Evans David
Bristol North Primary Care Trust, King Square House, King Square, BS2 8EE Bristol, UK.
Soc Sci Med. 2003 Sep;57(6):959-67. doi: 10.1016/s0277-9536(02)00473-2.
Until recently, a medical qualification was required for senior public health posts in the UK National Health Service. Since 1997, the new Labour government has expressed its intention to take public health 'out of the ghetto' and to develop multi-disciplinary public health. In particular, it has announced the creation of a new senior professional role of specialist in public health equivalent to the consultant in public health medicine, and open to a range of disciplines. This paper asks 'what is really going on with the policy and practice of multi-disciplinary public health in the UK?' The answer draws on recent debates in the sociology of the professions, in particular the theoretical perspectives of Freidson (Profession of Medicine: a Study of the Sociology of Applied Knowledge, Dodd, Mead & Co, New York, 1970; Professional Powers: a Study of the Institutionalization of Formal Knowledge, University of Chicago Press, Chicago, 1986) and Larson (The Rise of Professionalism: a Sociological Analysis, University of California Press, Berkeley, 1977) concerning the 'professional project', Foucault's (Ideol. Consciousness 6 (1979) 5) notion of 'governmentality' and Harrison and Wood's (Public Admin. 77 (1999) 751) concept of 'manipulated emergence'. Key characteristics of the professional project are 'autonomy', the profession's ability to control its technical knowledge and application, and 'dominance', control over the work of others in the health care division of labour. Although useful as an explanatory framework for the period 1972-1997, the concept of the professional project does not easily explain the process of change since 1997. Here Foucault's concept of governmentality is helpful. Governmentality entails all those procedures, techniques, mechanisms, institutions and knowledges that empower political programmes. Professions are part of the process of governmentality, and their autonomy is always contingent upon the wider political context. Thus public health doctors have not abandoned the professional project; they have simply accepted the political reality that the boundaries need to shift rapidly from a politically unsustainable medical/non-medical distinction to one between those with and without expert knowledge. The concept of manipulated emergence helps explain why, having expressed a commitment towards multi-disciplinary public health, the government has not supported its policy more fully.
直到最近，英国国民医疗服务体系中高级公共卫生职位还要求具备医学资格。自1997年以来，新工党政府表示有意将公共卫生“从边缘地带解放出来”，并发展多学科公共卫生。特别是，政府宣布设立一个新的高级专业职位——公共卫生专家，相当于公共卫生医学顾问，并且面向一系列学科开放。本文探讨“英国多学科公共卫生的政策与实践究竟是怎么回事？”答案借鉴了职业社会学领域最近的一些辩论，特别是弗里德森（《医学职业：应用知识社会学研究》，多德·米德公司，纽约，1970年；《职业权力：形式知识制度化研究》，芝加哥大学出版社，芝加哥，1986年）和拉森（《专业主义的兴起：社会学分析》，加利福尼亚大学出版社，伯克利，1977年）关于“职业计划”的理论观点，福柯（《意识形态与意识》6（1979年）5）的“治理术”概念，以及哈里森和伍德（《公共行政》77（1999年）751）的“操纵性涌现”概念。职业计划的关键特征是“自主性”，即职业控制其技术知识和应用的能力，以及“主导性”，即在医疗保健分工中对他人工作的控制。尽管职业计划的概念作为1972年至1997年期间的一种解释框架很有用，但它并不容易解释1997年以来的变革过程。在此，福柯的治理术概念很有帮助。治理术包含所有那些赋予政治计划权力的程序、技术、机制、机构和知识。职业是治理术过程的一部分，它们的自主性总是取决于更广泛的政治背景。因此，公共卫生医生并没有放弃职业计划；他们只是接受了这样一个政治现实，即界限需要迅速从政治上不可持续的医学/非医学区分，转变为有专业知识者与无专业知识者之间的区分。操纵性涌现的概念有助于解释为什么政府虽然表示致力于多学科公共卫生，但却没有更充分地支持其政策。
