If health inequalities in Britain are ever going to narrow, the impetus will have to come from somewhere other than the accumulation of still more evidence. That, at bottom, is the wager of Healthy Societies. Graham Scambler, Emeritus Professor of Sociology at UCL and founding co-editor of Social Theory & Health, has occupied a distinctive position in the sociology of health for decades. Much of the field settles for patient documentation of unequal outcomes. He presses a harder question. Why do inequalities persist, and indeed widen, despite half a century of evidence, official reviews and exhortation? The twelve chapters of this compact volume, barely two hundred pages in all, distil his answer with combative clarity. Societies are not aggregates of individuals, and population health will not improve until the deep structures that produce and protect inequality are named, theorised and confronted. A healthy society, on his criteria, avoids extremes of material inequality, refuses to export exploitation to poorer societies, acts on climate change without penalising the most disadvantaged, and pursues peace. Britain fails on every count, he concludes, and it fails more comprehensively under the rentier capitalism of the past four decades than it did under the postwar welfare settlement.

The sick and dying poor are collateral damage resulting from corporate profiteering.

Healthy Societies, p. 35

Two devices

Two linked devices carry the argument, both developed across Scambler’s earlier volumes and refined here. The first is the class/command dynamic, his thesis that a hard core of capital monopolists within the richest one per cent can now buy decisive influence over the command relations of the state. The second is the deliberately provocative greedy bastards hypothesis. Widening health inequalities, it holds, are the largely unintended consequences of self-serving decisions taken by transnational financiers, major shareholders and chief executives. In the book’s starkest formulation, ‘the sick and dying poor are collateral damage resulting from corporate profiteering’ (p. 35). Medical care, after all, contributes perhaps a tenth to a fifth of modifiable health outcomes. Explanation must therefore shift to the social determinants of health, and behind the determinants to structure itself.

Three movements

The twelve chapters unfold in three movements. The first five assemble the empirical and conceptual case. A historical typology of societies frames long-run change in mortality, and the contemporary numbers are stark. Men in England’s most deprived decile die more than nine years earlier than men in its least deprived, and the gap in healthy life expectancy is wider still. Scambler revisits the Black Report, endorses the primacy of material and structural explanations, and faults occupational proxies such as NS-SEC for deflecting analysis from relational class. Chapter Three narrates the incremental dismantling of the NHS through marketisation, outsourcing and calculated underfunding designed to manufacture dissatisfaction and legitimate private rescue, a sequence he traces from Thatcher’s reforms to the present. Chapter Five reads COVID-19 as a breaching experiment. The pandemic laid bare the cleavages of the fractured society, an eight-featured formation elaborated in Chapter Four, in mortality differentials by class and race and in procurement that Scambler judges corruption outright rather than mere cronyism. Chapters Six to Eight widen the canvas to global inequality, the Anthropocene and war, insisting that no national account of a healthy society survives isolation from planetary and geopolitical relations. The last four chapters supply the theoretical core. Marx, Habermas and Bhaskar ground a critical realist sociology. An insider realism of evidence-based reform, associated generously with Marmot, is set against the outsider realism Scambler favours, and Burawoy’s four sociologies are extended by two of Scambler’s own coinage, foresight sociology and action sociology.

Strengths

The strengths are considerable. The framework of seven health-relevant asset flows (biological, psychological, social, cultural, spatial, symbolic and material) remains one of the more serviceable devices in the literature for linking macro-structure to embodied outcomes, since it accommodates fluctuation, clustering and partial compensation across the life course. Scambler is unusually candid about values, and he refuses the comfortable separation of is and ought behind which much quantitative research shelters. Bhaskar’s concept of absence does real work too, licensing a sociology of what might have been and what might yet be. The sharpest contribution, though, is reflexive. The structures that generate health inequality, Scambler argues, also shape research funding, audit cultures and publication metrics, and the result is a discipline that mentions class in closing paragraphs and moves on. Whatever one makes of the full indictment, the underlying question deserves exactly this sustained attention. Why have decades of accumulating evidence produced so little structural reform? The prose is accessible, the boxed summaries will earn their keep in teaching, and the insistence on bringing war and planetary health inside the frame marks a genuine advance on narrower treatments.

Reservations

Reservations remain. The greedy bastards hypothesis is retroductively inferred rather than empirically traced. Readers are shown compelling correlations and a plausible mechanism, but the causal chain from boardroom decisions to embodied harm is pitched at a level of abstraction that leaves unclear what evidence could count against it. The claim that class is prepotent over gender and race leans heavily on Sayer’s distinction between classism as a response to inequality and sexism or racism as causes of it, and intersectional scholarship receives briefer engagement than its current standing warrants. For a book urging global analysis, moreover, the treatment remains England-centred, and the chapters on world-systems, climate and war sketch agendas rather than develop them. The political programme, which runs from trade union rights and rentier taxation to trimming the monarchy, mixes attainable and aspirational objectives in ways that illustrate rather than resolve the book’s central tension. Scambler is, to my mind, more persuasive on obstacles than on pathways, a limitation his notion of permanent reform partly concedes. And the polemical register that powers the book may narrow its purchase on the policy audiences it hopes to move.

Verdict