Health Disparities Persist for Men, and Doctors Ask Why

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 Health Disparities Persist for Men, and Doctors Ask Why


The New York Times
By RONI RABIN
November 14, 2006

In recent years, women’s health has been a national priority. Pink ribbons warn of breast cancer. Pins shaped like red dresses raise awareness about heart disease. Offices of women’s health have sprung up at every level of government to offer information and free screenings, and one of the largest government studies on hormones and diet in aging focused entirely on older women.

Yet statistics show that men are more likely than women to suffer an early death. Now some advocates and medical scientists are beginning to ask a question that in some circles might be considered politically incorrect: Is men’s health getting short shrift?

The idea, they say, is not to denigrate the importance of women’s health but to focus public attention on the ways in which men may be uniquely at risk — and on what a growing men’s health movement has termed the “health disparity” between the sexes and its most glaring example, a persistent longevity gap that has narrowed but still shortchanges men of five years of life compared with women.

“We’ve got men dying at higher rates of just about every disease, and we don’t know why,” said Dr. Demetrius J. Porche, an associate dean at Louisiana State University’s Health Sciences Center School of Nursing in New Orleans, and the editor of a new quarterly, American Journal of Men’s Health, that will publish its first issue next March.

The Men’s Health Network, a not-for-profit educational foundation based in Washington, has called for creating a federal office of men’s health to mirror the office on women’s health within the Health and Human Services Department, and it is backing a bill sponsored by Senator Mike Crapo, Republican of Idaho, and Representative Vito Fossella, Republican of New York, to do so. Several federal offices on women’s health were recently established to compensate for years in which women were often excluded from medical research, but there is no federal office of men’s health.

Men’s health advocates say that men are silently suffering through what may be a serious health crisis. “We keep throwing out lifestyle as an explanation for the differences in longevity, saying that men come in later for care and have unhealthy behaviors, but I’m not sure we really know the reason,” Dr. Porche said.

“And we haven’t answered the question: Is there a biological determinant for why men die earlier than women?” It is a question that has piqued the interest of some medical scientists, including Dr. Marianne J. Legato, founder of the Partnership for Gender-Specific Medicine at Columbia University.

Five states — Maryland, Georgia, New Hampshire, Louisiana and Oklahoma — have either established or plan to establish offices or commissions on men’s health, and the Nov. 15 issue of JAMA, The Journal of the American Medical Association, is entirely devoted to studies on the topic.

But the mere suggestion that men need their own health bureau or that they must advocate for their rights like a victimized minority rankles some women’s health advocates, and some politicians are reluctant to take men’s health on as a cause, for fear of alienating women.“

Saying we need an office of men’s health ignores the fact that men’s health always was the main focus of medical research,” said Cynthia Pearson, executive director of the National Women’s Health Network in Washington, a membership organization for improving women’s health.“ During the first half-century of our nation’s investment in medical research, the majority of resources went to studying men and the conditions that affected men disproportionately,” she said. “Is their health perfect?

No. But they don’t need a movement.”Still, by just about any measure, men’s health is abysmal. American men have an average life expectancy of 75.2 years, and even less — 69.8 years — for black men, compared with 80.4 years for women over all. Men die of just about every one of the leading causes of death at younger ages than women, from lung cancer to influenza and pneumonia, chronic liver disease, diabetes and AIDS.

One notable exception is Alzheimer’s disease: more women than men die of it.

Topping the list for both sexes is heart disease.But while the American Heart Association has been conducting an aggressive public education campaign to raise awareness about heart disease among women, called Go Red for Women and featuring pins in the shape of dresses, progress among men has been slipping, said Dr. Steven Nissen, the chairman of the department of cardiovascular medicine at the Cleveland Clinic and president of the American College of Cardiology.

Yet, he added, the illness exacts a disproportionate toll on men. Although heart disease occurs in women in their 30s and 40s, he said, it is “extremely unusual,” while severe heart disease in men that age is “not exceptionally rare.” Heart disease in women increases as they age, he noted. “We’ve got to put it all in perspective,” Dr. Nissen said.

“Coronary heart disease has a devastating impact on men, particularly on men who are in the prime of life — 45-year-old men with major heart attacks, who may never work another day in their life, who may have children.” Cancer also strikes men disproportionately: one in three women at some point in life; one in two men. In part, that is a result of the fact that more men than women smoke, and possibly of occupational exposures.

But experts and advocates say that when it comes to government financing for the most common sex-specific reproductive cancers, breast cancer financing exceeds prostate cancer financing by more than 40 percent, with prostate cancer research receiving $394 million in 2005, and breast cancer receiving $710 million.

The figures, for financing by the National Cancer Institute and Defense Department, were provided by the not-for-profit Prostate Cancer Foundation. More women die of breast cancer than men do of prostate cancer: some 40,970 women will die of breast cancer this year, compared with 27,350 deaths of men from prostate cancer, according to the American Cancer Society.

Breast cancer also strikes young people more often. But men’s chances of receiving a prostate cancer diagnosis at some point in their lifetimes are high, with about 234,460 new cases expected to be diagnosed this year, compared with 212,920 new cases of breast cancer.

Nevertheless, said Dr. Peter Scardino, a prostate cancer surgeon and chairman of the department of surgery at Memorial Sloan-Kettering Cancer Center in New York, “there are still more people doing research on breast cancer than on prostate cancer, there’s more industry support for research on breast cancer drugs, there’s been more attention to the quality of life effects of breast cancer and we have more-effective chemotherapy agents for breast cancer because more trials have been done.” Men’s vulnerability appears to start quite early.

More male fetuses are conceived, but they are at greater risk of stillbirth and miscarriage, scientists find. Even as infants, mortality is higher among newborn boys and premature baby boys.As children, boys are at higher risk for developmental disabilities and autism. Boys and men are more likely to be colorblind, suffer higher rates of hearing loss and are believed to have weaker immune systems than women. They may also recover more slowly from illnesses.

“It’s not that we ‘could be’ the weaker sex — we are the weaker sex,” said Dr. Robert Tan, a geriatrics specialist in Houston who is on the advisory board of the Men’s Health Network. “Even when men and women have the same disease, we often find that men are more likely to die.

Hip fractures stand out, for instance: women seem more likely to recover, while men are more likely to die afterward.” Behavior plays a role in some of the extra deaths and illnesses among men: they tend to be more aggressive than women and to take more risks.

Men smoke at higher rates than women, drink more alcohol and are less likely to wear seat belts or use sunscreen. Men also suffer more accidental deaths and serious injuries and are more likely to die of injuries and car accidents. They are three times as likely to be victims of murder, four times as likely to commit suicide and, as teenagers, 11 times as likely to drown.

Some experts think that depression contributes to these reckless and self-destructive behaviors, but that just as heart disease was initially defined by men’s experiences and therefore ignored or missed in women, depression may have been framed by women’s experiences and therefore may be missed and go untreated in men. In any case, as a result, even though more baby boys are born, among people in their mid-30s, women outnumber men.

Among people age 100, women outnumber men by 8 to one.Among the questions research might explore, Dr. Legato said, are: “Why are there more miscarriages of boy fetuses?  What is it about the sexing of the fetus that makes a male more vulnerable? What makes a boy less mature in terms of lung function after he’s born? And what is this propensity for risk-taking?” One theory is that males are vulnerable because of their chromosomal makeup: where women have two X chromosomes, men have an X chromosome and a Y chromosome.

“It is said that even before implantation in the wall of the uterus, the newly fertilized XX entity has a leg up,” Dr. Legato said, “because it can use that extra X to combat mutations in the chromosome that might be lethal or detrimental. And that might be a reason why females have a more sturdy constitution.” Scientists and advocates who are concerned about men’s health are encouraging men themselves to take the first steps by accepting responsibility for their health status, seeking preventive care and making changes in habits, if necessary.

New drugs for erectile dysfunction have helped bring men into doctors’ offices in recent years, experts say, but that is not enough. “Men need to take as good care of their bodies as they do of their cars and trucks, and they don’t,” said Dr. Ken Goldberg, a urologist and the author of “How Men Can Live as Long as Women,” among other books. “We need men to come in” to the doctor’s office, he said, adding, “A lot of men think they’re bulletproof and invincible.

”Research based on a 2000 survey by the Commonwealth Fund found that almost a quarter of all men had not seen a doctor during the previous year, compared with only 8 percent of women, and that one in three men had no regular doctor, compared with one in five women. More than half of men had not gone in for a routine checkup or cholesterol test during the previous year.Even if something was bothering them, the survey found, men often expressed reluctance to seek medical help.

Nearly 40 percent said they would delay care for a few days, and 17 percent said they would wait at least a week.Strangely, some insights into men’s behavior in regard to their health have been gleaned from studies intended to yield information about women. A 2001 national study on ambulatory care found that women, who are in the habit of seeing doctors regularly if only because they need reproductive services, had double the number of annual exams that men had.

Other studies have found that because poor women with children may qualify for Medicaid, poor men are more likely to lack health insurance.Advocates say that research must be directed at how specific diseases develop in men, but that studies should also be done to explore the underlying reasons that men do not take better care of themselves.Many psychologists think the problems are rooted in how boys are raised.

“We’ve socialized men from the time they are boys that ‘You have to stand on your own two feet,’ ‘If you have a problem, handle it by yourself,’ ‘Be a man, take one for the team,’ ” said Dr. William Pollack, director of the Center for Men at McLean Hospital in Belmont, Mass., affiliated with Harvard Medical School.

“All of which means, ‘Don’t complain, don’t ask for help and solve the problem by yourself.’ ”He added: “Men think that being vulnerable is the worst thing. But to recognize there might be something wrong with you, you have to acknowledge: you’re vulnerable.”
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Contributed,
YNCS Don Harribine, USN(ret)