In our society, the majority of people are neither severely ill nor in perfect health. Virtually everyone has some ailment or condition. Simultaneously, adopting a healthy lifestyle has gained greater significance than ever before, resulting in a disparity between our current state and the aspirations we hold for ourselves. This essay focuses on the large portion of individuals who occupy this middle ground and suffer from it. It is crucial for us to become more attuned and sensitive to this emerging reality without excessively victimizing or medicalizing this swiftly expanding segment of society.
The majority of people would concur that suffering from a fever is considered abnormal, much like having a broken leg. Both health conditions deviate from the body's normal functioning. Barring any complications, the fever will subside, and the leg will eventually heal. At times, we require medical assistance for recovery. However, distinguishing between the normal and pathological has become increasingly complex. Consider individuals with asthma, allergies, obesity, diabetes, or the recently emerged long-COVID. Are these people abnormal or sick? And what about the prevalence of mental disorders such as attention deficit disorders, anxiety disorders, and burnouts in today's world? Should people with these afflictions be classified as normal or pathological?
In such instances, the boundary separating normalcy from pathology has grown increasingly indistinct. In addition to conventional health concerns, society must now address all sorts of "diseases of affluence" and the proliferation of mental disorders in the DSM-5. Moreover, it is in our welfare societies that we can readily comprehend the non-ironic meaning of phrases like "loneliness is the new smoking." The intricacies of aging societies further complicate matters. Beyond a certain age, multimorbidity seems to be the rule rather than the exception.
While it may not be apparent, this situation is partially a result of advancements in medicine. If various diseases no longer lead to death, then having a health condition becomes the new normal. Unless one envisions a future in which all forms of (chronic) disease are eradicated and we live happily ever after, our society's collective “sickness” is an inevitable outcome of progress that we must confront and manage.
On the flip side, these advancements in medicine are not without their drawbacks, which require contemplation. The success of medicine has been accompanied by a victimization and medicalization of daily life. This situation renders a medical diagnosis at some stage in our lives nearly inescapable. Furthermore, while medicalization can be lifesaving and pain-relieving, it also introduces new, unexpected vulnerabilities. A case in point is the development of antimicrobial resistance, which arises from the overuse and misuse of antibiotics.
In psychiatry, the issue of overdiagnosis and the inclination to label every condition have sparked heated discussions. On the one hand, the increase in mental disorders could signify the liberation of previously unacknowledged suffering in society. With reduced stigmatization and greater recognition, we are now better equipped to genuinely assist people in alleviating their concealed pain. On the other hand, the medicalization of life might also suggest an escalating inability within society to cope with any form of pain and suffering.
It is evident that the traditional biomedical view of health falls short in offering frameworks that effectively address these issues. What are the implications of everyone being considered ill? How can one’s normal state be perceived as an abnormality? Only by thoroughly reevaluating the concept of health can we comprehend the novel challenges it presents.
The insightful work of philosopher Georges Canguilhem, The Normal and the Pathological (1943), can aid us in understanding this unique situation.
Canguilhem posits that identifying pathological cases is not a difficult task. We are keenly aware of abnormalities around us and have limited capacity for self-deception. We may outrun disease for some time, but eventually, it tends to catch up with us. A burn-out may finally overwhelm us, or depression may set in. These moments of truth are undeniable. However, while pathological cases might be easy to recognize and challenging to evade, understanding what they mean remains a complex question. To address this existential question, we will examine Canguilhem's historical and phenomenological perspective on abnormalities.
When considering disease an abnormality, we must account for two meanings of the term "normal." One is the statistical sense of abnormal, which can be quantified and measured. In the 19th century, as mechanical thinking and statistics became integral components of medical sciences, the notion emerged that disease was merely a deviation from a normal pattern of excitation. Science aimed to eliminate the concepts of good and evil in medicine. Ideas of sickness as punishment or spirit possession were replaced by scientific concepts such as neurasthenia.
Consequently, healing or curing shifted to therapy primarily focused on restoring quantitative equilibrium. This 19th-century idea persists in our understanding of burn-out. A doctor might advise us that there has been excessive stress or excitement in our lives and that reducing it will eventually lead to healing.
However, the normative or valuative aspect of disease re-emerged in the latter half of the 20th century. The word "normal" contains the term "norm." Society once again acknowledged that disease and pathologies also possess an ethical dimension. Dr. Hans Selye, the founding father of the stress concept, already taught us the difference between eustress (good) and distress (bad). Our perception and judgment of the world determine whether something is considered a stressor.
Second, following the Second World War, the concept of social norms gained significance. These norms were often viewed as imposed on individuals by specific practices and institutions. Many French intellectuals took interest in how society created and enforced these norms, which could exclude or stigmatize people. For example, homosexuality was once considered an abnormality and, consequently, a pathological condition. It is not biological deviations but societal expectations and cultural traditions that determine normality and abnormality. As a result, the normal and pathological are now assessed not only through a biological lens but also from a social perspective. However, there is a third aspect to normality often overlooked in medicine: individuals can shape and create their own norms. Canguilhem's interest lay in the area between statistical medical sciences and social structures. He believed that individuals could transcend biological normality and social norms, a concept he referred to as biological normativity.
As living beings, we inhabit a space between these other two domains that define us. As physical entities, we obey to the laws of nature. As social beings, we adapt to social norms and expectations. But biological life not only obeys and adapts, it also integrates and shapes. Governed by physiological regularities and influenced by social norms, we search for ways to incorporate or transcend both in the journey we call life.
Based on his theory of biological normativity, Canguilhem provides insightful reflections on the concept of health for our society. We idealize health, yet we lack consensus on its precise meaning. This is not surprising; while recognizing sickness is relatively easy, describing a healthy state proves more challenging. Generally, medicine addresses abnormalities, infections, injuries, dysfunctions, and disorders. Your leg might be broken or you could be dealing with an inflammatory disease. Doctors mend us. Health, conversely, is often seen as the absence of these conditions. Everything functions as intended; your blood sugar levels are normal; your cognitive faculties operate properly, and so on.
There is undeniable truth to the statement that health relates to the normal functioning of our body. However, Canguilhem both expanded and critiqued this concept. He drew inspiration from René Leriche (1879-1955), who poetically noted that health is life lived in the silence of the organs.
When framed in this manner, the normal functioning of our organs represents the ideal conditions that ease our lives. It is only when we fall ill that our body makes itself known and starts to moan. Being healthy, therefore, means having silent yet functioning organs — which is precisely how Nietzsche desired his body, which so frequently tormented his spirit, to behave while writing.
Canguilhem sought to imbue the notion of health as silent organs with a more positive meaning. Following this line of thought, we might be inclined to view the body solely as an instrument for mental flourishing. However, this was not his intention. For Canguilhem, being healthy is a creative, dynamic, and propulsive state of being. It is primordial in the sense that it manifests primarily in the absence of disease, but it is also more than just this simple negation.
A helpful way to understand this is by recalling the last time you fully recovered from a bothersome fever or cold. In those moments, recovery feels like more than just the absence of illness — you feel energized and liberated, driven by a life force or vitality that has been missing for a while. This existential feeling is what Canguilhem means by being healthy.
Among other things, this state of healthiness translates into an openness towards the future. The healthy embrace the future because they can integrate unexpected events into their own norms and life situations or playfully transcend any norms imposed upon them. Thus, health is the inventiveness to forge new norms in the face of adversity. This goes beyond adapting to social norms, which is mere socialization. Being healthy is living life in accordance with spontaneity and self-transcendence.
Health, therefore, expresses a relationship with the environment and is characterized by tolerance. By contrast, diseases are marked by their tendency to reduce the margin of tolerance for fluctuations in the environment.
When we fall ill, Canguilhem explains, we do not lose our capacity to be normative creatures. However, our norm becomes inferior in the sense that we cannot tolerate much deviation from it and are incapable of shaping new norms or changing existing ones.
How should we understand this? When we are sick, our world generally “contracts” or "shrinks." Illnesses diminish our capacity to engage freely and comfortably with the world. With no desire to integrate into the world, the opportunities offered by the environment seem inaccessible and the solicitations fade. For instance, a migraine, severe injury or extreme fatigue can suffuse objects with unbearable weight and gloom, transforming simple stairs into insurmountable tasks. In this reevaluation of self and the world, even the brightness of an iPhone screen or the thought of grocery shopping can put too much strain on the body. We withdraw from the world to protect ourselves.
Accordingly, though sick individuals reach a new equilibrium with their environment, they often lose their capacity to tolerate change, and opportunities for participating in daily life become limited. As Canguilhem notes, “to be sick means that one lives another life”.
Consider a high fever when you can't handle anything, and the only thing you want to do is rest on the sofa. Any unexpected event is too much in that moment. You yearn for complete isolation, living in accordance with your singular life goal: resting. It's the only norm that matters and determines your behavior at that moment. Your organs are urging you to comply. Thus, being sick doesn't mean being without norms. Even the ill have their orderly way of living and abide by these self-imposed norms. In the case of someone with a severe case of the flu, this usually means a pattern of bed, couch, toilet, and medicine cabinet. If we deviate from this path and norm, we will pay the price for it.
The same is true for mental “disorders”, Canguilhem echoes the famous neurologist Kurt Goldstein. There is still order in the life of people with a mental disorder, but a reduced one that does not tolerate many unexpected events. For someone suffering from depression or burn-out, going outside is often a no-go, because what if you accidentally bump into someone you know?
Just as health does, sickness also expresses a relationship with the world. In accordance, Canguilhem carefully distinguishes between biological abnormality and pathology. There is no sickness as such, only in relation to the world someone inhabits. It is only a meaningful concept within the context of a life taking place somewhere and somehow.
This distinction becomes even clearer with a mild fever. For Canguilhem, a teacher with a mild fever of 38 degrees Celsius, which would be considered a physiological sign of “sickness”, is not actually sick if he is still able to give a lecture — perhaps in a creative and unexpected new way, such as by recording YouTube tutorials in collaboration with generative AI. The lecturer could even enjoy his mild fever if it enables unforeseen new states of mind.
Another modern example, greatly inspired by Canguilhem's seminal work, is the idea that people with disabilities are only handicapped when confronted with an environment that does not support them. From a Canguilhem perspective, Stephen Hawking only became truly sick when he lost his ability to practice science. Canguilhem would not argue that Stephen Hawking had a terrible and slowly deteriorating health condition, as for a long time, the brilliant scientist was still able to be normative in life. When he increasingly became hindered in establishing his own norms of life, he became sick.
People with disabilities may recognize that they are statistically abnormal, but they often resent being seen as mere victims. This perspective strips them of their humanity. With Canguilhem's insights, we can better understand this sentiment. To completely define sickness from an external viewpoint and victimize those considered abnormal is to deprive them of their capacity to be normative individuals. This is the humiliating aspect of victimization. It is typically difficult for us to acknowledge this, because victimization is also a consequence of societies becoming more sensitive to the pain and suffering inflicted upon their members. Striking a balance between the sensitizing and dehumanizing aspects of victimization will be one of the primary challenges for medicine in the future.
Although people who fall sick still have norms, they must create a new order to cope with their diminished ability to handle challenges. Canguilhem provides us with more than just the simple notion that if you don't feel sick, you aren't sick (more about the difference between disease and illness in the next article). He doesn't dismiss the idea that a biological deviation is inconsequential unless it genuinely affects you. Being sick means losing our capacity for normativity in the sense of creating new life norms or playfully integrating social norms into our lives.
To illustrate his point, Canguilhem differentiates between normality and normativity. The first is the synergy between typical living beings and their surroundings, which mutually shape and influence one another. For instance, suppose you feel dizzy and fatigued from long COVID but believe your employer expects you to continue working from home. In that case, you might feel capable of doing so because you can open your laptop while lying on the sofa and not actively participate. As a result, a new normality and adaptedness sets in. On the one hand, there are the reduced norms we impose on ourselves (e.g., feeling tired but pushing ourselves to log on to Zoom meetings). On the other hand, these norms now meet the environmental demands (e.g., "You just have to log on; you can do that, right?"). However, this differs from being genuinely healthy and normative, in which we not only synergize with the environment but find ways to transcend social norms in playful and creative ways. Being sick silently transforms us into passive and adaptive creatures whose main focus becomes adaptation or isolation.
It is evident that Canguilhem's philosophy reflects his prime of life, with an emphasis on a youthful and carefree existence. He was in his 30s when he wrote his dissertation, and it is not unwarranted to refer to him as the forefather of the resilience ideal, as others have also highlighted. Canguilhem’s concept of health undeniably correlates with the modern ideal of resilience, which entails the ability to adapt to various challenges and uncertainties that the future may present.
However, contemporary advocates of resilience have adopted a limited interpretation, overlooking structural issues and oversimplifying complex situations. By focusing narrowly on resilience, we run the risk of placing excessive responsibility on individuals to cope with adversity. This emphasis on resilience can inadvertently foster a culture in which expressing vulnerability or seeking help is viewed as a sign of weakness. This perspective may contribute to the stigmatization of vulnerability, which has occurred frequently in recent decades. As a counter-narrative to this oversimplified interpretation, some now choose to emphasize the power of vulnerability. While this counter-movement is valid in our individualistic society, it also carries its own risks, such as overly cultivating victim mentalities and the medicalization of pain and suffering, which I have described above.
While Canguilhem's philosophy may have a blind spot where the power of vulnerability is concerned, a careful reading of his work shows that it should not be reduced to a narrow-minded emphasis on individual responsibility and banal masculinity. Although he can be seen as the forefather of resilience, Canguilhem possesses a richer vocabulary and a keener awareness of the complexity of health and disease than many contemporary resilience advocates do. Canguilhem demonstrates greater sensitivity with respect to the experiences of individuals who become ill than many of today's resilience proponents. This is particularly evident in his assertion that health is the luxury to fall sick and recover.
Individuals who fall sick should not be perceived solely as victims in need of protection and medicalization at all costs. Canguilhem urges us to be more attuned to the shifting experiences of the life-world of those who are sick and to understand how we can support them in establishing new norms while their capacity to do so is hindered. Addressing the challenges of 21st-century medicine demands a blend of heightened sensitivity and empathy with others, without merely reducing them to vulnerable victims of broader social structures.
Medical gaslighting or labeling people as snowflakes is unhelpful, but excessive victimization is not a solution either. Hence, in societies where illness will become more prevalent, the emphasis should be on fostering resilience, while still taking into account an individual's diminished capacity to establish norms in their lives. This approach is particularly valuable in a society where most individuals are neither severely ill nor in excellent health. It becomes even more relevant in an era marked by cultural conflicts that extend beyond the realm of medicine, where it is increasingly challenging to escape the dichotomy of being either a hypersensitive snowflake or an apathetic stoic.