Beyond meaning, discourse and the empirical world: critical realist reflections on health

Beyond Meaning, Discourse and theEmpirical World: Critical RealistReflections on Health

SIMON J WILLIAMS

Centre for Research in Health, Medicine and Society, Department of Sociology,University of Warwick, UK E-mail: [email protected]

This paper provides a series of critical realist (CR) reflections on the limits of

approaches, within and beyond the sociology of health and illness, which begin

and end with meaning, discourse and the empirical world. The first part of the

paper provides a brief review of traditions, trends and tensions within the

sociology of health and illness, with particular reference to the shortcomings of

positivist and interpretivist legacies. This in turn provides a backdrop and paves

the way, in the second main part of the paper, for a detailed discussion of the

merits of CR in moving beyond these former impasses, with particular reference to

(i) non-conflationary approaches to ontological and epistemological matters,

(ii) principles of stratification and emergence, (iii) habitus and the ‘primacy’ of

practice, and (iv) the (morphogenetic) relationship between structure and agency.

The relevance of these insights to health is then hammered home in the third part of

the paper, through three key examples of realist research in action, so to speak. The

paper concludes with some further reflections on the promise and potential of

critical realism for health, as an ‘underlabouring philosophy’, and the future agendas

it signals.

Social Theory & Health (2003) 1, 42–71. doi:10.1057/palgrave.sth.8700004

Keywords: critical realism; health; positivism; interpretivism; biology; practice;

structure–agency; inequalities

Social Theory & Health, 2003, 1, (42–71)r 2003 Palgrave Macmillan Ltd All rights reserved. 1477-8211/03 $25.00

www.palgrave-journals.com/sth

I am a man for whom the outside world exists (Theophile Gautier: Histoirede Romantisme)

Human kind/Cannot bear very much reality (T.S. Eliot, Four Quartets ‘BurntNorton’, 1)

INTRODUCTION

There are many ways to study or carve the world up, sociologically speaking.Dawe (1971), for example, speaks of ‘two sociologies’, both of which emergedfrom a reaction to the Enlightenment. One takes as its problem theestablishment of social order and asserts the ontological primacy of socialsystems and social structures over social actors. To the extent that individualmotive and intention is theorised, it is said to derive from the central societalvalue system, hence the charge of the ‘over-socialised’ concept of man(Wrong, 1961). The second ‘tradition’, in contrast, is premised on the notionof ‘autonomous’ man and takes as its problem the critical question of howhumankind can achieve control over the institutions that it creates. Thus avocabulary of social action, will and agency follow: society is the creation orconstruction of its members, not a reified entity or reality sui generis.

These views in turn mesh more or less closely with key (methodological)debates of the positivist versus interpretivist kind. While positivists mimic orhanker after a natural science model for the social sciences – onecharacterised by a commitment to instrumental knowledge, the observablecum empirical world, ‘hard’ data, the separation of facts from values, and soforth – interpretivists distinguish between the subject matter of the naturaland social sciences, and the methods appropriate to each, thereby placing apremium upon meaning (hermeneutics) and the inter-subjective cum sociallyconstructed world.

In part, these traditions and debates continue to the present day, aswitnessed, for example, in various strands of thinking in which structure ispitted against agency, objectivity against subjectivity, quantitative againstqualitative, reason against emotion, and so forth. In part, however, they havebeen challenged if not superseded by other recent developments that seek, onthe one hand, new ways of combining or reconciling these former (sterile)divisions – as in structuration theory or its morphogenetic rival, and variousother methodological debates that seek to break down the quantitative/qualitative divide1 – and, on the other hand, to liquidate any such(modernist) dualistic terms of reference, through the relativising twists andthe discursive/deconstructive desires of postmodernism/poststructuralism.

SJ WilliamsBeyond Meaning Discourse and the Empirical World

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Social Theory & Health

In this paper I take a closer look at these legacies, and the problems theyraise, as played out in the sociological field of health. The focus, in doing so,is on the limits of approaches that begin and end with meaning, discourseand/or the observable/empirical world. The paper, in this respect, tackles keyquestions to which this fledgling journal is devoted, from the problems ofpositivism to the dilemmas of postmodernism, and from the credibility of laytheorising to the role and scope of social theory in explaining health(inequalities). The underlying argument here, it will be apparent, in keepingwith other recent critiques in this vein (Forbes and Wainwright, 2001;Wainwright and Forbes, 2000; Scambler, 2002) is critical in content and realistin tone, a critical realist (CR) stance in fact, which provides a viable defenceand a re-vindicated ontology of the (stratified) world, including deep,enduring structures and mind-independent generative mechanisms, resistingformer pitfalls and conflationary traps along the way.

The paper, essentially, falls into three main parts. The first, fittinglyenough, takes a brief, preliminary look at the current state of play within thesociology of health and illness. This in turn paves the way, building on theabove-mentioned critiques, for the airing of a series of (critical) realist pointsand principles which, without discounting these former insights, takes us farbeyond the empirical, meaningful, discursively constructed world. Therelevance of these insights to health is then hammered home in the thirdsection of the paper, which showcases three concrete examples of realistresearch, thereby underlining how the world may profitably be ‘put backtogether again’ in precisely these terms – an ontologically stratified andepistemologically diverse world at that. The paper ends with some concludingremarks on these issues and their implications for current and futureresearch, in health and beyond.

What then of the current state of play within the sociology of health andillness? Where are we now? It is to this preliminary question that we nowturn, as a backdrop to the paper as a whole and a foil for the (critical) realistarguments that follow.

TRADITIONS, TRENDS AND TENSIONS IN THE SOCIOLOGY OF HEALTH ANDILLNESS: POSITIVISM, INTERPRETIVISM AND BEYOND

Medical sociology, or the sociology of health and illness as it is now morecommonly known (Gerhardt, 1989; Stacey and Homans, 1978), is a diverseand vibrant field of inquiry comprising an eclectic array of theoreticalperspectives and substantive areas of research. Any attempt at summarytherefore is bound to be partial, if not problematic. It is possible, nonetheless,


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to point toward certain traditions, trends and tensions that, for presentpurposes at least, provide instructive points of reference in any suchundertaking.

Neo-positivism and the Empirical World: The Search for Regularities andthe Challenge of the Gradient

First, of course, there has been a long tradition of empirical research intoinequalities in health which, broadly speaking, suggest an inverse relation-ship between social class position, health status and longevity (Townsendand Davidson, 1982). Much of this, until quite recently, remains heavilyindebted to a social ‘book-keeping’ or epidemiological perspective, withsocial class position conceptualised in largely a-theoretical terms; measured,in the main, through the Registrar General’s (RG’s) classification ofoccupation. The identification and description of more or less ‘patterned’statistical relationships between indicators of occupational class, indicators ofmorbidity and mortality, and factors that might mediate between the two, hasin this respect been a characteristic feature if not a core concern of thisresearch. Inequalities in health it is clear, given this accumulating body ofevidence, have not only persisted, but have actually widened in some cases(Shaw et al., 1999), with Britain faring relatively poorly compared to otherEuropean countries such as Sweden (Acheson, 1998).

Research has also proceeded apace on the relative role and contributionof the four different explanations first laid out in the seminal Black Report of1980 (Townsend and Davidson, 1982) – work that ranges from a criticalreassessment of artefact (Bloor et al., 1987) and health-selection explanations(West, 1991; Blane et al., 1993), to the ‘biological programming’ of socialdisadvantage in utero (Barker, 1991) and the importance of longitudinalresearch across the lifecourse (Wadsworth, 1997; Blaxter, 2000). Wilkinson’s(1996, 2000a) work on income inequalities adds another importantdimension to these research agendas, bringing psychosocial factors andsocial relativities into the picture, including issues of social cohesion, capitaland trust. This in turn has provoked a lively series of debates, themselveshinting at if not ushering in a new era of more rigorous attempts toadequately theorise these and other relations, including a resurgence of neo-materialist and neo-liberal critiques (of which more below).

Much of this work however, both past and present, remains trappedwithin a neo-positivist paradigm (Forbes and Wainwright, 2001), explicitlystated or not, the limits of which are all too apparent. What this amounts to,in effect, as the foregoing discussion suggests, is a commitment to theempirical, observable, measurable world, as exemplified in the survey: onewhich, to a large extent, ‘de-contextualises’ and ‘atomises’, losing the very


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dynamics of these relationships in the process (Popay et al., 1998).Relationships in this respect, as Wainwright and Forbes rightly comment,‘exist in the mathematical world of survey statistics and not in the socialworld which is determined not by numbers but by human relationships andpower’ (2000, p. 264). This in turn highlights yet another major weakness ofthe positivist approach, namely that it is geared toward ‘prediction and notexplanation’. Positivists, that is to say,‘confuse predictive success (in this casethe relationship between variables within survey data) with both causationand explanation’ (Wainwright and Forbes, 2000, p. 265).

Lay Beliefs/Knowledge: Who are the ‘Experts’?

A second key arena of research, in many ways the (interpretivist) counterpartto these neo-positivist research agendas, concerns ongoing research into layconcepts and ideas, beliefs and knowledge, attitudes and accounts of health,illness and disease causation. Classic studies in this vein, to mention but afew, include Blaxter’s (1983) early work on women’s ideas about diseasecausation; Helman’s (1986) analysis of folk classifications of ‘colds’ and‘fevers’; Herzlich’s (1973) research on images and representations of healthand illness in France; Cornwell’s (1984) study of concepts of health andillness in the East-End of London; and Williams’ (1990) analysis of attitudesto death and illness among older Aberdonians.

What clearly emerges from these studies, diverse as they are, is thecomplexity of lay beliefs and lay knowledge on these matters – thinking,Blaxter (1984, 1990) stresses, which is not in principle ‘unscientific’ –including both the multi-dimensional nature and the strongly moral quality ofhealth (see also Crawford, 1984). Few people, it seems, wish to say they areanything other than healthy, however the term is understood (Blaxter, 1990).These concepts, in turn, have been shown to vary by social position accordingto factors such as class, gender and age. Views, moreover, as Cornwell’s(1984) study shows, may differ depending on whether ‘public’ or ‘private’accounts are given: the former more concerned with the reproduction of‘conventional’ (medico-moral) wisdom, the latter more personal, storied andcritical in character (see Radley and Billig (1996), however, for a criticaldiscussion of this very distinction).

These issues have in turn been augmented in recent years through otherimportant developments and debates, especially those concerning people’sown conceptions and narrative understandings of health inequalities, therebysupposedly linking the ‘macro’ and the ‘micro’ through biography, time andplace (Popay et al., 1998; Blaxter, 2000, 1997, 1993). The salience andsignificance of ‘lay epidemiology’ (Davison et al., 1992, 1991) has likewisecome to the fore in recent years, alongside other equally pertinent/pressing


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questions concerning just how ‘lay’, lay beliefs are in fact (Shaw, 2002)? Inthese and other ways, a shift is detectable in recent years, as part and parcelof the broader dynamics of ‘contested’ expertise in late modernity, from (lay)beliefs to (lay) knowledge if not (lay) accounts of health and illness, set in thedynamic context of people’s everyday lives (Shaw, 2002; Bury, 1997; Radleyand Billig, 1996; Good, 1994).

Again this research has proved highly illuminating, producing anintriguing and important body of findings. To the extent however that itforms part of the alternative interpretive research tradition, it too suffers froma number of limits and weaknesses, particularly when lay accounts areaccorded ‘privileged’ status (cf. Popay et al., 1998) on whatever grounds andin relation to whomsoever (Wainwright and Forbes, 2000). The social world,in this respect, becomes little or nothing more than the (inter)subjectiveaccounts, interpretations and viewpoints of those studied: a sociallyconstructed world of sorts, with its own empiricist overtones to boot viathe commitment to qualitative research methods (Bryman, 2001), filteredthrough a biographical lens and/or a narrative reference point. The resultingpicture, to put it bluntly, is at best partial and at worst misleading: partial tothe extent that there is a world beyond what people think and/or say about it;misleading to the extent that they may well be looking or pointing in the‘wrong’ places, so to speak (another important finding, of course, whetherexplained through ‘false consciousness’ or some other such device). It issmall wonder, for example, from this latter stance that many of Blaxter’s(1997, 1993) respondents, particularly those in the poorest social circum-stances, were unaware of the extent of social inequalities or the widerdeterminants of health. The upshot of this, as Wainwright and Forbes rightlycomment in relation to the inequalities in health debate in general, is that thefield to date remains ‘only partially charted, with explanations from afarwhich only go so far and certainly nowhere near as far as some would suggest(positivism); and explanations from within which largely remain within(interpretivism)’ (2000, p. 269).

The Meaning and Experience of Illness: Biography, Narrative and the‘Suffering Self’

Similar issues apply in the case of related (interpretivist) research agendas onthe meaning and experience of chronic illness. Key concepts advanced here inrecent years, building on Strauss and Glaser’s (1975) pioneering work onChronic Illness and the Quality of Life, include the notion of chronic illness asbiographical disruption (Bury, 1982), the role of narrative in repairingruptures between body, self and society (Williams, 1984), the negotiation ofselfhood and identity, particularly the stigmatising consequences of various


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chronic illness conditions (Scambler, 1989), as well as the positive actionsthat people take in the face of their adversity – responses, analyticallyspeaking, that include coping, strategy and styles of adjustment to chronicillness (Bury, 1991; Radley and Green, 1987). The ‘negotiation’ of chronicillness and identity in everyday life, in this respect, provides an importantcontrast to previous approaches within the symbolic interactionist tradition –the ‘crisis’ model of illness in Gerhardt’s (1989) terms – in which thestigmatising effects of labelling were seen to be more or less all-pervasive andall-encompassing.

In documenting the meaning as well as the consequences of chronicillness across a wide range of conditions, this work has indeed provedvaluable. Bury (1988), for example, distinguishes two types of meaning (‘atrisk’) here: (i) as consequence, which pertains to the practical problems thatchronic illness poses; (ii) as significance, which captures the social andsymbolic connotations of chronic illness both for sufferers and their families.This has also, in keeping with the above commitment to lay perspectives,served to articulate if not champion the voices and life-world concerns ofthose who might otherwise not have been heard, both inside and outsideformal health care settings.

A particularly striking feature of this work in recent years, echoing theseabove points, has been the ever-increasing emphasis on narrative storytelling,as witnessed for example in much cited books such as Frank’s (1995) TheWounded Storyteller and Kleinman’s (1988) The Illness Narratives. Narratives,Williams (1984) declares, help bridge the gap between the clinical reductionsof biomedicine and a lost metaphysics, serving as biographical referencepoints in an unfolding process that has become profoundly disrupted. Whenillness is told, Frank states, its ‘lack’ becomes ‘producing’ (Frank, 1991). Byfocusing on narrative therefore, it is claimed, one is able to shift the dominantcultural conception of illness away from passivity to activity, thustransforming ‘fate’ into lived ‘experience’ (Frank, 1995). Stories can ‘heal’,we are told, just like physicians. It is through narrative, moreover, that bodiesare ‘joined together’ in a ‘shared sense of vulnerability’ and a search for a lost‘ethics of existence’ (Frank, 1995) – see Bury (2001), however, for a recentcritique of ‘facts’ and ‘fictions’ regarding this narrative turn, including thecharge that narratives are more contradictory (if not mundane) than manywriters allow, and that the potential for social distance as well as personalworth should not be forgotten here either.

Meaning and experience then, to summarise, are very much on the agendathrough notions such as biographical disruption, the suffering self, and thewounded storyteller: issues that themselves intersect with the recent upsurgeof interest in body matters, if not the matter of bodies, in sociology today. It is


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at this very point, however, that we encounter what is perhaps the most recentand radical set of challenges, within and beyond the sociology of health andillness, namely the entree of postmodern and post-structuralist scholarship.

The Linguistic Turn: Discursive Dissolution and the (De)ConstructedWorld

If the foregoing concerns, be they positivist or interpretivist, form part andparcel of a modernist or late modernist research programme within thesociology of health and illness, then these very assumptions have themselvesbeen critically interrogated or deconstructed in recent years through therelativising twists and turns of postmodernist and poststructuralist thought:2 akind of ‘ultra’-constructionism if you will. Foucault, of course, has been hugelyinfluential here, not simply through his early writings on power/knowledgeand the ‘discursive body’ (Foucault, 1980), but also with respect to his laterconcerns regarding ‘technologies of the self’ and issues of governmentality(Foucault, 1988). Armstrong (1983a), for example, has been a key exponent ofthis Foucauldian viewpoint within medical sociology. Medical knowledge,he boldly declares, both ‘describes and constructs the body as an invariatebiological reality’ (1983a, p. xi). These and other essays by Armstrong on the‘invention of infant mortality’ (1986); ‘silence and truth in death and dying’(1987); the ‘problem of the whole-person in holistic medicine’ (1986); and therise of ‘surveillance medicine’ (1995), have all been part and parcel of agrowing corpus of Foucauldian inspired work on health and medicine in recentyears (see also Petersen and Bunton, 1997; Lupton, 1995).

Fox (1999, 1993) too has advanced a number of provocative postmodernarguments and bold poststructuralist assertions, forging his own distinctiveblend of Foucauldian, Derridean and Deleuzo-Guattarian borrowings – thelatter called upon, it appears, to counter Foucault’s somewhat pessimisticconclusions with respect to the critical possibilities of resistance. With respectto modernist readings of the ‘suffering self’ (of the kind identified above), forexample, Fox provides a number of liquidating postmodern objections. Theanatomical body is not in fact, he declares, the ‘carapace of the self’. If the selfdoes inhabit such an ‘interior’ location, then this is seen as the consequence ofdiscourse. In contrast, following Deleuze and Guattari (1984, 1988), theorganism is, Fox argues, an effect or ‘pattern of intensitities on the Bodywithout Organs (BwO)’ – the latter conceived as a ‘political surface of (de/re)territorialised intensities and flows of desire’ – which in the modern periodis exemplified, par excellence, by medical discourse (1993, p. 145).

Discourses on health and illness within the medical and human sciences,from this postmodern/poststructuralist viewpoint, contribute to a particularterritorialisation of the BwO, ‘suffering’, ‘pained’ or otherwise, organised in


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terms of the ‘organism’: a biomedical or biopsychosocial body with organs,that is to say. Similarly, the modernist focus on issues such as biographicaldisruption and the search for meaning and legitimacy merely serves, we aretold, to ‘fabricate’ a subject who is effectively ‘trapped’ within his/her‘pained’ or ‘painful’ body and is required to ‘adjust’ or ‘adapt’ to thelimitations this engenders. As a consequence, the effects of the disciplines ofthe body (including sociology) in constructing this kind of subject remainobscured (Fox, 1993, p. 146). The proposed solution to these modernistdilemmas, for Fox, lies in a process he cryptically refers to in Derridean termsas ‘arche-health’, something which, of necessity, defies definition but non-etheless involves a ‘deterritorialisation’ of the BwO as a prerequisite for new‘nomadic’ forms of subjectivity and the endless process of becoming ‘Other’.

The promises, perils and pitfalls of postmodernism are more or less fullyevident here, in equal measure, including the radical dissolution of structures,bodies (ie the writing out of bodies through the writing in of bodies, quadiscursive products or intertextual effects), and the ‘abyss of relativism’which beckons in a world where ‘truth’ is all but abandoned (Bury, 1986).Postmodernism, nonetheless, has raised a series of important issues regardingmodernist categories and forms of explanation. It also, of course, comprises avariety of different strands, thereby making sweeping statements or general-isations problematic. As such, it too demands a critical engagement ratherthan wholesale dismissal or rejection (Sayer, 2000, p. 31).

All in all then, to summarise this first section of the paper, what we havehere are a variety of stances or takes on the world, be it the positivist cum(observable) empirical world, or the interpretivist cum socially constructed/discursive world. Is this however, echoing the critical points above, the end ofthe matter? To what extent, in other words, have these approaches led to aneglect or downplaying, if not a denial or rejection, of a world beyond anysuch terms of reference: an ontologically stratified world that is more, muchmore in fact, than our sense perceptions, our knowing grasp, our meaningfulendowments or our discursive renderings of it. It is in search of answers tosuch questions, and the deeper ontological levels of inquiry they entail, in aspirit of constructive dialogue and debate, that we now turn. An exercise in‘going beyond’, one might say, ‘without leaving out’.

‘RECLAIMING REALITY’: ‘TO BOLDLY GO WHERE . . . ’OR ‘ALL THAT YOUCAN’T LEAVE BEHIND’?

The starting point here, to repeat, is that the above traditions or strands ofresearch take us so far, but not perhaps quite far enough when it comes to the


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world and our place within it. They all of course, in their different ways,pertain to key facets and features of (observable) social reality, if not thesocial construction of reality itself, but other important (non-observable,mind-independent) dimensions of the world, including nature–societyrelations, remain hidden, out of reach, or out of bounds. The world, in otherwords, is not exhausted by their explanatory coverage, whether or not anysuch claims are made. Critical realism (CR) in this respect, I venture, inkeeping with other like-minded critics in health (Wainwright and Forbes,2000; Scambler, 2002), helps us ‘reclaim’ these vital lost dimensions anddomains of reality, thereby enabling us ‘to boldly go where no otherapproaches have gone before’, so to speak (splitting infinitives in the processperhaps!).

Variants of realism, to be sure, have been around for some time insociology, from Durkheim’s notion of society as a reality sui generis, toMarx’s historical materialism. Critical realism, however, is a somewhat morerecent addition or revision to these debates. Bhaskar, in particular, has been akey figure here, from his early work on A Realist Theory of Science (Bhaskar,1975), through books such as The Possibility of Naturalism (Bhaskar, 1989a)and Reclaiming Reality (Bhaskar, 1989b), to other more recent offerings orbold attempts to diagnose, explain and resolve the ‘problems of philosophy’in books such as Plato Etc. (Bhaskar, 1994). Critical realism, nonetheless, newor old, is gathering momentum in social theory today, providing what someindeed, given the limits of positivism and interpretivism alike, have termed aviable ‘Third Way’ (Wainwright and Forbes, 2000).

Detailed expositions of CR, and its philosophical underpinnings, can befound elsewhere (see, for example, Archer et al. (1998) and Sayer (2000) forauthoritative/definitive accounts). What follows instead is a partial orselective review, in the light of the foregoing traditions, trends and tensions,of what I take to be some of the most important insights and implications ofCR for the sociology of health and illness in general. Four main issues inparticular, I suggest, themselves ‘correctives’ of a sort to current researchagendas in health, merit further discussion here.

Epistemology and Ontology/the Transitive and The Intransitive: ResistingConflation

One of the defining features, if not key premises, of CR is that epistemologicaland ontological matters cannot and should not be collapsed or conflated.There are a number of ways of putting this, but all boil down to onedeceptively simple, yet profoundly important point or principle; namely, theontological claim that the world exists independently of our thoughts orknowledge about it, and hence the meanings we place upon it. What we know


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and how we know it (epistemology), in other words, should not be confusedwith what there is to know (ontology). Knowledge we might say, in CRparlance, has both transitive and intransitive dimensions: the formerpertaining to our changing, contingent, fallible theories about the world,the latter to the mind-independent world this knowledge is about. Those who(regularly, unwittingly, whatever) collapse the ontological into the epistemo-logical therefore, as strong constructionists are prone to do, are falling prey tothe ‘epistemic fallacy’. Disease, for example, returning to the previousdiscussion of the linguistic turn/discursive dissolution of the world, ispatently more than just a social construct, however important the latter mightbe. Disease labels, one might say, describe but do not constitute disease. Thereality of disease, from this viewpoint, is not exhausted by our descriptions ofit. If only it were!

This in turn gives rise to a related set of distinctions, introduced by

Bhaskar, concerning three key domains of the social and natural world. Firstwe have the empirical, a domain founded upon (observable) experience. Notall events however are experienced – itself a crucial point in the light of theresearch traditions reviewed above. The actual, in contrast, the second ofBhaskar’s three domains, consists both of events and experiences. Deepunderlying mechanisms or causes, nonetheless, insofar as they are notrealised, do not belong here either. They are real nevertheless, whetherexperienced or not. As such, they properly belong to a third and final domainthat Bhaskar, unsurprisingly, terms the real: a domain in which mechanisms,events and experiences can all occur. Mechanisms, in this sense, are notsimply intransitive (ie existing whether detected or not), they are alsotransfactual, given their activities are continuous and invariant, stemmingfrom their relatively enduring properties and powers. It is this third domain ofthe real, including the generative causal mechanisms it contains independentof our knowledge or sense perception of them, that takes us to those realistparts that ‘other approaches can’t reach’, so to speak, or which (at the veryleast) they gloss through conflationary forms of thinking.

We cannot therefore, it follows, in keeping with the above non-

conflationary principles, reduce the real to events qua the actual (as in‘actualism’), and then to the empirical (as in ‘empirical realism’). As Bhaskarputs it with respect to the latter positivist trait:

By constituting an ontology based on the category of experience, asexpressed in the concept of the empirical world and mediated by ideas ofthe actuality of causal laws and the ubiquity of constant conjunctions, threedomains of reality are collapsed into one. This prevents the question of theconditions under which experience is in fact significant in science from


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being posed; and the ways in which these three levels are brought intoharmony or phase with one another from ever being described (1998a,p. 41).

These principles, it should be stressed, are as applicable to ourknowledge of the social world as they are to the natural world, save thatthe former is an ‘open system’ (with variable outcomes) compared to thelatter where experimental ‘closure’ is a (real) possibility.

If these preliminary (non-conflationary) moves leave both the neo-positivist commitment to the empirically observable world, and theinterpretivist/constructionist/postmodernist commitment to the meaningfulcum discursive world wanting, they also pave the way for a deeper series ofontological reflections and realist insights into the stratified world, includingnature–society relations and the emergent properties contained therein.

Stratification and Emergence: Bringing the Biological Back in?Already, in the foregoing account of the real, the actual and the empirical, a‘stratified ontology’ has been proposed, explicitly stated or not, whichcontrasts with the ‘flat’ ontologies of the actual or the empirical, or theirconflation (Sayer, 2000, p. 12). Critical realists, in keeping with thesestratified principles, also propose the notion of emergent properties ascharacteristic features of the world; a process, that is to say, in which two ormore components or features of the world combine to produce a newemergent phenomenon whose properties comprise yet are irreducible to theseformer constituents, even though the latter are necessary for their existence(Sayer, 2000, p. 12). A cake, for instance, is the emergent product of itsconstituent ingredients, including flour and eggs, butter and sugar, yet isirreducible to any one of them. Water, or H2O to be more precise, is anotherfavourite case or obvious example to cite here.

Approaching issues in this manner, it is clear, unlocks a number ofimportant doors, not least concerning nature–society relations in general andbiology–society relations in particular. Sayer, for example, has a number ofimportant points to make here. To account for nature–society relations in away that avoids biological reductionism without denying natural powers, heventures, we first need to ‘disambiguate ‘nature’’, and secondly, echoing theabove points, to hold on to a ‘stratified ontology’ (2000, p. 99). While therealist concept of nature is concerned with what is common to the human andnon-human worlds, it is inadequate on its own, Sayer stresses (quoting Soper(1995) approvingly), for understanding how they differ. Nature also needs tobe understood as the concept through which humanity ‘thinks its differenceand specificity’ – see also Creaven (2000), Geras (1983) and Archer (2000)below. Two different concepts are required here, in other words, neither of


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which should be stressed to the detriment of the other. From a realistviewpoint, therefore, we need to be able to grasp how the social qua humancan be both dependent on and irreducible to (or emergent from) the materialprocesses studied by the natural sciences. What this amounts to, succinctlystated, is the following:

ybiological, chemical and physical powers are necessary conditions for theexistence of the social world but the latter has properties – particularly or‘essentially’, communicative interaction and discourse, which areirreducible to or emergent from these ontological strata. If we couple thisstratified ontology with a realist analysis of causation, in whichytheexistence of a causal power is not uniquely and deterministically linked to aparticular outcome, then it becomes possible to see that theacknowledgement of a biological (and other physical) substratum ofsocial life need not be seen as denying diversity and agency at the sociallevel (Sayer, 2000, p. 100).3

Realism, therefore, gives the biological and the social its due, without the

reductionist baggage of old.This, to be sure, is a welcome development, connecting as it does to other

recent calls in a similar (realist) vein to bring the biological back into ourtheorising, in health as elsewhere. Benton (1991), for example, over a decadeago now, has noted how new ways of understanding science and itsrelationship to culture, new ways of philosophically orderingscientific knowledge, and newly influential social movements – from ecologyto animal welfare/rights – have combined in recent years to impel or facilitatenew ways of thinking about biology and the human sciences. The task for anyproposed re-alignment of the human social sciences with the life sciences, hestates, in keeping with these foregoing realist concerns:

ycan now be seen as one of providing conceptual room for organic, bodily,and environmental aspects and dimensions of human social life to beassigned their proper place without, at the same time, abandoning the veryreal intellectual achievements of the ‘founding figures’ of the modern socialsciences in defence of the autonomy and specificity of those disciplines vis-a-vis the life-science specialisms (1991, p. 25).4

Birke (1999) too, in similar fashion, argues for new ways in which

biological science and feminist theory may be brought together through apolitics, as she puts it, that includes, rather than denies, our fleshy bodies andtheir biological predicaments.

These arguments in turn find echoes within medical sociology, not least

with respect to the sociology of chronic illness. Kelly and Field, for instance,


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while mindful of the need to avoid the pitfalls of biological reductionism,argue that a sociology that fully integrates the physicality of the body in atheoretically direct way is ‘essential for an adequate sociological under-standing and analysis of chronic illness’ (1994, p. 34). The body, they stress,remains theoretically elusive within many sociological narratives to date, itsexistence seldom denied, yet its presence somewhat ethereal, constantlygliding out of analytic view. Even in cases that eloquently express physicallimitations and difficulties (as in some of the examples of work within thesociology of chronic illness discussed earlier), Kelly and Field maintain, the‘physical bodily reality’ underpinning these limitations and difficulties‘remains under-theorized’ (1994, p. 34) – see also Kelly and Field (1996).

Much still remains to be done therefore, in health as elsewhere, in orderto bring the biological (body) back in, thereby redressing this traditionalsociological neglect – see, for example, Williams (2002) and Williams et al.(2003). (Critical) realism, it is ventured, helps us do just that.

The ‘Primacy’ of Practice: Habituated Knowledge/Unthinking Disposi-tions?The next set of issues to tackle here, head on, concerns the salience if not theprimacy of practice: an issue that further qualifies if not problematises thenotion of the conscious, knowing subject, actor or agent. It is Bourdieu (1984,1990, 2000), more than any other theorist perhaps, who has done most todocument and detail, debate and discuss the realm of practical consciousnessand the logic of practice. Much of daily life, according to Bourdieu, is simplytaken for granted and organised according to a practical, largely unthinking,logic of which actors are only dimly aware. To focus on practice, as Bourdieuputs it, is to stress to the ‘intentionality without intention’, the ‘knowledgewithout cognitive intent’, that ‘pre-reflective, infraconscious mastery’ whichagents acquire in their social world by virtue of their durable immersionwithin it (Bourdieu and Wacquant, 1990, p. 20).

Habitus, in this respect, understood as an ‘acquired systems of generativedispositions’ which themselves are ‘objectively adjusted to the particularconditions in which it is constituted’ (Bourdieu, 1977, p. 95), plays a crucialrole here, not simply in accounting for the logic, durability and unthinkingnature of practice, but also in straddling the structure–agency divide; a‘structuring structure’, in effect. More specifically, it is in the relationshipbetween habitus and capital – itself of many different kinds, from economic tocultural, social to symbolic (see also the next section of this paper) – locatedin the context of the different social fields within society, that practice isgenerated for Bourdieu: a formula that runs as ‘((habitus)(capital))+field=practice’ (Bourdieu, 1984, p. 101).


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The implications of practice for the doing of sociological research, health-related or otherwise, are many and varied. A research strategy that isdesigned to elicit informants’ accounts and explanations of their behaviour(practice), for instance, is not only misplaced, according to Bourdieu, butliable to (re)produce a misleading picture. It is, he maintains, quite literallyasking ‘too much’ of informants to explain the principles that structure theiractions, precisely because much of this is accomplished, via habitus and thelogic of practice, unthinkingly and unknowingly. Asked to reflect upon andaccount for their actions, informants in other words move from what Giddens(1984) terms ‘practical consciousness’ to a form of ‘discursive conscious-ness’, relations between the two being far from clear-cut or unproblematic. AsBourdieu puts it in his own inimitable style:

The explanation agents may provide of their own practice, conceals, evenfrom their own eyes, the true nature of their practical mastery, i.e. that it islearned ignorance (docta ignorantia), a mode of practical knowledge notcomprising knowledge of its own principles. It follows that this learnedignorance can only give rise to the misleading discourse of a speakerhimself (sic) misguided, ignorant both of the objective truth about his (sic)practical mastery (which is that it is ignorant of its own truth) and of thetrue principle of the knowledge his practical mastery contains (1977, p. 19).

To invite people in an interview context, therefore, to account for andexplain their behaviour is at best problematic, and at worst misguided fromthis Bourdieuesque viewpoint. Much of what is conventionally referred to orunderstood as health-related behaviour, indeed, may itself be viewed in theseterms as part and parcel of this implicit, unthinking practical logic (Williams,1995). This in turn goes some way toward explaining the gap between(official) health-related knowledge, evident in ‘lay’ accounts, and (everyday)actions or practices: the former lying in realm of discursive consciousness,the latter in the dispositional domain of practice which itself, as we haveseen, is the dynamic product of habitus, capital and field, expressed in class-related terms (Williams, 1995).

Bourdieu’s take on these issues, of course, is far from unproblematic, notleast with respect to the charge that for him ‘behaviour has its causes butactors are not allowed their reasons’ (Jenkins, 1992, p. 97). One does nothave to buy (wholesale) into Bourdieu’s particular variant of realism,however, nor his attempted resolution of former divisions of the objectivism–subjectivism kind, to defend the primacy of practice. Archer (2000), forexample, in her recent work on Being Human, takes an alternative line here.What this amounts to, simply stated, is that human being depends upon aninteraction with the real world in which practice takes primacy over language


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in the emergence of human self-consciousness (our continuous sense of self,that is to say), thought, emotionality and personal identity; all of which, it isclaimed, are prior to and more basic than our acquisition of social identity.Pitted against both ‘Modernity’s Man’ (qua instrumentally rational bargain-hunter) and ‘Society’s Being’ (qua ‘cultural artefact’ or ‘gift’ of society), thegoal here for Archer, contra these partial viewpoints, is to ‘re-vindicate’ ourinner lives and thereby to ‘rescue’ humanity from any such ‘impoverishment’.What we are, she argues, is ‘forged between our potential species’ powers andour encounters with the world’ (2000, p. 317). Our ‘prime emergent power’ inthis respect, namely our ‘human self-consciousness’, is ‘firmly lodged in ourfully material embodiment and our ineluctable interactions with an equallymaterial world’ (2000, p. 318). Herein lies the significance of concretepractices, enduring, life-long practices at that, which themselves are accorded‘primacy in the emergence of our selfhood’. These self same practices,moreover, by virtue of these very facts, are held to be ‘pivotal to ourknowledge of the world’ (2000, p. 318). Self, reflexivity, thought, skill, evendiscursive ability itself, are all therefore, from this alternative stance, ‘fullyactivity-dependent’ upon how we make out in confronting reality (2000,p. 318).

Yet reality itself, Archer insists, in keeping with the stratified realistontological points outlined earlier, is constituted of ‘irreducible natural,practical and social domains’ which represent multiple sources of the self,thereby allowing the social its due in our constitution ‘without making all thatwe are the gift of society’ (2000, p. 318) (cf. the fallacy of ‘Society’s Being’mentioned above). The fact that we have to attend and accommodate to allthree realms, indeed, makes our ‘personal identities greater than that onesub-set of them represented by our social identities’ (2000, p. 318). Our ownparticular prioritisation of concerns in natural, practical and social reality, itfollows, is what secures our strict identities as unique persons with explicableinner and outer lives which themselves interact; a ceaseless interplay, in fact,between ‘inner deliberations and their public outworkings’ (2000, p. 318).

For Bourdieu then, to summarise, practice is more or less completelysevered from theoretical discourse or discursive consciousness, possessing a‘fuzzy logic’. For Archer, in contrast, practice is viewed as the ‘fons et origio oflanguage and the discursive domain in general’: both ‘prior to participation insociety’s conversation’, that is to say, but also ‘necessary to our acquisition ofthe logical cannon which is quintessential to our rationality’ (2000, p. 153).Either way, practice (in keeping with habitus) provides yet another tellingreminder of the stratified world and the limits of approaches, in health aselsewhere, which begin and end with (‘lay’) knowledge/accounts or thelinguistic/discursive domain. If Bourdieu’s supposed ‘resolution’ of the


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structure–agency debate is more apparent than real, however, then whatalternative does CR provide, and what light does this shed on health?

Structure and Agency: How Critical is Critical Realism?To take up the issue of structure and agency at this point in the paper is, ofcourse, to reiterate many of the foregoing CR points and principles, includingissues to do with practice, this time albeit in an elaborated and extendedfashion. CR that is to say, in responding to this key sociological issue, beginsfrom the three basic ontological premises about the nature of social realityoutlined earlier, namely intransitivity (existence beyond knowledge ordetection), transfactuality (enduring rather than transitory mechanisms)and stratification (ontological ‘depth’ versus ‘flat’ ontologies). The socialontology of CR in this respect, in keeping with its commitment to the threedomains of the empirical, actual and real, involves a substitution of theontology of structures for one of observable events (the latter construed,broadly speaking, as positivist empiricism based on experience) (Archer,1998, p. 195).

From these basic premises, as we have seen, flow related notions of ‘pre-existence’, ‘relative autonomy’, ‘causal influence’ and ‘emergent’ propertiesand powers. Causal relations for instance, it will be recalled, contra Humeanappeals to the ‘constant conjunction of events’ (cf. the infamous billiard ballexample), are best viewed as tendencies, grounded in the interactions ofgenerative mechanisms that may or may not produce events, which in turnmay or may not be observed (Outhwaite, 1998, p. 282). Generativemechanisms, in other words, may be ‘possessed, unexercised, exercised,unactualised and actualised independently of human perception anddetection’ (Bhaskar and Lawson, 1998, p. 6). Reasons, moreover, may becauses from a realist point of view (Bhaskar, 1989a). While CR, in thisrespect, shares with interpretivism the view that social phenomena areconcept-dependent and hence have to be understood, it also argues, incontrast to interpretivism, ‘that this does not rule out causal explanationbecause (a) material change in society has to be explained too, and (b)reasons can also be causes, in that they prompt us to do things, thinkdifferently, etc.’ (Sayer, 2000, p. 18).

Perhaps most importantly, in the present context, is the analyticaldecoupling of structure and agency advanced here, not in order to abandontheir articulation, but on the contrary, so as to examine their mutual interplayacross time; something that can result both in stable reproduction or changethrough the emergence of new properties and powers. Separability, Archer(1998, 1995) argues, contra Giddens (1984) and other conflationary theorists,is the indispensable predicate for examining the interface between structure


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and agency upon which practical social theorising, in health as elsewhere,depends. Only on this basis, Archer claims, is it possible to talk about thestringency of structural constraints versus degrees of agential freedom. Socialstructure and human agency, in other words, recalling Bhaskar’s transforma-tional model of social activity (TMSA), are:

Existentially interdependent but essentially distinct. Society is both theever-present condition and continually reproduced outcome of humanagency: this is the duality of structure. And human agency is both work(generically conceived), that is, (normally conscious) production, and(normally unconscious) reproduction of the conditions of production,including society: this is the duality of praxis (Bhaskar, 1989a, p. 92).

Schematically what this amounts to, in Archer’s (1995) morphogeneticterms, is a temporal process of structural conditioning – which necessarilypre-dates the actions that transform it, and about which we may or may notbe consciously aware – socio-cultural interaction, and either structuralelaboration (morphogenesis) or structural reproduction (morphostatis). Forthe realist indeed, pressing home these points, the essential factor whichguarantees that social systems remain forever ‘open’ is that they are ‘peopled’by actors and agents who possess a critical reflexivity and creativity towardthe world in which they live (Archer, 1998, 1995). The fact, however, that notall is revealed to consciousness because it is shaped outside our consciousawareness, makes for the ‘critical’ or ‘emancipatory’ potential of CR,including an explanatory critique of consciousness (and being) unparalleledin the domain of natural science (Bhaskar, 1998b, p. xvii). As Sayer states:

Critical realism offers a rationale for a critical social science, one that iscritical of the social practices it studies as well as of other theoriesy Socialpractices are informed by ideas which may or may not be true and whetherthey are true may have a bearing on what happensyone has toacknowledge this dependence of actions on shared meanings whileshowing in what respects they are false, if they are. If social scientificaccounts differ from those of actors then they cannot help but be critical oflay thought and action. Furthermore, as Bhaskar argues, to identifyunderstandings in society as false, and hence actions informed by themas falsely based, is to imply that (other things being equal) those beliefs andactions ought to be changed (2000, p. 9, my emphasis).5

What this amounts to, I venture, as far as the inequalities in health debate

is concerned, is nothing short of a ‘re-invigorated’ agenda: one that doesindeed take us far beyond the limits of positivism and interpretivism alike,while holding on to the critical possibility and emancipatory potential for


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social change through transformatory action. Important dynamic factors suchas power relations, moreover, can also be brought back in here in doing so.This, as Wainwright and Forbes (2000) rightly comment, is particularlyimportant for health inequalities research, given the ontological andepistemological problems and constraints identified earlier (see also Forbesand Wainwright, 2001). To neglect the impact on health inequalities of deepunderlying mechanisms within capitalism such as exploitation and alienationbecause they are non-observable, unmeasurable, or not expressed by thosebeing researched, in other words, leads to:

yhuge gaps in any subsequent ‘explanation’ and ultimately to partialityand theoretical weakness. Because the realist position accepts that thatwhich is unseen is seen to be of equal importance to that which can,this opens up the possibility for researchers to examine and accommodatesuch forces within their research and subsequent theory. The theorygenerated, therefore, will offer more comprehensive and robustexplanations of inequalities than are presently available. Such theorieswould be based on an understanding of the underlying structures andrelationships within the inequalities being studiedyand would aim todescribe the fundamental processes that actually explain the observedregularities in statistical associations to the underlying socio-economic andhistorical context in which these associations are located (Wainwright andForbes, 2000, p. 271).

This, to repeat, is not of course to discount or rule out the role ofinterpretation or understanding. On the contrary, as Sayer notes, CRacknowledges that social phenomena are intrinsically meaningful and hencethat ‘meaning is not only externally descriptive of them but constitutive ofthem (though of course there are usually material constituents too)’ (2000,p. 17). A weak form of constructionism is therefore entirely consistent withCR, including a commitment to lay viewpoints as an important startingpoint in the explanatory programme, while also accepting the fallibility of ourknowledge and hence the possibility of explanatory critiques (therebyunderlining the critical in critical realism). Compared to positivism andinterpretivism, moreover, CR endorses or is ‘compatible with a relatively widerange of research methods’, including both ethnographic and quantitativeapproaches, but it also implies that ‘the particular choices should depend onthe nature of the object of study and what one wants to learn about it’ (Sayer,2000, p. 19).

Critical realism then, to say the least, has its merits. To fully drive thesepoints home, however, particularly for those wavering voters, it is to someactual concrete examples of CR research in health that we now turn.


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PUTTING IT ALL BACK TOGETHER AGAIN: EXAMPLES OF CRITICALREALIST RESEARCH IN HEALTH

Variants of realism, as noted earlier, have been around for some time. Wemight, indeed, go further here by stating that many researchers, in health aselsewhere, are realists despite themselves, or perhaps more correctly implicit(closet) realists rather than explicit (out and out) realists, critical orotherwise: endorsing certain realist premises and principles, that is to say,without necessarily being fully paid up, card-carrying members of theBhaskar brigade or any other such fraternity, past or present. Popay et al.’s(1998) research, for example, as Wainwright and Forbes (2000, p. 269) note,has certain realist leanings or overtones, although not explicitly cast in theseterms. So too, some of the work within the sociology of chronic illness anddisability (cf. Kelly and Field, 1996), and related fields of inquiry such as thesociology of death and dying (see, for example, Lawton, 2000).6 This perhapsmay appear to fly in the face of the critical sketch presented earlier about thecurrent state of play within the sociology of health and illness, where variantsof positivism and interpretivism were said to be much in evidence,acknowledged or not. Instead I suggest, in keeping with Wainwright andForbes (2000), it merely serves to underline the need for a more explicitdebate of this kind about these very issues, so that various epistemologicaltraps and ontological pitfalls are avoided in future.

On the one hand then, realism may already have something of a foothold,

if not be gaining ground within the sociology of health and illness today,without anybody explicitly saying so or declaring it (Wainwright and Forbes,2000, p. 269). On the other hand, it is now possible to point toward certainstudies that do indeed pin their colours to the CR mast, so to speak, in anexplicit, up-front fashion. Three key examples in particular, themselvespertaining to different dimensions of health, medicine and society, will sufficehere for present purposes.

The first, immodestly perhaps, pertains to my own recent CR inspired

musings on the chronic illness and disability debate (Williams, 1999), therebyreconnecting with some of the issues raised earlier concerning the need tobring the biological (body) back in (Benton, 1991; Kelly and Field, 1993,1996). Taking as its starting point the tendency to credit the body more or lesswholesale to the social side of the balance sheet, the case is made here thatthe body, impaired or otherwise, is a real entity that cannot be reduced to thesocial any more than it can be to the biological. This in turn paves the way fora view of disability as the sole product of neither the impaired body nor asocially oppressive society. Rather, it is an emergent property involving theinterplay of biological and physiological impairment, structural enablements/


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constraints, and socio-cultural interaction leading to structural elaboration/reproduction over time. Within such a model, it is contended, re-connectingwith the likes of Archer (2000, 1998, 1995) and others, structures may befaithfully reproduced or critically transformed through social praxis oragency, both individually and collectively: a factor of considerableimportance to the disability movement (Oliver, 1990; Barnes and Mercer,1996). ‘Personal tragedy’ and ‘social oppression’ views of disability therefore,on this reading, are somewhat extreme models of what is perhaps best seenas a dynamic, dialectically unfolding relationship between body and society,located in a temporal framework (see also Shakespeare and Erickson, 2000;Williams, 2002; Williams et al., 2003).

The second example comes from a detailed CR ethnography by Porter(1993) of racism and professionalism in a medical setting, with particularreference to relations between (white Irish) nurses and doctors (some ofwhom belonged to ‘racialised minorities’). Porter’s explicit aim here, he tellsus, is to demonstrate the possibility of using CR to overcome some of theepistemological weaknesses associated with ethnography (see Hammersley,1992, for example). As such it provides an interesting methodologicalillustration of CR in action, so to speak, in a particular real-world researchsetting. Racism, Porter stresses, in keeping with CR principles discussedabove, is ‘a structural phenomenon, displaying both relational power andontological depth’ (1993, p. 598). Its effect upon action, however, ‘cannot beconstrued in terms of the constant conjunction of events. Rather therelationship between structure and action can better be described asgenerative – the former providing the condition for the latter’ (1993, p.598). Conversely, ‘structural racism is dependent upon the consciousness andmotivated action of agents, because it is that action that maintains andtransforms it’ (1993, p. 598).

The tendency of racism, conceived in these terms, was ‘exercisedunrealised’ (or latent) in Porter’s study, a finding that contrasts with thatof a comparable previous study by Hughes (1988) where it was indeedrealised. The countervailing mechanism that explained this occurrence,or perhaps more correctly this non-occurrence, Porter ventures, wasthat of professionalism, conceptualised in similar generative terms. The‘universalist-achievement ethos’ of professionalism, in other words, tended tocounter the ascriptive nature of racism: relations that displayed the aura of‘starched propriety’ whereby nurses gave the ‘outward appearance of‘knowing their place’ in the occupational hierarchy’ (Porter, 1993,p. 601). Racism in this respect, Porter concludes, can be seen as a ‘tendencythat is realised in some circumstances, but exercised unrealised in others’(1993, p. 607).


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Both these example it is clear, in their different ways, elaborate on

relations between structure and agency, the former bringing the biologicalbody back in to these debates in the very process of doing so. The thirdexample, building on these issues, returns us foursquare to the broaderinequalities in health debate, realising that re-invigorated research agendaonly hinted at above through a re-theorisation of the linkages between realclass relations and health inequalities. Taking his lead from recent debatesconcerning the limits of the neo-positivist programme to explain/predicthealth inequalities in general and the relative merits of Wilkinson’s work onincome inequality and psychosocial pathways in particular – as witnessed forexample in neo-materialist and neo-liberalism critiques (Muntaner andLynch, 1999; Coburn, 2000a, b; Wilkinson, 2000b) and the philosophicaland methodological reflections of Forbes and Wainwright (2001) – Scambler(2002) proposes that it is neo-liberalism’s class-generated ideological proper-ties (its potential, that is to say, to rationalise core capitalist executive action)that matter here (see also Scambler and Higgs, 2001, 1999; Higgs andScambler, 1998). More specifically, Scambler argues, what this amounts to‘without a hint of hyperbole’, is nothing short of a ‘greedy bastards hypo-thesis (GBH)’ which points to one, perhaps even ‘the prepotent sociologicalmechanism’ concerning relations between class and health (2002, p. 103).

The GBH states that ‘Britain’s persistent – even widening – health

inequalities might reasonably be regarded as the (largely unintended)consequences of the ever-adaptive behaviours of members of its (weaklyglobalized) power elite, informed by its (strongly globalized) capital-executives’ (Scambler, 2002, p. 103). This, Scambler argues, may be graspedthrough a model of ‘logics/relations/figurations’ that pertain, respectively, tothe regime of accumulation/mode of regulation of disorganized capitalism,relations of class, and the British nation-state (2002, p. 103). These insights,in turn, are augmented by the suggestion (echoing Bourdieu) that one fruitfulmeans of investigating this mechanism may be through its effects on types ofcapital flow known to affect health and longevity (e.g. biological capital,psychological capital, social capital, cultural capital, spatial capital, materialcapital, even perhaps emotional capital (cf. Williams, 1998)). The argumenthere, succinctly stated, is that:

yrelations of class (allowing for the hugely disproportionate sway of theGBs) systematically affect the flows (typically variable, and arguably ofspecial salience for particular conditions at critical periods of thelifecoursey) to individuals of different types of capital with potential toimpact on health and longevity. The point of intersection between thesecapital flows and the individual is the class habitus. It is important to


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acknowledge, of course, that class relations are not the only relations toaffect these capital flows; and that uninterrupted flows do not in any caseguarantee health and longevity, nor (even heavily) interrupted flows rulethem out (2002, p. 104).

Again we confront here the salience and significance of habitus inassociation with related notions of capital. Prime significance however,Scambler insists, returning to the Wilkinson debate, should be attached tomaterial capital. There may, in other words, be a ready interaction betweenthese capital flows, but it is clearly the case, Scambler stresses, that ‘materialcapital is fundamental and an influence on all others’. The Black Report, inthis respect, which sided heavily with materialist explanations, ‘got it moreright than wrong’ (2002, p. 105). If then, as many now argue, there is a‘clustering’ of (dis)advantage across time and place (cf. Bartley et al., 1998;Wadsworth, 1997):

yone way of pursuing this empirically may be by developing the conceptof capital flows, with priority accorded to material capital, variably affectedby class relations as generative mechanisms. But if class is important, it is ofcourse not the only provider of pertinent generative mechanisms (Scambler,2002, p. 105).

Scambler does not therefore, as the tail end of this quote suggests,preclude issues of gender, ethnicity or racism. These too, he suggests, areimportant mechanisms, which in turn may be regarded as categorical (whenthey bear a strong causal responsibility for the outcome of interest), derivative(when their causal relevance is apparent, but in large part a function of other(categorical) mechanisms) or circumstantial (if their causal role is apparentbut neither categorical nor derivative) (2002, p. 106). While gender, forinstance, may be seen as a categorical mechanism from this viewpoint, ethnicrelations, qua generative mechanism, may in large part be derivative ofcategorical class relations (Scambler, 2002, pp. 106–107). A complex andhighly suggestive explanation of contemporary health inequalities, therefore,building on the above premises and principles of CR, is provided here byScambler: one that translates more or less readily into a viable researchprogramme within and beyond the sociology of health and illness.

CR then, to summarise, as these brief health-related examples show,delivers on many fronts, shedding important new light on former debateswhile simultaneously opening up promising new ones. Other examples, itshould be stressed, could equally well be added here, including Abraham’s(1997, 1995) realist (though perhaps not avowedly critical realist) account –based on the ‘weak’ programme in the sociology of scientific knowledge


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(SSK) – of the science and politics of medical regulation. Realism, in short,critical or otherwise, helps us ‘put the world back together again’, recoveringmany lost parts and processes in doing so.

CONCLUDING REMARKS

By now I hope the conclusions of this paper are clear. Both the positivist andinterpretivist legacies it has been argued, evident in the sociology of healthand illness in various shapes and forms, have their limits, epitomised (albeitin extreme form) on the one hand by certain strands of inequalities researchcharacterised by the hunt for empirical regularities and a commitment to theobservable, predictable, empirical world, and on the other hand by certainultra or radicalised forms of social constructionism in the guise ofpostmodern and poststructuralist scholarship in which linguistic andepistemic fallacies abound. Realism, in this respect, does indeed appear toconstitute a viable alternative, if not a ‘Third Way’ (cf. Wainwright andForbes, 2000) which, while endorsing a ‘weak’ form of social construction-ism, allows us to ‘reclaim reality’ through principles of stratification,irreducibility and emergence, rethinking the very nature of causal explanationalong the way in the ‘open systems’ of society. It also, as we have seen,provides a ‘re-invigorated’ series of research agendas, in health and beyond,not least concerning the inequalities debate and the need to bring thebiological (body) back in new non-reductionist ways: non-reductionist, that isto say, from a social as well as a biological viewpoint (Williams et al., 2003).Even the sociology of scientific knowledge (SSK), in the ‘weak’ form of thisprogramme, is compatible with an avowedly realist approach. As such, CRmay indeed profitably serve as an ‘underlabouring’ philosophy, in health aselsewhere.

This, coupled with a commitment to a range of methods, bothquantitative and qualitative (including CR ethnography), makes CR aversatile and vital position which will, one might speculate, gather forceand momentum within the sociology of health and illness in years to come.CR, to repeat, does not so much deny or do away with these otherperspectives and approaches – not even, one might add, some of theimportant insights of postmodern critiques (cf. Sayer, 2000) – as attempt toengage with yet ‘go beyond’ them, thereby moving toward a more satisfactoryapproach to the natural and social world, themselves inextricably andirreducibly bound together in relational, emergent, open terms.

In truth, as I have already admitted and am more than happy to restatehere, there are doubtless many implicit (if not explicit) realists among us


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already. A more explicit set of debates of this kind, however, including acritical interrogation of the philosophical underpinnings of current researchagendas in health, is clearly needed and long overdue (cf. Wainwright andForbes, 2000). For some, no doubt, this paper will smack of preaching, with aproselytising or sermon-like tone. For others, perhaps, the somewhat arcaneand off-putting language of CR notwithstanding, it is nothing short of good,plain old-fashioned common sense: a refreshing contrast, maybe, to the frothand fizz of postmodernism that all too readily turns the world into anythingyou want it to be through a wave of the discursive magic wand. On this, ofcourse, I will have to leave readers to judge. To the extent, however, that itstimulates discussion and debate, putting the CR cat among the positivist andinterpretivist or postmodern pigeons, so to speak, it will indeed have servedits purpose. A case, perhaps, of reality fighting back or a war of the worlds,which on closer inspection turns out to be no real war at all, just a desire toput the world back together again, with critical emancipatory promise andpotential to boot.

ENDNOTES

1 Bryman (2001, 1988), for example, raises a number of important points here on this latter

methodological front, noting inter alia how the quantitative/qualitative divide is not in fact a hard-

and-fast one. Aspects of quantitative research, he notes, may contain elements of interpretivism,

while aspects of qualitative research may contain elements of the natural science model. This is a

valuable point, the implications of which are not discounted in what follows.

2 One may distinguish in fact, following Bauman (1988, 1992), between a sociology of postmodernism

and a postmodern sociology: the former reflecting on postmodernism as a social phenomenon, the

latter converting more or less wholesale to its view of the world.

3 Sayer (2000), interestingly, also defends certain forms of essentialist thinking here.

‘Misplaced’ essentialism, he notes, is ‘a common sin’, but a ‘moderate non-deterministic’

version of essentialism ‘doesn’t have to be misplaced, and indeed is often necessary for explanation

and for critical social science’. Moderate essentialists, he continues, ‘can acknowledge that some

important social phenomena do have essences, without concluding that nothing has an essence’

(2000, p. 101).

4 See Franklin (2002) for a critical discussion of the various (‘unproductive’) controversies and

debates that have raged between social constructionist and realist accounts of nature, biology and

the environment question.

5 Here we return to the importance of recourse to the biological (qua critique of prevailing social

arrangements) and the need for a moderate, non-determinist form of essentialist thinking (as in note

3). In order to be able to critique oppressive social practices, in other words, we clearly need to be

able to say what it is they are ‘bad for’ or ‘oppressive of’, and how they constrain or limit ‘human

flourishing’ – i.e. the need to invoke ‘common, extra-discursive capacities for human suffering’

(Sayer, 2000, p. 99). See also Nussbaum (1992), whom Sayer himself cites approvingly in this

connection, and Williams (2002) and Williams et al. (2003).

6 Lawton’s (2000) work, in fact, is a prime case in point here, providing what amounts to a powerful

(‘realist’?) challenge to the playful deconstructions of postmodernism through a graphic


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ethnographic study of the fleshy predicaments and ravages of terminal disease: processes, quite

literally, that render bodies unbounded and uncontainable.

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