Introduction: The Changing Discourses and Practices of ‘Normality’

‘Normality’ is not customarily associated with originality and diversity. It was Foucault (1977[1975]) who described how, regarding the mentalities of government of the nineteenth and much of the twentieth centuries, the concept of normality worked within a framework of homogeneity ensuring: ‘the constraint of a conformity that must be achieved’ (Foucault, 1977[1975], p. 183). Thus, at first glance it might confidently be assumed that normality would play a slight, if any role, in late modernity where late modern selfhood is predicated on reflexively shaped individualized narratives, the ending of traditional roles and expectations and the obligation to self-fulfillment and self-determination, within the context of unique visions of ‘the good life’ (for example, Giddens, 1990, 1991; Beck, 1992).

In fact, as the article sets out to show, normality remains as important as ever both to governance strategies and to individual subjectivities within late modernity, albeit operating through transformed discourses and practices. Normality, indeed, in late modernity is predicated on diversity, on the ability and willingness of individuals to exercise choice in all areas of life. In discussing this transformed meaning of normality, the article focuses on older people, a group or class that, in line with modernity's valorization of productivity and youthfulness, has been consistently problematized by several discursive regimes. However, in late modernity old age has lost its marginal position and become a key arena for the continued project of the self (Jones and Higgs, 2010). One appropriate life choice for this project in old age can be identified in policy and professional discourses as that of the maintenance of ‘health’. While health is synonymous with normality, maintaining health is ‘normative’ and is represented in policy documents by the ideal-typical image of a super-fit senior citizen. Meanwhile, those older people unable to conform to this imperative are subject to professional intervention utilizing technologies such as case management.

The article will proceed as follows. The first section will review the discourses and technologies associated with normality genealogically, describing how, in late modernity, normality has come to be associated with a certain set of practices around health. I will then briefly describe how these practices problematize older people. The second section, taking its data from the United Kingdom, will look at how normalizing practices have been applied to older people historically through geriatric medicine, both as an expertise and then in the course of its professionalization in the UK National Health Service (NHS) after 1948, and in social policy. The third section reviews the contemporary normalizing technologies of late modernity with regard to old age, utilizing in the discussion the more finely grained distinction between the normal, the natural and the normative (Jones and Higgs, 2010). The conclusion will consider ways in which old age can be perceived outside the framework of such binary classifications underpinned by transformed conceptualizations of ‘health’.

Normality: A Genealogy of Theory and Practice

The foundation for the discourses and practices of normality were laid in the seventeenth and eighteenth centuries in the form of a particular conception of order, based on the ‘Industrious and Rational’ behaviour of citizens (Locke, 1967). This was directed first, as Elias (1978 [1939]) has documented, at the elite aristocracy from whence it dispersed through the lower strata of society, shaped by a combination of internal controls (education, etiquette, spiritual training) and external constraints, especially via disciplinary institutions such as armies, schools, hospitals, prisons, workhouses and (later) factories. It was recognized within these technologies that ‘civilization’ was not a state that, once attained, was always maintained: rather, it involved great efforts of self-mastery to impose (and retain) upon the raw material of human nature. As Rose puts it, ‘Normality was natural but those who were to be civilized would have to achieve normality through working on themselves … under the guidance of others’ (1999, p. 76). That individuals could civilize themselves, within this context, however, was an axiom of the Cartesian ideal of a ‘human agent who is able to remake himself [sic] by methodical and disciplined action’ (Taylor, 1989, p. 159), which suited simultaneously the disinclination of liberal governments for overt intervention.

This notion – that normality was at once both ‘natural’ and yet had to be ‘achieved’ – nicely encapsulates the slippery and ambiguous nature of the concept, which comprises, for etymological reasons as well as those of common usage, both evaluative and objective elements, signifying in turn an ideal state or one that is numerically average or one that is mundane, or indeed various combinations of all three with whichever meaning is at the fore possessing a glint of all the others like a sheen or iridescence of possibility. It also suggests how the term ‘natural’ served as a rhetorical device with the culture/nature polarity contingent, shifting and redolent with moral overtones made possible by the contestability of whether ‘human nature’ itself could be seen to belong to nature or to culture (Keller, 2008).

Increasingly during the nineteenth century, ‘irregular’, that is, irrational, disordered and violent populations (who, though ‘uncivilized’ were not, however, deemed ‘natural’) were targets for intervention by the ruling class. Around the middle of the century, Comte and Broussais together played a significant role in transforming the relationship of normality and pathology such that, from being the default position, normality became the ideal. That is, where normality had once been plurality to pathology's singularity, henceforth this was reversed and the pathological was defined as (multiple) deviation(s) from the (singular) normal (Porter, 1997b). Normality thereby became a much more powerful tool of governmentality: for example, by introducing a division between the ‘respectable’ and the ‘rough’ working classes, normalization obfuscated class consciousness and any associated threat to the social order (Perkin, 1989). Thus, in England, following the collapse of Chartism, together with the improvement in living conditions, the upper echelons of the working class turned away from reform or revolt and concentrated instead on self-improvement.

Around the turn of the nineteenth and twentieth centuries, however, a new approach to liberal government began to focus upon collective solidarities in the ‘social’ conceived of as a space where class antagonisms would be by-passed by all parties working together to facilitate social progress (Rose, 1999). The ‘social’ here bestowed identity upon individuals through their place in the institutionalized life cycle – as school children, workers, parents, pensioners – where people were classed according to their relationship with production (Gilleard and Higgs, 2000) and where the progressive sequence of age-linked roles normalized the development of particular virtues (Cole, 1992).

Normality in late modernity

Late modern or post-industrial ‘consumer’ society is associated with another kind of governmentality, making use of a contrasting kind of normality, and constituting a third stage in the attempt to render people capable of ruling themselves. Governmentality here operates in a more hands-off fashion utilizing psychological techniques and therapeutics to mould the concept of normal conduct within the context of a market or consumer society. Identity is no longer bestowed through production but determined by lifestyle choices, within the context of diversity and heterogeneity, marking the end of a clear separation of social and personal identities (see Gilleard and Higgs, 2000, especially Chapter Three). Most important is the emphasis on consumer choice: ‘individual freedom is constituted as, first and foremost, freedom of the consumer’ (Bauman, 1988, p. 8). This is associated with the transformation of modernity's ‘society of producers’ to late modernity's ‘society of consumers’ (Bauman, 2007) who might be more accurately described as ‘productive consumers’. Although associated with a post-industrial phase in western modernity, in accordance with the capillary nature of power identified by Foucault, one can see this shift as constituted by multiple professional and institutional practices. Meanwhile, in such a context of individualization the relationship of the technologies of normality to order might appear vague, competing and perhaps incapable of providing cohesive social order (Mol, 1998). There are indeed multiple versions of the good life, which take the form of contrasting and, at times, agonistic discourses; however, all cohere around the theme of the ‘responsibilized citizen’. Pickard (2010a), for example, shows how informal care-giving is variously framed in policy discourses as a personal obligation, a public good and a choice, which reflect three narrative positions that variously conceive of older care-giving as a duty, an inescapable fate, and/or a means of personal ‘growth’, with particular narratives linked strongly with class position.

Normality as health

Within what has been called the ‘normalization of diversity’ (Jones and Higgs, 2010), one – perhaps the – key aspect of the discourse of autonomous self-fulfillment is the emphasis on remaining healthy. ‘Health’ in late modernity, moreover, is associated with a range of practices that differ from its formulation in welfare-era modernity. The changing practices of governmentality associated with this new imperative are exemplified in the way the ‘sick role’ has mutated into the ‘health role’ (Frank, 1991). Health, in this context, is a range of practices that includes maintaining oneself in a non-diseased state for as long as possible, performing self-care during chronic illness, and finally what Bauman terms ‘fitness’, which refers to a capacity of the body to be tuned and modulated sufficiently through multiple bodily regimens that it may serve as a vehicle for the ever-more sophisticated sensations of late modern consumerism. As such it ‘knows no upper limits … . However fit your body is – you could make it fitter’ (Bauman, 2005, p. 93; original emphasis). ‘Health’ so conceived has become the defining feature of moral citizenship: for example, the report by Derek Wanless, which set out to chart the levels of future funding required by the NHS, linked this forecast explicitly with the extent to which individual citizens take active management of their own health (Department of Health, 2002). The ‘future patient’ is thus responsible for ‘the future NHS’ (where it was previously the converse).

This position is stated explicitly in ‘Choosing Health’ (Department of Health, 2004b) in which the then Prime Minister, Tony Blair, embedded health firmly within a consumerist discourse stating: ‘We are clear that Government cannot – and should not – pretend it can ‘make’ the population healthy. But it can – and should – support people in making better choices for their health and the health of their families’ (p. 3). One technology highlighted by the document is that of the ‘marketing’ of ‘health’ to the consumer, thereby creating ‘a stronger demand for health’ as a product (see pp. 20–21). The policy paper states the government's intention to promote health ‘on the principles that commercial markets use – making it something people aspire to’ (p. 21): turning it, that is, into ‘fitness’.

For those who are sick, ‘expert patient’ discourses have appeared in the context of chronic disease management, which are normative and ‘focused on what sort of person the patient should become’ (Rogers et al, 2009, p. 735). This ideal patient is one able to internalize control in order to take responsibility both for his/her own sake and for the sake of conserving resources.

The problematization of older people within this paradigm

As the government itself acknowledges, some groups or classes of individuals may find such normality more difficult to achieve than others and older people remain one such groupFootnote 1. Many official discourses have targeted older people in terms of their cost burden to the NHS (for example, Department of Health, 2001, 2005, 2006) particularly highlighting their ‘multiple chronic diseases' and high use of hospital beds, resulting in an emergent and heterogeneous collection of screening and preventive technologies involving diverse aims, roles and techniques. The problematization of old age, however, has a long history traceable at least to the years immediately before and after the establishment of the welfare state when Richard Titmuss described the ageing of the population as detrimental to the economy, to social mobility, to Britain's role in the Commonwealth and to ‘progress’ more generally (Titmuss, 1943). Today, however, it is not the ageing of the population as such which is detrimental, but its ageing in a particular way that links up with older ‘modernist’ discourses associated with decline and death (Jones and Higgs, 2010).

In the next section we will explore how the changing conceptions regarding normality impact on perceptions of old age. The discussion will utilize the distinction between the natural, normal and the normative suggested by Jones and Higgs (2010) to demonstrate that the idea of ‘normal’ ageing gradually replaced the concept of natural ageing over the course of modernity and with medicine one of the technologies that instituted this distinction. Nevertheless, the ‘natural’ continued to play a part in terms of constructing ‘moral boundaries’ (Jones and Higgs, 2010, p. 1514) between forms of human behaviour that were considered more or less useful for the social order (a right and wrong way to age).

We look now at the ‘natural’ and the ‘normal’ as they were framed by geriatric medicine associated with the Paris School, by the discourses of social policy and by the institutionalization of geriatric medicine in the UK NHS after 1948.

Normalizing Old Age: Historical Perspective

Normality, medicine and the older body

In medicine, a new epistemology of normality was associated largely with the work of physicians from the Paris School, especially Broussais and Bichat who developed a ‘discourse of senescence’ (Katz, 1996). Replacing vitalism, this new discourse removed the body from its place within the cosmic order, individualized and separated it from other bodies, interpreted the signs and lesions upon it with reference to events within, rather than outside it, with organs being further separable from organ systems and individually classifiable as normal or pathological.

A tissue-based, then cellular model, following Virchow, further individuated, separated and pathologized the ageing body. However, this pathological framework did not translate into therapeutics: on the contrary, it revealed even hale and hearty older people to be suffering from pathology and deterioration of tissue with the difference between old age and disease ‘seem(ing) to mingle by an imperceptible transition and be no longer distinguishable’ (Charcot, 1881, p. 20).

Charcot focused on classifying disease in old age rather than on developing therapeutic interventions (Haber, 1986). However, medicine here was located within a broader governmentality, operating by dividing and subdividing populations against the norm. Older people were classified as an irregular population, with roots sunk deep in what Cole calls a ‘single bifurcated vision of ageing’ (1992), which separated a ‘good’ old age of virtue, health and self-reliance from a ‘bad’ old age of dependence, decrepitude and death. There is obvious ambiguity inherent in this depiction as ultimately all old age ends in ‘natural’ decline. However, there were two ways to age, of which the first alone was consistent with the civilized mores of nineteenth century governmentality and thus served as the normative version. We will discuss this binary next.

‘Good’ and ‘bad’ ageing in the nineteenth century

In early modernity, which still bore the imprint of medieval and earlier epistemes, older people were not conceptualized as a distinct category until and unless they were unable to provide for themselves and at the same time lacked family support, which then necessitated receipt of outdoor relief: the distinction then was between the deserving and the undeserving and not between the elderly and the rest of the population (Katz, 1996).

This changed in the nineteenth century when demographic surveys constituted the elderly as one of several special population groups defined as problematic and introduced a new disciplinary mechanism through the workhouses. The emphasis on ‘civilized qualities’, drawing upon the deserving/undeserving binary, remained evident in official discussions on the elderly poor at this time. For example, in discussions for the Royal Commission on the Poor Laws in 1909, it was suggested that institutional accommodation was to be supplied in ‘various grades of comfort’ and ‘permitting of various degrees of liberty’ depending on virtue and moral conduct (quoted in Offer, 2004, p. 899).

Thus, the first official policy recognition of old age was accompanied by a moral distinction between ‘good’ and ‘bad’ old age, which also underpinned medical practice. For example, while holding a positive approach to the potentialities of old age, in contrast to physicians like William Osler, Nobel-prize winning immunologist Elie Metchnikoff nevertheless believed that a healthy old age required the insights afforded by bacteriology and only then would it ‘no longer be necessary to give pensions at the age of 60 or 70 years. The cost of supporting the old, instead of increasing, will diminish progressively’ (Metchnikoff, 1908, pp. 133–134, quoted in Cole, 1992).

Meanwhile, geriatric medicine, when it professionalized in the United Kingdom after the Second World War, was to play a key part in welfare governmentality. We will look now at the concept of the normal for old age that emerged in this process.

The normalizing discourses of the profession of geriatric medicine in the United Kingdom

Geriatric medicine became a professional discipline in the United Kingdom in 1948 and its associated discourses of legitimation stressed the discipline's ability to differentiate normality from pathology and to intervene, with preventive techniques, to prevent the former from becoming the latter (Pickard, 2010b). In such a way, in combination with discourses of reformers outside medicine, a generic association between old age and pathology was advanced (Pickard, 2010b).

Geriatric medicine developed its expertise through two techniques: laboratory or hospital medicine and community surveys associated with the social medicine movement. In the following sections we consider how each technique helped shape and define normality.

Experimental research on older bodies

The legacy of the Paris School was a direct and conscious one for British geriatricians: for example, Trevor Howell, one of the great pioneers of this discipline and a founding member of the British Geriatrics Society, spoke in his monograph of 1944 explicitly of continuing the work of Charcot. Following Canguilhem (1978 [1966]), Katz summarizes the problematic they inherited as follows:

When medicine reorganized the perception of the body according to the measurement of physiological differences, it produced both normal and pathological as co-related, mutually defining values … . [However] normal physiological conditions are not synonymous with healthy physiological conditions. Normal is a constraining concept representing a state of singularity; healthy is an open concept representing a state of plurality. Since modern medicine reduces physiological reality to one hegemonic set of norms and pathologies, alternative conceptions become improbable or marginal. (Katz, 1996, pp. 43–44, original emphasis)

Other legacies of the Paris School included the assertion that old age and pathology were conceptually distinct and distinguished by two separate cellular processes – tissue involution (or the natural changes of old age) and pathology (see Armstrong, 1981) – which were, however, hard to differentiate. The pioneers of geriatric medicine in the United Kingdom all grappled in various ways with determining such a distinction and several carried out experimental research to determine what constituted normal measurements for physiological functions in old age in a range of domains. For example, Howell and colleagues (1942, 1944) found blood pressure in older people to be generally higher, or much higher, than in younger groups with frequent variations ‘normal’. Moreover, older people with high blood pressure were among the fittest in the sample while raised blood pressure seemed to be a positive adaptation to arteriosclerosis and was associated with good recovery from injuries and infection. Howell concluded: ‘It seems that the raised blood pressure arising in old age is beneficent compared with that of younger persons’ (1942, p. 148).

A further legacy of the Paris School was the fact that, in establishing the foundational nature of the autopsy in medical epistemology, medicine moved away from the patient's experience of illness and the need for interpretation thereof, towards a more scientific objectivity. However, in the hands of the British geriatricians this was complicated, almost from the outset, by the relationship between the hospital and the community it served, as we discuss next.

Social medicine and the survey

From the late 1940s experimental research was complimented by surveys of older people in their domestic environments. This was intended to establish benchmarks for normality, in its functional sense, against which hospitalized older people could be measured, and to examine the sorts of domestic contexts that could give rise to hospital admissions in the first place. Moreover, many pioneering geriatricians who were engaged in administering such surveys were either involved with (for example, Pemberton, Lowe, McKeown), or influenced by (for example, Sheldon, Howell), the ‘social medicine’ movement, therefore it is worth discussing this in more detail.

The aim of social medicine was explicitly functionalist in orientation. It was the belief of one of its founders, John Ryle, that a social-science informed medicine would be able to identify the point at which normality was passed and disease or pathology was defined by understanding the fit between the organism and their environment and asking ‘normal for what?’ (Ryle, 1947). Within this paradigm, it was not just individuals but whole population subgroups who could be pathological where, for example, they might be unable to keep up with changing ideas and behaviours in modern society and thus impede progress (Gillin, 1933; Porter, 1997b). Indeed, despite Ryle's emphasis on the study of ‘hygiology’ or health, it was rather upon pathology and dysfunction that the early geriatricians focused, continuing in this sense in the spirit of Charcot, and consistent with the broader legitimating discourses of their professional project (Pickard, 2010b).

One of the first, and most important examples of surveys of older people in their homes is J.H. Sheldon's ‘The Social Medicine of Old Age’ (1948). His team interviewed 477 older people (defined as women over 60 and men over 65) in Wolverhampton. The physical status of older people was divided into three categories: normal, normal-plus and subnormal. Sheldon acknowledged these to be ‘subjective’ categories, dependent on the viewpoint of the investigator and based both upon the (self-rated) answers given on the questionnaire and on visual cues ascertained during the interviews. He did recognize that ‘normality’ for old age should not be judged by the standards used to judge other ages: ‘The older they are the more probable it is that a routine examination will discover local defects and the only adequate criterion of normality would be the average for that age’ (1948, p. 186). But operationalizing this proved difficult. One problem Sheldon highlighted was the difficulty in determining ‘normality’ status for an ‘individual whose general health is good but who suffers from a single local disability’ (1948, p. 21), which might be quite severe. Thus: ‘how is one to assess the woman who was only able to hobble across the street on Sundays owing to extremely deformed and painful feet … and whose general activity was similarly restricted – though apart from this defect her health was good’? (Sheldon, 1948, p. 21). In practice, Sheldon advocated the division into mechanical and constitutional disturbances: a mechanical defect allowed a classification of normality, where a constitutional disturbance was taken to be subnormal for example, oedema of the feet (although later in the monograph he explains that two cases of oedema of the feet in his survey are caused by varicose veins, which then rather oddly advances the link between the latter and subnormality). Moreover, when ‘testing’ the robustness of these classifications through investigation of the range of movement possessed by individuals, inherent inconsistencies emerged. Therefore, for example, in the category of those whose movement was ‘limited to their house’ the majority gave weakness, lack of confidence or vertigo as determining causes and one gave lack of desire to go out – none of these reasons sufficient, one would suggest, to advance a classification of ‘abnormality’, which, in Sheldon's survey, was closely connected with ‘degree of movement’ (1948, p. 22). This demonstrates how the failure of such surveys to incorporate the subjective perceptions of older people and their views of what constituted ‘health’ and normality for them could lead to potentially inappropriate assumptions about what constituted problems and in what lived normality consisted. As Katz and Marshall point out, ‘even if self-reports express what a person can do, they bypass what a person likes to do or resists doing’ (2004, p. 64).

One might see this as a striking example of a lost opportunity for geriatric medicine to reconsider medicine's approach to normality and pathology and to ponder Katz's (1996) ‘alternative conceptions’ of health. In fact, it was not the first time such an opportunity was lost. Charcot's belief that, despite the continuum he observed between normality and pathology, the essential polarity of this binary would be vindicated by future advances was perhaps the first. Howell also missed an opportunity to review this paradigm with his discovery of abnormal blood pressure in the context of robust good health and the ability to recover from infection. Similarly, geriatricians administering surveys within a tradition of social medicine explicitly, which aimed at re-inserting the ‘sick man’ back into medicine (Porter, 1993), might have also challenged the notion of ‘health’ as synonymous with ‘normality’ and, drawing upon older people's own subjective experiences, asserted its essential plurality. Instead, however, they set about classifying the older age group as socially as well as clinically pathological. Thus, Francis Crew (1946), who along with John Ryle was one of the founding fathers of the discipline, spoke of ‘dependent senescents’ and compared them unfavourably to the ‘productive group’.

It is striking, indeed, that despite the very positive health status of the majority of older people surveyed; Sheldon maintained his view of older people as ‘burdensome’. The majority of older people in his survey are categorized as normal or normal-plus; less than one-third of those interviewed were currently receiving medical attention; ‘strain on younger generation’ was noted in less than 15 per cent of cases; and finally the majority of older people were responsible for their own domestic care until at least 79 years of age after which they still made substantial contributions. Nevertheless, discussing the projected increase in older people he warns: ‘The care of old age is … likely to cast an increasing burden on the community’ (1948, p. 1). Meanwhile, social medicine was linked to normalizing political reform and direct or indirect practical consequences of the geriatric surveys, which problematized both older people and their contexts, included local slum clearances and rebuilding projects, the appointment of more regional geriatricians and the employment of more home helps to assist older people in their homes (Denham, 2006).

The emphasis on ‘functional’ normality viewed within a social setting also extended geriatricians’ use of normality in a temporal dimension, which resulted in them claiming two interlinked areas of expertise, first in that of ‘chronic’ illness and second in preventive medicine. Previously, ‘chronic’ had been a term frequently used to refer to those older people suffering from incurable complaints who required housing in dedicated establishments (Denham, 2006). This new use – applicable even to functioning old people – fitted with social medicine's preventive goals in identifying and remedying the social causes of health and illness and its belief ‘that everyone was ill because the borderline with health was simply a matter of variation’ with ‘the population of the hospital as the tip of a clinical iceberg’ (Porter, 1993, p. 263). This was simply more extreme in older people than in other populations (Armstrong, 1995). Contemporary works attesting to this include that of Last (1963) for the general population and Williamson and colleagues (1964) for older people, with the latter finding a large degree of unmet need that pointed to a ‘serious crisis of ill-health and disability’ among the aged (1964, p. 1120). Moreover, the iceberg phenomenon also included ‘social pathology’ by which was meant ‘illegitimate’ births, deaths, crime, receipt of national assistance, people over retiring age living alone, alcoholism and abortion (Last, 1963).

The ‘ubiquity of illness’: Screening and preventive techniques

This problematization of old age led to a continued and expanding emphasis on health screening. In the 1960s, geriatric consultants moved on from community surveys to setting up screening clinics in the community (Williams, 1986) and assessed patients referred by general practitioners (GPs) in an attempt to identify and remedy illness at an early stage. This also represents a move to a more ‘individualist’ model of prevention that was to focus more and more on lifestyles rather than on life conditions, such as socio-economic inequality (Porter, 2006), and, following studies from the 1950s onwards into the roles of diet, exercise and smoking in disease aetiology. Thereafter, the impetus for prevention came from GPs chiefly because of the GP's ability to influence patients’ health behaviours, complimented by geriatricians’ focus on their (more prestigious) hospital role. Primary care-based prevention comprised three components, each of which assessed normality according to different criteria. In keeping with the ‘clinical iceberg’ theory ‘primary’ prevention aimed to intervene at a point before any abnormality had developed through health education and emphasis on health maintenance and self-care. Where social medicine had recognized the patient as an actor in terms of his/her illness beliefs there was still a passive element to such action – health being determined by environment and genetic disposition – but the new surveillance medicine increasingly targeted their discourses of normality within the subjectivity of the patient themselves (Armstrong, 1995, 1997). However, what this medicine still did not do was incorporate the patient's lived experience of health into its model and therefore what happened was the re-insertion of the normalized sick man into medicine, one who objectified his or her body in accordance with medicine's definition of pathology/normality and associated behaviours. ‘Secondary’ prevention consisted of screening (the identification of an ‘unrecognized disease or defect’ in ‘apparently well persons’) and case finding (the detection of unreported but symptomatic disease) (see Wilson and Jungner, 1968) again asserting a polarity between health and morbidity. ‘Tertiary’ prevention was the sort of prevention that took place during routine interaction between GP and patient and was concerned with known illness. Significantly, in contrast to the original hospital-driven aims of the geriatricians, with their focus on preventing and rehabilitating bed blocking, the aim of these early general practice-based approaches was linked to the new epistemology, which ‘problematized the normal’ ensuring that all persons were potentially or actually patients (Armstrong, 1995) without obvious end.

This approach has continued through a variety of mutations to the present day. Geriatric screening of older populations in the form of annual ‘75 and over’ checks was introduced into the 1990 GP contract; its success, however, was limited in terms of preventing both morbidities and hospital admissions (Fletcher et al, 2004) and thus was dropped from the 2004 GP contract. The assertion of unmet need in older people generated by Williamson and colleagues in 1964 continues today and even among the minority of physicians that dispute the iceberg thesis (for example, Jagger et al, 1996), the challenge is rather to the extent of the pathological class than to that of the paradigm itself. Thus, attitudes to older people in the community continue to be underpinned by a general problematization of the normal, that is, functional, community-dwelling older person which, in turn, is based on an enumeration of morbidities. This ignores the possibility that older people do not report such ‘problems’ because they do not consider them problems and also fails to compare this with degrees of unreported need in younger populations (for example, Victor, 2005).

We look now at how old age has become a central field in which, through a variety of means including health-related practices, it has become germane to the continued project of the self (Jones and Higgs, 2010).

Normalizing the Older Body/Older Self in Late Modernity

Late modern governmentality, working especially through health policy and primary care practices, continues these earlier themes and utilizes a combination of approaches targeted at classes of bodies that differ from the ‘standard’ population and at individual ‘marginal’ bodies, while working to mould all older people's subjectivities. It therefore targets both social identities (older people as a chronological group) and personal identities (distinguishing between the third and fourth ages). It also maintains the ambiguous border between the ‘natural’ and the ‘normal’. Although it is recognized that individuals naturally decline in old age, this process is infused with the idea that normal ageing requires self-care, which is aimed at delaying or denying bodily decline and banishing dependency to the margins (Jones and Higgs, 2010). The latter becomes a ‘defining feature of “successful” third age identities while the natural discourse of decline is either seen as a precursor of a highly dependent “fourth age” … or as a target for intensive health and social care intervention’ (Jones and Higgs, 2010, p. 1516).

This emphasis is reflected in a shift in the policy rhetoric towards old age, especially since around the year 2000. While older people continue to be highlighted as a pathological population group, especially as a result of harbouring multiple chronic diseases that are overtly discussed in terms of their actual or potential cost burden upon the NHS (Department of Health, 2001, 2002, 2004a, 2005), the ‘burden’ they pose to the economy is for the first time linked not just to the well-worn theme of the ageing of the population but also to the degree to which all older people, whether patients or not, are engaged in self-care (Department of Health, 2002). In this, the good/bad old age dualism in official discourse is evident across three overlapping themes relating to older people's health, which include: (i) a general emphasis on autonomy, self-care and ‘health’ as a choice; (ii) professional management of long-term conditions utilizing standard measurements of normality for biological functions and (iii) intensive targeting of the ‘frail’ and dependent. We look at each in turn.

Choosing health

The particular implications of the ‘health as a choice’ discourse for older people are made explicit in several related policy documents, including ‘Better Health in Old Age’ (2004a), ‘Independence, Well-being and Choice’ (Department of Health, 2005), and ‘A New Ambition for Old Age’ (Department of Health, 2006). For example, the eponymous ‘Choosing Health’ (Department of Health, 2004b) talks enthusiastically about health promotion for older people. Of course, it is indeed important, as it notes, that older people are not discriminated against, either in their health or social care needs, on account of age. As Standard One of the National Service Framework points out ‘NHS services will be provided, regardless of age, on the basis of clinical need alone’ (Department of Health, 2001). This underlines a change from the days when, for example, renal dialysis was implicitly rationed in the United Kingdom on age grounds (Gillick, 1994). However, there is then a radical leap to normatively emphasizing alongside this a particular mentality as illustrated by case studies that focus on what we might call ‘Super Senior citizens’. ‘A week in the life of 81-year-old Ted Howarth’, a retired newsagent, we are told ‘would exhaust many people half his age.’ He walks briskly before breakfast and then cycles, golfs, goes horse riding, bowling or to Tai chi on different days of the week. ‘And that doesn’t include his activity holidays, which often involve canoeing and abseiling’ (2004a, p. 9). This reflects, as noted earlier, Bauman's ‘goal of fitness’ in old age. This is firmly individualized: the Department of Health (2005) posits a role for social care services as one that helps older people to help themselves: ‘In future, social care should be about helping people maintain their independence, leaving them with control over their lives’ (p. 6). Finally, Department of Health (2006) begins by celebrating the existence of older people: ‘An ageing population is not a burden – it's a benefit’ (p. 1.) But it then goes on to restrict this benefit (albeit implicitly) to those older people capable of exercising appropriate agency: such individuals will take advantage of ‘more opportunities … to increase their levels of physical, mental and social activities’ (p. 18) and thereby ‘contribute more to the lives of their families and their local communities’ (p. 18). ‘Fitness’ in this sense is a disposition, affording distinction (in the Bourdieusian sense), which bifurcates populations to some extent regardless of their point in the life cycle or ascribed characteristics such as class, gender and race.

Indeed, the message across all these official discourses is that ‘normal’ old age is indistinguishable from earlier points in the life cycle. Thus, normal older age affords one the opportunities to engage in more self-improvement, to become more industrious and rational than ever before, simultaneously enabling the role of the state to shrink. Mr Howarth continues his panegyric to exercise: ‘Unfortunately, I wish I’d known more about the benefits of exercise so I could have helped my wife more’ (Department of Health, 2004a, p. 9). He concludes, ‘She died of a stroke after suffering a mini-stroke’, suggesting that the discourse of good/bad old age is one that potentially bisects married couples according to their dispositions.

Standardized disease management

Routine management of ‘chronic illness’ in those still capable of autonomy and self-care takes place in primary care and proceeds via regular annual or bi-annual reviews drawing upon standardized protocols deriving from quantitative measurements of physiological functioning in ‘standard’ (that is youthful) population groups. Abnormal biological readings – synonymous or virtually synonymous with chronic illness even where they are merely symptomatic, such as high blood pressure or high cholesterol – are then normalized through drugs and/or patient behavioural change. Extrapolating from the measurements of ‘normality’ in younger populations effectively treats older people who do not conform to such measures as an irregular ‘subclass’ that must be restored to regular (youthful) normality. Such ‘abnormalities’ are often routinely discovered in older people who visit the doctor for other reasons and who may perceive themselves as healthy but who are henceforth classified as ‘patients’.

Unresolved debates about the possible ill effects of these practices continue to be aired in the pages of medical journals (for example, Oliver, 2008) which question, among other things, the appropriateness of the measurements of normality used for older people as well as the particular diseases or conditions selected as significant (which do not necessarily include those conditions most relevant to the bodies of older people). Moreover, older people, and those with multiple long-term conditions, continue to be excluded from clinical trials and other research in which such baseline health data are established (for example, Iliffe and Drennan, 2000; Hamzelou, 2010) so perpetuating the notion of the older body as abnormal. We can link this standardization with the concept of ‘functional age’, which is predicated upon the inadequacy of measures of chronological age alone to accurately signpost the division between the third and fourth ages (Katz and Marshall, 2004). This is a rejection of earlier insights in geriatric medicine into the qualitative and quantitative differences in function of the organ systems of older people and an emphasis on universality and functional homogeneity across ‘productive’ populations. This standardization is based on assumptions that

organisms age at different rates and thus chronological age is not a good predictor of remaining life expectancy, that different tissues, organs and organ systems within an organism may age at different rates, that these differences can be measured and predicted. (Sprott, 2002, p. 133, quoted in Katz and Marshall, 2004)

A few examples will illustrate this process. In the case of hypertension, targets are geared to the achievement of blood pressure of 150/90 mmHg or less; there are indications that targets may be tightened up in future years. However, there is no acknowledgement in the guidelines for such protocols that older people be recognized to deviate ‘normally’ from such measurements in this area. Yet, simultaneously, the thrust of the original findings by Howell in the 1950s are given continued weight in textbooks of geriatric medicine, which support treatment to lower systolic blood pressure equal to or above 160 mmHg or diastolic pressure above 90 mmHg (significantly higher than the Quality and Outcomes Framework guidelines in primary care) (Beckett and Bulpitt, 2007). This textbook notes that there is no good evidence to make treatment decisions based on these levels alone, without the more general health of the older person being taken into consideration. Another example is that of chronic kidney disease (CKD). Whilst decline in renal function is a feature of ‘normal’ ageing, progresses slowly and is not clinically significant, the current definition and measurement of CKD has resulted in its exaggerated prevalence in older people (Abdelhafiz et al, 2010). Moreover, studies demonstrating a decline in renal function with ageing do not include a correction for associated comorbidities – such as hypertension and diabetes – which means that it is currently difficult to separate the impact on renal function of physiological ageing versus pathological ageing associated with comorbidity.

Normalizing the frail

Alternatively, those fourth agers unable to retain full moral citizenship (measured by emergency hospital admissions – the specter of ‘bed blocking’ or clinical assessment of being ‘at risk’ thereof) are targeted by the intensively individualized technology of case management (Department of Health, 2005). The aim of case management is to reduce hospitalization of those 5 per cent of patients who experience repeated hospital admissions, most of whom are older. Risk of hospitalization is calculated through a mixture of statistical (previous admissions to hospital) and interpretive means (judged to be potentially ‘at risk’ by health or social care professionals owing to clinical or social attributes such as falls, loneliness and bereavement) with older people thus classified as frail (for example, Boaden et al, 2006).

These individuals are, then, subsumed within the discourse of frailty, which is a key concept of contemporary geriatric medicine, despite the persistent difficulty of either defining or operationalizing it. In the latest (seventh) edition of Brocklehurst's Textbook of Geriatric Medicine and Gerontology (Fillit et al, 2010) several contrasting definitions can be found. Firstly, it features as ‘a state of increased vulnerability that arises from multiple, interacting medical and social problems’ (Fillit et al, 2010, p. 1). Later on, Rockwood and Mitniski (2010) state that frailty is a ‘multiple-determined at-risk state’ (p. 59) and go on to suggest two more, contrasting, definitions. The first utilizes a ‘clinical phenotype’ which concentrates on five clinical characteristics: a self-report of exhaustion, a self- or observer-report of a decline in activity level, demonstrated or reported weight loss, impaired strength and slow gait. Individuals who have three or more of these at any time are said to be frail. (Those with one or two are, of course, ‘pre-frail’). Rockwood and Mitniski (2010), however, advocate the ‘deficit accumulation’ model in which the more deficits (which include social, as well as physical and cognitive factors) people have the more likely they are to be frail in a dynamic process that could mean frailty reduces as well as increases.

In terms of operationalizing this discourse, case management's mixed success in reducing hospital admissions has, inevitably, resulted in the development of methods to identify those older people in the ‘pre-risk’ category using mathematically sophisticated probabilistic methods. However, this imprecision points rather to the constructed nature of the frailty discourse which Kaufman (1994) suggests results from the intersection of two agonistic paradigms: that of medicalization and that of autonomy. She suggests, ‘the very old become the field on which the discourse on autonomy and freedom of choice competes with the discourse on intervention, surveillance, safety and risk’ (Kaufman, 1994, p. 47). The frailty/case management discourse, then, is not only situated at the boundary between the third and fourth ages, but is also instrumental in constructing it, by delineating ‘good’ (autonomous) from ‘bad’ (threat to NHS resources) and mapping also onto the distinction between ‘natural’ decline of the fourth and the ‘normal’ continued health and autonomy of the third age which are here held together, as throughout modernity, in uneasy tension.

In fact, despite the individualizing discourses of biopolitics, the most important factor in longevity continues to be socioeconomic status (Hadler, 2004, p. 13), a fact which is not necessarily negated by shaping the dispositions of older people (where our case study Super Senior was, and this surely cannot be a coincidence, but a ‘humble newsagent’). Similarly, the evidence as to whether active engagement in self-care actually translates directly into improved outcomes for chronic conditions is equivocal (Rogers et al, 2009). The weak evidence of effectiveness seems less important than the emphasis on (self) surveillance as an end in itself, a moral technology designed primarily to inculcate in its subjects an attitude of ‘fitness’.

Discussion and Conclusion: Beyond the ‘Edifice of Normalization?’

In discussing normality throughout the period of modernity, including late modernity, this article confirms Hacking's observation that ‘normality is both timeless and dated, an idea that in some sense has been with us always, but which can in a moment adopt a completely new form of life’ (1990, p. 160). As we have seen, the self continues to be guided by the imperative to be ‘industrious and rational’ although the grand teleological narratives of progress have been transformed into individual narratives of self-improvement and self-fulfillment as ends in themselves. If there is any concealed telos in such action it is the pursuit of eternal good health serving simultaneously in the interest of society and as a salvific ideal. These discourses today emphasize self-motivation rather than the heavy-handed correction of the state, as a normative condition, germane to hands-off governmentality and presented as a way – the only way, indeed – of being ‘free’. It is not, however, self-evident that febrile activity, such as that exhibited by our Super Senior, in itself renders one free or constitutes a freedom all would value.

The problem, or part of the problem, is at its root, a matter of what health is judged to be. To return to a point made earlier, one may conclude that geriatricians, in acquiescing in the biomedical paradigm of pathology and normality as polar opposites missed, during several key points in the history of their discipline, a key opportunity to reconsider the view of health enshrined therein. But, having thus acquiesced, they were epistemologically bound to draw the assumption that most older people were ill, because of the identified presence of morbidity and impairment, leading to ‘unmet need’ that was both potentially limitless and highly problematic for society. Meanwhile, the return of the ‘sick man’ that resulted from social medicine and its survey methodology took the form of an idealized and normalized sick man, whose subjectivity was shaped by self-surveillance and self-care, but whose lay perceptions and experience of situated health were ignored or marginalized. The shift from ‘normal’ to ‘normative’ ageing logically extends this subjectification into aspirational third age mentalities of productivity, autonomy and ‘fitness’. Thus, ultimately, as Cole suggests, the dualism between good and bad old age which still persists (whether as normality/pathology, function/dysfunction, autonomy/medicalization or indeed natural/unnatural among other binaries) ‘has hindered our culture's ability to sustain morally compelling social practices and existentially vital ideals of aging’ (1992, p. 230).

One way out of this constraining polarity, however, might be to revisit this ‘moment’ or moments of the birth of the geriatric patient and make the leap to recognizing most people as healthy despite the presence of morbidity. An emphasis on ‘health’ in all its plurality of guises would be most suited to late modernity's heterogeneous and diverse culture. This would mean that, whilst many older people describe themselves as well, or even in ‘excellent health’ despite the presence of objectively measurable morbidity (Sidell, 1995), it would not be automatically assumed that they are not well. Moreover, such a re-conceptualization would have significance beyond old age alone. This ontological position conforms to Antonovsky's model of ‘salutogenesis’ (1979, 1984) which posits that, rather than valorizing as normative the concept of homeostasis and order, we acknowledge the normality of entropy, disorder and disruption of homeostasis with health represented as a range, and co-existing with morbidity. This paradigm focuses not on the normals but on the deviants, but with a very different motivation, identifying them as: ‘those who make it against the high odds that human existence poses’ (Antonovsky, 1984, p. 117). It then asks, ‘Why does this person, whatever the extent of her morbidities, move to the healthy end of the range?’ and ‘How can we learn to live and live well with stressors and difficulties?’ (Antonovsky, 1984). For some older people, such a way of living healthily might encompass not super-activity but, at times at least, doing very little at all and relaxing one's grip on mastery and control of self, others and world. As Dass, in recounting his own experience of illness in old age, describes, an older friend, ‘who's been a beehive of activity all her life, told me on the phone, “I don’t know what's happening to me – I just want to lie around all the time.” … I said, “Well, it sounds to me like one of the things you’ve got to do is to lie around. Would you add that to your list …?”’ ‘He continues, ‘We should ask ourselves in moments of fatigue whether slowing down may not be a message to attend to the moment – to be with it … to taste it … to embrace it; a way of making us take time, finally, to tend to what's here now.’ (2000, p. 61). Thirdly, and developing the last point, a re-aligning of the relationship between body, self and society, for which the critiques of science, technology and politics in the ‘risk society’ (for example, Beck, 1992) and the ecological movement's re-enchantment of nature have already prepared us, would be conducive to a re-valuing of human old age. Aristotle's model of growth, maturity and decline is mirrored in nature and is our common fate, as it is with all other species; indeed these three stages are necessary for existence itself to be meaningful. ‘So this is life. Youth into old age, health into disease’ was the realization of the Buddha that started his quest for Enlightenment (for example, see Temkin, 1977), positioning it at the very heart of our existential dilemmas as human beings. This is not, in any way, however, to deny the positive role that biomedicine has and continues to make, nor to argue for an anti anti-ageing stance. Indeed, I would heartily agree with Jones and Higgs (2010) who query the anti anti-ageing stance as somehow missing the point that these discourses are embedded in the wider cultural discourses of late modernity which valorize plurality and individual choice – and which cannot, therefore, be artificially revoked. Instead, whilst exercising our health and lifestyle choices as late modern citizens, perhaps we would benefit from reflecting upon visions of health and disease associated with earlier epistemes, where the body is seen to be labile and health exists where there is no serious impeding of the ordinary activities of life. This is a salutogenic view, of health-in-illness, that accepts most people as healthy (and thus normal) and health as heterogeneous, whilst recognizing that the ability to fall sick and to recover is a key characteristic of health (Canguilhem, 1978 [1966]). This concept of normality would open up the possibility of combining the wisdom of the ancients, beyond any governmentality associated with modernity, with democratic self-determination and personal choice of the good life in a mixture that, in suggesting a new alignment between the natural, normal and normative, is incomparably late modern.