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The Sociology of Health,
Illness, and Health Care
A Critical Approach
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The Sociology of Health,
Illness, and Health Care
A Critical Approach
EIGHTH EDITION
ROSE WEITZ
Arizona State University
Australia ● Brazil ● Mexico ● Singapore ● United Kingdom ● United States
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and Health Care: A Critical
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In memory of my mother, Lilly Weitz, with love
Brief Contents
PA R T I Social Factors and Illness 1

Chapter 1 The Sociology of Health, Illness, and Health Care 3
Chapter 2 The Social Sources of Modern Illness 18
Chapter 3 The Social Distribution of Illness in the
United States 46
Chapter 4 Illness and Death in the Less Developed Nations 69
PA R T II The Meaning and Experience of Illness 93

Chapter 5 The Social Meanings of Illness 95
Chapter 6 The Experience of Disability, Chronic Pain, and
Chronic Illness 116
Chapter 7 The Sociology of Mental Illness 139
PA R T III Health Care Systems, Settings, and Technologies 169

Chapter 8 Health Care in the United States 170
Chapter 9 Health Care Around the Globe 195
Chapter 10 Health Care Settings and Technologies 221
PA R T IV Health Care, Health Research, and Bioethics 247

Chapter 11 The Profession of Medicine 248
Chapter 12 Other Mainstream and Alternative Health Care
Providers 276
Chapter 13 Issues in Bioethics 303
GLOSSARY 325
REFERENCES 340
INDEX 381
vi
Contents
PREFACE xvi
ABO UT THE AUTHO R xxvi
PA R T I Social Factors and Illness 1
Chapter 1 The Sociology of Health, Illness, and Health

Care 3
The Sociology of Health, Illness, and Health Care: An Overview 5
The Sociological Perspective 6
A Critical Approach 8
A Brief History of Disease 10
The European Background 10
Disease in the New World 11
The Epidemiological Transition 11
Understanding Research Sources 13
Evaluating Research Sources 13
Evaluating Research Data 14
Summary 15
Review Questions 16
Critical Thinking Questions 17
Chapter 2 The Social Sources of Modern Illness 18

An Introduction to Epidemiology 20
The Modern Disease Profile 22
vii
viii CONTENTS
The New Rise in Infectious Disease 22

Today’s Top Killers 23
The Social Sources of Premature Deaths 24
Diet, Exercise, and Obesity 25
Tobacco 27
Medical Errors 28
Alcohol 29
Bacteria and Viruses 30
Toxic Agents and Risk Societies 31
Firearms 32
Motor Vehicles 32
Sexual Behavior 33
Illicit Drug Use 34
The Health Belief Model, Health Lifestyles, and Health
“Projects” 37
The Health Belief Model 37
Health Lifestyles 37
Health Projects 40
Social Stress and Social Networks 40
Social Stress 40
Gender, Race, Class, and Social Stress 42
Social Networks 42
Implications 43
Summary 43
Review Questions 44
Chapter 3 The Social Distribution of Illness in the

United States 46
Social Class 48
Overview 48
The Sources of Class Differences in Health 49
Race and Ethnicity 52
African Americans 53
Hispanic Americans 56
Native Americans 57
CONTENTS ix
Asian Americans 57
Case Study: Environmental Racism 59
Age 59
Overview 59
Sex and Gender 60
Overview 60
Case Study: Intimate Partner Violence and Health 62
Transgender Health Issues 63
Intersex Health Issues 64
Social Capital 65
Implications 66
Summary 66
Review Questions 67
Chapter 4 Illness and Death in the

Less Developed Nations 69
Setting the Stage: Key Concepts 71
Understanding Development Patterns 71
Understanding Globalization 73
Understanding Global Health 73
Explaining Death and Disease in Less Developed Nations 74
Chronic Disease 74
Poverty, Malnutrition, and Disease 75
Infectious and Parasitic Diseases 77
Neglected Tropical Diseases 81
Infant Mortality 82
Maternal Mortality 83
Respiratory Diseases 86
War 87
Disasters 87
Structural Violence 88
Implications 89
Summary 90
Review Questions 91
x CONTENTS
PA R T II The Meaning and Experience of Illness 93
Chapter 5 The Social Meanings of Illness 95

Explaining Illness Across History 97
Models of Illness 98
The Medical and Sociological Models of Illness 98
Medicine as Social Control 102
Creating Illness: Medicalization 103
Genetic Research and Social Control 108
Social Control and the Sick Role 110
Implications 113
Summary 113
Review Questions 115
Chapter 6 The Experience of Disability, Chronic Pain,

and Chronic Illness 116
Understanding Disability 118
Defining Disability 118
People with Disabilities as a Minority Group 119
The Social Distribution of Disability 120
Understanding Chronic Pain 122
Living with Chronic Pain 122
Gender, Ethnicity, Class, and Chronic Pain 123
Living with Disability and Chronic Illness 123
Responding to Initial Symptoms 123
Managing Health Care and Treatment Regimens 126
Managing Social Relationships and Social Standing 131
Implications 135
Summary 136
Chapter 7 The Sociology of Mental Illness 139

The Epidemiology of Mental Illness 141
The Extent of Mental Illness 141
Social Stress and Mental Illness 142
CONTENTS xi
Ethnicity, Gender, Social Class, and Rates of Mental Illness 142

Social Capital and Mental Illness 144
Defining Mental Illness 145
The Medical Model of Mental Illness 145
The Sociological Model of Mental Illness 146
The Problem of Diagnosis 148
The Politics of Diagnosis 149
A History of Treatment 150
Before the Scientific Era 150
The Rise and Decline of Moral Treatment 151
Freud and Psychoanalysis 153
The Antipsychiatry Critique 154
Deinstitutionalization 155
The Rise of Managed Care 157
The Remedicalization of Mental Illness 158
Mental Health and the Affordable Care Act 160
Recent Challenges to Medical Diagnoses and Treatment 160
The Experience of Mental Illness 161
Becoming a Mental Patient 161
Mental Illness and Identity 164
Implications 164
Summary 165
PA R T III Health Care Systems, Settings, and Technologies 169
Chapter 8 Health Care in the United States 170

A History of U.S. Health Insurance 172
The Birth of U.S. Health Insurance 172
The Government Steps In 173
The Rise of Commercial Insurance 174
The Rise (and Partial Fall) of Managed Care 174
The Attempt at “Health Care Security” 175
The 2010 Patient Protection and Affordable Care Act 176
Passing the Affordable Care Act 176
Understanding the Affordable Care Act 176
xii CONTENTS
The ACA Under Attack 177

The Impact of the ACA 178
The Continuing Crisis in Health Care Costs 178
The Myths of Health Care Costs 178
Understanding Health Care Costs 180
Health Care Costs and the ACA 183
Health Care Costs and “Big Pharma” 183
The Continuing Crisis in Health
Care Access 188
Uninsured Americans 188
Underinsured Americans 189
The Consequences of Underinsurance and Lack of Insurance 189
The Prospects for State-Level Reform 190
Implications 191
Summary 192
Chapter 9 Health Care Around the Globe 195

Evaluating Health Care Systems 197
Universal Coverage 197
Portability 198
Geographic Accessibility 199
Comprehensive Benefits 200
Affordability 200
Financial Efficiency 201
Consumer Choice 201
Health Care in Other Countries 201
Germany: Social Insurance for Health Care 203
Canada: National Health Insurance 205
Great Britain: National Health Service 207
China: Promises and Perils 210
Mexico: Moving toward Equitable Health Care 213
Democratic Republic of Congo:When Health Care Collapses 216
Implications 217
Summary 218
CONTENTS xiii
Chapter 10 Health Care Settings and Technologies 221

The Hospital 223
The Premodern Hospital 223
Beginnings of the Modern Hospital 224
The Rise of the Modern Hospital 225
Hospitals Today 225
The Hospital–Patient Experience 226
The Shift Away from Hospitals 227
Nursing Homes 227
Gender, Age, Ethnicity, Class, and Nursing Home Usage 227
Financing Nursing Home Care 228
Working in Nursing Homes 229
Life in Nursing Homes 229
Hospices 231
Origins of Hospice 231
Modern Hospices 231
Use of Hospice 233
Outcomes of Hospice Care 234
Home Care 234
The Nature of Family Caregiving 235
Easing the Burdens of Caregiving 236
Health Care Technologies 237
The Nature of Technology 237
The Social Construction of Technology 239
The Technological Imperative 240
Technology and the Changing Nature of Health Care 241
Implications 242
Summary 243
PA R T IV Health Care, Health Research, and Bioethics 247
Chapter 11 The Profession of Medicine 248

American Medicine in the Nineteenth Century 250
The Rise of Medical Dominance 253
The Flexner Report and Its Aftermath 253
Doctors and Professional Dominance 254
xiv CONTENTS
The Threats to Medical Dominance 255

The Rise of Corporatization 255
The Rise of Government Control 256
The Decline in Public Support 258
The Decline of the American Medical Association and Countervailing
Powers 258
The Continued Strength of Medical Dominance 259
Medical Education and Medical Values 261
The Structure of Medical Education 261
Ethnicity, Sex, Class, and Medical Education 262
Learning Medical Values 263
The Consequences of Medical Values 267
Patient–Doctor Relationships 268
Power and Paternalism 269
Ethnicity, Class, Gender, and Paternalism 269
Paternalism as Process 270
Shifting Patient Roles and the Decline of Paternalism 271
Reforming Medical Training 271
Implications 272
Summary 273
Chapter 12 Other Mainstream and Alternative Health

Care Providers 276
Mainstream Health Care Providers 278
Nursing:The Struggle for Professional Status 278
Osteopathy: A Parallel Profession 284
Dentistry: Maintaining Independence 288
Alternative Health Care Providers 289
Chiropractors: From Marginal to Limited Practitioners 290
Direct-Entry Midwives: Limited but Still Marginal 292
Curanderos 296
Acupuncturists 298
Implications 299
Summary 300
CONTENTS xv
Chapter 13 Issues in Bioethics 303

History of Bioethics 305
The Nazi Doctors and the Nuremberg Code 306
The Rise of Bioethics 308
Contemporary Issues in Bioethics 311
Reproductive Technology 311
Enhancing Human Traits 312
Resource Allocation and the Right to Refuse to Treat 313
CRISPR Technologies 314
Athletes and Concussions 314
Institutionalizing Bioethics 316
Hospital Ethics Committees 316
Institutional Review Boards 316
Professional Ethics Committees 317
Community Advisory Boards 317
The Impact of Bioethics 317
The Impact on Research 318
The Impact on Medical Education 320
The Impact on Clinical Practice 321
Implications 322
Summary 323
GL O S S ARY 325
REF ERENCES 340
I NDEX 381
Preface
The sociology of health, illness, and health care has changed dramatically over the
past few decades.The field was started primarily by sociologists who worked closely
with doctors, taking doctors’ assumptions about health and health care for granted
and primarily asking questions that doctors deemed important. By the 1970s, how-
ever, the field had begun shifting toward a decidedly different set of questions. Some
of these new questions challenged doctors’ assumptions, whereas others focused on
issues that lay outside most doctors’ areas of interest or expertise such as how poverty
affects health or how individuals develop meaningful lives despite chronic illness.
I entered graduate school during this shift, drawn by the opportunity to study
how health and illness are socially created and defined and how gender, ethnicity,
social class, and power affect both the health care system and individual experi-
ences of health and illness. As a result, over the years I have researched such topics
as how medical values affect doctors’ use of genetic testing, how midwives and
doctors have battled for control over childbirth, and how social ideas about AIDS
affect the lives of those who live with this disease.
Although I had no trouble incorporating this new vision of the sociology of
health, illness, and health care into my research, I consistently found myself frus-
trated by the lack of a textbook that would help me incorporate it into my teach-
ing. Instead, most textbooks still seemed to reflect older ideas about the field and
to take for granted medical definitions of the situation. Most basically, the books
assumed that doctors define illness according to objective biological criteria, so
they failed to question whether political and social forces underlie the process of
defining illnesses. Similarly, most textbooks ignored existing power relationships
rather than investigating the sources, nature, and health consequences of those
relationships. For example, the textbooks gave relatively little attention to how
doctors gained control over health care or how the power of the more developed
nations has affected health in less developed nations. As a result, these textbooks
used sociology primarily to answer questions posed by those working in the health
xvi
P R E FA C E xvii
care field, such as what social factors lead to heart disease and why patients might
ignore their doctors’ orders. Consequently, these textbooks often seemed to offer
a surprisingly unsociological perspective with their coverage of some topics differ-
ing little from coverage of those topics in health education textbooks.
Because the textbooks available when I first began working on this book
often avoided critical questions about health, illness, and health care, they seemed
unlikely to encourage students to engage with the materials and to question either
the presented materials or their own assumptions such as the belief that the United
States has the world’s best health care system, that medical advances explain the
modern rise in life expectancy, or that all Americans receive the same quality of
health care regardless of their ethnicity, gender, or social class. Instead, the text-
books primarily gave students already-processed information to memorize.
My purpose in writing this textbook was to fill these gaps by presenting a
critical approach to the sociology of health, illness, and health care. This did not
mean presenting research findings in a biased fashion or presenting only research
that supported my preexisting assumptions, but it did mean using critical skills to
interpret the available research and to pull it together into a coherent “story” in
each chapter. In addition, I hoped to tell these stories in a manner that would en-
gage students—whether in sociology classes, medical schools, or nursing schools—
and encourage them to learn actively and think independently. These remain the
primary goals of this eighth edition. Both of these goals led me to decide against
trying to please all sides or cover all topics because I believe such a strategy leads
to a grab-bag approach that makes textbooks hard to follow and to an intellectual
homogenization that makes them seem lifeless.
THE CRITICAL APPROACH
The critical approach, as I have defined it, means using the “sociological imag-
ination” to question taken-for-granted aspects of social life. For example, most
of the available textbooks in the sociology of health, illness, and health care still
view patients who do not comply with prescribed medical regimens essentially
through doctors’ eyes, starting from the assumption that patients should comply.
More broadly, previous textbooks have highlighted the concept of a sick role—a
concept that embodies medical and social assumptions regarding “proper” illnesses
and “proper” patients and downplays all aspects of individuals’ lives other than the
time they spend as patients.
In contrast, I emphasize recent research that questions such assumptions. For
example, I discuss patient compliance by examining how patients view medi-
cal regimens and compliance, why doctors sometimes have promoted medical
treatments (such as hormone therapy for menopausal women) that later proved
dangerous and how doctors’ tendency to cut short patients’ questions can foster
patient noncompliance. Similarly, this textbook explains the concept of a sick role
but pays more attention to the broader experience of illness—a topic that has gen-
erated far more sociological research than the sick role has over the past 20 years.
xviii P R E FA C E
CHAPTER ORGANIZATION
This textbook demonstrates the breadth of topics included in the sociology of

health, illness, and health care. Part I discusses the role that social factors play in
fostering illness and in determining which social groups experience which ill-
nesses. Chapter 1 offers an introduction to the field, the sociological approach, and
the history of disease. Chapter 2 describes the major causes of preventable deaths
in the United States, demonstrating how social as well as biological factors affect
health and illness. Building on this basis, Chapter 3 describes how age, sex, gender,
social class, race, and ethnicity affect the likelihood, nature, and consequences of
illness in the United States. Finally, Chapter 4 explores the nature and sources of
illness in the poorer countries of Asia, Africa, and Latin America.
Part II analyzes the meaning and experience of illness and disability in the
United States. Chapter 5 explores the social meanings of illness and social ex-
planations for illness as well as the social consequences of defining behaviors and
conditions as illnesses. With this as a basis, Chapter 6 first explores the meaning of
disability and then offers a sociological overview of the experience of living with
chronic pain, chronic illness, or disability, including the experience of seeking care
from both medical doctors and alternative health care providers. Finally, Chapter 7
provides a parallel assessment of mental illness.
Part III moves the analysis to the macro level. Chapter 8 describes the U.S.
health care system, the battles surrounding the 2010 Patient Protection and
Affordable Care Act, and the continuing crises in health care costs and accessibil-
ity. Chapter 9 offers some basic measures for evaluating health care systems and
then uses these measures to evaluate the systems found in Canada, Great Britain,
Germany, the People’s Republic of China, Mexico, and the Democratic Republic
of Congo. Finally, Chapter 10 examines four common health care settings—
hospitals, hospices, nursing homes, and family homes—and provides a social
analysis of the technologies used in those settings.
Part IV shifts the focus from the health care system to health care providers.
Chapter 11 analyzes the nature and source of doctors’ professional status as well
as the threats to that status. The chapter also describes the process of becoming a
doctor, the values embedded in medical culture, and the impact of those values on
doctor–patient relationships. Chapter 12 describes the history and social position
of various health care occupations, including dentistry, nursing, osteopathy, and
acupuncture. Finally, Chapter 13 presents a sociological overview of bioethics.
COVERAGE
Although I have tried in this book to present a coherent critical view, I have not
sacrificed coverage of topics that professors have come to expect. Consequently,
this book covers essentially all the topics that have become standard over the years,
including doctor–patient relationships, the nature of the U.S. health care system,
P R E FA C E xix
and the social distribution of illness. In addition, I include several topics that until
recently received relatively little coverage in other textbooks in the field, includ-
ing bioethics, mental illness, the medical value system, the experience of illness
and disability, and the social sources of illness in both more and less developed
nations. As a result, this text includes more materials than most teachers can cover
effectively in a semester. To assist those who choose to skip some chapters, each
important term is printed in bold the first time it appears in each chapter, alerting
students that they can find a definition in the book’s Glossary. (Each term is both
printed in bold and defined the first time it appears in the book.)
In addition, reflecting my belief that sociology neither can nor should exist in
isolation but must be informed by and in turn inform other related fields, several
chapters begin with historical overviews. For example, the chapter on health care
institutions discusses the political and social forces that led to the development of
the modern hospital, and the chapter on medicine as a profession discusses how
and why the status of medicine grew so dramatically after 1850. These discussions
provide a context to help students better understand the current situation.
CHANGES IN THE EIGHTH EDITION
Throughout the textbook, I have worked to update statistics as well as reviews of

topical issues and theoretical issues.Two-thirds of references in this new edition are
from the last 10 years, and fewer than 10% are from books or articles written be-
fore 1990—a level of timeliness that significantly surpasses that of most textbooks.
The reader can thus safely assume that, wherever possible, the statistics, policy
summaries, and legal information are the latest available.
New and Updated Chapter Topics

Chapter 2
■ E-cigarettes
■ Distracted driving and rise in automobile fatalities and distracted driving
■ The opioid epidemic
■ Updated discussion of premature causes of death
Chapter 3
■ Climate change, poverty, and ill health
■ Transgender health
■ Mass incarceration and health
Chapter 4
■ Neglected tropical disease
■ Zika virus
xx P R E FA C E
Chapter 7
■ Recent challenges to psychiatric diagnosis
■ Mental health and the Affordable Care Act
Chapter 8
■ The impact of the ACA
■ The ACA under attack
Chapter 9
■ Updated statistics and descriptions of health care in five nations
Chapter 10
■ Technology, terrorism and public health
■ Updated statistics on hospice care, hospitals, nursing homes, and home care
Chapter 11
■ “Boutique medicine”
Chapter 12
■ Updated statistics on each health care occupation
Chapter 13
■ CRISPR technologies
New or Revised Tables and Figures
■ Map 2.1 Overdose Deaths Per 100,000 Persons, United States
■ Table 2.1 Main Causes of Deaths, 1900 and 2016
■ Table 2.2 Underlying Causes of Premature Death in the United States, 2010
■ Figure 3.1 Life Expectancy by Race and Ethnicity and Sex
■ Table 3.1 Infant Mortality Rates in Different Nations and U.S. Ethnic Groups
■ Table 3.2 Top Causes of Death by Ethnicity
■ Table 4.1 Life Expectancy and Infant Mortality by Development Level
■ Table 4.2 Leading Causes of Death around the World
■ Table 6.1 Percentage of Americans with Basic Activity Limitations
■ Table 7.1 Sex, Ethnicity, and Social Class Groups with the Highest Lifetime
Risks of Specific Mental Illnesses
■ Figure 7.1 Antidepressant Use in the Past 30 Days, United States
■ Figure 8.1 Health Expenses and Inpatient Days in Acute Care Hospitals in
30 Nations
■ Figure 8.2 Health Expenses and Number of Doctor Visits in 30 Nations
■ Figure 8.3 Health Expenses and Life Expectancy in 30 Nations
■ Table 9.1 Characteristics of Health Care Systems in Seven Countries
■ Figure 11.1 Median Salaries by Percentage Women in Specialty
P R E FA C E xxi
PEDAGOGICAL FEATURES FOR STUDENTS
Learning Objectives
Each chapter opens with a list of learning objectives matched to the chapter’s main
sections. These objectives help students focus their studying by alerting them to
the chapter’s main themes.The objectives also can help students demonstrate their
ability to apply what they have learned and can help both students and faculty
assess students’ understanding.
Chapter Openings
Unfortunately, many students take courses only to fill a requirement. As a result, the
first problem professors face is interesting students in the topic. For this reason, the
main text of each chapter begins with a vignette taken from a sociological or literary
source that is chosen to spark students’ interest by demonstrating that the topic has
real consequences for real people—that, for example, stigma is not simply an abstract
concept but something that can cost ill persons their friends, jobs, and social standing.
Chapter “Road Maps”

To help orient students to the chapters, each chapter’s introductory section ends
with a brief overview of what is to come.
Contemporary Issues
To further raise student interest and add to their knowledge, most chapters include
a boxed discussion of a relevant topic taken from recent news reports. Topics in-
clude the debate over full-body computed tomography scans and the decline of
primary care. These boxes should spark student interest while helping them make
connections between textbook topics and the world around them.
Ethical Debates
To teach students that ethical dilemmas pervade health care, most chapters include
a discussion of a relevant ethical debate.The debates are complex enough that stu-
dents must use critical thinking skills to assess them; teachers can use these debates
for classroom discussions, group exercises, or written assignments.
Key Concepts
To help students understand particularly important and complex topics, such
as the difference between the sociological and medical models of illness or the
strengths and weaknesses of the sick role model, I have included Key Concepts
tables or boxes in several chapters.
xxii P R E FA C E
Implications Essays
Each chapter ends with a brief essay that discusses the implications of the chapter
and points the reader toward new questions and issues. These essays should stimu-
late critical thinking and can serve as the basis for class discussions.
Chapter Summaries
Each chapter ends with a detailed, bulleted summary that will help students to
review the material and identify key points.
Review Questions and Critical Thinking Questions

Each chapter includes both Review Questions that take students through the
main points of the chapter and Critical Thinking Questions that push students to
extrapolate from the chapter to other issues or to think more deeply about issues
discussed within the chapter.
Glossary
The book includes an extensive Glossary that defines all important terms used
in the book. Each Glossary term is printed in bold and defined the first time it
appears in the text. In addition, each term is also printed in bold the first time it
appears in each chapter, so students will know that they can find a definition in
the Glossary.
SUPPLEMENTAL AND PEDAGOGICAL FEATURES

FOR FACULTY
Instructor’s Manual with Test Bank

For each chapter, the Instructor’s Manual contains a detailed summary, a set of
multiple-choice questions, and a list of relevant books, narrative films, and docu-
mentaries. In addition, the Instructor’s Manual includes several questions for each
chapter that require critical-thinking skills to answer and that teachers can use
for essay exams, written assignments, in-class discussions, or group projects. The
manual also includes for each chapter a set of Internet exercises designed both to
familiarize students with materials available on the Web and to facilitate critical
reading and use of those materials. Finally, the manual lists for each chapter a few
relevant nonprofit organizations. Organizations listed in the manual can serve as
sources for more information or as sites for out-of-class assignments.
The Test Bank contains up to 20 multiple-choice questions, five true/false
questions, and five essay questions per chapter, all fully updated according to match
the eighth edition’s content.
P R E FA C E xxiii
To guarantee the quality of the Instructor’s Manual with Test Bank, I wrote ev-
erything in it rather than relying on student assistants. The manual is available for
downloading at http://login.cengage.com.
PowerPoint Lectures
PowerPoint lectures for each chapter, including all tables and figures, can be down-
loaded from http://login.cengage.com. These lectures should prove useful both
for new adopters and for past users who would like to incorporate more visual
materials into their classrooms. As with the Instructor’s Manual, I put these lectures
together myself to ensure their quality.
Critical Thinking
In this textbook, I have aimed not only to present a large body of data in a coher-
ent fashion but also to create an intellectually rigorous textbook that will stimulate
students to think critically. I have tried to keep this purpose in mind in writing
each chapter. Debates discussed within the chapters, as well as the various chapter
features, all encourage students to use critical thinking, and all serve as resources
that teachers can use in building their class sessions.
ACKNOWLEDGMENTS
In writing this textbook, I have benefited enormously from the generous assis-
tance of my colleagues. I am fortunate to have had several exceptional scholars
as colleagues over the years—Victor Agadjanian, Jill Fisher,Verna Keith, Bradford
Kirkman-Liff, Jennie Jacobs Kronenfeld, and Deborah Sullivan—who shared my
interest in health issues and helped me improve various chapters. I am also excep-
tionally fortunate to have had the assistance of several research assistants—Natasha
McLain, Allex Raines, Ashley Fenzl, Allison Hickey, Ann Jensby, Melinda Konicke,
Christopher Lisowski, Stephanie Mayer, Leslie Padrnos, Zina Schwartz, Diane
Sicotte, Lisa Tichavsky, Caroleena Von Trapp, and especially Karl Bryant, Lisa
Comer, and Amy Weinberg, who worked on the first edition.
Because, of necessity, this textbook covers a wealth of topics that range far
beyond my own areas of expertise, I have had to rely heavily on the kindness of
strangers in writing it. One of the most rewarding aspects of writing this book
has been the pleasure of receiving information, ideas, critiques, and references
from individuals I did not previously know. This edition was undoubtedly
improved by suggestions from Ellen Annandale (University of York), Maria
Dolores Corona (Universidad Autónoma de Nuevo León), Georgiann Davis
(University of Nevada, Las Vegas),Victoria Fan (University of Hawai`i at Mānoa),
Siegfried Geyer (Hannover Medical School), Lei Jin (Chinese University of
Hong Kong), Tey Meadow (Harvard University), Melissa A. Milkie (University
of Toronto), Jiong Tu (Sun Yat-sen University), Carla A. Pfeffer (University of
xxiv P R E FA C E
South Carolina), Helen Rosenberg (University of Wisconsin-Parkside), Ian Shaw

(University of Nottingham), Lisa Strohschein (University of Alberta), and Diane
Kholos Wysocki (formerly of University of Nebraska–Kearney).
In addition, I would like to once again thank those who gave me the ben-
efit of their expert advice on previous editions: Astrid Eich-Krohm (Uni-
versity Hospital Magdeburg), Krista Hodges (University of Hawaii), Michael
Polgar (Penn State University), Jennifer Schumann, Ian Shaw (University of
Nottingham), Julia Stumkat, and Wei Zhang (University of Hawaii), Emily Abel
(University of California–Los Angeles); James Akré (World Health Organization);
Ellen Annandale (University of Leicester); Ofra Anson (Ben Gurion University
of the Negev); Judy Aulette (University of North Carolina; Charlotte); Miriam
Axelrod; James Bachman (Valparaiso University); Kristin Barker (University of
New Mexico); Paul Basch (Stanford University); Phil Brown (Brown Univer-
sity); Peter Conrad (Brandeis University); Timothy Diamond (California State
University–Los Angeles); Luis Durán (Mexican Institute of Social Security);
Elizabeth Ettorre (University of Liverpool); Michael Farrall (Creighton Uni-
versity); Kitty Felker; Arthur Frank (University of Alberta); María Hilda García-
Pérez (Arizona State University); Alya Guseva (Boston University); Frederic W.
Hafferty (University of Minnesota–Duluth); Harlan Hahn (University of Southern
California); Ida Hellander (Physicians for a National Health Program); Paul
Higgins (University of South Carolina); Allan Horwitz (Rutgers University);
David J. Hunter (University of Durham); Joseph Inungu (Central Michigan
University); Michael Johnston (University of California–Los Angeles); Stephen
J. Kunitz (University of Rochester); Donald W. Light (University of Medicine
and Dentistry of New Jersey); Judith Lorber (City University of New York);
William Magee (University of Toronto); Judy Mayo; Peggy McDonough (Uni-
versity of Toronto); Jack Meyer (Economic & Social Research Institute); Cindy
Miller; Jeanine Mount (University of Wisconsin); Marilynn M. Rosenthal (Univer-
sity of Michigan); Beth Rushing (Kent State University); C. J. Schumaker (Walden
University); Wendy Simonds (Georgia State University); Teresa Scheid (University
of North Carolina at Charlotte); Clemencia Vargas (Centers for Disease Con-
trol and Prevention); Olaf von dem Knesebeck (University of Hamburg); Robert
Weaver and his students, especially Cheryl Kratzer (Youngstown State University);
Daniel Whitaker; David R. Williams (University of Michigan); Irving Kenneth
Zola (Brandeis University); and Robert Zussman (University of Massachusetts–
Amherst). This book undoubtedly would have been better if I had paid closer
attention to their comments. I apologize sincerely if I have left anyone off this list.
Similarly, I am deeply grateful for the advice received from reviewers of this
edition: Andrew Bedrous (Kansas Wesleyan University), DeAnna Gore (Univer-
sity of South Carolina, Aiken), Muhammad Haque (McNeese State University),
Caroline Hartnett (University of South Carolina), Marta Jankowska (San
Diego State University),Yushi Li (Northern Kentucky University), Elgin Mannion
(Western Illinois University), Jewrell Rivers (Abraham Baldwin Agricultural
College), Sharon Sassler (Cornell University), and Paul Sutton (University of
Denver).
P R E FA C E xxv
I also remain grateful for the suggestions from reviewers on previous edi-
tions: Jennifer Bulanda (Miami University), Benjamin Drury (Indiana Univer-
sity at Columbus), Jamie Gusrang (Community College of Philadelphia), David
Mullins (University of Saint Francis), Claire Norris (Xavier University of Louisiana),
Michael Polgar (Penn State University), Richard Scotch (University of Texas at
Dallas), Nicole Vadino (Community College of Philadelphia, Thomas Allen (Uni-
versity of South Dakota), Karen Bettez (Boston College), Linda Liska Belgrave
(University of Miami), Pamela Cooper-Porter (Santa Monica College), Karen
Frederick (St. Anselm College), Stephen Glazier (University of Nebraska), Linda
Grant (University of Georgia), Janet Hankin (Wayne State University), Heather
Hartley (Portland State University), Alan Henderson (California State University–
Long Beach), Simona Hill (Susquehanna University), Frances Hoffman (Uni-
versity of Missouri), Joseph Kotarba (University of Houston), Lilly M. Langer
(Florida International University), Christine Malcom (Roosevelt University),
Keith Mann (Cardinal Stritch University), Phylis Martinelli (St. Mary’s College
of California), Dan Morgan (Hawaii Pacific University), Larry R. Ridener
(Pfeiffer University), Susan Smith (Walla Walla University), Kathy Stolley
(Virginia Wesleyan College), Deborah Sullivan (Arizona State University), Gary
Tiedman (Oregon State University), Diana Torrez (University of North Texas),
Linda Treiber (Kennesaw State University), Robert Weaver (Youngstown State
University), and Diane Zablotsky (University of North Carolina–Charlotte).
Finally, I would like to express my appreciation to the current and former
Cengage staff who made the process of revising this book for its eighth edition as
smooth as possible: Sharib Asrar, Mike Bailey, Julie Dierig, Deanna Ettinger, Ava
Fruin, Jayne Stein, Wendy Huska, and Jenny Ziegler.
About the Author
Rose Weitz received her doctoral degree in sociology fromYale University in 1978.
Since then, she has carved an exceptional record as both a scholar and a teacher.
She is the author of numerous scholarly articles, the book Life with AIDS, and the
book Rapunzel’s Daughters: What Women’s Hair Tells Us About Women’s Lives. She
also is coauthor of Labor Pains: Modern Midwives and Home Birth and coeditor of The
Politics of Women’s Bodies: Appearance, Sexuality, and Behavior.
Professor Weitz has won several teaching awards (including the Pacific So-
ciological Association’s Distinguished Contributions to Teaching Award, the ASU
Last Lecture Award, and the ASU College of Liberal Arts and Sciences Outstand-
ing Teaching Award) and has served as director of ASU’s graduate and under-
graduate sociology and gender studies programs. In addition, she has served as
president of Sociologists for Women in Society, as chair of the Sociologists AIDS
Network, and as chair of the Medical Sociology Section of the American Socio-
logical Association.
xxvi
PA R T
I
Social Factors and Illness
Chapter 1 The Sociology of Health, Illness, and Health Care
Chapter 2 The Social Sources of Modern Illness
Chapter 3 The Social Distribution of Illness in the United States
Chapter 4 Illness and Death in the Less Developed Nations
Illness is a fact of life. Everyone experiences illness sooner or later, and everyone
eventually must cope with illness among close friends and relatives.
To the ill individual, illness can seem a purely internal and personal experi-
ence. But illness is also a social phenomenon with social roots and social conse-
quences. In this first part, we look at the role that social factors play in fostering
illness within societies and in determining which groups in a given society will
experience which illnesses with which consequences.
Chapter 1 introduces the sociological perspective and illustrates how sociol-
ogy can help us understand issues related to health, illness, and health care. The
chapter also provides a brief history of disease in the Western world, which high-
lights how social factors can foster disease. In the subsequent chapters, we explore
the role social forces play in causing disease and in determining who gets ill in
the modern world. In Chapter 2, we review the basic concepts needed to discuss
diseases and look at modern patterns of disease. After that, we look at the social
sources of illness in the contemporary United States and at some social factors that
help predict individual health and illness. In Chapter 3, we investigate how four
social factors—age, sex and gender, social class, and race or ethnicity—affect the
1
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Bockley Station. As she went on little groups of returning revellers
passed her by. Most of them had just come in by train from the City
after an evening at the theatre. Some of them stared at her curiously
as she hurried by. So did the policeman at the corner of the Station
Road.
Outside the booking-office she met, of all people in the world,
Helen Trant.... Since the episode between herself and George,
Catherine had not seen much of Helen.
Catherine nodded casually, as if it were the most natural thing in
the world for her to be catching the 11.37 p.m. to the City.
“Where’re you off to?” said Helen.
“City,” replied Catherine, curtly.
“Whatever for at this time of night?”
“Oh ... business ... that’s all. ... Excuse me, I shall miss my
train....”
“No, you won’t. You’ve eleven minutes to wait. Come here.”
There was a queer undefinable something in Helen’s voice that
commanded and usually obtained implicit obedience. Catherine
came.
“Well? ... What do you want?”
Helen put her arm in Catherine’s.
“It’s not my business,” she said, “but I should like you to tell me
what’s been happening to you.”
“Happening? What do you mean?”
“You know what I mean ... Cathie!”
“Yes?”
“Something’s happened. I can see it in your eyes. Tell me.”
Catherine clicked her heels nonchalantly.
“Well, if you’re so keen, I don’t suppose there’s much harm in
letting you know. I’ve run away from home.... That’s all....”
“Run away?”
“Yes, run away. Oh, for God’s sake, don’t look so surprised. I
suppose it isn’t respectable to run away, is it?”
“Don’t be silly.... What were you going to the City for?”
“To get a shake-down in a railway waiting-room.”
“I see.... Well, you needn’t do that. You can come home with me
for to-night.”
“Really, Helen, I can’t. It’s awfully good of you, but——”
“You must.”
“But your mother——”
“Mother and father are away for the week-end.”
“Really, I’d much rather not.”
“That doesn’t matter. You’ve got to. You can easily sleep with me.
We’ll talk the whole question over to-night before going to sleep. You
can’t do a big thing like this all on your own.”
“That’s just what I can. I’m going to, anyway....”
“Well, you’re coming home with me to-night, anyway....”
“If you insist——”
“I do.”
A man came striding up the stairs three at a time from the
platform. It was George Trant.
“Sorry I’m late,” he said. “The luggage-office was shut, and I had
to waken somebody up....” Then he saw Catherine. “... Er ... I say ... I
didn’t see you, Miss Weston! Or shall I call you Catherine, as I used?
And how are you? I haven’t heard of you for ages.”
He held out his hand, but Catherine made no movement.
“I’m quite well,” she said quietly. “I’m sorry I can’t stop here
talking; I’ve a train to catch. Good-night!”
“Cathie!” cried Helen, but Catherine was too far down the steps to
be recalled. Helen followed her on to the platform and overtook her
near to the further end.
“You’re coming back, Cathie. Don’t be silly.... You must ...”
Catherine held herself passionately erect. The signal lights
winked from red to green.
“It’s no good your trying to persuade me, Helen.... I’m not coming.
I wouldn’t enter the same house with that man.... No, no, no, no, I’m
not coming.”
The train came in to the platform.
“Cathie!”
“No, no! ... I’m not coming, I tell you....” She opened the door of a
third-class compartment and entered.
“You’ll wish you hadn’t done this, Cathie.”
“Never.”
The train slid away into the night and Helen was left standing on
the platform. She had a swift impulse to jump into the tail-end of the
now quickly-moving train and go with Cathie to the next station. But
the train was moving too rapidly for her to attempt this manœuvre in
safety. And behind her stood George a little bewildered (he had
followed her slowly down the steps).
“What’s all the fuss about?” he queried suspiciously.
“Nothing,” replied Helen. Then, as they walked together along the
platform, “You’ll have to tell the man we gave up our tickets before.”
As they hurried along the Bockley High Street the clock on the
Carnegie library chimed the three-quarters....
At Liverpool Street, Catherine discovered that the waiting-room
did not keep open throughout the night for the benefit of girls who
have run away from home. There was a man at the door inspecting
tickets. Catherine was struck by a brilliant notion. There is an all-
night hourly service of trains from Liverpool Street to Bockley, the
same train proceeding backwards and forwards. She went to the
booking-office and purchased a return ticket to Bockley (sixpence).
She had a good sixpennyworth, for the next five hours she spent in
the corner seat of a third-class compartment. About two a.m. she fell
asleep, and when she awoke the train was jerking to a standstill at
Upton Rising. The clock said twenty minutes past six. Evidently the
train had undergone a change while she had slept. All those dark
hours it had paraded the inner suburbs, but now it had become a
thing of greater consequence: it was the first early morning train to
Chingford. At the tiny Forest town Catherine left it, paying excess
fare on the journey from Bockley. Dawn came as she was tramping
the muddy paths of Epping Forest. She had no idea where she was
going. The main thing was to get the time over. About eight o’clock
she returned to Chingford, purchased some notepaper and
envelopes, and went into the post-office. On the desk provided for
composing telegrams she wrote a letter accepting the situation of
pianist at the Royal Cinema, Upton Rising. That done, and the letter
stamped and posted, she felt calmer than she had been for some
time. Then came hunger. She had a glass of milk (threepence) at a
dairy and two of yesterday’s buns (a penny each) from a
confectioner’s. Out of five and sevenpence half-penny and two
penny stamps she had now left four shillings and a half-penny and
one penny stamp, plus a third-class return half from Bockley to
Liverpool Street.
She persisted in being joyous. This was to be an adventure, and
she was to enter into the spirit of it. She took her buns to the top of
Yardley Hill in order that she might imagine herself picnicking. She
lay down on the damp grass eating, and told herself she was
enjoying herself immensely. She admired the loveliness of the view
with all the consciousness of a well-trained tourist. She refused to be
melancholy. She discovered hundreds of excuses for feeling happy
which would never have occurred to her if she had been feeling
happy. As she was descending the hill after her meal it commenced
to rain. She tried to see beauty in the rain. The grey sky and the
sodden leaves, the squelch of her heels in the mud, the bare trees
swathed in slanting rain, these, she decided, were infinitely
preferable to Kitchener Road.... Nevertheless she would have to find
lodgings.
She decided to seek them in Upton Rising.
CHAPTER V
DISILLUSIONMENTS
§1
GIFFORD ROAD, Upton Rising, seemed to be composed of various
architectural remnants which had been left over from other streets.
No. 14 was a dour, gloomy-looking edifice built of a stone-work that
showed up in lurid prominence the particular form of eczema from
which it suffered. The front garden was large, with evidences of
decayed respectability, including a broken-down five-barred gate and
the remains of a lawn. The wooden erection at the side of the house
may once have been a coach-shed.... A flight of stone steps, much
chipped and scarred, led up to a massive front door, but the usual
entrance was clearly the small door underneath the steps, which
generally stood ajar.... In the basement window appeared the
“apartments” card and the ubiquitously respectable aspidistra plant.
Cats of all sizes and colours haunted the long, lank grass of the front
garden, and at the back there was a noisy, unkempt chicken-run.
Inside the tiny basement sitting-room Catherine tried to feel at
home. The dried grasses and bric-à-brac on the mantelpiece did
remind her somewhat of the front room at Kitchener Road, but the
old faded photographs of the landlady’s relatives, most of them
mercifully obscure, made her feel strange and foreign. A stuffed
canary under a glass shroud surmounted the sideboard, and
Catherine decided mentally that after she had been here awhile she
would remove it to a less conspicuous position. A dull piety brooded
over the room: there were floridly decorated texts on the walls, “I am
the Bread of Life” over the doorway, and “Trust in the Lord” by the
fireplace. The small bookshelf contained bound volumes of The
Quiver and various missionary society reports, as well as several
antiquated volumes, of which Jessica’s First Prayer was one,
presented to the landlady, as the flyleaf showed, by a certain Sunday
school in South London. A couple of pictures above the mantelpiece
represented the Resurrection and the Ascension, and in these there
was a prolific display of white-winged angels and stone slabs and
halos like dinner-plates. On a November afternoon the effect of all
this was distinctly chilly.
And under the cushions of the sofa there were many, many
copies of Sunday newspapers, both ancient and modern.
Mrs. Carbass was a woman of cheerful respectability. She
accepted Catherine as a lodger without any payment in advance. At
first she was doubtful, but the production of the letter offering
Catherine the situation at the Upton Rising Royal Cinema overruled
her misgivings. She was apparently an occasional patron of this
place of amusement.
“Sometimes I goes,” she remarked. “Of a Sat’d’y night, gener’ly....
In the ninepennies,” she added, as if excusing herself.
Catherine lived very quietly and economically during her first few
weeks at Gifford Road. She had to. Her earnings did not allow her
much margin after she had paid Mrs. Carbass. Out of this margin
she had to buy all kinds of things she had not counted on—chiefly
changes of clothing, and ranging down to small but by no means
negligible articles such as wool for darning and a toothbrush. She
decided to have no communication whatever with her father, though
at first she had considered whether she would not write to him to ask
him to send her all the property that was her own. Finally she
decided against this, thinking that she would not care to let him
imagine she was in need of anything. Sometimes the fear came to
her that he would find her out: he could easily discover her address
by enquiring at the Cinema. At times the fear became a definite
expectation, and on rare occasions the expectation developed into
what was perilously near to a hope. Often in the streets she met
people who knew her, and to these she never mentioned either her
father or her attitude towards him. Most people in Kitchener Road
knew or guessed what had happened: it did not cause much of a
sensation, for worse things were common enough in Kitchener
Road.... Kitchener Road was quite blasé of domestic estrangements.
Whenever Catherine was asked how she was getting on she replied,
“Oh, quite nicely, thanks,” and would not pursue the subject.
At the Cinema she found work easy but not particularly
interesting. She was annoyed to find herself agreeing with her father
that the Upton Rising Royal Cinema was “third-rate.” It was a tawdry
building with an exterior of white stucco (now peeling off in great
scabs), and an interior into which the light of day never penetrated. A
huge commissionaire with tremendously large feet, attired in the sort
of uniform Rupert of Hentzau wears on the stage, paced up and
down in front of the entrance, calling unmelodiously: “Nah showin’
gran’ star progrem two, four, six, nine an’ a shillin’ this way children a
penny the side daw ...” all in a single breath. For this trying
performance he was paid the sum of sixteen shillings a week. Inside
the building a couple of heavily powdered, heavily rouged, heavily
scented girls fluttered about with electric torches. There was no
orchestra, save on Saturday nights, when a violinist appeared in a
shabby dress suit and played the Barcarolle from “Tales of Hoffman,”
and similar selections. The rest of the time Catherine was free to
play what she pleased, with but a general reservation that the music
should be appropriate to the pictures shown.
On Saturday mornings there was a children’s matinée, and that
was nothing but pandemonium let loose. Screams, hooting, cheers,
whistlings, yells and cries of all kinds.... On Saturday evenings the
audience was select, save in the front seats near the piano. In the
pale glare of the film all faces were white and tense. The flutter of the
cinematograph went on, hour after hour. The piano tinkled feebly
through the haze of cigarette smoke. Here and there the beam of an
electric torch pierced the gloom like a searchlight. The sudden
lighting of a match was like a pause of semi-consciousness in the
middle of a dream....
And at eleven, when bedroom lights were blinking in all the
residential roads of Upton Rising, Catherine passed out into the cool
night air. Her fingers were tired; sometimes her head was aching.
To pass along the Ridgeway now did not always mean thinking of
things that had happened there....
§2
For three months she played the piano at the Upton Rising Royal
Cinema; then she applied for and was appointed to a similar position
at the Victoria Theatre, Bockley. The salary was better and the hours
were not so arduous.... And yet she was becoming strangely restless
and dissatisfied. All through her life she had had a craving for
incident, for excitements, for things to happen to her. The feeling that
she was doing something almost epically magnificent in living on her
own whilst not yet out of her teens gave her an enthusiasm which
made bearable the dull monotony of life in Gifford Road. It was this
enthusiasm which enabled her joyously to do domestic things such
as making her bed every morning, darning stockings, cleaning boots,
etc., things that normally she loathed. For the first few months of her
independence everything was transfigured by the drama of her
position. The thought would occur to her constantly in trams and
omnibuses when she noticed someone looking at her: “How little you
know of me by looking at me! You cannot see into my mind and
know how firm and inflexible I am. You don’t know what a big thing I
am doing.”
Reaction came.
It interested Catherine to picture various meetings with her father
and to invent conversations between them in which she should be
unquestionably the winner. The ideal dialogue, she had decided after
much reflection, would be:
her father (stopping her in the street). Catherine!
she (haughtily). I beg your pardon!
her father (tearfully). Oh, don’t be so cruel, Cathie—why don’t
you come back?
she. I am not aware that I am being cruel.
her father. You are being horribly cruel (passionately). Oh,
Cathie, Cathie, come back! I give in about your going out to work, I
give in about anything you like, only do come back, do, do come!
she (coldly). Please don’t make a scene.... I am perfectly
comfortable where I am and have no desire to make any alteration in
my arrangements.
her father. Oh, Cathie, Cathie, you’re breaking my heart! I’ve
been lonely, oh, so lonely ever since——
she (kindly but firmly). I’m sorry, but I cannot stay to carry on a
conversation like this. You turned me out of your house when you
chose: it is for me to come back when I choose, if I choose.... I bear
you no ill-will.... I must be going. Please leave go of my arm....
That would be magnificent. She was sure she was not in the least
callous or hard-hearted, yet it pleased her to think that her father was
lonely without her. One of her dreams was to be passionately loved
by a great man, and to have to explain to him “kindly but firmly” that
she desired only friendship....
One day she did meet her father.
She walked into a third-class compartment at Bockley Station
and there he was, sitting in the far corner! Worse still, the
compartment was full, saving the seat immediately opposite to him.
There is a tunnel soon after leaving the station and the trains are not
lighted. In the sheltering darkness Catherine felt herself growing hot
and uncomfortable. What was she to do? She thought of her ideal
conversation, and remembered that in it he was supposed to lead
off. But if he did not lead off? She wished she had devised a
dialogue in which she had given herself the lead. Yet it would be
absurd to sit there opposite to him without a word. She decided she
would pretend not to see him. She was carrying a music-case, and
as the train was nearing the end of the tunnel she fished out a piece
of music and placed it in front of her face like a newspaper. When
the train emerged into daylight she discovered that it was a volume
of scales and arpeggios, and that she was holding it the wrong way
up. The situation was absurd. Yet she decided to keep up the
semblance of being engrossed in harmonic and melodic minors.
After a while she stole a glance over the top of her music. It was
risky, but her curiosity was too strong for her.
She saw nothing but the back page of the Daily Telegraph. It was
strange, because he never read in trains. It was one of his fads. He
believed it injurious to the eyes. (Many and many a time he had
lectured her on the subject.)
Obviously then he was trying to avoid seeing her, just as she was
trying to avoid seeing him. The situation was almost farcical.... There
seemed to be little opening for that ideal dialogue of hers. She
wished he would lean forward and tap her knee and say:
“Catherine!”
Then she could drop her music, look startled, and follow up with:
“I beg your pardon!”
Unfortunately he appeared to have no artistic sense of what was
required of him.
It was by the merest chance that at a certain moment when she
looked over the top of the scales and arpeggios he also looked up
from his Daily Telegraph. Their eyes met. Catherine blushed, but it
was not visible behind her music. He just stared. If they had both
been quick enough they might have looked away and let the crisis
pass. Unfortunately each second as it passed made them regard
each other more unflinchingly. The train ground round the curve into
Bethnal Green Station. Catherine was waiting for him to say
something. At last the pause was becoming so tense that she had to
break it. She said the very first thing that entered her head. It was:
“Hullo!”
Then ensued the following conversation.
“Good-morning, Catherine ... going up to the City, I suppose?”
“Yes. Are you?”
“Yes. I’m going to see some friends at Ealing. Bus from Liverpool
Street.”
“Oh, I go by tube to Oxford Circus. I’m seeing if they’ve got some
music I ordered.”
“Don’t suppose they’ll have it ... very slack, these big London
firms....”
Pause.
“Getting on all right?”
“Oh, fine, thanks.”
“I heard you’d got a place at the Royal Cinema.”
“Oh, I soon left that ... I’m on at the Victoria Theatre now. Much
better job.”
“Good ... like the work, I suppose?”
“Rather!”
Pause.
“Nasty weather we’re having.”
“Yes—for April.”
Pause again. At Liverpool Street they were the first to leave the
compartment.
“You’ll excuse my rushing off,” she said, “but I must be quick. The
shop closes at one on a Saturday.”
“Certainly,” he murmured. Then he offered his hand. She took it
and said “Good-bye” charmingly. A minute later and she was leaning
up against the wall of the tube subway in a state bordering upon
physical exhaustion. The interview had been so unlike anything she
had in her wildest dreams anticipated. Its casualness, its sheer
uneventfulness almost took away her breath. She had pictured him
pleading, expostulating, remonstrating, blustering, perhaps making a
scene. She had been prepared for agonized entreaties, tearful
supplications. Instead of which he had said: “Nasty weather we’re
having.”
And she had replied: “Yes—for April.”
As for the ideal dialogue——
§3
There was another surprise in store for Catherine.
In the front row of the stalls at the Bockley Victoria Theatre she
saw George Trant. She was only a few feet away from him in the
orchestra, and it was inevitable that he should notice her.
Now if Catherine had been asked if she would ever have
anything to do with George Trant again, she would have said “No”
very decisively. She had made up her mind about that long ago. If he
ever spoke to her she had decided to snub him unmercifully.
But George Trant stood up and waved to her.
“I say, Cathie!” he said.
And Catherine looked up and said, quite naturally, “Hullo,
George.”
It was a revelation to her. What had she said it for? What was the
matter with her? A fit of self-disgust made her decide that at any rate
she would not continue a conversation with him. But curiously
enough George did not address her again that evening. She wished
he would. She wanted to snub him. She wanted to let him see how
firm and inflexible she was. She wanted to let herself see it also.
§4
At Gifford Road, in the little bedroom, Catherine’s dissatisfaction
reached culminating point. Life was monotonous. The humdrum
passage of day after day mocked her in a way she could not exactly
define. She wanted to be swept into the maelstrom of big events.
Nothing had yet come her way that was big enough to satisfy her
soul’s craving. Things that might have developed dramatically
insisted on being merely common-place. Even the fire of her musical
ambition was beginning to burn low. Things in her life which had at
first seemed tremendous were even now in the short perspective of
a few months beginning to lose glamour. She thought of those dark
days, not a year back, when the idea of saying “hullo” to George
Trant would have seemed blasphemy. She thought of those June
evenings when she had paced up and down the Ridgeway in the
spattered moonlight, revelling in the morbid ecstasy of calling to
mind what had happened there. All along she had been an epicure in
emotions. She loved to picture herself placed in circumstances of
intense drama. She almost enjoyed the disappointment and passion
that George Trant had roused in her, because such feelings were at
the time new to her. Yet even in her deepest gloom something within
herself whispered: “This is nothing. You are not really in love with
George Trant. You are just vaguely sentimental, that’s all. You’re just
testing and collecting emotions as a philatelist collects stamps. It’s a
sort of scientific curiosity. Wait till the real thing comes and you’ll lose
the nerve for experimenting....” Yet the episode of George Trant had
stirred just sufficient feeling in Catherine to make her apprehensive
of similar situations in the future....
Now, as she undressed in the attic-bedroom in Gifford Road, life
seemed colourless. The idea of refusing to speak to George Trant
because of what had happened less than a year ago struck her as
childish. She was glad she had spoken to him. It would have been
silly to dignify their absurd encounter by attempting magnificence.
Catherine decided that she had acted very sensibly. Yet she was
dissatisfied. She had built up ideals—the ideals of the melodrama—
and now they were crumbling at the first touch of cold sense. She
had imagined herself being pitifully knocked about by fate and
destiny and other things she believed in, and now she was beginning
to realize with some disappointment that she had scarcely been
knocked about at all. It was a very vague dissatisfaction, but a very
intense one for all that.
“Oh, Lord, I want something, and I’m hanged if I know what it is....
Only I’m tired of living in a groove. I want to try the big risks. I’m not a
stick-in-the-mud....”
She herself could not have said whether this ran through her
mind in the guise of a prayer or an exclamation. But perhaps it did
not especially matter. “I guess when you want a thing,” she had once
enunciated, “you pray for it without intending to. In fact you can’t
want anything without praying for it every minute of the time you feel
you’re wanting it.... As for putting it into words and kneeling down at
bedtime, I should say that makes no difference....”
But she did not know what she wanted, except that it was to be
exciting and full of interest....
She fell asleep gazing vacantly at a framed lithograph on the
opposite wall which a shaft of moonlight capriciously illumined. It was
a picture of Tennyson reading his In Memoriam to Queen Victoria,
the poet, long-haired and impassioned, in an appropriately humble
position before his sovereign....
§5
The following morning a typewritten letter waited her arrival in the
basement sitting-room. It bore on the flap the seal of a business firm
in London, and Catherine opened it without in the least guessing its
contents.
It began:
my dear cathie,
You will excuse my writing to you, but this is really nothing but a
business letter. I found your address by enquiry at the theatre box-
office: the method is somewhat irregular, but I hope you will forgive
me.
What I want to say is this——
Catherine glanced down the typewritten script and saw the
signature at the bottom. It was George Trant. Her face a little
flushed, she read on:
The Upton Rising Conservative Club, of which I am a member, is
giving a concert on May 2nd, in aid of the local hospitals. A friend of
mine (and a fellow-member) was so impressed by your playing this
evening that he suggested I should ask you to play a pianoforte solo
at our projected concert. I cordially agree with his idea, and hope you
will be able to accept. I enclose a draft of the musical programme so
that you may realize that we are having some really “star” artists
down. Bernard Hollins, for instance, has sung at the Queen’s Hall.
Please write back immediately in acceptance and let me know the
name of the piece you propose to play, so that the programmes can
go to press immediately. Excuse haste, as I must catch the 11.30
post.
Yours sincerely,
george trant.
Catherine re-read the letter twice before she commenced to
criticize it keenly. Her keen criticism resulted in the following
deductions. To begin with:
This was some subtle cunning of his to entrap her. He was clever
enough to devise it.... What had she played last evening at the
Bockley Victoria Theatre that could have “impressed” anybody so
much? The show had been a third-rate revue, the music of which
was both mediocre and childishly simple. The piano was bad. She
had played, if anything, not so well as usual. The piano was, for the
most part, drowned in the orchestra. Moreover, there were scores of
pianoforte players in the district who would have been eager to
appear on such a distinguished programme as the one he had sent.
It was absurd to pick her out. She had no musical degree, had never
played at a big concert in her life. The other artists might even object
to her inclusion if they knew who she was. In any case, no astute
concert-organizer would risk putting her in. She was well-known, and
scores of people would say, as soon as they saw her on the
platform: “Why, that’s the red-haired girl who plays the piano at the
theatre.”
Catherine came to the definite conclusion that the letter was
thoroughly “fishy.”
Yet she wrote back saying:
dear george,
Thanks for letter and invitation, which I am pleased to accept. My
piece will be Liszt’s Concert Study in A flat, unless you think it too
classical, in which case I can play a Polischinelle by Rachmaninov.
Yours sincerely,
catherine weston.
Catherine thought: If I can make use of George Trant to further
my ambitions, why shouldn’t I? If this leads to anything in the way of
bettering my earnings or getting engagements to play at concerts, it
will be no more than what George Trant owes me. And if this is
merely a trap laid for me, we’ll see who’s the more astute this time.
In any case it should lead to some interesting situations, and it will at
least vary the monotony of life....
It suddenly struck her that perhaps her father would come and
hear her play. The possibility opened up wild speculations. Her
dramatic interest pictured him rising from his seat in the middle of the
Concert Study in A flat, and crying with arm uplifted—“God!—My
daughter!”
Or perhaps he would sob loudly and bury his head in his hands.
Yet, remembering their meeting in the railway carriage, she knew
he would do nothing of the sort....
... The audience would sit spell-bound as the Concert Study rang
out its concluding chords. As the last whispered echo died on the air
the whole building would ring with shouts of tumultuous applause.
Those nearest the front would swarm on to the platform, seizing her
hand in congratulation. A buzz of conversation would go round,
startled, awe-stricken conversation: “Who is that red-haired girl?—
Who is she?—Plays at the theatre?—Oh, surely not. Impossible!”
They would demand an encore. She would play Chopin’s Study,
“Poland is Lost.”
And the Bockley and District Advertiser would foam at the
headline with: “Musical Discovery at Upton Rising. Masterful playing
by local pianiste....”
No, no, all that was absurd....
The audience would listen in bored silence punctuated only by
the “scrooping” of chairs. She would probably tie her hands up in
some of the arpeggios. There would be desultory, unenthusiastic
clapping of hands at the finish. She would be asked for no encore.
Somebody might say: “I fancy I’ve seen that girl at the theatre. She
leads the orchestra.” And the Bockley and District Advertiser would
say with frigid politeness: “Miss Catherine Weston gave a tasteful
rendering of Liszt’s Concert Study in A flat....” Or, if they had used
the word “tasteful” previously, they would say “excellent” or “spirited”
or “vivid.”
“I suppose I’m getting cynical,” she thought, as she mercilessly
tore to pieces her ideal imaginations.
Yet she was very joyous that morning.
Life was going to begin for her. If events didn’t carry her with
them she was just going to stand in their way and make them. If not
followed, she would pursue. Life, life, her soul cried, and life was
mightily interesting. There came a silver April shower, and in her
ecstasy she took off her hat and braved both the slanting rain and
the conventional respectability of Upton Rising. Then came the sun,
warm and drying, and her hair shone like a halo of pure flame.... She
made herself rather foolishly conspicuous....
CHAPTER VI
CRESCENDO
§1
LONG hours she practised on the Chappell grand in the room over
Burlington’s Music Emporium. The Concert Study in A flat began to
take shape and cohesion. April swept out of its teens into its
twenties, and posters appeared on the hoardings outside the Upton
Rising Public Hall announcing a “Grand Evening Concert.” Her name
was in small blue type immediately above the ticket prices. The rest
of the programme was not quite the same as the rough draft that
George had sent her. It was curious, but the best-known people had
been cut out.... Bernard Hollins, for instance, who had sung at the
Queen’s Hall. Those who remained to fill the caste were all people of
merely local repute, and Catherine ceased to have misgivings that
her performance would be mediocre compared with theirs.
One unfortunate coincidence seemed likely to disturb the
success of the evening. In the very afternoon of the same day
Razounov, the famous Russian pianist, was playing at the
Hippodrome. Razounov did not often come to Bockley, and when he
did he drew a large audience. It seemed probable that many who
went to hear him in the afternoon would not care for a Grand
Evening Concert on top of it....
Already the bills outside the Hippodrome were advertising
Razounov in letters two feet high.
§2
The “Grand Evening Concert” was a tame, spiritless affair.
Catherine’s pianoforte solo was introduced at the commencement to
tide over that difficult period during which the local élite (feeling it
somewhat beneath their status to appear punctually at the
advertised time) were shuffling and fussing into the reserved front
seats. Her appearance on the platform was greeted with a few
desultory claps. The piano (grand only architecturally) was placed
wrongly; the sound-board was not raised, and it appeared to be
nobody’s business to raise it for her. She played amidst a jangle of
discordant noises: the rustle of paper bags and silk dresses, the
clatter of an overturned chair, the sibilant murmur of several score
incandescent gas lamps. All through there was the buzz of
conversation, and if she looked up from the keyboard she could see
the gangways full of late-comers streaming to their seats, standing
up to take off their cloaks, making frantic signals to others for whom
they had kept seats vacant, passing round bags of sweets, bending
down to put their hats under the seat, diving acrobatically into
obscure pockets to find coppers for the programme girls, doing
anything, in fact, except listen to her playing. Somehow this careless,
good-humoured indifference gave her vast confidence. She felt not
the least trace of nervousness, and she played perhaps better than
she had ever done before. She had even time to think of subsidiary
matters. A naked incandescent light lit up the keyboard from the side
nearest the rear of the platform, and she deliberately tossed her
head at such an angle that the red cloud of her hair should lie in the
direct line of vision between a large part of the audience and the
incandescent light. She knew the effect of that. At intervals, too, she
bent her head low to the keyboard for intricate treble eccentricities.
She crossed her hands whenever possible, and flung them about
with wild abandon. It would be absurd to say she forgot her
audience; on the contrary, she was remembering her audience the
whole time that she was playing. And during the six or seven
minutes that Liszt’s Concert Study in A flat lasted, her mind was
registering vague regrets. She regretted that nobody had thought to
raise the sound-board for her. She regretted the omission of all those
little stylish affectations which in the first thrill of appearing on the
platform she had forgotten all about. She had not polished her hands

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The Sociology of Health, Illness, and

Health Care: A Critical Approach 8th

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PA R T I Social Factors and Illness 1

PA R T II The Meaning and Experience of Illness 93

PA R T III Health Care Systems, Settings, and Technologies 169

PA R T IV Health Care, Health Research, and Bioethics 247

PA R T I Social Factors and Illness 1

Chapter 1 The Sociology of Health, Illness, and Health

Chapter 2 The Social Sources of Modern Illness 18

The New Rise in Infectious Disease 22

Chapter 3 The Social Distribution of Illness in the

Chapter 4 Illness and Death in the

PA R T II The Meaning and Experience of Illness 93

Chapter 5 The Social Meanings of Illness 95

Chapter 6 The Experience of Disability, Chronic Pain,

Chapter 7 The Sociology of Mental Illness 139

Ethnicity, Gender, Social Class, and Rates of Mental Illness 142

PA R T III Health Care Systems, Settings, and Technologies 169

Chapter 8 Health Care in the United States 170

The ACA Under Attack 177

Chapter 9 Health Care Around the Globe 195

Chapter 10 Health Care Settings and Technologies 221

PA R T IV Health Care, Health Research, and Bioethics 247

Chapter 11 The Profession of Medicine 248

The Threats to Medical Dominance 255

Chapter 12 Other Mainstream and Alternative Health

Chapter 13 Issues in Bioethics 303

THE CRITICAL APPROACH

This textbook demonstrates the breadth of topics included in the sociology of

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South Carolina), Helen Rosenberg (University of Wisconsin-Parkside), Ian Shaw

Social Factors and Illness

Chapter 1 The Sociology of Health, Illness, and Health Care

Chapter 2 The Social Sources of Modern Illness

Chapter 3 The Social Distribution of Illness in the United States

Chapter 4 Illness and Death in the Less Developed Nations

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