409.Farley, P. J., “Who are the underinsured?” Milbank Quarterly 63 (1985): 476-503.

410.根据不同的经济假设，国会预算办公室预测了2000年和2002年的三种情形：

See: Schroeder, S., “The medically uninsured — will they always be with us?” New England Journal of Medicine 334 (1996): 1130-1133.

411.U.S. Public Health Service, U.S. Immunization Survey. Washington, D.C.: Centers for Disease Control, GPO, 1978.

412.Interview with the author, 1984.

413.Lurie, N., Ward, N., B., Shapiro, M. F., et al., “Termination from Medi-Cal—does it affect health?”New England Journal of Medicine 311 (1984): 480-484.

414.Interview with the author, International Cancer Congress, Seattle, September 1981.

415.Burkitt, D. P.,“Etiology and prevention of colorectal cancer.” Hospital Practice (February 1984):67-77.

416.Interview with the author, International Cancer Congress, Seattle, September 1981.

417.Bielke, E., “Dietary vitamin A and human lung cancer.” International Journal of Cancer 15 (1975):561; Greenwald, P., “Manipulation of nutrients to prevent cancer.” Hospital Practice (May 1984): 119-134;Mettlin, C., Graham, S., and Swanson, M., “Vitamin A and lung cancer.” Journal of the National Cancer Institute 62 (1979): 1435; Peto, R., “Can dietary betacarotene materially reduce human cancer rates?” Nature 290 (1981): 201; Wald, N., “Low serum-vitamin-A and subsequent risk of cancer: Preliminary results of a prospective study.” Lancet 2 (1980): 813; etc..

418.For examples of the thinking about viruses, oncogenes, and carcinogenesis during the early 1980s,see Baltimore, D., “Retroviruses and cancer.” Hospital Practice (January 1978): 49-57; Bishop, J. M., “Enemies within: The genesis of retrovirus oncogenes.” Cell 23 (1981): 5-6; Bishop, J. M., “The molecular biology of RNA tumor viruses: A physician's guide.” New England Journal of Medicine 303 (1980): 675-682; Bishop, J.M., “The molecular genetics of cancer.” Science 235 (1987): 305-311; Bishop, J. M., “Oncogenes.” Scientific American 246 (1982): 80-92; etc..

419.National Research Council, Diet and Nutrition. Washington, D.C.: National Academy Press,1982.

420.Wynder, E. L., Hall, N. E. L., and Polansky, M., “Epidemiology of coffee and pancreatic cancer.”Cancer Research 43 (1983): 3900-3906; “Decaffinating and cancer.” San Francisco Chronicle (June 18,1982): A6.

421.Stolberg, S. G., “Fiber does not help prevent colon cancer, study finds.” New York Times (January 21, 1999): A14.

422.Holmes, M. D., “No apparent relationships between total fat intake or consumption of certain types of fat and breast cancer risk.” Journal of the American Medical Association 281 (1999): 914-920.

423.Rehak, M., “To drink or not to drink.” New York Times Sunday Magazine (March 14, 1999): 20.

424.Marmot, M. G., “From alcohol and breast cancer to beef and BSE- improving our communication of risk.” Editorial. American Journal of Public Health 86 (1996): 921-923.

425.Marmot, M. G. and Mustard, J. F., “Coronary heart disease from a population perspective.” In Evans, R. G., et al., 1994, op. cit.

426.美国心脏协会，《心脏病和中风的统计数据更新版》，达拉斯：美国心脏协会，1999年。苏联和华沙条约的国家都没有遵循相同的模式。在那里，二战后心脏病的激增更不易察觉，部分原因是，在20世纪30年代，这些国家的心脏病发病率已经很高了，而20世纪80年代因烟草使用量激增，膳食中的脂肪含量没有改变而继续攀升。1991年苏联解体后，男性心脏病死亡率急剧上升。见本书第三章。

427.Kochanek, K. D., Maurer, J. D., Rosenberg, H. M., “Why did black life expectancy decline from 1984 through 1989 in the United States?” American Journal of Public Health 84 (1994): 938-944.

例如，在1976—1980年间，43.9%的白人男性成年人患有高血压，而非裔男性的这一比例为48.7%。到1994年，白人男性高血压患病率下降到24.4%，非裔男性为35%。女性差异性更明显。1976—1980年间，白人女性的患病率为32.1%，到1994年为19.3%。非裔女性从47岁开始。6%的患病率为34.2%，但是当西班牙裔和亚裔被输入数据库时，很明显二者的区别不仅仅是非裔和白人。亚裔的高血压发病率一直很低，在1970-1994年间，西班牙裔人的高血压患病率在男性和女性中都保持在22%到25%之间，随着时间的推移没有明显的变化。（资料来源：美国心脏病协会，1999年，同前文。）

一些人把这个问题归咎于贫困，但当非裔和西班牙裔的人口比例与社会经济地位相匹配时，这种差别似乎就消失了：所有阶层的非裔都有较高的高血压发病率。非裔、白人获得医疗保健的机会明显较差，但非裔与西班牙裔人相比不一定如此。有证据表明，非裔不太可能接受积极的治疗，如心脏搭桥手术或移植，这可能会影响他们的死亡率。但这并不能解释高血压的高发病率。也有人寻求基因原因，但都没有满意的答案。

从公共卫生的角度来看，由于缺乏对这种差距根源的明确认识，预防工作就无的放矢：若不知道为什么美国非裔心脏病多，那要如何才能确定是否最好将稀缺资源和公共卫生公信力集中投放于饮食、压力、肥胖，运动干预方面，还是其他导致非裔美国人社区的行为改变因素？

See: Bhopal, R. and Donaldson, L., “White, European, Western, Caucasian or what? Inappropriate labeling in research on race, ethnicity, and health.” American Journal of Public Health 88 (1998): 1303-1307; Blendon,R. J., Aiken, L. H., Freeman, H. E., et al, “Access to medical care for black and white Americans.” Journal of the American Medical Association 261 (1989): 278-281; Centers for Disease Control and Prevention, “Health beliefs and compliance with prescribed medication for hypertension among black women—New Orleans, 1985-86.”Morbidity and Mortality Weekly Report 39 (1990): 701-704; etc..

428.低密度脂蛋白胆固醇（LDL）在20世纪70年代末80年代初被证明了能够附着在血管和动脉的内壁上，形成斑块。这些斑块，除非被高密度脂蛋白（“好”胆固醇）“清理”掉，否则随着越来越多的低密度脂蛋白胆固醇进入血流，这些斑块会随着时间的推移而增长，而血液中的低密度脂蛋白胆固醇是由肝脏通过摄入饱和脂肪而产生的。最终，血管壁会变厚，为血流提供的空间会变小。然后，人就会患动脉粥样硬化，或者说“动脉硬化”，这样一来，心脏病或脑卒中的风险就非常高。

429.Brody, J. E, Jane Brody's Good Food Book. New York: W. W. Norton, 1985; Brody, J. E, Jane Brody's Nutrition Book. New York: W. W. Norton, 1981; Butrum, R. R。, Clifford, C. K., and Lanza, E.,“NCI Dietary Guidelines: Rationale.” American Journal of Clinical Nutrition 48, Supplement (1988): 888-895; U.S. Departments of Agriculture and Health and Human Services, Dietary Guidelines for Americans.Washington, D.C.: U.S. Departments of Agriculture and Health and Human Services, 1985; U.S. Food and Drug Administration, Division of Consumer Studies, Health and Dietary Survey (1988), unpublished; Life Sciences Research Office, Federation of American Societies for Experimental Biology, Physiologic Effects and Health Consequences of Dietary Fiber. Bethesda: Federation of American Societies for Experimental Biology, 1987; etc..

430.1980年的数据分类如下：

来源：Centers for Disease Control, National Health and Nutrition Examination Survey. Washington, D.C:U.S. Department of Health and Human Services, yearly 1970-1980.

在20世纪80年代和90年代，美国经济和文化的变化使家庭做饭的时间减少，因此他们会更多地去餐馆或快餐连锁店就餐，那里的食物通常含有更多的脂肪。在外就餐的平均热量中38%以脂肪形式存在13%来自饱和脂肪。

431.例如，一个人的总胆固醇水平可能是220，这并不好。但是如果其中35%或更多的是由高密度脂蛋白（HDL）而不是令人担忧的低密度脂蛋白（LDL）构成的话，医生就不会建议进行疾病干预。还有许多其他膳食中存在的化学物质，如甘油三酯、烟酸、咖啡因、酒精、apo-B脂蛋白、雌激素、钙，这些也都是是否患心脏病的独立风险因素。甚至有一些家庭，不管他们吃什么食物，似乎都对体重增加和胆固醇积聚有抵抗力。

432.Callahan, D., False Hopes: America's Quest for Perfect Health Is a Recipe for Failure. New York: Simon & Schuster, 1998.

433.关于预防带来的健康改善的经济学价值，哈佛大学的大卫·卡特和伊丽莎白·理查森表述如下：“我们将‘健康资本’定义为与个人健康相关的当前和未来效用的贴现价值。我们使用疾病死亡率和发病率的数据，以经验性的方式来衡量卫生资本。据估计，在1970年至1990年间，出生时的健康资本增加了大约10万美元，而65岁时则增加了大约16万美元。老年人健康资本的大幅增加，是因为老年人的健康改善大多数是由于心血管疾病死亡率的降低导致的……”

See: Cutter, D. M. and Richardson, E., Measuring the Health of the United States Population.Washington, D.C.: Brookings Institute, Brookings Papers on Economic Activity, Microeconomic Edition, 1997.

434.Kindig D. A., Purchasing Population Health: Paying for Results. Ann Arbor: University of Michigan Press, 1997.

435.GISSI-Prevenzione Investigators, “Dietary supplementation with n-3 polyunsaturated fatty acids and vitamin E after myocardial infarction: Results of the GISSI-Preventione trial.” Lancet 354 (1999): 447-455.

事实证明，鱼类中的ω-3脂肪酸并没有像先前所想的那样降低乳腺癌的风险。参见Holmes, M. D., “Lower fat consumption not associated with decreased breast cancer risk.” Journal of the American Medical Association 281 (1999): 914 920。

436.有些鱼看起来对心脏是有帮助的，例如鲑鱼。其他种类的鱼似乎没什么好处，例如金枪鱼。至少根据20世纪90年代的研究，关键的仍在于ω-3脂肪酸。列表仍在扩充。

437.作者将在此处仅仅是提出一个关于中毒性休克综合征的肤浅观点，关于出现该病的详细分析参见：“Feminine Hygiene” in Garrett, L., 1994, op. cit。

438.Centers for Disease Control,“Update: Toxic Shock Syndrome in the United States.” Journal of the American Medical Association 20 (1983); 1017; Institute of Medicine, Toxic Shock Syndrome:Assessment of Current Information and Future Research Needs. Washington, D.C.: National Academy Press, 1982; Schlievert, P. M., Shands, K. M., Dan, B. B., et al., “Identification and characterization of an exotoxin from Staphylococcus aureus associated with Toxic-Shock Syndrome.” Journal of Infectious Diseases 143(1981): 509-516; and Schlievert, P. M., Bettin, K. M., and Watson, D. W., “Purification and characterization of Group A streptococcal pyrogenic exotoxin Type C.” Infection and Immunology 16 (1977): 673-679.

439.1982年，35岁的男性或女性的平均额外预期寿命如下：

资料来源：明尼苏达州卫生局。

440.Minnesota Planning, Line Item. St. Paul: Minnesota Planning, December 1994.

441.1968年，明尼苏达州卫生厅的预算为4110256美元，其中1794124美元来自地方和州，2316132美元来自联邦政府。

442.1985年，明尼苏达州和地方对卫生厅预算的投入总额为30750200美元，联邦政府对其的投入是38206500美元。

443.1998年，明尼苏达州卫生厅的财政收入中，来自州和地方的是120321297美元，107280502美元来自联邦政府。然而，即使是慷慨的明尼苏达州人在努力弥补华盛顿做出的变化，卫生厅在里根时代还是受到了影响。从1980年到1983年，该部门解雇了17%的全职员工，直到1987年，员工配置才恢复到1980年的水平。

444.White, K. E., Hedberg, C. W., Edmonson, L. M., et al.,“An outbreak of Giardiasis in a nursing home with evidence for multiple modes of transmission.” Journal of Infectious Diseases 160 (1989): 298-304.

445.MacDonald, K. L., White, K. A., Heiser, J., et al., “Evaluation of a sick child day care program: lack of detected increased risk of subsequent infections.” Pediatric Infectious Disease Journal 9 (1990): 15-20.

446.1993年，在华盛顿州那家快餐连锁店出售的汉堡包中发现了大肠杆菌，人称“盒子里的杰克虫病”。疫情在美国各地都有发生，但“盒子里的杰克”与这种流行病并没有特别的联系。在华盛顿州、爱达荷州、内华达州和加利福尼亚州暴发的疫情中，超过700名儿童感染了该病，其中178人住院治疗，4人死亡。华盛顿州卫生当局确定，所有四个州的病例都与同一个汉堡供应商有关。令人震惊的是，在未煮熟的汉堡包馅饼中发现，仅仅14种大肠杆菌0157∶H7细菌就足以引起溶血性尿毒症综合征。参见Swerdlow,D., 1994, op. cit.; and “The emergence of Escherichia coli 0157 : H7 infection in the United States.” Editorial.Journal of the American Medical Association 269 (1993): 2264-2266。

447.Swerdlow, D., Comments to the USDA, E coli 0157 Conference. Washington, D.C., July 11-13,1994.

448.Belongia, E. A., MacDonald, K. L., White, K. E., et al.,“Outbreak of Escherichia coli 0157 : H7 colitis associated with precooked hamburgers.” Twenty-ninth Interscience Conference on Antimicrobial Agents and Chemotherapy, Houston, Texas, September 17-20, 1989; Belongia, E. A., MacDonald, K. L., Blaser, M.T., et al., “Outbreak of Escherichia coli 0157 : H7 in a day care center: Patterns of transmission and control methods.” Twenty-ninth Interscience Conference on Antimicrobial Agents and Chemotherapy, Houston,Texas, September 17-20, 1989; Griffin, P. M. and Tauxe, R. V., “The epidemiology of infections caused by Escherichia coli 0157 : H7, other enterohemorrhagic E. coli, and the associated hemolytic uremic syndrome.”Epidermiologic Reviews 13 (1991): 60-98; etc..

449.1996年，日本遭受一场涉及1万个病例的大规模流行病，导致全国各地的学校关闭。经过数年的调查，美国和日本的研究人员确定，疫情起源于爱达荷州的一家萝卜种子农场。农场用感染了大肠杆菌的动物牛粪给萝卜施肥，萝卜种子被卖给日本的种植者。种子中含有休眠的大肠杆菌，它很容易定植于从种子中生长出来的芽。由于日本萝卜是生吃的，所以这些芽中的大肠杆菌比未煮熟的汉堡中的大肠杆菌更危险。

See: Brever, T, Shapiro, R., Hall, W., et al., “Escherichia coli 0157 : H7 first linked to consumption of alfalfa sprouts.” First International Conference on Emerging Infectious diseases, Atlanta, March 8-11, 1998;Efron, S., “Food poisoning outbreak causes alarm.” Los Angeles Times (July 23, 1996): A1; Garett, L,, “Mutant superbug strikes in Japan.” Newsday (July 24, 1996): A4; Garett, L., “Superbug raging in Japan; experts baffled.” Newsday (July 26, 1996): A20; Garett, L., “U.S. to aid Japan on E. coli.” Newsday (July 27, 1996):A7; Garrett, L., “Unsolved mystery plagues Japan.” Newsday (July 26, 1996): A20; Gutierrez, E. and Netley, G.,“Japanese Escherichia coli outbreak is still puzzling health officials.” Lancet 348 (1996): 540; etc..

450.Cannon, L., 1991, op. cit.

451.Address to the annual National Gay and Lesbian Health Conference. Washington, D.C,July 25, 1988, and interview comments afterward.

452.如详细列出一长串导致研制艾滋病病毒疫苗彻底失败的原因清单，例如挫折、金钱问题、政治阴谋和智力障碍等，已超出了这本书的范围。尽管当局多年来对公众和华尔街发表了许多高度乐观的声明，但到20世纪末，没有人手中有一种产品能像索尔克的疫苗对小儿麻痹症的治疗作用那样，为艾滋病病毒带来希望。原因详见Cohen,J., “Glimmers of hope from the bottom of the well.” Science 285 (1999): 656-657; Cohen, J., Shots in the Dark: The Wayward Search for an AIDS Vaccine, to be published in 2000, manuscript shared by author;Institute of Medicine, The Potential Value of Research Consortia in the Development of Drugs and Vaccines Against HIV Infection and AIDS. Washington, D.C: National Academy Press, 1988; and various authors,“AIDS: The Unanswered Questions.” Science 260 (1993): 1219-1293。

453.Institute of Medicine, Confronting AIDS. Washington, D.C: National Academy Press, 1988;Mann, J. M., Tarantola, D. J., and Netter, T. W., editors, AIDS in the World. Cambridge, Mass4 Harvard University Press, 1992; National Research Council, AIDS: The Second Decade. Washington, D.C. National Academy Press, 1990; National Research Council, AIDS: Sexual Behavior and Intravenous Drug Use.Washington, D.C.: National Academy Press, 1989; Nichols, E. K., Mobilizing Against AIDS. Washington,D.C.: National Academy Press, 1986; Sepulveda, J., Fineberg, H., and Mann, J. M., editors, AIDS: Prevention Through Education. Boston: published privately by computer, 1986.

454.Institute of Medicine, Contronting AIDS, 1988, op. cit.

455.尤其是血库和血液制品行业阻碍了净化血液供应，使成千上万的美国人因输血或使用血液因子而感染。一旦他们意识到他们必须得让步，否则将面临巨大的诉讼。这个行业有两种姿态：首先，它谨慎地出口未经过滤的血液制品，在日本和其他国家引发了艾滋病病毒的流行；其次，同意“自愿”筛查工作，但反对一切形式的法定筛查。里根食品药品监督管理局允许这样做，而强制筛查却是直到疫情首次被确认后才开始实施。

456.See National Center for Health Statistics, “AIDS knowledge and attitudes for May and June 1988.”Advancedata 160 (1988): 1-5; and Garrett, L., in Sepulveda, J., et al., editors, 1989, op. cit.

457.例如，许多活动人士认为，有关艾滋病的会议不应在那些有歧视艾滋病病毒阳性者的移民政策的国家举办。直到人们清楚地认识到这将美国，还有几乎所有亚洲和非洲国家以及欧洲大部分地区排除在外之前，这一立场都被称赞并得到了著名公共卫生领导人的支持。这迫使会议组织者在瑞典、瑞士、日本等出访费用极高的国家召开会议。对于发展中国家的人，因费用问题被拒之门外，这仅仅安抚了来自美国、加拿大和西欧的少数活动家。尽管各国没有改变他们的政策，最终艾滋病会议在世界各地举行，而不管移民政策如何。

458.Comments made at the American Blood Bank Meeting, Washington, D.C., November 1985.

459.根据他们所能获得的数据，美国疾病预防控制中心认为，感染艾滋病病毒的人平均有45%的概率会死亡，而死亡会在感染两年后发生。根据报告的艾滋病病例，柯伦的研究小组还认为，男同性恋是风险最大的群体，注射毒品者及其性伴侣在艾滋病病毒感染者中所占比例不到10%。他们估计全美国每10万人中有0.1人感染艾滋病，但是每10万旧金山男同性恋者中就有1000人感染艾滋病。

460.Curran, J., “Summary of meeting on AIDS and the bathhouses, with medical experts and representatives of the S. F. medical community.” San Francisco, September 25, 1984, unpublished.

461.莫斯在高级法院发表讲话，此前该市采取行动试图通过关闭同性恋浴室来遏制艾滋病病毒的传播。

462.1988年1月6日，州长库莫下令全州所有的产前治疗场所鼓励孕妇接受艾滋病病毒检测。在全州强制对新生儿进行匿名筛查后发现，1987年，有1%的人出生时艾滋病病毒呈阳性。

463.Carroll, M., “To combat AIDS, New York may order bathhouses shut.” New York Times (October 25, 1985): B1.

464.1983年至1988年，由于艾滋病，纽约市的死亡率增加了5%。1988年，该市有3739人死于该病。这只是个开始。截至1989年11月，自艾滋病开始流行以来，纽约市报告了大约2.22万例艾滋病病例，艾滋病是30至49岁男子和20至39岁妇女的主要死因。

See: Smith, P. F., Mikl, J., Hyde, S., et al., “The AIDS epidemic in New York State.” American Journal of Public Health 815 (1991): 54-60.

465.Kramer, L., Report from the Holocaust. New York: St. Martins, 1994; Nussbaum, B., Good Intentions. New York: Atlantic Monthly Press, 1990; and Shilts, R., And the Band Played On. New York: St.Martins, 1986.

466.New York State Department of Health. AIDS in New York State. Albany: New York State Department of Health, 1989.

467.Centers for Disease Control and Prevention, “Update: Reducing HIV transmission in intravenousdrug users not in drug treatment—United States.” Morbidity and Mortality Weekly Report 39 (1990): 529-538; U.S. General Accounting Office, Needle Exchange Programs: Research Suggests Promise as an AIDS Prevention Strategy. GAO/HRD-93-60. Washington, D.C.: House of Representatives, 1993; Kaiser Family Foundation, Needle and Syringe Availability and Exchange for HIV Prevention. Menlo Park: Kaiser Family Foundation, 1992; etc..

468.“Let's move quickly in battling AIDS.” Editorial. USA Today (March 3, 1988): 10A.

469.Hahn, R. A., Onorato, I. M., Jones, S., et al., “Prevalence of HIV infection among intravenous drug users in the United States.” Journal of the American Medical Association 261 (1989): 2677-2684; and Wysowski, D. K., Schober, S. E., Wise, R. P., et al.,“Mortality attributed to misuse of psychoactive drugs, 1979-1988.” Public Health Reports 108 (1993): 565-570.

470.以纽约市为例，1988年，进入治疗中心的注射吸毒者中有38.5%是艾滋病病毒阳性，44%承认共用针头的人感染了艾滋病病毒。总的来说，到那时纽约市估计有23.5万艾滋病病毒感染者，其中至少1/3是通过共用针头而感染的。

471.Reagan, R., “Remarks on signing Executive Order 12368, concerning drug abuse policy functions.” White House, June 24, 1982.

472.Gray, M., 1998, op. cit.

473.代替正当程序和刑事诉讼，联邦和地方机构可以通过没收个人的土地和个人车辆或资产来迫使供应商倒闭。而机构可以出售这些物品，以资助进一步的警察行动，所有这些都没有审判或实际证据证明这些人是非法的毒品制造商或供应商。

474.Wysowski, D. K., et al., 1993, op. cit.

475.Baum, D., 1996, op. cit.

476.Davidson, J., “Cries for help.” Wall Street Journal (September 4, 1990): Al.

477.Institute of Medicine, ibid.

478.New York Academy of Sciences, Statement on AIDS Initiatives in Drug Treatment, Services in New York City. New York City: Academy of Sciences, May 30, 1991.

479.Duke, S. B. and Gross, A. C., America's Largest War: Rethinking Our Tragic Crusade Against Drugs. New York: Putnam Books, 1994.