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Editorial: Fads and fallacies in rural men's health promotion

Robert H. Hall

Publication Date: 30 July 1998

Introduction

The groin is not where men’s health is at…. Social factors, money and place in the community, seem more important than prostate size or cholesterol as predictors in men’s health. We’ll discuss feelings/emotions and some aspects of body functioning as we explore issues of promoting the health of rural men.

I imagine that Men’s Health may have entered the political agenda when Dr Carmen Lawrence, a woman and the Commonwealth Minister for Health at the time, didn’t want to be known as the Minister for Women’s Health, and decided to put a bit of money into men’s health. But almost all the community health promotion people were women, who had been working on Papanicalaou smears and breast self examinations, fertility control and sexually transmitted diseases. It seemed a sensible start to use that same analogy for men’s health.

Question: What’s the male analogy to pap smears?
Answer: Testis self examination and getting prostates tested

That has got only a little to do with men’s health and so today I’m going to talk about an approach to men’s health which is based on men’s survival and men’s issues, not men’s health as defined by analogy to women.

Epidemiological Research on Men’s Survival

A long-term major study on health parameters and survival has been conducted for over thirty years in Alameda County in California. Breslow et al monitored the population in 5 year age groups, with lots of epidemiological correlations, and saw what happened to them.

Question: What was the best predictor, for boys up to age 15, as to whether they lived or died in the next 5 years?
Answer: This predictor was whether they had a family who provided loving support or not.

For white middle class men 20-50 years old, the best predictor was whether they were satisfied with their job. Controlling for whether they smoked, whether they had high cholesterol or whatever, if they were satisfied with their job they survived more than the others. Looking at the men who were over age 50, the important issue was whether they had a partner who loved them. We must realise that when we are talking about rural men’s health, it is not just about the body. We include injuries and heart problems, concerns about the mind and feelings, but most importantly we’re talking about relationships, about connectedness.

A Research Question

There are many interesting aspects to research and evaluation in rural men’s health - How do you tell these things? How and what should you measure?

It’s an interesting scientific question as to how you demonstrate the importance of a man’s intimate relationship to his survival. How do you know, for individuals in a population of men in their sixties, if they have a wife who loves them or not. The research in fact got down to self reports of frequency of sexual intercourse, and it correlated with survival over the next five years. The more they had sexual intercourse the longer they lived. But the issue is not just a biological phenomenon, because it didn’t correlate with masturbation; so it’s not just orgasm. It seems to me it has something to do with the quality of relationship, which results in increased intercourse.

And yet that same issue of connectedness is there for other age groups. Satisfaction with work has got a lot to do with relationships. Survival of young boys again has to do with relationships within their families. What we are facing here is an issue that men’s health is not based on "man as well-functioning meat" but it’s based on "connectedness".

What I want to concentrate on here today is in fact matters of relationships. If those relationships are satisfying, loving relationships then men’s health is so much better.

The next area links to the man’s feelings. In particular, if we are talking about young men’s risk of dying, it is suicide and vehicle accidents which figure the most.

Question: What seems to be the underlying real problem?"
Answer: It’s actually risk taking behaviour

In our society at the present time we require young men to be risk takers. We’ve got the Special Air Service commandos and we’ve sent them off in the Gulf at the present time and we consider Australia needs to have SAS type people in our society. To have SAS type people in our society we’ve got to have a culture of men being risk takers. To play a good game of football, you’ve got to be a risk taker. To get a game with the Sydney Swans, you’ve got to be a risk taker. And that’s one of the issues about men’s health. That we encourage people to be risk takers but they bugger their knees, they injure themselves, and so their health goes down as they are meeting this social requirement for being risk takers.

How do you prevent suicide? The interesting thing is that, again, it’s got to do with relationships. It involves connectedness. It’s got to do with belonging. If you want to help young men avoid suicide, then you have to help them to belong. So if they play footy, you encourage them to belong to the footy club. You link them to the Rural Fire Brigade. If they’re a computer nerd you encourage them to belong to a computer users club or a games group. Basically you’ve got to find out what it is that turns them on and help them link up.

There can be problems, however, with belonging. If you belong to the drug sub-culture, for example, you can get into trouble. So it’s not the mere fact of belonging but what you belong to.

If we come finally to the well-functioning body and consider what’s going on there, we all know that it’s a good idea to have a little bit of most things, everything in moderation. We know about exercise and diet, we all know about stopping smoking. But with these behaviours, when they are in excess, belonging can be a problem. I mean men who eat too much generally don’t eat too much alone, they might eat too much with other people. Men who smoke too much quite often smoke down the pub or drink too much down the pub with other people; with their social belonging linked into it. So we need to consider this dimension of belonging also when we’re thinking about health and body behaviours as well.

We’ll now consider some fads and fallacies for promoting health for rural men, and some commonsense about the common senses.

If I think about one of the fads and fallacies for promoting health for rural men, it’s not so much how many kilograms they weigh, but it is in fact how many centimetres they are around the waist. It’s fat around the belly button that’s the key problem with respect to heart disease.

With the aim of identifying diseases early, focussing on the prostate contains some major fads and fallacies when it comes to men’s health promotion and prevention. It may be assumed that it is good to discover a health problem early. The whole point about discovering things early is that it is fine if there’s a good treatment. But there are a whole lot of things which you discover early and then you just have to suffer the knowledge that you’ve got them for a long long time and there’s no benefit to you from doctors intervening. Now particularly can that be true when it comes to the prostate. The argument for investigating with tests, for discovering it early is that if you happen to have a prostate cancer you might get something done about it.

It has been said what you have to get done about it is that someone gets a wine cork screw and puts it up your cock and bores you out and you finish up with leaking in your underpants and a three and a half inch floppy. And that’s not much use to you. I mean, what’s the benefit of incontinence and impotence for 30 years. Most people die with prostate cancer but not of prostate cancer. If you get to age 90 you’re going to have prostate cancer, but you will probably later die for some other reason. So that early discovery is not necessarily a benefit.

Health promotion to ensure maintenance of the common senses is much more beneficial.   Sight and hearing are very important. Rural elderly men need their senses. As a rural health practitioner, if you’re really going to help people you need to make sure that the men go to the optometrist and get their eyes checked, they go to the audiologist; that they in fact use the hearing aid and the spectacles. That you recommend to them that they get a mirror and look at the sole of their feet to see if there are any ulcers coming up or anything like that. So that you help them to use their senses to maintain their own health.

And that spills over into preventing injuries and accidents. The big problem in prevention for people is falls; particularly falls in the home. If you actually fall over at home and break the neck of your hip, the chances are 50% that you’ll be dead in six months. One of the big reasons why people fall is that they are not seeing well. Now that might be just that they need to have some light globes in their house with 100 watts in them instead of the 40 or 60 watts that they’ve got. Or it might be that they’ve got a rug that slides and don’t have their carpets tacked down. There are all sorts of simple things and the issue there is that of course you won’t know about those things unless you actually go and see people in their homes. So as a GP or rural nurse, if you do a home visit for your elderly people, you will actually be of benefit to people. And as a doctor, if you don’t give people sleeping pills then they won’t get out of bed to piss, stagger and fall and break their leg. So that it’s important to remember that prescribing can sometimes be harmful - in preventing their sleeplessness, you produce an injury.

One of the big problems with health promotion/preventive care is over treatment. There’s a billion dollar industry at the present time and that billion dollar industry is called alternative or complementary health care, with a sales pitch that it is "prevention" when the gains seem hard to demonstrate. It basically may do good if it’s massage on offer, but it is not good if it’s iris diagnosis or Bach flower remedies or other different flavours of bull….. The issue for rural health practitioners who get into "prevention" is that there’s a lot of over treatment, of dubious benefit.

One example of this involves skin cancer. Because there’s been a lot of publicity and slip- slop- slapping and wearing hats, people go along to their doctor with their skin lesions and what happens then is the doctor cuts them off and charges them $100 for the privilege. Now Medicare has got smart to this and a couple of years ago, they realised they were spending millions of bucks on this sort of work and so they said "We will only pay $100 if it turns out to be a cancer and if it doesn’t turn out to be a cancer we’ll pay $30"; and that’s the best way to stop over treatment. Suddenly they’ve only got half as many millions being spent on skin cancers because over 90% of them weren’t skin cancers. If people get anxious about prevention then you tend to get over treatment; the community pays and doesn’t benefit.

The fundamental financial reason why the community is in trouble with preventive treatment and paying for treatment is that you pay for it now, in advance, and you’ve got to recognise interest on that money. If the benefit’s not there within 10 years then it’s cost you twice as much. So you may not actually save any money by preventing it now. Only if you get a quick pay-off. If you get a quick pay-off next year or in three years, then there might be some economic benefit. But certainly if the pay-off comes after 10 years then the interest component has destroyed the financial benefit.

So there are lots of fads and fallacies when it comes to preventative care for rural men’s health.

In summary, if we think about prostate matters, the Preventive Guidelines, put out by those who don’t benefit financially by the treatment, recommend doctors to treat when the person has symptoms. You don’t take the poor person who’s heard the advertisement on the radio that they should have their prostate checked and order blood tests and transrectal ultrasounds. If you find something, you must explain the benefits of "watchful waiting", and help them protect themselves from sentence to a life of misery when they may never have needed it.

The next issue is that you must pay attention to whether rural older men wear glasses or have their false teeth or, if a patient doesn’t hear you, then send them to the audiologist to get their hearing improved so then they’ll hear the car coming up beside them on the road and get off the road and not get run over.

If you’ve got elderly people and you’re worried about falls you need to do home visits and know the people in their homes. You might say "What can I do as a doctor about injuries?" You can help people if you do home visits. You can look after your patients by getting them to look after themselves. Not by overtreating them and not by doing lots of investigations on their groins.

Summary

For rural men’s health, the groin is only a small part. The waist is much bigger, and the heart seems to be central. We need to move up to the head, to impact on the health promoting behaviours emphasised in the "Cancer and Heart Offensive"

As far as skin cancer goes, don’t forget the sun screen. But rural men’s health promotion is more then "the man as meat". We need to consider the individual, in his relationships and context. The societal requirement for military capability necessitates willingness for risk-taking, particularly by men in the fifteen to twenty-nine age group, which may otherwise be viewed as problematic.

The crucial role of "Connectedness", indicated by the Alameda county studies of Breslow and Somers, and Cassell, and further emphasised from the Women’s Health Movement, impinges on family support for children; social and work involvement into older age; loving partnership and social networking for the elderly. We need the Rural Fire Brigade, and the equivalent of the Country Women’s Association.

So we need to realise that men’s health is not just about men as meat but man as a human in relationship, connected to a healthy cultural context.

Click for further background about this article and Dr. Robert Hall

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