If you’re not rich and you get sick, in which industrialized country are you likely to get the best treatment?

如果您并不富有却生病了，在哪个工业化国家最有可能得到最好的医疗呢？

The conventional answer to this question has been: anywhere but the United States. With its many uninsured citizens and its relatively low life expectancy, the United States has been relegated to the bottom of international health scorecards.

这个问题的传统答案是：除了美国，哪里都行。由于其许多无医保的国民和相对较低的预期寿命，美国屈居世界医疗卫生排名榜的末位。

But a prominent researcher, Samuel H. Preston, has taken a closer look at the growing body of international data, and he finds no evidence that America’s health care system is to blame for the longevity gap between it and other industrialized countries. In fact, he concludes, the American system in many ways provides superior treatment even when uninsured Americans are included in the analysis.

但是，一位名叫塞缪尔H普雷斯顿的知名研究人员对大量的各国数据仔细研究后发现，没有证据显示美国的医疗卫生系统需要对本国国民和其他工业化国家国民的寿命差距负责。

普雷斯顿断定，实际上，即便把未享受到医保的那部分国民也纳入分析，美国的医疗卫生制度也是在很多方面提供了优异的医疗服务。

“The U.S. actually does a pretty good job of identifying and treating the major diseases,” says Dr. Preston, a demographer at the University of Pennsylvania who is among the leading experts on mortality rates from disease. “The international comparisons don’t show we’re in dire straits.”

普雷斯顿是美国宾夕法尼亚大学的人口学家，疾病死亡率方面的首席专家。他说：“美国实际上在重大疾病的诊断和治疗方面做得相当不错，世界各国间的对比不能说明我们处境悲惨。”

No one denies that the American system has problems, including its extraordinarily high costs and unnecessary treatments. But Dr. Preston and other researchers say that the costs aren’t solely due to inefficiency. Americans pay more for health care partly because they get more thorough treatment for some diseases, and partly because they get sick more often than people in Europe and other industrialized countries.

众所周知美国的医疗制度一直倍受责难，包括高昂的医疗费用支出和过度治疗。普雷斯顿博士说，高昂的医疗费用并非只归咎于效率低。美国人之所以在卫生保健上的支出庞大，一部分是因为某些疾病受到了更为彻底的治疗，另外一部分原因则在于他们比欧洲和其他工业化国家的国民更容易生病。

An American’s life expectancy at birth is about 78 years, which is lower than in most other affluent countries. Life expectancy is about 80 in the United Kingdom, 81 in Canada and France, and 83 in Japan, according to the World Health Organization.

美国人出生时的平均预期寿命大约是78岁，这比大多数富裕国家的国民寿命要低。据世界卫生组织的统计，英国的国民预期寿命是80岁，加拿大和法国是81岁，日本是83岁。

This longevity gap, Dr. Preston says, is primarily due to the relatively high rates of sickness and death among middle-aged Americans, chiefly from heart disease and cancer. Many of those deaths have been attributed to the health care system, an especially convenient target for those who favor a European alternative.

普雷斯顿博士说，这个寿命之间的差距，主要归咎于美国中年人的相对高患病率和高死亡率（主要为心脏病和癌症）。许多美国人的死亡被怪罪到了医疗卫生体制的弊端，对那些鼓吹欧洲健保模式的人来说，美国的体制真是个方便的靶子。

But there are many more differences between Europe and the United States than just the health care system. Americans are more ethnically diverse. They eat different food. They are fatter. Perhaps most important, they used to be exceptionally heavy smokers. For four decades, until the mid-1980s, per-capita cigarette consumption was higher in the United States (particularly among women) than anywhere else in the developed world. Dr. Preston and other researchers have calculated that if deaths due to smoking were excluded, the United States would rise to the top half of the longevity rankings for developed countries.

但是美国和欧洲的医疗卫生体制之外还有其它更多差异。美国是多民族国家，他们的食谱不同，他们更胖。而最重要的是，通常他们烟抽的更凶。四十年来，直到80年代中期，美国的人均香烟消费比任何发达国家都高（尤其是美国妇女）。普雷斯顿博士和其他研究人员统计，若排除吸烟造成的死亡，美国就能在发达国家的寿命排行榜上排到中游以上。

As it is, the longevity gap starts at birth and persists through middle age, but then it eventually disappears. If you reach 80 in the United States, your life expectancy is longer than in most other developed countries. The United States is apparently doing something right for its aging population, but what? 事实上，寿命差距始于出生，到中年时依然存在，再往后就消失了。若你在美国活到了80岁，你的预期寿命将会比大多数发达国家国民的预期寿命更长。美国在老龄人口的医疗保健方面做了一些什么呢？

One frequent answer has been Medicare. Its universal coverage for people over 65 has often been credited with shrinking the longevity gap between the United States and other developed countries.

一个常见的答案是老龄人口医疗保险。它完全覆盖了65岁以上的国民，因此被看作是缩小了美国和其他发达国家国民预期寿命差距的原因。

But when Dr. Preston and a Penn colleague, Jessica Y. Ho, looked at mortality rates in 1965, before Medicare went into effect, they found an even more pronounced version of today’s pattern: middle-aged people died much more often in the United States than in other developed countries, but the longevity gap shrunk with age even faster than today. In that pre-Medicare era, an American who reached 75 could expect to live longer than most people elsewhere.

但是，普雷斯顿和宾夕法尼亚大学的同事杰西卡Y何研究了1965年的国民死亡率，那时，医保制度尚未生效，能够更清楚明白地看出：美国的中年人比其他发达国家的中年人死亡率更高，但是随着年龄增长，寿命差距缩小得甚至比今天更快。在那个无医保时代，活到75岁的美国人要比大多数其他国家的人活得更久。

Besides smoking, there could be lots of other reasons that Americans are especially unhealthy in middle age. But Dr. Preston says he saw no evidence for the much-quoted estimates that poor health care is responsible for more preventable deaths in the United States than in other developed countries. (Go to nytimes.com/tierneylab for details.)

除了吸烟，还有更多的原因导致美国人中年时健康状况不佳。普雷斯顿博士说，没有证据支持此类被多方引用过的猜测：因为美国的医疗保健措施不良，导致可预防的死亡人数多于其他发达国家。

For all its faults, the American system compares well by some important measures with other developed countries, as Dr. Preston and Ms. Ho enumerate. Americans are more likely to be screened for cancer, and once cancer is detected, they are more likely to survive for five years.

普雷斯顿博士和何女士说，尽管存在种种缺陷，美国的医疗卫生体制仍然比其他发达国家采用的措施更好。美国人有更多机会接受癌症的筛查，一但被诊断患有癌症，他们的五年存活律更高。

It’s been argued that the survival rate for cancer appears longer in America merely because the disease is detected earlier, but Dr. Preston says that earlier detection can be an advantage in itself, and that Americans might also receive better treatment. He and Ms. Ho conclude that the mortality rates from breast cancer and prostate cancer have been declining significantly faster in the United States than in other industrialized countries.

关于美国人的癌症存活期更长只是因为癌症被诊断得更早的说法，一直存在争议。普雷斯顿博士说，不仅因为受惠于早期诊断，而且美国人还能受到更好的治疗。他和何小姐得出的结论是：美国的乳腺癌、前列腺癌的死亡率下降的速度比其他工业发达国家快得多。

Americans also do relatively well in surviving heart attacks and strokes, and some studies have found that hypertension is treated more successfully in the United States. Compared with Europeans, Americans are more likely to receive medication if they have heart disease, high cholesterol, lung disease or osteoporosis.

美国人突发心脏病和中风的存活率也相对不错，研究发现，美国的高血压病治疗更为成功。和欧洲相比，美国人有更多的机会受到心脏病、高胆固醇、肺病和骨质疏松症方面的药物治疗。

But even if the American system does provide more treatment for more sick people, couldn’t it do something to reduce its workload?

但就算美国的医疗卫生制度没能给更多的患者提供更充分的医疗，就没有办法降低负担了么？

When I brought up Dr. Preston’s work to Ellen Nolte and C. Martin McKee, two prominent European critics of the American system, they suggested that he was taking too limited a view of health care. They said the system should take responsibility for preventing disease, not just treating it.

当我把普雷斯顿博士的结论拿给欧洲著名的两位美国医疗卫生系统评价家，艾伦诺尔蒂和C马丁麦基，这两位专家评论说，普雷斯顿博士关于医疗卫生系统的看法有局限性，医疗卫生系统的责任应该包括预防疾病，而不仅仅是治病。

Dr. Preston acknowledges that the United States might do more to keep young and middle-aged people from getting sick, but he says it’s not clear that other countries’ systems are more effective.

普雷斯顿博士也承认，美国应该更重视维护年轻人和中年人的健康，降低他们染病的可能，不过他不认为，其他国家在这方面就一定做得更好。

“The U.S. has had one spectacular achievement in preventive medicine,” he says. “It has had the largest drop in cigarette consumption per adult of any developed country since 1985.” If Americans keep shunning cigarettes, the longevity gap could shrink no matter what happens with the health care system.

普雷斯顿博士说：“美国在预防医学领域有一项卓著成就，从1985年起，美国的人均香烟消费在发达国家当中降幅最大。” 如果美国人能坚持不吸烟，那么无论美国的医疗卫生体制状况如何，美国人和其他发达国家国民之间的寿命差距都会缩小