想要修復公共衛生嗎？ 別再像醫生一樣思考了。
公共衛生需要從集體的角度看世界，但美國機構仍然由接受過個人工作訓練的醫生主導。
艾瑞克·萊因哈特 / 2023 年 3 月 6 日 / The Nation
美國國家過敏症和傳染病研究所所長安東尼·福奇在 2022 年的新聞發布會上。
（Ken Ceden / Getty Images）
美國公共衛生領域的換崗即將到來，隨之而來的是一個重振搖搖欲墜的領域的機會。 安東尼·福奇（Anthony Fauci）在歷史上最嚴重的可預防災難之一的陰影下退休，拜登總統正在做出新的任命，同時建立一個永久性的白宮流行病防範和應對政策辦公室。 在這樣做的過程中，拜登和他的顧問必須面對這樣一個事實：公共衛生領域的惡化是結構性的：不能透過簡單地輪調負責公共衛生的傀儡來治癒這個問題。 建立有效的國家衛生基礎設施需要正視普遍存在的公共衛生扭曲現象，並重新制定導致美國公共衛生機構受制於黨派利益的領導任命制度。
該領域的逐漸醫療化是導致公共衛生脆弱並成為黨派政治玩物的部分原因。 例如，考慮美國最重要的公共衛生機構的歷史。 自 1953 年以來，美國疾病管制與預防中心 (CDC) 的每位主任都擁有醫學博士或 (醫師，MD) 之學位作為其主要學歷，而次級的學位則主要作為簡歷的裝飾。 鑑於醫療介入僅佔影響健康的可改變因素的10-20%，CDC以及大多數州和地方公共衛生機構領導層所反映的背景值得注意的是，他們始終優先考慮狹隘的生物醫學專業知識的花費，而犧牲了在制定公共衛生政策上所代表剩餘 80-90%之其他領域的相關知識。
身為醫生兼具公共衛生學者之米爾頓·羅默（Milton Roemer）曾觀察到，對於公共衛生工作來說，「大部分醫學教育都是無關緊要的」。然而既非是醫師不相關的醫學知識抑非是對勞動史、社會人類學、政治經濟學、流行病學、環境科學等重要領域上相對的無知，這都不是醫生控制公共衛生的最令人不安的方面。 相反地，這是缺乏認識上的謙遜，導致他們無法認識到臨床推理的局限性和危險，而醫學培訓卻經常灌輸這樣的觀點。臨床推理不僅不是公共衛生基於人群層面上的邏輯，它更常常與之相反。
臨床治療的危害
當我們治療病人時，醫生會適當地關注照顧我們面前的人。 我們認識到，我們通常無法改變他們的生活環境，例如經濟和住房條件、雇主的要求、學債和醫療債務、鄰里暴力或社會孤立，因此我們在現有的限制下將臨床注意力集中在幫助他們在盡可能好的情況下生活。
相較之下，公共衛生的重點是治療族群。 與醫學一樣，公共衛生的目標是使個人充能以擺脫限制他們隨心所欲地生活的能力之健康限制，從而。 但公共衛生部門透過非常不同的方式來實現這一目標。 我們的任務不是幫助個人適應壓迫性的社會或勞動環境。 相反地，它是利用政府的權力來改變限制人們自由的條件。 因此，公共衛生的核心工具不僅是疫苗或實驗室檢測，還包括與企業監管和消費者安全標準相關的政策；勞動保護；公共就業和住房計畫；並對社區衛生工作者、去刑事化和解除監禁上的投資；以及民權訴訟。
Want to Fix Public Health? Stop Thinking Like a Doctor.
Public health requires seeing the world from a collective perspective, but US agencies are still dominated by doctors trained to work on an individual level.
ERIC REINHART / The Nation
Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, during a news conference in 2022.(Ken Cedeno / Getty Images)
This article appears in the March 6/13, 2023 issue.
Achanging of the guard in US public health is impending—and, with it, a chance to rejuvenate a flailing field. Anthony Fauci has retired in the shadow of one of the worst preventable disasters in history, and President Biden is moving to make new appointments while establishing a permanent White House Office for Pandemic Preparedness and Response Policy. In doing so, Biden and his advisers must confront the fact that the rot in public health is structural: It cannot be cured by simply rotating the figureheads who preside over it. Building effective national health infrastructure will require confronting pervasive distortions of public health and remaking the leadership appointment systems that have left US public health agencies captive to partisan interests.
Part of what has made public health vulnerable and a plaything of partisan politicking is the field’s gradual medicalization. Consider, for example, the history of the nation’s most important public health agency. Since 1953, every director of the Centers for Disease Control and Prevention (CDC) has had a doctor of medicine, or MD, degree as their primary credential, with secondary degrees serving mostly as résumé decor. Given that medical interventions constitute only 10–20 percent of modifiable factors affecting health, the backgrounds reflected in CDC leadership—and, likewise, at most state and local public health agencies—are notable for their consistent prioritization of narrow biomedical expertise at the expense of other fields that represent the remaining 80–90 percent of pertinent knowledge for making public health policy.
Physician and public health scholar Milton Roemer once observed that for the work of public health, “most of medical education is irrelevant.” But neither doctors’ irrelevant medical knowledge nor relative ignorance of essential fields—labor history, social anthropology, political economy, epidemiology, environmental sciences—is the most troubling aspect of physician control of public health. Rather, it’s the lack of epistemic humility, conferring an inability to recognize the limits and hazards of clinical reasoning, with which medical training often imbues them. Clinical reasoning is not only not the population-level logic of public health; it is frequently antithetical to it.
The Hazards of Clinicism
When we treat patients, doctors are appropriately oriented around taking care of the individual in front of us. We recognize that we typically cannot change their life circumstances—such as economic and housing conditions, employers’ demands, student and medical debt, neighborhood violence, or social isolation—and so we focus our clinical attention on helping them live as well as possible within existing constraints.
Public health, by contrast, is about treating populations. As with medicine, the goal of public health is to enable individuals to be free of health limitations that curtail their ability to live as they please. But public health pursues this by very different means. The task is not to help individuals accommodate to oppressive social or labor contexts. It is instead to use the power of government to change conditions that are constraining people’s freedom. The core tools of public health, then, are not just vaccines or lab tests but also policies pertaining to corporate regulation and consumer safety standards; labor protections; public jobs and housing programs; investments in community health workers, decriminalization, and decarceration; and civil rights lawsuits.