Health, illness and neoliberalism: an example of critical realism as a research resource

Abstract

Neoliberalism, health and illness are all vast topics that range from global to local, personal to political. Critical realism offers valuable concepts, which help to extend and deepen analysis of these large, complex research areas. These include attending to unseen causal influences, absence, values, power, interests, structure and agency and morphogenesis. The four planes, which connect all interrelating forms of social being, provide a framework for managing large, wide-ranging and inter-disciplinary research data and for contextualizing small studies. Critical realism is contrasted with paradigms such as positivism, realist evaluation and actor network theory. This paper is based on a 20-hour generic course about critical realism for doctoral students, initiated by Roy Bhaskar. It uses the example of neoliberalism, health and illness to illustrate how useful critical realism can be as a research resource. The paper is also about the importance of understanding contemporary health in the context of neoliberalism. KEYWORDS: Democracypolitical economyrandomized controlled trialrealist evaluationstructure and agencytheory IntroductionThe topic of health, illness and neoliberalism feels overwhelming, too vast, diverse, political, controversial and alarming to address usefully in a journal paper. Unsurprisingly, the average health and illness paper deals with far smaller, more manageable, and seemingly apolitical and neutral matters that attract research funding, such as evaluating a healthcare programme in a randomized controlled trial (RCT). However, the social RCT literature and research methods are political. They align with the neoliberal position that individuals are responsible for health -therefore they can be blamed for illness -and these individuals can be randomised and therefore assessed. They deflect attention away from powerful social, political and economic structures, which are too large and omnipresent to be evaluated through random allocation (Stein, Cunningham, and Carmody 2021). Relations between health and neoliberalism are further complicated as a topic for journal papers in being largely invisible, denied in most public and open policy debate, and discouraged as topics in academic and commercial research. Even the existence of 'neoliberalism' is questioned, and therefore banished from the mainstream research world of evidence based medicine and demonstrable proof. Although there is much good research that addresses the political economy of health (Bambra 2019; Marmot et al. 2020), nevertheless, as Porpora (2015) concludes, the research could be even better if informed by critical realism. This brief review of critical realism as a research resource is written mainly for readers who are new to critical realism. It draws on my recent book (Alderson 2021), which is based on the 20-hour reading group course for doctoral students initiated by Roy Bhaskar in 2006. Very sadly, Roy died in 2014. I continued convening his course, which changed from being mainly philosophical to being mainly about cri...

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