Poverty and men's health

The text of a presentation to OXFAM's Men, Gender and Poverty Seminar (20 March 2001) by Peter Baker, Co-ordinator, Men's Health Forum.

Thank you for the opportunity to speak here today.

What is the Men's Health Forum? It's an independent organisation that seeks to promote the health of men by providing health information and, in particular, by undertaking research and developing good practice and policy.

The Forum has for many years felt that it's something of a voice offstage and that men's health receives as little attention from policy makers and health practitioners as many individual men give their own health.

The fact that I've been invited to speak to you today reflects the fact that the level of interest in men's health appears to be increasing almost exponentially.

The Government, and particularly the public health minister Yvette Cooper, are now saying many positive things about the need to tackle men's health inequalities.

Earlier this month, the Men's Health Forum helped launch a new All Party Parliamentary Group on Men's Health, a development that will hugely assist our efforts to get the issues on political and public agendas.

More generally, health organisations like the Health Development Agency, the Institute of Cancer Research, the Imperial Cancer Research Fund and many others are realising that men's health requires specific initiatives if the overall health of the nation is to be improved.

Before I address the specific issues of poverty and men's health, I thought it would be useful to mention some of the overall problems with men's health that help explain why the Men's Health Forum exists and why the Government and others are now taking an interest in the subject.

Whichever way you slice the statistics, men's health is poor on a wide range of indicators. These are some of the most significant:

• The average male life expectancy at birth is currently under 75 years.
• The average man can expect to be seriously or chronically ill for 15 years of his life.
• Heart disease remains a major cause of early death among men, accounting for about 18,000 deaths (one-third of all male deaths) before the age of 65.
• Nearly 22,000 men in the UK are newly diagnosed with prostate cancer each year and about 9,500 die; the number of new cases diagnosed is expected to treble over the next 20 year. Benign prostatic hyperplasia (BPH) affects an estimated two million men in the UK - 40 per cent of men in their 70s have clinical symptoms of BPH.
• The incidence of testicular cancer has doubled in the past 20 years.
• The suicide rate among men is increasing; the rate has doubled among 15-24 year old men in the past 25 years. Depression is a widespread but under-recognised problem in men.
• Sexual problems are common amongst men: almost one-fifth of men in their 50s experience problems maintaining or achieving an erection.
• 45 per cent of men are overweight and another 17 per cent are obese.
• 28 per cent of men smoke. The average male smoker smokes 111 cigarettes a week.
• 27 per cent of men drink more than the recommended limits. 36 per cent of men aged 16-24 drink excessively.

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If we look at a wide range of risk-taking behaviours, we find that men are more likely to smoke, drink at dangerous levels, drink and drive, use illegal drugs (cannabis, ecstasy, cocaine, etc.), eat unhealthy food, be overweight, practice unsafe sex, play dangerous sports, avoid the doctor and avoid the dentist.

You may have noticed that for much of this description of the health problems facing men, I've avoided comparing men and women. That's deliberate.

Comparing men's and women's health directly is actually rather problematic.

First, it implies that women's health is a sort of 'gold standard' even though women face a wide variety of health problems too.

Secondly, it creates in many people's minds some sort of competition between men and women and leads some to argue that men's health problems are in some way caused by women, perhaps because they've managed to siphon off all the research money for work on breast cancer while prostate cancer remains marginalised.

And, thirdly, comparing men and women isn't helpful because it masks some of the important inequalities within men's health. And that's the subject I now want to move onto.

It's no secret that the poorer you are the worse your health is likely to be. There's increasingly good evidence that health mirrors income very closely consistently. There aren't just differences between people living in poverty and everyone else. In fact, for every extra pound you earn, your health is likely to be better, right across the social scale.

A study analysing the death rates of over 300,000 American men discovered an astonishingly close relationship between family income and mortality. Every $2000 a year increase in income was linked to significant health benefits.

Even men with a family income of $28-30,000 (at 1980 levels) lived longer than men with an income of $26-28,000 while they, in turn, outlived men earning $24-26,000.

A well-known UK study of 17,500 civil servants came to similar conclusions. It found that those in the lowest ranks were three times more likely to die in a given period than the senior administrators in the top ranks and that each employment grade had a higher risk of dying than the one above it.

This is also, as you'd expect, reflected in broad social class data.

Although life expectancy at birth has improved for men of all social classes over the past 30 years, it has improved far more for professional and managerial men than for partly skilled and unskilled men. Men in social classes 1 and 2 can now expect to live to almost 75 years while men in classes 4 and 5 can expect to live over five years fewer.

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If we compare just social class 1 and social class 5, the difference in life expectancy extends to 9.5 years.

Table showing life expectancy by social class - England and Wales, 1987-91

Source: Office for National Statistics, Health Inequalities: Decennial supplement (The Stationery Office; London, 1997).

Research recently published by the Office for National Statistics also demonstrates marked inequalities in men's health between affluent and deprived parts of the UK.

Men living in central Glasgow in 1995-97, the area with the lowest average life expectancy, can expect to make it to 68.4 while men in the Chiltern area of leafy Buckinghamshire live exactly 10 years longer.

In fact, men in central Glasgow in 1995-97 have a life expectancy which is lower than that of UK men in general in 1966.

All the data on socio-economic status and health shows a similar picture for men and women. What's particularly interesting, however, is that it appears that there is a larger effect for men than women. In other words, poverty appears to have a bigger impact on men's health than it does on women's.

The ONS study, for example, correlated life expectancy and key Indices of Deprivation at the local authority level and found a highly significant correlation for both men and women, but the correlation was stronger for males.

The life expectancy by social class data points to the same conclusion. Men in social classes 4 and 5 have a lifespan at birth which is 93 per cent that of men in social classes 1 and 2.

However, women in social classes 4 and 5 have a lifespan which is 96 per cent that of women in social classes 1 and 2.

A similar effect was demonstrated in a different way in a Joseph Rowntree Foundation study by Richard Mitchell and others which looked at what would happen to health if Britain became a more equal society. [Richard Mitchell, et al, Inequalities in life and death: What if Britain were more equal? (The Policy Press; Bristol, 2000)]

This concluded that if full employment was achieved in Britain, 2,504 lives a year would be saved among 16-64 year olds. 83 per cent of the lives saved would be male.

The research also looked at the impact of a slight redistribution of wealth across Britain. This would prevent an estimated 7,597 deaths each year among under 65 year olds. Again, men would benefit disproportionately - 75 per cent of the lives saved would be male.

This raises the obvious question of why men's health is so sensitive to deprivation.

It doesn't take much insight to appreciate why anyone, male or female, brought up in poverty or living on a low income is likely to have poorer health.

It's becoming clearer that factors like maternal nutrition have a key role to play in determining future health, particularly in terms of the risk of heart disease.

It's also clear that low income households are more likely to eat less healthy food and have higher rates of smoking and drinking. The priority for many people living in poverty can understandably be to meet immediate needs for nutrition and personal satisfaction.

The stress of living in poverty is also likely to have an impact on mental and physical health.

Access to health care services and access to information about health may also be poorer.

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But what about men specifically?

For a start, we know that men are at greater risk of premature death for biological reasons. They lack the protective effect oestrogen offers women when it comes to heart disease and they tend to put on weight around their waists, just about the worst place in terms of developing heart disease and diabetes. It may well be therefore that the impact of an unhealthy lifestyle which is related to poverty has a disproportionate effect on men because they are at greater genetic risk.

But there is surely also a wider issue here. To understand more about the impact of poverty on men's health it is important to understand something about the impact of poverty on men's sense of themselves as men.

Poverty is clearly disempowering. Yet men in our culture are supposed to be powerful and in control. The 'role strain' this dissonance is likely to create for many men can lead to both emotional stress and low self-esteem, with consequences for mental and physical health, and risk-taking behaviours which are believed (albeit often unawarely) to compensate for feelings of emasculation. These behaviours can include drinking heavily, driving dangerously, unsafe sex, acts of violence, etc.

One particularly important health risk for poorer men is smoking. While 16 per cent of professional men smoke, 40 per cent of men in unskilled manual jobs do so.

Another factor for men is that they tend to have less supportive social networks than women. These networks can to some extent mitigate other health risk factors. Men tend to be more isolated from others and to disclose less personal information. Men on lower incomes who are unemployed may be particularly excluded from social networks linked to the workplace.

I want to say a word hear about the health of ethnic minority men because there are factors of double disadvantage here.

The 1999 Health Survey for England showed that:

• Higher rates of heart disease (angina and heart attack) were reported by Indian, Bangladeshi and Irish men and higher rates of stroke by Black Caribbean, Bangladeshi and Indian men (all compared to the general population).
• Higher rates of diabetes were reported by men from all the ethnic minority groups.
• Irish men more likely to be obese.
• Bangladeshi men were nearly twice as likely to smoke as men in the general population; smoking rates were also higher among Irish and Black Caribbean men.
• Irish men consumed more alcohol than the general population.

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So what can be done about men's health, especially for those living in poverty?

One obvious strategy is to eliminate poverty and to reduce social inequalities. As the Joseph Rowntree study shows this could have a particularly significant effect on men's health.

But there are other possibilities too:

Men are largely absent from health policy, despite some of the positive rhetoric from health ministers. But health inequalities in terms of social class are now more firmly on the Government's agenda. We need to get men's health inserted into this agenda as part of a broader approach to health inequalities. And, obviously, the main focus should be on those men in the poorest health, ie. those living on lower incomes.

The same process of policy development needs to take place at the local level. Health authorities are now obliged to produce Health Improvement Programmes which set out local strategies with a focus on tackling health inequalities. With one notable exception (Worcestershire HA), men are absent from HiMPs. They need to be included.

The Government launched an initiative known as Health Action Zones in 1998. 26 HAZs are now operational in the most deprived areas. HAZs are partnerships between the NHS, local authorities, community groups, the voluntary sector and the private sector and are intended to link health, regeneration, housing, employment, education and anti-poverty initiatives. Again, as yet there appears to be little awareness of the importance of health action targeted at men but there are two projects which suggest the potential for this sort of work.

One involves an initiative in Merseyside to set up a helpline for men feeling depressed and suicidal and the other, based in Wolverhampton, involves a project which works with Wolverhampton FC supporters to increase awareness of safer sex and encourage the use of condoms.

Other types of projects which could work particularly well with men include pub clinics, working men's clubs and work-based health initiatives.

One big problem is men's use of primary care. Interestingly, men aged 16-39 in social classes 4 and 5 are fractionally more likely to consult a doctor than men in social classes 1 and 2 but the total number of visits each year is still under half that made by women. Men of all social classes tend to present later in the course of any given condition by which time it could well be harder to treat.

Primary care needs to be made more attractive to men. It seems that many men prefer easily-accessible clinics, preferably offering greater anonymity than the average GP surgery. Drop-in centres are one possibility and it will be interesting to see whether the recently-established national network of NHS drop-in centre succeeds in attracting more men. It would also be useful if part of the promotion of these centres was directed at men specifically.

What's clear is that it's important to go where men are and to base health promotion activities on men's particular need and experiences. Traditional health promotion initiatives that don't target men, or particular groups of men, are much less likely to be effective.

We are seeing a greater interest in men's health at all levels now, although this hasn't yet been reflected in the grim statistics on health outcomes. However, one thing is clear: the idea that men are largely uninterested in their health is almost certainly not true, at least for most men. What does remain true is that they don't like talking about it and are reluctant to ask for help. However, the right kind of information and services targeted in the right way could begin to make a difference, albeit within the limitations of an unequal society.

Professional men are now taking greater interest in their health and, although they are the men who need to do this least, that is nevertheless an important step forward. It also means that the idea that it is normal and acceptable for a man to take better care of his health can begin to ripple through male culture as a whole. There is the prospect in the next 10-20 years of not ending male health inequalities but at least beginning to make some impression on the figures. We can begin to see a time when the concept of 'men's health' no longer seems a contradiction in terms.

For more information about OXFAM's UK Poverty Programme, contact Sue Smith - ssmith@oxfam.org.uk.