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 in my role as a Nurse Educator and interested sociologist. 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 novice nurse 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 and an empirical bent. Graham does not write for the student nurse alone, his audience is much wider than that. His latest book is aimed at students and scholars in the areas of philosophy, sociology, critical realism and those who work in health and social care. I believe there is a great deal to be gained by nurses and public health workers, in the thinking underpinning this book.


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’ 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:


Jurgen Habermas: Critical Theory.

Roy Bhaskar: Critical Realism.

Margaret Archer: Morphogenic Society and Critical Reflexivity.


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


Already I can hear groans from many undergraduate student nurses 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 above. My personal belief and experience is that ideas such as ‘Greedy Bastards Hypothesis’ can be readily understood by the novice.

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 repays handsomely. Much of public health is a nonsense without it.


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 is a damn 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 is falling 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, so why are we in the UK still getting fatter?


Right, I’m going to get a cup of tea and dive right in to his latest.