「口罩防疫」忽略的事:從常民生活,一起建立一套「在地公共衛生學」

【轉貼自獨立評論專欄@天下】

作者:劉懿德 安欣瑜

大家過去對社區醫療的概念,大多是從「預防保健」到「健康促進」。近幾年因為全球化,加上長期社會政策對公衛體制建制的弱化,以及各種具傳染力的病毒迅速演化,使得社會整體面對許多突如其來的鉅變,有點措手不及。然而如果把社區醫療視為一種基礎建設來看,它就好像一座城市的下水道,如果汙水淤塞不通,自然引發許多潛在的健康風險,而大多數人民也不知道到底生活中有多少可能的危險因子。檢視與清淤,就是社區醫療第一步需做的事。

從這次的武漢肺炎(COVID-19)事件,或許社會大眾又回想起當年SARS封院與封街的景象。這個景象訴說著台灣醫療體制在長期漠視與缺乏公衛意識的教育文化下,所代表的一種集體的未知與恐懼。在台灣,公衛專業對政府乃至於對普羅大眾而言,似乎都並不是生活中重要的一環,但試想,我們是否都要碰到重大傳染病,才會從昏睡中覺醒一下?公衛體系是否只有在這樣的情況下,才得以顯示它的重要性?其實不然。公共衛生從較急性的傳染病防治到慢性的疾病管理,無不具有它必要的價值。但由於它相對於醫療,是一種隱性的存在,所以常沒機會登上檯面。

從「還沒生病的人」找出問題的蛛絲馬跡

對國民健康問題而言,真正重要也需要長期關注的,是生活型態對社區民眾健康的影響。或許過去執行社區醫療的專業人員,許多都是直接跟著政府的計畫走,政府想到什麼,在社區就做什麼,較少有時間跟心力去思考社區增能(community empowerment)對當地民眾有什麼實質意義。

眾所皆知,若撇開突發的傳染病事件,再將社區醫療視為公共衛生實踐的平台,真正需要長期關注的,是台灣人的國病──三高(高血壓、高血糖、高血脂)。無論是都會或偏鄉,三高一直都是家喻戶曉的常民健康問題,或許我們也會認為台灣在這類慢性病的預防上已經做了普遍控管,但除了疾病控管,實踐公共衛生的社區醫療,難道只有倡議的功能,或在社區辦辦衛教和篩檢而已嗎?就好像面對武漢肺炎,只倡導全民戴口罩,會不會被誤解為戴了口罩就一定能預防肺炎傳染呢?或許根本問題,在於我們未知的生活習慣。

長期的國病也關乎於未知的生活習慣。執行阿里山南三村社區醫療的嘉義基督教醫院部落健康中心,由於觀察到南三村高血壓與高血脂的普遍現象,改變以往的思維,開啟全新的部落健康因素踏查計畫,主動嘗試以口述歷史方式進行探索,更脈絡化的了解當地飲食文化,理解並記錄部落居民生活型態,透過當地民眾自我生命敘事,進一步綜觀與彙整出一幅具體的圖象,用以建置出文化變遷所代表的社會意涵,以及與當地慢性疾病發生率的相關性。

相較於以往,這是一種社區醫療的典範轉移,從過去醫療人員習慣關注的臨床記錄轉移到關注醫療公共性的價值,執行社區醫療的觀念似乎進行一次跨域突破,可能同時形成一種長期而全新的公衛思維與實踐軌跡。這一切都是源自於對醫療的關懷以及對公共性的關注。

第一線醫療人員從完整的社會脈絡中探索並試圖解決社區民眾集體的健康狀況,或許很多人會質疑:透過自我敘事就能從生活型態了解其與疾病發生的相關性嗎?如果從微觀的視角當然想不通,但從巨觀的視野,就能看到社區集體社會行為模式所存在的社會病因。就公共衛生的立場,無論是從傳染疾病到慢性疾病致病機轉,其範疇都同樣指涉著某種生活型態與慣習的外部因素。這也是為什麼社區醫療除了照顧社區中已經生病的人之外,更必須關注未生病者的生活型態。社區是社會現象的縮影,也會是健康危險因子存在的表徵。

從生活開始,進行更有效的疾病防治

為落實社區醫療,從嘉義基督教醫院部落健康中心在阿里山南三村的實踐經驗中,可以感受到醫療公共性與社會環境因素所代表的意義。例如經由訪談記錄了解當地民眾的飲食習慣與生活方式(如文化傳統與城鄉差距等),以及部落平常可獲取哪些食材(如資源分配與產業結構等),進行整體性的資源評估與衛教設計,經過近半年與民眾密集的溝通互動,將專業知識融入當地生活並建立信賴關係,成功的改變部落民眾的健康意識,甚至達到降低三高指數(特別是高血脂)的成效,不但讓民眾相信許多慢性疾病的不健康因素是可逆、可避免的,更促使社區逐步做到健康意識的自我增能,這就是社區醫療作為公共衛生實踐平台的意義。

最後,我們用同樣的觀點反思當前武漢肺炎的防疫。口罩或許是防疫的助手,也可能是防疫的破口。當政府不斷宣傳口罩政策之時,民眾自然而然只學習到用口罩防疫,但作為社區醫療的實踐者,如何多一份細膩,了解民眾使用口罩與接觸的習慣,再與民眾進行深度的互動與溝通,從常民認知中與民眾一起建立一套在地的公共衛生學,為未來不可知的疾病變異,先檢視可能的淤塞問題。所以,疫情的發生雖是危機,但也是做為社區醫療典範轉移的最佳契機。

(作者劉懿德為台灣在宅醫療學會副秘書長,嘉義基督教醫院醫研部助理研究員,安欣瑜為嘉義基督教醫院部落健康中心主任。)

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