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本文是波士頓大學桑德羅·加利亞博士分析錯綜復雜的醫療和公共衛生問題的系列文章之一。

人們的健康是一種公共產品。

估計該說法與大多數讀者與健康的看法并不一致。畢竟，健康難道不是由行為、飲食和運動量決定的嗎？雖然事實確實如此，但從根本上講，行為不可避免地由周圍的世界決定。我來詳細解釋下。

公共產品是需要集體投資支持的公共資源。像圖書館、公園、高速公路、國家安全之類，都屬于公共產品。全民支持，供全民使用。這些之所以是公共產品而非個人商品，是因為人們認為相關產品對全民福利非常重要，不應該完全由私人投資，也不應受市場力量左右。例如，教育可造福所有人，可以改善每個人的生活。因此，教育作為公共產品得到全民支持。

健康也屬于同一類。每個人都看重健康，也渴望健康，不管是為了自己還是為了關心的人。不管政治立場如何，我還沒有發現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。每年醫療保健方面耗資巨大。然而，正如我經常寫到，絕大多數投資都用于開發藥物和醫療技術，并未用于推動核心的社會、經濟和環境力量，影響周圍的世界從而影響人們的行為。如果相關努力缺失，就很難真正實現全民健康。

當然，人們很容易想到，健康不依賴集體投資，個體同樣可以為健康支出。人們可能相信，如果能夠請最好的醫生、買最好的藥品，健康就可以得到保障。

但這真有可能嗎？畢竟，如果沒有干凈的空氣和水、沒有安全的社區、沒有公平經濟和提供支持的社區網絡，很難保持健康。以上列出的條件全部都是公共產品，依賴集體投資才能發展。健康可以說是一種典型的公共產品，因為它依賴一系列由共同投資的組合產品。

可惜的是，過去30年里美國的公共產品投資不斷衰退。投資不力的根源在于政治理念，主要由里根政府時期的思路主導，將個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自由的潛在威脅。

然而，該理念的失誤在于，世上有不同類型的自由。有“主動的自由”，例如言論自由、機會自由，自由選擇想做的事以及做的時間，符合當前政治對自由的定義。但還有另一種自由，即“遠離的自由”，指遠離傷害和疾病、遠離無知、遠離可預防的損害健康的危險。

維護“遠離的自由”就要投資公共產品。雖然過去35年里政治可能忽視了這一目標，但以前曾采取能引起共鳴的愿景努力實現。該愿景是雄心勃勃的羅斯福新政核心，在通過政府大規模干預改善美國社會各階層的生活。

新政期間，富蘭克林·羅斯福總統曾經表示，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。他倡導的理念在“主動的自由”和“遠離的自由”之間取得了平衡，然而當前人們過于關注主動的自由，卻失去平衡，忽視了遠離的自由。

同時，如果沒有集體投資創造條件推動自由，人們既不可能免于匱乏，也不可能免于恐懼。為了最大限度實現自由，就要恢復歷史上國家對公共產品的尊重。

盡管政治上面臨挑戰，但公共產品在美國仍然可行，因為對人們的安全和健康來說，它非常必要。以道路安全為例。世紀之交，美國人開車的人數是1925年的6倍，路上的機動車數增加了11倍。然而在1925年至1997年期間，每年機動車導致死亡率下降了90%。為什么？是因為美國人駕駛技術提升了嗎？

不完全如此。事實上，死亡率下降是因為我們選擇將道路安全作為公共產品進行投資。通過法律，設立機構，向人們提供培訓，建立健全的規則和安全流程以確保道路安全。確實很奏效。更重要的是，該體系一直在運轉，基本上沒有政治干預。很少有政客拿道路安全法規說事，攻擊政府權力過度擴張。原因就在于道路安全法與人們的健康息息相關。

在道路上保護人們的法律法規與其他保護健康的法律差別能有多大？當缺乏教育縮短壽命，當污濁的空氣導致疾病和死亡，當經濟不公平擴大貧富之間健康差距，我們有充分的理由像對待危險道路一樣，通過投資公共產品來解決影響健康的問題。

必須理清公共物品和健康之間的聯系，要達到對安全帶和安全關系的認識水平。此舉對考慮全民醫療保健，對基礎設施、住房、教育、交通和環境的投資選擇影響深遠。我們也從中明白，如果真想實現健康，一定要意識到公共產品是集體健康的關鍵。（財富中文網）

桑德羅·加利亞，醫學博士，波士頓大學公共衛生學院教授和院長。他的最新著作是《談起健康應該討論什么》。

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.