Sociology, Health and the Fractured Society


Sociology, Health and the Fractured Society: A critical realist account.

Graham Scambler, (2018) Routledge. London.


I have been following Graham’s work for quite some time now. I have used some of his ideas in my own work and encouraged students of nursing to read his output. To that end I have included some of his ideas in my upcoming book on ‘Psychology and Sociology for Nursing’, and in another, ‘Communication and Interpersonal Skills in Nursing (co-written with Alec Grant). I have rather enjoyed his ‘Greedy Bastards Hypothesis’ which points to the unintended consequences for health of the actions of the capitalist class executive (CCE) and the political power elite (PPE). Of note also is the ‘health assets approach’ for understanding health outcomes. A good deal of this is accessible on his website:



Graham can write clearly and succinctly but it has to be acknowledged that for a health care professional with no social science background at all, some of his output will be incomprehensible. However, that is no different to any student coming to a field of enquiry for the first time. His work may be particularly baffling to those schooled in the biomedical sciences with an empirical bent. Graham does not write for the health care professional alone, his audience is much wider than that. This latest book is aimed at students and scholars in the areas of philosophy, sociology and critical realism as well as those who work in health and social care. I believe there is a great deal to be gained by all those interested in health.


In this book there is a focus on the ‘fractured society’ and its consequences for health outcomes characterised by inequality, most notably in the difference in life expectancy between social groups. A core premise is that much of health and health care is socially determined, and to better understand the processes at work ‘behind our backs’ (‘generative mechanisms’) we need a philosophical and theoretical foundation. Delivering Health Care without a critical theory is like sex without a condom: very common, highly possible and most enjoyable, but also ill-informed, ill-considered and possibly dangerous, as who knows what unintended consequences might occur as a result?


Three key names underpin Graham’s analysis:


  1. Jurgen Habermas.
  2. Roy Bhaskar.
  3. Margaret Archer.


Mention must also be made of C Wright Mill’s ‘The Sociological Imagination’.


Already I can hear groans from many undergraduate health professionals who are currently struggling with biomedical concepts such as homeostasis, acute coronary syndromes and haemorrhagic shock. To them I would say, relax. You do not have to be a social scientist to gain a great deal from examining some of the key ideas in this book. My personal belief and experience are that ideas such as the ‘Greedy Bastards Hypothesis’ can be readily understood by the novice social science student.


A key theme underpinning our understanding of our health outcomes and health behaviours is the relationship between ‘freely’ determined personal action i.e. our ‘agency’, and social structure, and human culture. I will concede that understanding human action, our personal agency, as arising within and in relationship to ‘structure’ and ‘culture’ is more of a challenge but addressing it, repays handsomely.


A Sociological Premise for Health

Graham has often written


Humans, I have contended elsewhere, are simultaneously the products of biological, psychological and social mechanisms whilst retaining their agency.


Acknowledgement must be made also of the sometimes mundane and sometimes dramatic interruptions of contingency.


Thus, humans can be said to be biologically, psychologically and socially ‘structured’ without being structurally determined.


If you studied just one premise in your attempt to understand who and what we are, and why we make the decisions we do – to smoke, to drink alcohol, to eat certain foods, to be sedentary, to self-harm, to fall pregnant – then this is a fine start. I also assert that this premise also calls into question a good deal of ‘common sense’ that underpins health messages, such as that of Change4Life’s ‘eat well, move more, live longer’. For millions across the globe, this is about as efficacious as entreating a dog to stop licking its own testicles. This entreaty of Change4life falls into the trap of offering individual solutions to individual problems while ignoring such determinants of health as social, political and economic structures. You might want to ask yourself why ‘eat well, move more’ is so hard to do for billions of people. As a health message it could not be simpler to understand, and of course has causal validity for improving weight loss, so why are we in the UK and elsewhere still getting fatter?


A simple answer is that the focus on personal agency as the main and only causal factor in health outcomes and behaviours misses the vital, and for some people the overriding, interplay of their place in the social structure. For example, being born into poverty can have deleterious effects on psychological decision making and feelings of self-worth. A fuller understanding of health seeking behaviour requires thinking about social and psychological mechanisms, and of course the impact of contingency upon our lives.


That being said, because society is an ‘open system’ we can never nail down our explanations as the final answers as to why an individual person gains or loses weight. Sociology, Graham argues, cannot ‘wrap things up’, nor can biology and psychology. Interdisciplinarity is required, even then there are things we cannot know.

Sustainable Development – why is this relevant?

This addresses one of the three core aspects of sustainability:

  1. Social Sustainability
  2. Economic Sustainability
  3. Financial Sustainability


The health of a society is one of the underpinnings for individual survival, well-being and flourishing and as such contributes to social sustainability.


#health #sociology #socialtheory #Archer #Bhaskar #Habermas #fracturedsociety #greedybastards