail.

但事實上，那時的法蘭克

So his choice was either

是個海洛因成癮者，而且他被關在監獄裡。

to accept that dirty needle or not to get high.

所以他只能選擇

And if there's one place you really want to get high,

接受骯髒的針頭或是不要吸毒

it's when you're in jail.

如果真有個地方會讓你想吸毒，

But I'm a scientist

那一定是在監獄了

and I don't like to make data out of anecdotes,

我是個科學家，

so let's look at some data.

我不根據八卦軼聞做數據，

We talked to 600 drug addicts

所以讓我們來看看以下的數據吧。

in three cities in Indonesia,

我們訪談了在印尼三大城市的

and we said, "Well, do you know how you get HIV?"

600個毒癮者，

"Oh yeah, by sharing needles."

我們問：「你知道你是如何感染愛滋的嗎?」

I mean, nearly 100 percent. Yeah, by sharing needles.

「噢!那當然! 透過共用的針頭。」

And, "Do you know where you can get a clean needle

幾乎全部的人都知道，是透過共用針頭感染的。

at a price you can afford to avoid that?"

「你知道你可以在哪裡取得乾淨

"Oh yeah." Hundred percent.

而且你也負擔得起的針頭來避免感染愛滋病呢?」

"We're smackheads; we know where to get clean needles."

「知道啊!」全部的人都知道。

"So are you carrying a needle?"

「我們是吸毒的人，我們當然知道去哪弄到乾淨的針頭。」

We're actually interviewing people on the street,

「那你會隨身攜帶針頭嗎?」

in the places where they're hanging out and taking drugs.

我們真的就在馬路上採訪這些人，

"Are you carrying clean needles?"

他們就在這些地方出沒和買賣毒品。

One in four, maximum.

「你隨身會帶著乾淨的針頭嗎?」

So no surprises then that

最多，四個中會有一個帶著。

the proportion that actually used clean needles

這也就難怪

every time they injected in the last week

上週注射毒品時，

is just about one in 10,

使用乾淨針頭的

and the other nine in 10 are sharing.

比例只有十分之一，

So you've got this massive mismatch;

其他的十分之九都是共用針頭。

everyone knows that

你看這是多麼地矛盾，

if they share they're going to get HIV,

大家都知道

but they're all sharing anyway.

如果他們共用針頭就會感染HIV，

So what's that about? Is it like you get a better high if you share or something?

但他們會共用針頭

We asked that to a junkie and they're like, "Are you nuts?"

那到底是為什麼呢? 是不是共用東西會讓你比較過癮嗎?

You don't want to share a needle anymore than you want

我們問這些吸毒者，他們會說「你瘋了不成?」

to share a toothbrush even with someone you're sleeping with.

你當然不會想跟別人共用一個針頭

There's just kind of an ick factor there.

就像是你也不想跟別人共用牙刷，就算是枕邊人也一樣

"No, no. We share needles because we don't want to go to jail."

會共用針頭只有一個令人討厭的原因。

So, in Indonesia at this time,

不，不。我們共用針頭是因為我們不想進監獄。

if you were carrying a needle and the cops rounded you up,

所以，現在的印尼，

they could put you into jail.

如果你隨身帶著針頭，那警察就會把你圍起來，

And that changes the equation slightly, doesn't it?

然後把你丟到牢裡。

Because your choice now is either

這有點改變了整件事，對吧?

I use my own needle now,

因為當下你的選擇

or I could share a needle now

我可以用自己的針頭

and get a disease that's going to

不然就是共用針頭，

possibly kill me 10 years from now,

然後染上愛滋病，

or I could use my own needle now

很可能在十年後就因此死掉，

and go to jail tomorrow.

或是用我自己的針頭，

And while junkies think that

然後明天就進監牢。

it's a really bad idea to expose themselves to HIV,

雖然毒蟲們覺得

they think it's a much worse idea

把自己暴露在愛滋病病毒下是個極糟的主意，

to spend the next year in jail

但他們深信在牢裡度過一年

where they'll probably end up in Frankie's situation

會是個更糟的決定，

and expose themselves to HIV anyway.

他們很可能在牢裡會面對到法蘭克遇到的狀況，

So, suddenly it becomes perfectly rational

然後不管怎樣，還是暴露在HIV的威脅下。

to share needles.

突然間，共用針頭似乎

Now, let's look at it from a policy maker's point of view.

是個相當理性的決定。

This is a really easy problem.

現在，讓我們從決策者的角度來看這個問題。

For once, your incentives are aligned.

這真的是個很簡單的問題。

We've got what's rational for public health.

有那麼一度，你有很足夠的動機做對的決定。

You want people to use clean needles --

我們已經知道就公共衛生而言何謂理性。

and junkies want to use clean needles.

政府想要人們使用乾淨的針頭，

So we could make this problem go away

這些毒癮者也想要使用乾淨的針頭。

simply by making clean needles universally available

所以我們很簡單地就可以解決這個問題，

and taking away the fear of arrest.

就是讓大家廣泛地拿到乾淨的針頭，

Now, the first person to figure that out

他們也不用擔心被捕的問題。

and do something about it on a national scale

第一個想出這一個方法的

was that well-known, bleeding heart liberal

並把它全國性推廣的

Margaret Thatcher.

就是眾所皆知、心腸善良的民主主義者，

And she put in the world's first

瑪格麗特·柴契爾夫人。

national needle exchange program,

她實施的世界上第一個

and other countries followed suit: Australia, The Netherlands and few others.

全國性的針頭交換計畫，

And in all of those countries, you can see,

其他的國家也跟進，包含澳洲、紐西蘭還有一些其他國家，

not more than four percent of injectors

在這些國家中，你可以看到的，

ever became infected with HIV.

注射者之中

Now, places that didn't do this -- New York City for example,

感染上HIV的不超過4%

Moscow, Jakarta --

目前，沒有實施這項政策的地方，像是紐約，

we're talking, at its peak,

莫斯科，雅加達，

one in two injectors

我們講的是高峰期，

infected with this fatal disease.

每兩個注射者

Now, Margaret Thatcher didn't do this

就有一個會感染上這個致命的疾病。

because she has any great love for junkies.

瑪格麗特·柴契爾夫人並不是

She did it because she ran a country

出自於對毒癮者的愛而實施這個政策。

that had a national health service.

她這麼做是因為她治理著一個

So, if she didn't invest in effective prevention,

實施全國性健康福利的國家。

she was going to have pick up the costs

所以，如果她不先投資來做有效的預防，

of treatment later on,

她就得為後來的治療

and obviously those are much higher.

付出昂貴的代價，

So she was making a politically rational decision.

很明顯的，後者的代價也高多了。

Now, if I take out my

所以她做了一個很理性的政治決定。

public health nerd glasses here

現在，如果我戴上了

and look at these data,

公共衛生怪胎眼鏡，

it seems like a no-brainer, doesn't it?

再看看這些數據，

But in this country,

這一切看起來很簡單，不是嗎?

where the government apparently does not feel compelled

但在這個國家，

to provide health care for citizens, (Laughter)

政府很明顯地覺得並沒有這樣的迫切性

we've taken a very different approach.

去為大眾提供健康醫療，

So what we've been doing in the United States

於是我們採取了一個很不一樣的解決方法。

is reviewing the data -- endlessly reviewing the data.

我們在美國一直做的事就是

So, these are reviews of hundreds of studies

驗證這些數據，不停地驗證。

by all the big muckety-mucks

你看到的就是數百篇研究的驗證，

of the scientific pantheon in the United States,

都是由美國頂尖科學界中的

and these are the studies that show

菁英科學家們所整理出來的，

needle programs are effective -- quite a lot of them.

這裡則是一些研究指出

Now, the ones that show that needle programs aren't effective --

針頭交換計畫是有用的，絕大部分都有。

you think that's one of these annoying dynamic slides

現在，這些秀出了針頭交換計畫沒有成效的研究，

and I'm going to press my dongle and the rest of it's going to come up,

你們可能會認為這只是一張煩人的幻燈片，

but no -- that's the whole slide.

而我接著會按下控制，然後其他的幻燈片會接著播放，

(Laughter)

不過並沒有，這就是全部了

There is nothing on the other side.

(笑聲)

So, completely irrational,

另外一面沒有東西了

you would think.

所以，這是非常不理性的，

Except that, wait a minute, politicians are rational, too,

你會想，

and they're responding to what they think the voters want.

甚至期待，政客也是有理性的，

So what we see is that voters respond

而且他們會回應選民所想要的。

very well to things like this

所以我們看到選民會

and not quite so well to things like this.

很樂於回應像這樣的情況，

(Laughter)

而不願意看到這樣的狀況。

So it becomes quite rational

(為孩童創造美好世界) (為毒蟲創造美好世界)

to deny services to injectors.

所以拒絕提供針頭給成癮者

Now let's talk about sex.

變得相當有道理。

Are we any more rational about sex?

現在讓我們來談談性。

Well, I'm not even going to address

我們面對性會更有理性?

the clearly irrational positions

我甚至不會去講到

of people like the Catholic Church,

那些天主教教會

who think somehow that if you give out condoms,

完全不合邏輯的論點。

everyone's going to run out and have sex.

他們認為如果你發送保險套，

I don't know if Pope Benedict

那麼人們就會跑出去性交。

watches TEDTalks online,

我不知道教皇班尼迪克

but if you do, I've got news for you Benedict --

會不會在線上看TEDTalks

I carry condoms all the time

但如果你有在看，那我有話想跟你說。

and I never get laid.

我隨身都帶著保險套，

(Laughter) (Applause)

我卻從沒有機會使用過。

It's not that easy!

(笑聲)

Here, maybe you'll have better luck.

這沒那麼簡單。

(Applause)

也許你運氣會好些。

Okay, seriously,

(掌聲)

HIV is actually not that easy

好的，嚴格來說，

to transmit sexually.

HIV不是這麼簡單

So, it depends on how much virus there is

就透過性交傳染的。

in your blood and in your body fluids.

是否會傳染是要看你的血液和體液裡

And what we've got is a very, very high level of virus

含著多少愛滋病的病毒。

right at the beginning when you're first infected,

當感染上的最初期，就在一開始，

then you start making antibodies,

我們身體內會有非常非常高量的病毒數，

and then it bumps along at quite low levels

然後你會開始製造抗體，

for a long time -- 10 or 12 years --

之後很長的時間內，10年或12年，

you have spikes if you get another sexually transmitted infection.

病毒的數量都會維持在相當低的數目，

But basically, nothing much is going on

如果你又因性交感染到，那病毒數量會再向上衝。

until you start to get symptomatic AIDS,

但基本上來說，身體並不會產生變化

and by that stage,

直到你開始有愛滋病的症狀。

you're not looking great, you're not feeling great,

但到了這個階段，就在這，

you're not having that much sex.

你看起來狀況不會太好，你也會覺得不舒服，

So the sexual transmission of HIV

你也不會像以往性交地那樣頻繁。

is essentially determined by how many partners you have

所以人們是否因性交而感染HIV

in these very short spaces of time

基本上是取決於這些為期相當短的階段中

when you have peak viremia.

你有多少個性伴侶，

Now, this makes people crazy

而這時你體內的病毒數量正值高峰期

because it means that you have to talk about

現在，這就會讓大家抓狂了，

some groups having more sexual partners

因為這意味著你必須討論

in shorter spaces of time than other groups,

有些人會在較短的時間內

and that's considered stigmatizing.

比其他人擁有更多性伴侶，

I've always been a bit curious about that

而這是很侮辱人的。

because I think stigma is a bad thing,

我一直很好奇，

whereas lots of sex is quite a good thing,

因為我覺得恥辱是一件不好的事，

but we'll leave that be.

而頻繁的性交是相當好的一件事，

The truth is that 20 years

不過我們姑且先不討論這個吧。

of very good research

事實是，耗時20年的

have shown us that

詳盡研究

there are groups that are more likely to turnover

告訴我們

large numbers of partners in a short space of time.

有一群人會更傾向於在短時間內

And those groups are, globally,

換大量的性伴侶，

people who sell sex and their more regular partners.

而這些人，基本上來說

They are gay men on the party scene

是賣春者，他們的性伴侶

who have, on average, three times more partners

多半是舞會上的同性戀者，

than straight people on the party scene.

而這些人，平均而言都有著比異性戀

And they are heterosexuals

多上三倍的性伴侶，

who come from countries that have

這其中有異性戀，

traditions of polygamy

他們的國家有著

and relatively high levels of female autonomy,

一妻多夫制的傳統，