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A Practical Introduction

Critical realism, as a toolkit of practical ideas, helps researchers to extend and clarify their analyses. It resolves problems arising from splits between different research approaches, builds on the strengths of different methods and overcomes their individual limitations.

This original text draws on international examples of health and illness research across the life course, from small studies to large trials, to show how versatile critical realism can be in validating research and connecting it to policy and practice.

To meet growing demand from students and researchers, this book is based on the course at UCL, first taught by Roy Bhaskar, the founder of critical realism.

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There are high rates of cancer in Bayelsa State in the Niger Delta in an ‘eco-genocide’.1 Families drink toxic water and breathe toxic air. Children climb over great oil pipes on their way to school. For decades, multinational oil companies have left old pipes and machinery to leak oil into the rivers and across the land, destroying local wells, crops, herds and wildlife. Around 40 million litres of oil are spilled annually in the Niger Delta, in comparison to 4 million litres of oil spilled in the whole United States each year. It is estimated that oil spills could have killed around 16,000 babies within their first month of life. Life expectancy in the Niger Delta is about ten years lower than the national average.

A Commission of Inquiry reviewed environmental, health, socio-economic, cultural and human damage and also identified unseen influences.2 The Commission concluded that the oil companies put profit first. Their policies are racist and neo-colonialist when Nigerian lives in the delta are deemed to be worthless. The oil sales bring in 40 per cent of the GNP, which could deter government action to prevent pollution.3 No national or international standards can be enforced to control the companies. The ten Commission members advised on a new legal framework to ensure accountability: the oil companies should agree to a global standard of behaviour and operate in Bayelsa as they would in Norway, Scotland or the USA.

The Inquiry’s proposed remedy partly depends on the market reforming itself, and the Inquiry members seem to overlook further problems.

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Jerome, aged 14, is in a school isolation cubicle again for three days after he kicked another student. He feels anxious, depressed and angry. Recently, his best friend was fatally stabbed. Jerome is on an 18-month-long waiting list for mental healthcare. He used to be in top sets, but is now in third or fourth ones, and has lost touch with his friends. His father is in prison. His mother does three cleaning jobs and once more has failed to get all the Universal Credit payments she is owed. So after school, he is usually alone in the cold damp flat. He misses the youth club, now closed, where he could be warm and relax with friends, have fun, play music, and talk to supportive adults. He has been to A&E twice with knife wounds and was told to go to his GP for follow-up care. But the receptionists did not see this as urgent enough and told him he would have to wait for three weeks, so he did not make an appointment.1

There were 4.1 million children living in poverty in the UK in 2017– 18, 30 per cent of everyone aged under 18 years and up to 58 per cent in the most deprived areas.2 How can critical realism (CR) add to the present extensive health and illness research about them? This chapter summarises a range of useful CR concepts linked to transformative change over time.

Research reports tend to be static, presenting data about a brief period in the lives of the people concerned.

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The Democratic Republic of Congo (DRC) needs continued international help with its fragile health services that try to cope with TB, Malaria and HIV, as well as Lassa, Marburg, Dengue, Nipah and Mers, which could soon become major epidemics, intensified by global heating, global mobility and trade, and crowded cities. Epidemics could quickly spread around Africa and to Asia and Europe. Effective treatment of Ebola means that ‘if you can get to people and treat them within four days of them becoming infected, mortality will only be about 10%. A few years ago, it was more like 80%’. Yet healthcare workers and researchers in DRC and West Africa face ‘extreme violence and fear, with colleagues being killed. It is a staggering, astonishing story.’1

WHO (the World Health Organization) estimates that two billion people have no access to toilets or latrines, and more than 430,000 people die each year from diarrhoea. Millions more die or suffer from other avoidable conditions, including intestinal worm infections and diseases that cause blindness. From 2011 to 2018, ‘WHO did battle with 1483 epidemics.’2 These occurred mainly among Black and Asian people, many already suffering from other diseases. About one in every eight people in South Africa has HIV and two-thirds of them also have TB. When drug companies occasionally develop treatments for tropical diseases, they are likely to overcharge. There are 100,000 Black people with sickle-cell disease in the US, and millions more around the world. Two transformative new drugs to help them were recently approved, the first in 20 years.3

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During 2020, governments faced questions about how they should work to reduce the spread of COVID-19. How should they first impose the lockdown and later manage its gradual ending? How could they protect public health while planning the slow return to ‘normal’ life? How could they best guide the public to cope with differences between pre- and post-pandemic views of what is ‘normal’ and healthy? The UK government’s Scientific Advisory Group for Emergencies, SAGE, consisted mainly of scientific advisers to government departments, virologists, epidemiologists, statisticians and medical experts with risk management and ‘nudge’ behavioural scientists. Their expert advice varied,1 and was widely criticised. Just as COVID-19 starkly revealed many problems in our present unequal society, it has highlighted limitations in scientific expertise and its

relations to policymaking.

Among innumerable policy decisions, just one example was prisons. There had long been campaigns to close many prisons. England and Wales had the largest prison population in Western Europe in April 2020, when there were plans for the early release of up to 4,000 of the 82,500 prisoners. Prison governors advised that thousands more prisoners should be released early. The aims were to reduce prison overcrowding and thereby reduce COVID-19 infection rates and deaths among prisoners and staff as well as in the communities around the prisons.

Instead, only 33 prisoners were released, and in a double confinement the rest were locked up in their cells for over 23 hours a day. A prison ship and 500 shipping containers were ordered to provide extra cells. The policy increased physical and mental illness and suicide rates among already severely disadvantaged social groups.2

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During a cholera epidemic in the Soho area of London in 1854, Dr John Snow hoped to find the cause of the illness.1 He mapped the households where the people with cholera lived and tracked their daily life and movements in the area. These centred on a water pump used by poorer families. The pump was next to a workhouse and a brewery that had their own water supplies and where people seemed to be safe from the disease. Snow questioned the dominant view that cholera and malaria (‘bad air’) are airborne. To test his theory that cholera is waterborne, he had the infectious handle removed from the pump. Numbers of cholera cases quickly fell.

Snow is also renowned for another innovation. He administered chloroform to Queen Victoria while she was having her eighth child, and her doctors at last agreed to grant her wish to be relieved of the pain of childbirth. He helped to transform public attitudes towards anaesthesia as well as to hygiene and public health. Public patronage from aristocratic and wealthy clients was as vital then, to develop and spread new ideas, as research grants and academic journals are today.

John Snow set examples of health and illness research that critical realism (CR) supports. He used three methods. Induction: when he observed many cases and began to form theories about the cause of cholera. Deduction: when he formed his hypothesis that cholera is waterborne and set out to test it through counting households and mapping people’s daily movements and habits.

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[My discovery of the cardiovascular system] is of so novel and unheard-of character that I not only fear injury to myself from the envy of a few, but I tremble lest I have mankind at large for my enemies, so much doth want and custom, that become as another nature, and doctrine once sown and that hath struck deep root, and respect for antiquity, influence all men: still the die is cast, and my trust is in my love of truth, and the candour that inheres in cultivated minds.

William Harvey, 16281

William Harvey’s difficulties (which will be discussed later in this chapter), when trying to change theories that had lasted for millennia, relate to critical realism (CR). Partly because CR challenges very long-held theories, it can be emotionally as well as intellectually challenging. It is not easy for researchers to revise their central beliefs and review how they could have analysed their previous projects differently. There is great interest in CR among students and younger researchers, who have much to gain and less to lose by studying CR. Yet their ‘demand’ for CR teaching and supervision far exceeds the ‘supply’ from senior academics.2 Absorbing and adapting to CR concepts and rethinking social science require time and effort, and my aim is to help readers to do this as quickly and easily as possible.

As observed in Chapter 1, contradictions between positivists and interpretivists undermine the hope that sociology can be generally respected, convincing and useful in helping to resolve serious global problems of health and illness.

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Today, the two leading causes of death, cardiovascular diseases and cancer, are projected to continue to increase over the next generation. Chronic ailments … include alcohol- and drug-related conditions, diabetes, asthma, Alzheimer’s, dementia, multiple sclerosis, arthritis, and Parkinson’s, among others; and they are on the rise. Mental [chronic] conditions … including depression, addictions, and schizophrenia [and many others] are now the leading causes of disability, hospitalization, long-term use of prescribed pharmaceuticals, and a diminished quality of life … Reports suggest dramatic and continuing rises in chronic childhood disorders … including cancer, arthritis, autism, ADHD, diabetes, asthma, food allergies … Not generally considered curable, chronic diseases become the subject of ongoing ‘management’, that is, a life within the medical system. It is estimated that up to 50% or more of the world’s population has one or more such chronic conditions.1

The unsaid questions running through Teeple’s (non-critical realism (CR), pre-COVID-19) commentary include: Who is responsible? What is to blame? Is it inadequate individuals who do not choose to keep themselves healthy? Is it natural causes including genetics that overcome those with weaker bodies and minds, less resistant to physical or mental illness? Like many similar publications, the commentary goes on to list global problems in pollution of water, soil, air and food, oil spillage and nuclear waste as causes of illness. There are also socio-economic policies and inequalities, work-related stress and injuries, low pay and poor working conditions. Are global commerce and industry mainly to blame? Big Food, Big Drinks, Big Pharma companies are driven by cost-cutting and profit-led policies that promote unhealthy lifestyles.

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Child poverty is a key indicator of ill health throughout life. A report about hungry families in Britain recounted young people’s shame, guilt and sense of exclusion from normal, everyday activities. Bryony, aged 13, living with her mother and brother said about meal times, ‘It gets a bit to the point where we’ll start feeling guilty because Mum hasn’t had anything and we’ve had it’.1

The poverty researchers assumed that accurate reports about hunger include people’s moral responses. Mary O’Hara contends that powerful groups maintain inequalities partly by the moral blaming and shaming of the poor.2 The rich claim ceaselessly that they are the brightest and best and the hardest working group. They deserve their wealth and can be trusted to manage it, unlike the feckless poor.

Shame is how they get away with it. Shame is the weapon they use. Shame is the weapon you use on yourself that makes you feel so useless. And those who are shamed most often and most deeply, made to feel ashamed for so much of their life, are the poorest among us.3

Just before the 2020 pandemic:

In the UK, numbers of working families in poverty are at an all time high. They rely on benefits from a state system that is driving many more of them into debt and to use food banks, and some to starvation and suicide.4

This chapter is about how critical realism (CR) addresses values in health research and helps to extend moral analyses. Health research that describes, measures and provides much vital information is necessary but not sufficient.

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