004

129.Alter, M., “Hepatitis C in the United States.” Presentation to Infectious Diseases Society of America conference, San Francisco, September 15, 1997。奥尔特指出，在美国，25%的肝脏移植是由于丙型肝炎感染而进行的；70%的感染者在不进行肝脏移植的情况下会发展成慢性肝病。10%的人在感染后的13~28年内发展成肝细胞癌。1997年，美国90%的静脉吸毒者都是丙肝阳性。20世纪90年代，美国总共有400万人因感染丙肝而患上慢性肝病，占美国人口的1.8%。

130.Russian Academy of Medical Sciences, State Report, 1996, op. cit.

131.戈古连科也不相信敖德萨的血库供应，因为一些接受输血的人已经患上了肝炎。因此，他也敦促他的医生和护士给病人输血，或者让病人在接受手术前储备自己的血液。基辅的官员承认，该国的血液供应没有进行过丙型肝炎的例行检测，而且乙型肝炎的检测试剂盒供应不足，因此一些病人的血液肯定没有进行适当的丙型肝炎病毒检测。

132.Zmushko, E. and Bolekhan, V. N., “HIV- infection in the Russian Federation military forces.” Twelfth International Conference on AIDS, Geneva, June 28-July 3, 1998.

133.Wines, M., “Heroin Carries AIDS to a Region in Siberia,” The New York Times (April 24, 2000): A1.

134.Garrett, L., 1994, op. cit., pages 493-98.

135.欧洲的政府和私人机构都很缓慢地认识到这一趋势，在处理这一问题上也更加缓慢。详见：Open Society Institute.“Response to the illegal trafficking of women in Europe.”The Forced Migration Monitor 27 (1999): 1; Bohlen, C., “Exotic imports have. captured Italy's sex market.” New York Times (July 9, 1997): A4; Specter, M., “Traffickers' new cargo: Naive Slavic women.” New York Times (January 11, 1998): A1; “Giving the customer what he wants.” The Economist (February 14, 1998): 21-23; Farah, D., “Russian mobs form Colombian alliances.” San Francisco Chronicle (September 29, 1997): A1;等。

136.

苏联和东欧国家性病估计样本

137.Daigle, K., “Exposing the face of sex in Moscow.” The Moscow Times (April 4, 1997):20;以及多处妓女街头暗访。

138.Maksimovsky, E., Moscow Prostitutes: An anti- brothel guidebook. Moscow: Syravnika Press, 1996.

139.该地区有组织犯罪和卖**之间的界限极大地限制了这些妇女获得公共卫生服务的机会。详见：Pyroyshkina, E., Presentation to the Twelfth International Conference on AIDS,Geneva, June 28-July 3, 1998; Stanley, A., “A tale of murder and sex slaves to stun Dostoyevsky.”New York Times (August 28, 1997): A3; Stanley, A., “With prostitution booming legalization tempts Russians.” New York Times (March 3, 1998): Al。

140.Data from the Russian Ministry of Health, 1997.

141.Gerasimenko, op. cit; Renton, A., Ward, H., and Meheus, A., “Epidemiology, control and surveillance of syphilis and gonorrhea in the Russian Federation.” Report to UNAIDS, March 12, 1996; and Tichonova, L., Borsenko, K., Ward, H., et al., “Epidemics of syphilis in the Russian Federation: Trends, origins and priorities for control.” Lancet 350 (1997): 210-13.

142.所有数据来源于俄罗斯卫生部和莫斯科卫生局。

143.Russia Today Online. “Syphilis rise may worsen AIDS epidemic” (April 6, 1998).

144.其他有关梅毒发病率上升的数据从独立于当地政府的机构获得，发表在《柳叶刀》杂志上，详见：S. J., “Screening for Syphilis.” Lancet 353 (1999): 1441; and Glass, N.,“Syphilis cases are increasing in Czech Republic.” Lancet 353 (1999): 992。

145.See World Health Organization. “Task force to curb sexully transmitted disease epidemnic in Europe.” Press Release EURO/03/98, Copenhagen, April 1998.

146.Sinyavsky, A., 1997, op. cit..

147.高骨冷科的医院有1120张病床，其数据如下：

148.Associated Press. “Clinics vie for Russian health care”(February 17, 1995); Swarns, R.L., “Russia's cardiac patients, little care and grim prognosis.” New York Times (September 24,1996): Al; and Powell, B., “Heart to heart." Newsweek (September 16, 1996): 54-61.

149.Matlack, C., “Need surgery? Bring vodka and a bribe.” BusinessWeek (March 7,1997): 45; Spolar, C., “Polish health-care system is in critical condition.” Washington Post(May 5, 1997): A1; Specter, M., “Citadel of Russia's wasteful health system.” New York Times(February 4, 1998): A1; Kaplan, F., “Russian health crisis needs intensive care.” Boston Globe(December 6, 1992): Al; Saffron, I., “New life the old way; Russia's birth houses reflect '50s.”Chicago Tribune (May 19, 1996): 9; Simon, S., “Childbirth in Russia is miserable.” Los Angeles Times (February 22, 1996): Al; and Bilmes, L. and Lindquist, J., “The bear has a sore head.”Financial Times (London) (August 26, 1994): 1.

150.在苏联时期，医疗保健质量的阶级差别非常明显。贿赂—尤其是贿赂外科医生—成为常态。在许多情况下，外科医生会直截了当地拒绝给病人手术来换取大笔现金。他们可能曾是无产阶级国家的工人，但他们现在也是熟练的专业人士，靠一种假定的腐败模式发家致富。详见：Voslensky, M., Nomenklatura: The Soviet Class, An Insider's Report. Translated by Eric Nosbacher. New York: Doubleday & Co., 1984; and Smith, H., The Russians, 1973, op. cit。

151.Editorial. “Health in Russia is broke, but who is to fix it?” Lancet 353 (1999): 337;Burger, E. J., Field, M. G., and Twigg, J. L., “From assurance to insurance in Russian health care: The problematic transition.” American Journal of Public Health 88 (1998): 755-58; and Sheiman, I., “Forming the system of health insurance in the Russian Federation.” Social Science and Medicine 39 (1994): 1425-32.

152.Josephson, P. R., New Atlantis Revisited: Akademgorodok, the Siberian City of Science. Princeton, N.J: Princeton University Press, 1997.

153.Saltykov, B. G., “Transformation of Soviet science (1992-96).” AAAS, Seattle,February 13-18, 1997.

154.Centre of Science Research and Statistics. “Social status of scientists in Russia.”Science 275 (1997): 485.

155.Hamer, M., “East Germany's science breaks from the state.” New Scientist (December 9, 1989): 15.

156.Hamer, M., “Breaking walls, building bridges.” New Scientist (January 13, 1990):33-34.

157.Whitehead, C., “The remaking of Czechoslovakian science.” New Scientist (March 3,1990): 26-29.

158.Stone, R., “Civil war leaves once-proud Georgian science in tatters.” Science 272(1996): 1581-82.

159. Koenig, R, “Spirited academy faces painful cuts, consolidation.” Science 277 (1997):175; and Koenig, R., “Eastern Europe's research gamble.” Science 283 (1999): 22-26.

160.Stone, R., “Cash-starved researchers to undergo trial by peer review.” Science 271(1996): 1802-3.

161.Stone, R, “New minister sets lofty goals.” Science 282 (1998): 1979-80.

162.Holden, C., “Russia's science spending diving toward new low.” Science 283 (1999): 31.

163.Saltykov, B., op. cit.

164.Chuprikov, A. P., Linyov, A. N., and Martsenkovsky, I. A., Lateral Therapy. Kyiv:Zdorovie Publishers, 1994; and Merskey, H., “The Chuprikov file: Documents evaluating the scientific work of Professor A. P. Chuprikov.” Geneva Initiative on Psychiatry, Amsterdam,1994.

165.The reader is referred for details to the Geneva Initiative's journal, Mental Health Reforms, published quarterly out of Amsterdam since 1996. Available from gip@euronet.nl.

166.Mehilane, L., “Mental health care reforms in the Baltic States.” University of Tartu and Geneva Initiative, Amsterdam, 1996.

167.根据世界银行的数据，1996年俄罗斯的平均月工资约为150美元，比1992年的工资水平下降了10%；1997年，乌克兰的工资下降到平均每月80美元，积压的未付工资总额超过了该国一年的工资总额；格鲁吉亚的工资在1985—1995年间下降了17%，降到每月36美元。

即使在1995—1997年间工资上涨的东欧和波罗的海等国家，也普遍以牺牲许多工作岗位为代价。通过缩小劳动力规模，新私有化的产业在国际市场上变得更有竞争力。

俄罗斯实际发放失业救济金平均每月只有35美元，但在莫斯科，每月需要57美元的生活费。而低级别工作的失业工人每月只能得到12.5美元。

168.但是并没有人能确信知晓，因为自1991年以来政府并未公开发表相关数据。

169.自二战以来，心理学在俄罗斯实际上已经消失了，1948年秋天，物理学受到了抨击。统计学家不敢公布中央委员会不满意的结论。可能是独裁主义者根本不允许自由科学探索的智力标准的存在。引自Zirkle, C., ed. Death of Science in Russia. Philadelphia:University of Pennsylvania Press, 1949。

170.Ostrander, S. and Schroeder, L., Psychic Discoveries Behind the Iron Curtain. New York: Bantam Books, 1970.

171.Polavets, V. and Bilynska, M., “Psychiatry problems related to religious boom in Ukraine in late '80s- early '90s.” In documents on the Abolition and Prevention of Political Abuse of Psychiatry, Geneva Initiative, August- September 1995, Amsterdam.

172.Centers for Disease Control and Prevention.“Frequency of vaccine-related and therapeutic injections-Romania, 1998.” Morbidity and Mortality Weekly Report 48 (1999):271-74; Hutin, Y. F., Harpaz, R, Probeniuc, J., et al., “Transmission of hepatitis B virus in Moldova.” Thirty-seventh meeting of the Interscience Conference on Antimicrobial Agents and Chemotherapy, Toronto, September 1997; Hutin, Y. F., Craciun, D., Ion-Nedelcu, N., et al., “Using surveillance data to monitor key aspects of the epidemiology of hepatitis B virus(HBV) infection in Romania.” Thirty-sixth Annual Meeting of the Infectious Disease Society of America, Denver, November 1998; and Hutin, Y. J. F., “High frequency of therapeutic injections, Republic of Moldova.” Weekly Epidemiological Record 11 (1999): 84-86.

173.Soyfer, V. N., “New light on the Lysenko era.” Nature 339 (1989): 415-20;Medvedev, Z. A., The Rise and Fall of T. D. Lysenko. New York: Columbia University Press,1969; Adams, M. B., “The Soviet experiment: Genetics, eugenics, and Lysenkoism, 1910-1990.”American Journal of Human Genetics 49S (1991): 66; Shtilmark, F. R., and Sukhomirov, G. I.,“On two trends ('schools) in the Soviet hunting science.” Biologicheskii 96 (1991): 77-87; etc..

174.Malia, M., The Soviet Tragedy: A History of Socialism in Russia, 1917-1991. New York: The Free Press, 1994.

175.从本质上说，李森科和他的支持者都是拉马克派共产主义者，尽管他们从未以此自称。让·巴普蒂斯特·皮埃尔·安托万·莫奈·德·拉马克是18世纪晚期的法国博物学家，他认为有机体自发地从环境中获得特性。拉马克举例说，如果把一个苹果放在一个密封的容器里，几天后就会“变成”一群虫子。他说，只要适应了一个新环境，它就会从一件事转变成另一件事。拉马克的观点早已遭到世界上大多数科学界人士的反对，不仅因为它们表面上的荒谬，还因为英国的查尔斯·达尔文和斯洛伐克的格雷戈·孟德尔在遗传学方面取得的开创性成果。

达尔文证明，物种确实随着时间进化，但不是拉马克所认为的自发进化的结果。相反，达尔文指出突变变异存在于任何种群中，并可能在强大的选择力量（如捕食或气候）的存在下占据优势，这些力量杀死了该物种更常见的遗传形式。

孟德尔在19世纪将经验主义引入遗传学，在当代著名的豌豆研究中表明，性状是以算术上可预测的方式从父母传给孩子的，有些性状是显性的，有些是隐性的。孟德尔的实验预示了后来的认识，即这些特征携带在DNA中，由染色体组成，父母双方将一组染色体传递到卵子中，从而产生具有各自祖先特征的后代。

176.1948年8月，李森科获得了实验室科学家不寻常的特权—他在苏联中央委员会发表讲话。他的主要主张是：“我们作为苏联米丘林主义者的代表，认为动植物在其发育过程中所获得的特性继承是可能和必要的。”

在李森科的演讲之后，中央委员会做了一件史无前例的事情—正式颁布了“正确的科学”的法令来支持李森科的观点。

177.Some experts maintain that every single Darwinist in the USSR died during the 1940s. See Malia, M., 1994, op. cit.

178.“Another refuge from Lysenko?” Nature 329 (1987): 797.

179.1949年，泽克尔简明扼要地阐述了这一点：“当知识自由不存在时，知识诚信就成了一种负担，对科学发展产生的后果将是灾难性的。”

而早在两年前，达林顿用直白的语言总结了李森科的影响：“总而言之，经过13年的迫害，在革命中形成的俄罗斯生物研究的伟大团体已经被粉碎和破坏了……科学界从来没有像现在这样，这么多的烈士为科学事业而献身，这些人也得到了全世界的人们的尊敬和爱戴。”

180.一些专家甚至认为，该地区日益增长的“切尔诺贝利综合征”观点是李森科主义的直接产物。马利亚称之为“形而上学的乌托邦主义”。

181.Stone, R., “Estonian researchers lead the way in science reform.” Science 274 (1996):29-30; and Martinson, H., The Reform of R & D System in Estonia. Estonian Science Foundation,Tallinn, 1995.

182.Holden, C., “Eastern Europe's social science renaissance.” Science 283 (1999):1 620-22.

183.See, for example, Hammond, A., Which World? Scenarios for the 21st Century.Washington, D.C.: Island Press, 1998; and Yergin, D. and Gustafson, T., 1995, op. cit.

184.1999年4月的一项调查发现，如果允许，俄罗斯选民的投票倾向如下：

来源：The Economist (April 10, 1999): 48。

185.Feshbach, M., Georgetown University, 1997, op. cit.

186.See, for example: Human Resources Division, County Dept. II. “Staff appraisal report, Russian Federation, Community Social Infrastructure Project.” The World Bank, Report No.14977-RU, 1996, Washington, D.C.; World Bank.“Bank to lend over $880 million to Russia.” World Bank News (June 12, 1997): 1-2; Office of International and Refugee Health,Gore-Chernomyrdin Commission.“Summary documentation from the fourth meeting of the GC Health Committee.” Moscow, July 12, 1996; Rosenbaum, D. E., “Requests are to include more aid to Russia.” New York Times (January 19, 1996): A15; and USAID Zdrav Reform Project. “NIS strategy development: Transforming traditions into pluralism and partnerships.” U.S. Agency for International Development, 1996, Washington, D.C.

187.Burger, E. J., Field, M. G., and Twigg, J. L., 1998, op. cit.

188.爱沙尼亚神童般的健康规划师之一、管理国家疾病保险基金的年轻的玛丽斯·杰西更直截了当地说：“我们总是把美国当作一个负面的例子。有一种信念总认为私有制是好的，公有制则不好。我们会说，‘好吧，私有制对公共卫生不太好！’”

第四章

1.Callahan, D., False Hopes: Why America's Quest for Perfect Health is a Recipe for Failure. New York: Simon and Schuster, 1998.

2.Caldwell, M., The Last Crusade: The War on Consumption 1862-1954. New York:Atheneum, 1988.

3.医院内病毒性感染的负担难以计算。美国疾控中心确信，到1985年，血液筛查和医院基本的卫生措施已经消除了艾滋病病毒在医院内的传播。但是其他的血源性病毒，特别是乙型、丙型和丁型肝炎，以及疱疹病毒，一直在医疗场所内传播，直到20世纪90年代。

4.Blau, S. P. and Shimberg, E. F., How to Get Out of the Hospital Alive. New York:Macmillan, 1997.

5.Tenover, F. C. and Hughes, J. M., “The challenge of emerging infectious diseases.”Journal of the American Medical Association 175 (1996): 300-304.

6.Jones, R. N. and Verhoef, J., Presentation to the 37th Interscience Conference on Antimicrobial Agents and Chemotherapy, Toronto, September 29, 1997.

7.作者在20世纪90年代曾多次采访过汉堡和纽约的其他卫生专家。除非本节另有说明，个别人士的评论和意见都是从这些访谈中收集的。

8.Raad, I. and Darouchie, R. O., “Catheter related septicemia: risk reduction,” Infection and Medicine 13 (1996): 807-812; 815-816; 823. And Raad I., “Intravascular-catheterrelated infections,” Lancet 351 (1998): 893-898.

9.Austrian, R., “Confronting drug resistant Pneumococci.” Annals of Internal Medicine 121 (1994): 807-809.

10.Gleason, P. P., Kapoor, W. M., Stone, R. A., et al., “Medical outcomes and antimicrobial costs with the use of the American Thoracic Society guidelines for outpatients with community-acquired pneumonia.” Journal of the American Medical Association 278(1997): 32-39.

11.Garrett, L., “Tough bugs thrive.” Newsday (November 21, 1996): A20.

12.Patterson, J. E., “Making real sense of MRSA.” Lancet 348 (1996): 836-837.

13.Boyce, J. M., Opal, S. M., Chow, J. W., et al., “Outbreak of multidrug-resistant Enterococcus faecium with transferable vanB class vancomycin resistance.” Journal of Clinical Microbiology 32 (1994): 1148-1153; Fan, C., Moews, P. C., Walsh, C. T., et al., “Vancomycin resistance: Structure of D-alanine: D-alanine ligase at 2.3A resolution.” Science 266(1994):439-443; Gilmore, M. S. and Hoch, J. A., “A vancomycin surprise.” Nature 399 (1999): 524-527; and Novak, R., Henriques, B., Charpentier, E., “Penicillinase resistant S. pneumoniae with decreased vancomycin susceptibility.” Nature 399 (1999): 590-593.

14.Farrag, N., Eltringham, I., and Liddy, H., “Vancomycin-dependent Enterococcus faecalis.” Lancet 348 (1996): 1581-1582.

15.Blau, S. P. and Shimberg, E. F., 1997, op. cit.; Bolognia, J. L. and Edelson, R. L., “Spread of antibiotic-resistant bacteria from acne patients to personal contacts—a problem beyond the skin?” Lancet 350 (1997): 972-973; Burnie, J. P. and Loudon, K. W., “Ciproloxacinresistant Staphylococcus epidermis and hands.” Lancet 349 (1997): 649; Caul, E. O.,“Small round structured viruses: Airborne transmission and hospital control.” Lancet 343 (1994):1240-1241; Centers for Disease Control and Prevention, “Bronchoscopy-related infections and pseudoinfections—New York, 1996 and 1998.” Mortality and Morbidity Weekly Report 48 (1999): 557-560; Centers for Disease Control and Prevention, “Multistate outbreak of hemolysis in hemodialysis patients—Nebraska and Maryland, 1998.” Mortality and Morbidity Weekly Report 47 (1998): 483-484; etc..

16.哥伦比亚长老会，曼哈塞特的北岸大学医院和朗格斯兰犹太医院。详见Lam, S.,Singer, C., Tucci, V., et al., “The challenge of vancomycin-resistant enterococci: A clinical and epidemiologic study.” American Journal of Infection Control 23 (1995): 170-180。

17.Rice, L., Presentation to the annual meeting of the Infectious Diseases Society of America, San Francisco, September 15, 1997.

18.Rahal, J., Presentation to the annual meeting of the Infectious Diseases Society of America, San Francisco, September 15, 1997.

19.前抗生素时代的另一种杀死细菌的方法是使用噬菌体或细菌病毒。如果经过适当的培养和纯化，噬菌体对人类无害，但可以消灭特定细菌种类的所有细菌。19世纪末，德国的保罗?埃尔利希对这种噬菌体进行了实验，称其为对抗疾病的灵丹妙药。一个世纪后，由于担心抗生素时代即将结束，格鲁吉亚第比利斯的研究人员与西方制药公司合作，在抗生素真正失效之前再次开发噬菌体技术。详见Osborne, L., “A Stalinist antibiotic alternative,”New York Times Magazine; 2000: February 6, 50-55。

20.Senate Committee on Investigations. The Growing Menace of Bacterial Infections.Albany: New York State Senate, 1999.

21.In addition to the Senate report, see Roberts, R., Tomasz, A., and Kreiswirth, B., Antibiotic Resistance in New York City: A Growing Public Health Threat and a Proposal for Action. New York:Bacterial Antibiotic Resistance Group, 1995.

22.For details spanning 1600 to 1776 in New York, Boston, Philadelphia, and other colonial cities, see Carlson, L. W., A Fever in Salem. Chicago: Ivan R. Dee Publisher, 1999; Duffy,J., Epidemics in Colonial America. Baton Rouge: University of Louisiana Press, 1953; Duffy, J., A History of Public Health in New York City. New York: Russell Sage Foundation, 1968; McKeown, T.,The Origins of Human Disease. Cambridge, Mass.: Basil Blackwell, 1988; McKeown, T., The Role of Medicine: Dream, Mirage, or Nemesis? Princeton: Princeton University Press, 1979; McNeill, W. H.,Plagues and Peoples. New York: Anchor Books, 1977; Porter, R., The Greatest Benefit to Mankind.New York: Harper Collins, 1997; Powell, J. M., Bring Out Your Dead. Philadelphia: University of Pennsylvania Press, 1949; Watts, S., Epidemics and History. New Haven: Yale University Press, 1998.

23.

1679—1873年纽约市传染病数据统计表

（不含结核病）

数据来自多处文献资料，包括Condran, G., “Changing patterns of epidemic disease in New York City.” In D. Rosner, editor. Hives of Sickness: Public Health and Epidemics in New York City.New Brunswick, N.J.: Rutgers University Press, 1995; Duffy, J., A History of Public Health in New York City, 1625-1866. New York; Russell Sage Foundation, 1968; Duffy, J., Epidemics in Colonial America. Baton Rouge: Louisiana State University, 1953; Emerson, H. and Hughes, H. E., Populations,Births, Notifiable Diseases, and Deaths, Assembled for New York City, New York, 1866-1938, from Official Records. New York: The DeLamar Institute of Public Health, Columbia University, 1941; and Rosenwaike, I., Population History of New York City. New York: Syracuse University Press, 1971。