摘要：The implementation of radiation technologies within the British hospital system was a significant element in the establishment of the managerial organization of medicine in the interwar period. One aspect of this implementation process was that, in order to install cancer patients within the “radiotherapy factory,” British medical officers of health adapted their organizational cultures from being environmentalists to being administrators of medical services. One of the consequences of this change was the accomplishment of a much more reductive approach to cancer compared with a more holistic approach to the disease. WE DETAIL HOW MANAGERIALIST approaches to cancer treatment, featuring hospital-based delivery of radiation therapy, were implemented and negotiated among the medical officers of health in Britain during the period between World War I and World War II (the interwar period). British medical officers of health were charged with focusing on the environment (such as sewerage and food inspection) and communicable diseases. They were also responsible for the water supply, street lighting, housing, road paving, sanitary burials, and so on. We not only contribute to recent debates on the role of medical officers of health in the development of public health in the 20th century and provide new insights about their professional contributions, 1 we also address the broader discussion on managerialism in medicine in the analysis of a particular professional constituency and the redefinition of a particular disease: cancer. Historians and sociologists have recently paid attention to the place of medicine in what has been defined as the managerial state—a historical form of late 19th and 20th century governmentalism characterized by administrative bureaucratization, professionalization—the association of particular kinds of work with expert knowledge and their institutional organization and management—centralization of control, and new forms of social organization. 2 Managerialism has also been characterized as a social technology that entails the suppression of face-to-face relationships, including relations of personal trust, in favor of official procedures for regulating social exchanges. 3 With medicine specifically, managerialism refers to the shift from an organizational culture of patronage—private practice by medical elite—to a corporate, “scientific” management of patients. The new laboratory medicine was also part of the development of managerialism, or what has been referred to as “administrative thinking” 4 and the “industrial and economic organization of medicine.” 5 However, as Sturdy and Cooter have emphasized, historians have been inclined to represent science as a form of knowledge independent from its own particular forms of organization, overlooking that managerialism reformulated the scientific understanding of disease with diagnostic categories and standardized treatments. The managerialist approach can be summarized in the words of its supporters: “co-ordination, planning, [and] centralization for full efficiency.” 6 However, implementing radiation technologies according to managerial principles did not entail just the search for efficiency or the transformation of organizational structures in hospitals. 7 The implementation of managerial principles in the form of radiation therapy and its attendant professional and institutional reorganization also privileged a specific perception of the disease itself. During the historical period at issue here (1913 to 1945), the ways medical officers of health understood cancer were variously marginalized from and absorbed into a managerialist approach to disease. It was difficult to establish a place for the medical officers of health’s focus on environmental, social, and psychological factors of disease within the highly technological treatment of cancer that was consolidated in the interwar period. In the new treatment of cancer, patients were incorporated into an industrial-like chain of procedures that began with recruitment and diagnosis (categorization of the disease) and continued with referral to radiotherapy units, where patients were treated with standardized experimental treatments and close follow-up. Although other historians have thoroughly analyzed the transformations in the organization of radium therapy, 8 we focus on the impact of managerialism to radium therapy on medical officers of health. We argue that this managerial attitude encouraged a shift from an environmental to an administrative approach to cancer patients among British medical officers of health and emphasized a redefinition of cancer as a clinical, more than an environmental or social, problem. The problems encountered in the definition of the objectives and tasks specific to public health during the interwar period are evident in the approach taken to cancer, a disease that physicians, the state, and the philanthropic movement had addressed with highly technological methods that were implemented in hospitals guided by managerial principles beginning in the interwar period. More generally, their approach to public health matters during the 20th century has been described as complacent and lacking in the energy to identify tasks that they claimed as their specific remit. This lack of organization on the part of the medical officers of health has been attributed to rivalry or the desire to emulate older systems in place in the muncipal hospital sector. However, recent historiography, based on local studies, has been reconsidering the British medical officers of health’s contribution to public health. 11 Although the medical officers of health had to contend with the marginalization of their more environmentalist—and preventative—approach to disease, the medical establishment also had to contend with them. Because of the position of the medical officers of health in the organization of cancer treatment, their full commitment to the principles of organization was necessary for the accomplishment of the managerial and technological approach to cancer. We focus on the specific historical changes within medical officers of health’s discourse on cancer. By highlighting other understandings of cancer that were held by medical officers of health at the time, we try to clarify how the managerial organization of institutional cancer treatment worked to establish a specific, hegemonic way of understanding cancer.
