Theories of the real…control the vocabularies of healing…if one could construct a map to negotiate a way through rival beliefs on health and healing, its baseline would be ontology, what counts as real. From this line a path would lead to the status of individuals in competing realities, then to different understandings of therapy that follow from competing descriptions of the human person. Finally, the moral and political languages of liberty, privacy, competence, and authority would appear. The first position, though, is reality. It fixes directions for the traveler journeying through the languages of health and healing, and provides the baseline references to justify beliefs about health acts and possibilities. –Frohock (1992, pp. 47-48)

What constitutes health is a question recently posed by H. Gilbert Welch, M.D., a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. One technique he discusses is simply narrowing the definition of what is health. Think to yourself for example, how many people you know who have high cholesterol, low blood pressure, low vitamin D, low iron, diabetes, osteoporosis and so on. These abnormalities are important however; and often are a difference that makes a difference in health care.

But, as Dr. Welch points out, this strategy has generated a host of other problems. As he states: “Doctors who are overwhelmed by the number of ailments their patients allegedly have (and who are often distracted from the most important ones); doctors in training who are increasingly confused about who is really sick and who is not; lawyers who increasingly have a field day with the charge of ‘failure to diagnose’; patients who get too much treatment or lose health insurance because they been given a new diagnosis; and a frazzled, fearful public adrift in a culture of disease. Oh, and did I mention that it has been a disaster for health-care costs?”

Thinking through definitions of what is normal can be explained communicatively. In so doing, we begin to ask what counts as normal and why this concern should matter. What counts as normal calls our attention to “abnormalities” and “health” not as natural categories but as products of social construction maintained through interaction as Berger & Luckmann (1966) explain in greater depth. In short, our interactions are filled with contests for meaning. But definitions like what is normal, or what it means to be healthy or ill, are used by individuals and groups to construct their own preferred versions of reality in place of alternatives that may be uncomfortable for them.  Clearly, we have come to a lot of agreement about these things which allows us to communicate more easily with each other, but often less creatively and productively.

Understood communicatively, the point is not to resolve what constitutes health but rather to reclaim productive tensions as a critical aspect of all life – including health. Even more, thinking about what is normal, brings some relief – as well as a reminder – that these are perspectives rather than attributes of individuals and groups. Therefore, it is impossible to understand what it means to be normal without examining the assumptions that lie below our understandings of health and illness. These assumptions, like the dominant focus on the disease cancer and not dying from cancer, in general terms become “common sense”. But do these commonsensical assumptions leave room for understandings not based only in standardization but also on what individuals experience and express? For example, one of the best cancer hospitals in the world proclaimed in public advertising and on every one of their computers, “The Best Cancer Care…Anywhere.” How would we rethink cancer if it read, “The Best Care of Patients with Cancer…Anywhere?”

Rethinking what is normal in light of the healthcare reform messages flooding every headline is no simple task. If health is understood as the absence of abnormality as Dr. Welch alludes to, the only way to know you are healthy is to become a customer. But a customer of what? Or a customer for whom? And a customer to what extent? Further, he elaborates that health is a state of mind that when viewed as the absence of abnormality, conflicts with the desire and hope for a healthier society. In other words, our definitions of health fix meanings through the languages of health and healing, justify beliefs about health, move people to act in certain ways, and hold spaces of possibilities.

How do your own definitions of what is normal influence the care you seek/receive?

How do our understandings of health and illness impact the work environments of the medical providers doing this work?

What challenges face you and your practice of bringing comfort and care to your patients with increased expectations and restrictions as well as an inherently narrow albeit contestable definition of normal?

Looking forward to your thoughts!

With thanks to zen and dmason for their images…

Carey Candrian