In 2000, integrative medicine physician Bowen White published a book with the provocative thesis that “normal is not healthy”1 (p. 11). The default way of living, or being, in the U.S. is to focus on things neither of ultimate importance nor in our best interest, thus condemning ourselves to being consumed with chronic stress until our immune system is overwhelmed and, eventually, we die. This depressing scenario is a “normal” or routine life course trajectory for so many in this fast-paced contemporary world. Even those who eat right, watch their weight, exercise, monitor their cholesterol and blood sugar, and so on, travel this same road. But who can do every one of these things and avoid falling prey to illness? To alter this trajectory must require something more than simply being normal. This something more has been given various names, including “high level wellness.”2 Yet, as White1 (p. 79) laments,

When I quit doing what's predictable, . . . other people who in the past have been able to manipulate me into predictable patterns of response are not going to support my new behaviors. In fact, they may say, “I think he's gone over the edge.”

That's the irony. We're doing something that's healthier, and people, even people in our own families, may say, “What's wrong with you?”

We can be in the normal or normative range, sociologically speaking, or the ideal range, clinically speaking, for various biomarkers—the latter termed “within normal limits,” or WNL, according to medical lexicon—yet, overall, still be generally unhealthy and subject to morbidity and premature mortality. The same goes for health-promoting behavior: we may not smoke or abuse alcohol, yet still end up with chronic degenerative diseases that shorten our life. So even if WNL or moving toward high-level wellness, we might gain an edge to some extent, but it is no guarantee of a lengthy disease-free life. Yet we are so conditioned to see pursuit of normality as a medical get-out-of-jail-free card that one rarely ponders what it means to be normal with respect to the panoply of health risk factors. Is normal always good, is it a reasonable pursuit, does it always pay off in the end?

But White's provocative thesis begs an even more provocative question: is normal actually normal? Moreover, does it even exist, beyond a social or cultural construction?3 This requires us to address another question: what does it mean to be normal? This was posed 80 years ago,4 noting that in medicine at the time no single definition of “normal” dominated: the question of normality could be answered statistically or in terms of an absence of clinically observable pathology or in relation to an ideal disease-free state according to all indicators. At present, answering the question, “What is normal?,” in the context of health, suggests a few possibilities such as normal function;5 normal or optimal status, according to some biological markers;6 or normal or preventive health-related behavior.7 Numerically, the idea of normal, or normative, would seem to imply being at or above the median in the distribution of a respective indicator on the “healthy” side,. This might signify healthiness, or may be insufficient—the optimal or ideal level on a respective indicator may be greater than merely normal or above average. Or, for certain indicators, perhaps the norm or median indicates pathology or risk; maybe most of us do a bad job on that one. It probably depends on the marker and population.

This begs yet another question: is “normal” even a clinically meaningful concept? Further, how many people are normal on everything across the board—what we might term meta-normal? Do such people even exist? Similarly, what about “ideal” and what could be called meta-ideal? What proportion of the population is at the ideal level on a respective indicator, or better, according to all pertinent markers or behaviors? If meta-normal folks are few, are meta-ideal folks even fewer (or the other way around), or do they rarely exist in reality, only hypothetically? If so, would this imply that, as defined by medical norms or ideals, nobody is fully healthy? Everyone, in such a scenario, could be defined as filling what Parsons8 famously termed the sick role, or the “social role of the sick person”9 (p. 52) with associated obligations and entitlements. This cannot possibly be so, or can it?

To restate, we are distinguishing between normal and ideal, and between meta-normal and meta-ideal. The latter two terms are neologisms, but defined here for heuristic purposes—to enable estimates of the proportion of the adult population at or above the median points of the distribution (meta-normal) or below the clinically defined cut-off points for caseness or high risk (meta-ideal) according to 10 commonly used indicators (biomarkers and behavioral risk factors) of healthiness, physiological and behavioral.

What constitutes “health” or “healthy,” as noted, is socially constructed in part,10 as are other statuses that characterize parameters of human lives. These include not just healthiness according to particular indicators, but health in general, as well as particular diagnostic or nosological categories. Even the existence of certain presumed disease entities may be contested. For health, while there is an objective physical or physiological component,11 categorization of respective individuals as healthy or not healthy also has political, economic, cultural, and psychological influences. What is considered ideal for a respective biomarker, health indicator, or risk factor may be a product of deliberations among government, pharmaceutical companies, physicians, hospital chains, patient advocacy groups, and the latest research studies, and may not reflect unanimous consent regarding an indisputable physical reality.

Another complication: when responding to a population-survey question soliciting a rating of overall health, people may interpret the question differently.12 Respondents may have various incomparable understandings or definitions in mind when it comes to health and in assessing their own status. These referents include absence of health problems, physical functioning, general physical condition, energy, positive health behavior, health comparisons, and mental health, and they vary by age, education, and race. Further, they do not correlate well with closed-ended categorical self-ratings of global or overall health.12

For present purposes, we are focusing on 10 of the most commonly utilized behavioral and physiological indicators, including the well-known Alameda 5 health behaviors13, 14 and other measures. Each indicator is generally recognized by patients and physicians as a marker for a higher-order state labelled, by convention, health. Most of us probably know our own status or numbers on some of these indicators, and monitoring them may be a life-long pursuit or even obsession.15 Indeed, this is increasingly encouraged by the medical and pharmaceutical sectors. Taken together, such indicators are a useful way to summarize overall health, and the presence of recent national population data provides a serendipitous opportunity to gauge how the health of the population maps out against standards currently endorsed by the medical profession.

Thresholds for caseness or heightened risk have shifted over time as scientific knowledge has advanced, but also due to medicalization of human life, social institutions, and the body. Powerful interests have weighed in, too, creating changes in diagnostic cut-off points designating clinical caseness for reasons driven in part by non-medical interests. This has skewed public perception of population data, engendering belief that certain salutary states or behaviors are declining and, concomitantly, that certain deleterious conditions are increasing and may even constitute a “crisis.”16 Some may be, but other presumed crises may be a function of the reconstruction of a particular biomarker level or behavioral category as designating risk for other reasons, medically justified or not.

The concept of medicalization has a more longstanding provenance than typically acknowledged. Typically meant as “defining a problem in medical terms, using medical language to describe a problem, adopting a medical framework to understand a problem, or using a medical intervention to ‘treat’ it”17 (p. 11), the term became widely used in the 1970s,18, 19 notably within sociology.20 Other definitions have been proposed,21 mostly aligned with the above. Usage, however, dates back before the 1970s; the term “médicalisation” appears in a French journal in the 1950s22 and, according to PubMed, there are over 7 million uses of “medicalization” dating to 1781, although the NLM search engine does not enable this to be verified. Critiques and counter-critiques have been offered,23, 24, 25, 26 including proposal of “overmedicalization.”27 The stridency of discourse here is indicated by denunciatory referents to agents of “medical social control,”28 including accusations of “pathologizing” otherwise non-pathological conditions29 or of “disease mongering,” defined as “widening the boundaries of treatable illness in order to expand markets for those who sell and deliver treatments”30 (p. 886).

The increasing power and authority of the medical sector in American society, including in defining normative behavior and serving as an agent of social control, has been observed for decades.18 Entire institutions and sectors of society are said to have become medicalized, including criminal behavior,31 political dissidence,32 deviance from social norms,33 and since the COVID-19 pandemic, it is claimed, “[v]irtually our entire existence”34 (p. S-61). We suggest that health, too, as awkward as this may sound, is becoming medicalized. How health is defined, how it is “sold” to the public, and how we are told to achieve it is mostly dictated by the medical sector, by physicians and presumed biomedical experts whose recommendations lean mostly toward medication and medical and surgical interventions, instead of other therapies including behavioral interventions or social policies. Our findings, below, lend credence to this assertion.

A major force behind the medicalization of health is “overdiagnosis,”35, 36, 37 evidenced by the malleability of diagnostic criteria over time, manifesting in three ways. The population may become overdiagnosed due to the medical establishment (a) altering cut-off points defining clinical caseness for certain screening tests (e.g., for hypertension), potentially exacerbating the appearance of health disparities across particular population groups;38 (b) inventing diagnostic categories that enlarge the scope of existing diseases (e.g., pre-diabetes, pre-hypertension), dramatically increasingly the apparent prevalence of pathology in the population;39 and (c) and creating new diseases out of whole cloth by medicalizing unusual symptoms, signs, or behaviors not previously considered a medical condition (e.g., restless leg syndrome a.k.a. Willis-Ekborn Disease), reading additional people into a status of illness or sickness. This point is contentious, however, as many such new diagnoses (such as Willis-Ekborn) may involve real suffering and real pathophysiology, and perhaps Western medicine has only now come to recognize these conditions. Alternatively, some may be examples of what economists term rent-seeking behavior,40, 41 or “the socially costly pursuit of wealth transfers”42 (p. 820).

Either way, this has served to enlarge the proportion of the population defined as a medical case and thus subject to treatment and medication, creating new markets for pharmaceutical companies, for good or bad. The gold standard for validation of a diagnostic category ought to be something solid, such as standardized mortality ratios or rates of hospitalization or sick days, but this is not typically so. This creates an illusion of precision in the determination of health risks, where, in reality, there may be much uncertainty.43 Point “b,” above, is especially concerning, as proliferation of invented “protodiseases”44 (p 30) and “the semi-pathological pre-illness at-risk state”45 (p. 401) may be a harbinger of what is ominously termed “surveillance medicine.”45 Another factor: online culture, social media, and advertising encourage and persuade consumers to treat a diagnosis as “a core plank of an individual's sense of self.”46

Circling back to the questions posed earlier, the issue to be explored here is simple: is the prevalence rate of overall health substantial, by either reckoning, or, rather, barely above nil? That is, do multi-normality and multi-ideality even exist? Have cut-off points designating what is and is not healthy been so skewed that, after counting up all the recommended biomarkers and behavioral risk factors, national data suggest that almost no one in the U.S. is completely healthy? Is that possible? Does the present social construction of this issue lead to such an unlikely result? It is being proposed that when it comes to defining “healthy,” the ideal may not be normal and neither the ideal nor the normal may be real—that is, meaningfully grounded in reality. Or they may be, and there is indeed a health crisis among Americans. No matter, “normal” and “ideal” are partly social, political, and economic constructions and, while their interpretation is challenging, it would be worthwhile to examine how they map out in the population.