I have just undertaken the annual pilgrimage to Trondheim for the St Aksel health sociology workshop (and am now, incidentally, chilling with Annette and Marianne Hedlund at out-of-the-way Sparbu, a guest of Bodil Landstad and her delightful family). My contribution to the workshop was a paper entitled ‘the virtues of dialectical critical realism in health studies’. Ok, so it’s not a title to draw crowds; but it was a talk with a purpose. What I wanted to suggest was that Roy Bhaskar’s take on dialectics was worth sociologists thinking about. I was less interested in demonstrating a fidelity to Bhaskar and his arguments than to discussing the potential his general thesis might have to extend sociology’s agenda and reach.
Popper once confronted dialecticians with what he took to be a loud and unanswerable assertion from formal logic: ‘either ‘p’ or ‘not p’. You’ve missed the point Karl, was the riposte: its ‘p’ and ‘not p’ in that real world bypassed by logicians! Thinking dialectically, moreover, encourages ‘counterfactual’ enquiries: what would or might have happened if. Historians have taken advantage of this ‘device’ – what if, for example, France had won world supremacy instead of Britain, or Hitler had conquered Britain? – though we sociologists have on the whole been less adventurous. Thinking dialectically, in short, opens up fields for theorizing.
Basic critical realism (BCR) highlights the epistemic fallacy, that is, reducing what exists to what we know of what exists. It focuses on ontology or the study of being. In Sayer’s oft-cited tenets, there exists a reality independent of human input (ontological realism); this reality is understood differently according to the prevailing culture by time and place (epistemological relativism, although the term ‘relativism’ here grates); and/but theories of what is happening and why can be rationally compared and evaluated (judgmental rationality).
BCR recognizes three ontological tiers. The empirical refers to experience, the actual to events, and the real to the mechanisms that govern events. It is the task of the scientist, natural or social, to discern those mechanisms that help us to explain what experience makes available to us in the form of events. Sociologists, however, must conduct their studies in an open system; in other words, there is a lack of synchronicity between events and the mechanisms that govern them.
According to BCR too, humans have agency, or the causal power to elaborate on as well as to reproduce social structures.
I’ve outlined BCR often, so even my Norwegian friends must have been groaning inwardly at this point.
So what about dialectical critical realism, or DCR? Here’s my favourite quotation from this phase of Bhaskar’s work:
‘absence or non-being is an ocean, presence or being but a ripple on its surface’.
For Hegel, the dialectical process denotes the ‘logic’ of negation. Bhaskar’s ‘negative dialectics’, by contrast, focus on (in general terms) the absenting of absence and (more specifically) the absenting of constraints. To absent absence is to create presence; to absent constraints is to remove presence.
Absence for Bhaskar is not simply a property of the – incompleteness of – conceptual thought, as it is for Hegel, but of the ontological status of reality itself. Hegel is an idealist, Bhaskar a (depth) realist. For Bhaskar, absence is necessary given the open-ended nature of reality.
Negative dialectics focuses in particular on the absenting of constraints, that is, constraints on desires, wants, needs, and interests (absence is a condition of desire since desire presupposes lack). Humanity, Bhaskar contends, has an ‘inner urge’ to contest lack that flows from elemental needs and wants.
It is necessary at this point to introduce Bhaskar’s distinction between ‘power 1’ and ‘power 2’. The former refers to the transformative capacity intrinsic to the concept of agency. The latter refers to those social relations that govern the distribution of material goods, political and military authority and social and cultural stratification. Power 2 organizes an uneven distribution of the capacity of agents to exercise transformative power over their conditions of existence and subtracts from their autonomy.
So, to summarize at this juncture. Four themes have emerged relevant to my topic: (a) absence or non-being has priority over presence or being; (b) there is a universal, concrete human urge to absent constraints to elemental needs and wants; (c) power 2 relations stand in the way of satisfying this urge; and (d) what I have elsewhere called ‘action sociology’ necessarily and morally fuels power 1 relations in this context.
Gazing at my PowerPoint I spontaneously picked up on a fifth theme, that of totality (of which more at the end).
At this point I returned belatedly to the point of my talk. I considered three possible applications of the themes I had identified in my discussion of DCR.
Global sociology cannot simply be occidental sociology writ large, not least because it remains distinctively masculine, white and colonialist. No more can it simply be a matter of displacing occidental sociology with a ‘southern’ rival. I drew on the writings of Santos to suggest that (a) a ‘sociology of absences’ is indicated: that is, hearing the voices of the marginalized and silenced (allowing for an ‘insurgent cosmopolitanism’). Such a sociology of absences requires complementing by (b) a ‘theory of translation’: local struggles leading to ‘mutual intelligibility’. Finally, Santos refers to (c) Manifesto practices, or an emergent sociology beyond the occidental and the local.
Drawing this time on my own ‘work in progress’ with Sasha Scambler, I alluded to two notable absences. Absent, first, from Michael Marmot’s otherwise impressive WHO and UK Reports on health inequalities is any reference either to the contradictions of (financial) capitalism or to class as a real social structure/ relation, that is, as a causally efficacious mechanism. Marmot’s Reports are sanitized attempts to influence policy. ‘I want to make a difference in the real world Graham’, he used to say to me. ‘You haven’t made a difference’, I used to reply, ‘ and you are denying the existence of the real world’. Of course he is an epidemiologist not a sociologist, and I remain an admirer of his tireless campaigning.
No less absent in this domain of enquiry, second, is any reference to what I have come to cal the ‘governing oligarchy’. The literature on health inequalities is overwhelmingly socio-epidemiological in orientation and typically relies on secondary analyses of large data sets that do not permit identification of that fraction of the 1% who rule, and whose strategic decision-making leads indirectly to the premature deaths and impairment of the disadvantaged. The primary ‘serial’ killers thus slip away to their tax havens unseen and unaccountable.
INFORMATION COMMUNICATION TECHNOLOGIES (ICTs) AND HEALTH
Drawing directly on the analysis by Andreassen, Kjehshus and Tjora, I noted two absences here. The first is startling. It is the absence of a learning curve. Regardless of an accumulation of evidence to the contrary, funders and managers alike have not lost a jot of faith in the potential of eHealth to provide health and social care more effectively and efficiently than more orthodox hands-on services. Their faith has transmuted into a kind of Sartrian ‘bad faith’. Second, there is an absence of awareness and interest in the unintended consequences of what has become an unerringly optimistic series of pilot investigations of ICT innovation, many of which have led to monies being diverted to other, alternative ends.
Sasha and I included this passage in our latest paper:
‘comprehensively versed in what Schutz called the ‘natural attitude’, we very easily assume that ‘what is, must be’, that the socially structured world we inhabit is some kind of logical and necessary endpoint. Absence teaches us different and difference, opens us alternate ‘possible worlds’: ‘what is need not be’.
Finally, a brief return to totality. Bhaskar insists as part and parcel of his explication of negative dialectics that attention is paid to the related notion of totality. What this means in the proverbial nutshell, and for us here, is that micro- and meso-sociological studies should always be set in the context of (a macro-understanding of) society as a whole. None of ‘global sociology’, ‘health inequalities’ or ‘ICTs and health’ can be accounted for sociologically in the absence of an understanding of the contradictions of financial capitalism. And he’s right.
Andreassen,H, Kjekshus,L & Tjora,A (2015) Survival of the project: a case study of ICT innovation in health care. Social Science and Medicine 132 62-69.
Santos,B (2001) Nuestra America: reinventing a subaltern paradigm of recognition and redistribution. Theory, Culture and Society 18 185-217.
Scambler,G & ScamblerS (In Press) Theorizing health inequalities: the untapped potential of dialectical critical realism. Social Theory and Health.