Chapter 1
Men's health in Australia
What is Health?
1.1
Definitions of what constitute health range from the narrow - the
presence or risk of particular diseases or conditions - to the all-embracing,
in which every aspect of a person's or community's life becomes a 'health'
issue. A widely accepted definition is that of the World Health Organisation
(WHO) which defines health as “a complete state of physical, mental and social
well-being, and not merely the absence of disease or infirmity.”[1]
1.2
Such broad definitions are valuable in illustrating that the factors influencing
the health of a community or an individual extend far beyond the presence or
absence of a particular pathology. It is obvious that diet, housing, the
quality of water supplies and sewerage systems are key issues. Determinants of
health can range from the social acceptability of the consumption of tobacco,
alcohol and other drugs to intangibles such as the social and cultural
constructs of 'masculinity'. In the area of mental health many matters, such as
the extended experience of drought in South-Eastern Australia, can be powerful
influences.
1.3
In evidence to the committee the importance of the impact of social and
other factors on health was most clearly demonstrated with regard to road
trauma. Land transport accidents are the third biggest cause of potential years
of life lost in males, almost double the rate for women.[2]
The general category of injury, which includes road trauma and interpersonal
violence, imposes the highest direct and indirect causes on the health system.[3]
Yet many of the factors which influence the level of road trauma fall outside
what is generally considered to be health – road standards and design, vehicle
design and maintenance, driver education, attitudes to alcohol consumption and
geographic isolation.
1.4
At the same time the WHO definition has been criticised for being too
broad and being of little use as a guide to action.[4]
As one writer commented, a "complete ... state of wellbeing corresponds more
to happiness than health".[5]
Consideration of all-embracing definitions of health is important in that it
serves as a constant reminder of the range of factors that contribute to
'health'. However it can also lead to a sense of helplessness in the face of
intractable social problems or entrenched cultural attitudes. As a representative
of the Royal College of Surgeons cautioned,
You can lose sight of providing good clinical care and
dealing with the pointy end of a problem in violence, road safety and so on by
focusing too much on the things that are much more removed from the actual illness...[6]
1.5
The challenge for policy makers is to strike the appropriate balance
between addressing the broader social determinants of health while ensuring
that the research, education and service provision that underpins good clinical
care is properly funded and supported.
1.6
In its submission to the committee Foundation 49 provided the following
definition which covers both the specific and the general:
...disease[s] or condition[s] unique to men, more prevalent in
men, more serious among men, for which risk factors are different for men or
for which different interventions are required for men.[7]
1.7
In this report the committee has concentrated on those matters which
impinge most directly on men's health and the need to support research and
provide good clinical care and education and awareness campaigns that seek to
improve men's understanding of their health including the social and cultural
attitudes that have an impact on it.
1.8
The committee recognises that some health problems may be more amenable
to, or conditional on, actions in other areas, for example the impact on mental
health of the drought in rural communities or of relationship breakdown and
associated stresses which have been referred to in many submissions to the
committee. The committee has commented on the need for improved services to
respond to these while avoiding the temptation to examine broader contextual
issues which fall outside the terms of reference of the inquiry.
Men's Health Status
1.9
Men's health status in Australia, whether measured by the burden of
disease and injury or, ultimately, by life expectancy shows distinct
differences from that of women. The statistics presented in the rest of this
chapter show plenty of opportunities for improving men's health outcomes.
However, despite the heated language in some submissions about 'shocking'
outcomes and a 'crisis' in men's health, Australian men have the second highest
life expectancy in the world, bettered only by Japan.[8]
Overall Australia has the third lowest death rate among the membership of the Organisation
for Economic Cooperation and Development.[9]
Life Expectancy
1.10
Male average life expectancy at birth is 4.8 years less than that of
women – 78.5 years and 83.3 years respectively.[10]
Male and female life expectancy declines progressively from urban dwellers,
through inner and outer regional and remote areas to those in very remote
areas. Men's life expectancy declines from 79 years in urban areas to 72 years
in very remote areas, women's from 84 to 78 years.[11]
1.11
The median age at death (the age at which 50% of deaths occurred before
and 50% after) for men in 2005 was 76.8 years compared with 82.9 years for
women. Twenty-five per cent of male and fifteen per cent of female deaths
occurred at less than 65 years.[12]
In 2005 male deaths exceed female deaths in every age-group other than those
aged over 85 years. For some age-groups the difference is marked. In the 15-24
cohort there were 274 male deaths for every 100 female deaths and, in the 25-44
group, 208 male deaths per 100 female deaths.[13]
Overall in 2005 the ratio of male deaths to female was 106:100.[14]
Causes of Death
1.12
The most prevalent causes of death vary between the sexes, although
coronary heart disease is the most common underlying cause of death for both
men and women. It also exceeds the next most significant cause in either men or
women by a large margin, accounting for 18.5% of male deaths compared with second
ranked lung cancer with 7.0% of deaths. For female deaths, coronary heart
disease accounts for 17.5% of deaths while the second ranked cerebrovascular
disease accounts for 10.8%. Cerebrovascular disease (diseases of the blood
vessels in the brain - most commonly stroke) and 'other' heart disease are
ranked in the first four leading causes for both sexes. Lung cancer, the second
most common cause of death in men ranks sixth for women while dementia and
related disorders ranks fourth for women and eleventh for men.
1.13
Prostate cancer and breast cancer are the fifth most common cause
of death in men and women respectively and account for almost identical
percentages – 4.4% and 4.3% of total deaths. The actual number of deaths from
prostate cancer in 2005 was 2 946 and for breast cancer, 2 719.[15]
1.14
Proceeding down the list of the leading twenty underlying causes of
death greater differences begin to appear. Of significance to this inquiry,
suicide (10th), land transport accidents (14th) and liver
disease (15th) appear in the male list but not in the female list.[16]
1.15
Looking at contributing causes of death – conditions or diseases that
played a part in death – the pattern is similar. The three leading contributing
causes are coronary heart disease and 'other' heart diseases and
cerebrovascular disease and are the same in males and females. They comprise a
large proportion of underlying or associated causes of deaths – 70.2% for males
and 73.9% for females. It is important to keep these figures in mind. In terms
of reducing the male (and female) death rate, action to address heart and
cerebrovascular disease must remain a very high priority.
Potential Years of Life Lost
1.16
Another way of considering causes of death and their impact on society
is potential years of life lost (PYLL). This "... is an indicator of
premature or untimely death" taking 75 years as a 'normal' life span.[17]
Thus a person dying at 60 years is considered to have 'lost' fifteen years. In
terms of PYLL the difference between men and women is starker than simply
looking at life expectancy or the ratio of male to female deaths in any one
year, indicating the significantly higher number of men dying at younger ages.
Using this measure "Males lose 75% more potential years of life than
females".[18]
1.17
The leading contributors to PYLL for males are coronary heart disease,
suicide, land transport accidents and lung cancer. For females they are breast
cancer, lung cancer, coronary heart disease and suicide. PYLL from all causes
are significantly higher for men, 538 985 for men and 306 330 for women.
Suicide, which ranks second for men and fourth for women, accounts for 52 998 PYLL
in males and 13 270 in females; land transport accidents account for 42 505
PYLL in men and 12 678 in women.[19]
Avoidable Deaths
1.18
Avoidable deaths are those which "...could be avoided either through
prevention (a reduction in the incidence of the conditions), treatment (that
increases survival) or a combination of these".[20]
Deaths occurring before the age of 75 are considered avoidable.
Each hour in Australia, more than five men die from
conditions that are potentially preventable... Significant numbers of male-related
health problems, such as high blood pressure, diabetes, heart disease, prostate
cancer, testicular cancer, infertility and colon cancer, could be detected and
treated more effectively if men's awareness of these problems was greater.[21]
1.19
The differences between males and females by this measure are, again,
marked. The ratio of male to female avoidable deaths is 192:100; that is,
almost twice as many male deaths as female deaths are considered avoidable.[22]
When broken down by age the differences between men and women are even clearer.
In the 15-24 and 25-44 age groups the ratio between male and female avoidable
death rates are 288 male:100 female and 234:100 respectively. However the
overwhelming majority of deaths that are considered avoidable, over 78%, occur
in the older age groups, (45 and above).
1.20
The concept of avoidable deaths clearly demonstrates the importance of
improving education and awareness programs and service provision to encourage
men to monitor their own health, have regular check-ups and seek help at an
early stage where they are aware of a problem. Many of the conditions which
contribute most to avoidable deaths, particularly in the older age groups, coronary
heart diseases and stroke for example, can be managed given early identification
and treatment.
Burden of Disease
1.21
This term refers to the overall extent of health problems in Australia,
combining chronic illness and diseases leading to death and is expressed in
terms of Disability Adjusted Life Years (DALY).
1.22
Disability Adjusted Life Years seek to express the loss of years of
healthy life owing to illness or injury. DALYs have been developed as a tool to
enable policy makers and health professionals to make comparisons between a
"...common chronic disease that leads to long term disability, but rarely
causes death, ...[and]...a disease that is less common but often fatal".[23]
In calculating this measure diseases and other conditions affecting a person's
health status are given a severity weighting which seeks to quantify the loss
of quality of life for a person who lives with a chronic health problem or a
disease leading to death. For example, a severe health problem might result in
a decade of actual life being equated to three or four years of healthy life.
When combined with measures of years of life lost due to premature death DALYs
provide a measure of the overall impact of disease and injury.
1.23
This measure shows that cancers[24]
and cardiovascular diseases continue to have the largest impact, with early
death rather than reduced quality of life contributing a high proportion of
DALYs. However by measuring 'disability years' this process also shows the
impact of mental disorders, neurological and sense disorders, injuries and
chronic conditions such as respiratory diseases and diabetes, which have a
significant impact on quality of life without necessarily leading to early
death.
1.24
When these calculations are reduced to reasonably specific conditions
then the greatest number of DALYs are attributed to coronary heart disease,
anxiety and depression, type 2 diabetes, stroke and dementia.[25]
1.25
The most common non-lethal long-term health problems of both men and
women were long and short-sightedness, back pain and disc problems and hay
fever and allergic rhinitis. Back pain and disc problems were more commonly
reported among men while hay fever was more common among women. Lower ranked
conditions showed a greater variation between the sexes; for example men
reported a significantly higher incidence of deafness while women reported a
higher incidence of migraine.
Health Status
1.26
Generally, Australians rated their health status to be 'Good' to
'Excellent'. Though this rating declined with age, more than 60% of those over
75 years were in this group. AIHW notes that self-ratings "...were similar
for males and females".[26]
Trends
1.27
The AIHW report warns against comparisons over time because of changes
to methodology, however some trends with regard to the burden of disease can be
discerned.
1.28
There was a significant reduction of some 15% in the burden of disease
between 1993 and 2003 as measured by DALYs. The main contributors were the
reduction in the impacts of cardiovascular diseases, cancers and injury and the
reduction was predominantly in the fatal component of DALYs, i.e. years of life
lost through early death. The non-fatal component, i.e. loss of quality of life
through chronic illness, did not fall as much and in some cases, for example
diabetes, it actually increased.[27]
Regional & Rural Australia
1.29
As noted above, life expectancy declines as one moves away from major
cities through inner and outer-regional Australia and into remote and very
remote Australia. This pattern also shows up with some, but not all, indicators
of health. For example perinatal mortality and, of significance to this
inquiry, risky behaviours in relation to smoking and alcohol consumption,
increase with remoteness. However in other cases, for example the incidence of
cancer, while there is an increase in regional areas when compared with major
cities, the incidence is not statistically significant in remote areas and
actually declines in very remote areas.
1.30
In considering poorer outcomes in regional and remote areas it is
important to recognise that many of the social determinants of health that
contribute to adverse outcomes are more prevalent away from major cities. AIHW
summarises it thus:
Australians living in rural and remote areas generally have
less access to primary health-care ..., more driving risks ..., longer patient
transport times, and more jobs with higher risks ...[28]
1.31
To these should be added a disproportionately high number of the lowest
socio-economic areas and, particularly in very remote areas, the high
proportion of Indigenous people whose poor health status and early deaths when
compared with national population averages have a significant impact. At the
same time AIHW warns against easy generalisations, pointing to significant
variations within and between urban and non-urban areas.
1.32
AIHW also examines what it calls 'excess' deaths outside major cities,
i.e. the deaths above what would be expected if rates in regional and remote
Australia were the same as in major cities. This shows that the most
significant contributors to excess deaths are coronary heart disease, other
diseases of the circulatory system and motor vehicle accidents. Of particular
relevance to this inquiry is that suicide and prostate cancer appear among the
leading causes, both contributing 4% of excess deaths.[29]
Indigenous Australians
1.33
The poorer health status of Indigenous Australians is well known. Life
expectancy for Indigenous men in 1996-2001 was 59 years.[30]
71 % of Indigenous Australian deaths in 2001-2005 occurred below the age of 65
compared with 21% for the non-Indigenous population.[31]
1.34
Death rates from all causes are markedly higher in the Indigenous
community; for males the Indigenous rate is three times that of the
non-indigenous. Looking at the most common specific causes the rate for deaths
from diseases of the circulatory system is more than three times higher than
for non-Indigenous Australians. For accidents, assaults and self harm it is
slightly less than three times and for cancers, one and one half times. The
ratios are much higher for other significant causes of death, with the rate of
deaths as a result of diabetes being nearly eleven times higher for Indigenous
men compared with non-indigenous men (the comparable rate for women is 14.5)
1.35
In terms of the gap between Indigenous and non-Indigenous health
outcomes, while there has been some improvement in the infant mortality rate,
the decline in Indigenous death rates did not match that for non-indigenous
Australians leading the AIHW to conclude that "...the gap in mortality
between Indigenous and non-Indigenous Australians is widening".[32]
It also observes that only one of the five leading causes of death among
Indigenous people – diseases of the circulatory system - showed an improvement
in the period 1997-2005.
1.36
The committee acknowledges the efforts of successive governments to
address these problems but despite these efforts, it cannot but agree with the
conclusion of Professor Gruen, "Indigenous health is a national image problem.
It is a national disgrace."[33]
1.37
The need to adopt a 'social determinants of health' approach is most
pressing in Indigenous communities particularly those in regional, remote and
very remote areas. Issues such as low consumption of fruit and vegetables,
sedentary lifestyles, overcrowded housing and lack of access to clean water
supplies and proper sewerage systems are major factors in the poorer health
outcomes experienced by Indigenous Australians.
1.38
For Indigenous men the problems are compounded by the disempowerment
experienced by Aboriginal men:
As a reaction to the social dysfunction that exists in many
Aboriginal communities, all Aboriginal Males, as a group, have been targeted and
convicted as the cause of this dysfunction. This approach is wrong, adding
further burdens and causing greater pain within the community and to
individuals. “Aboriginal men have been targeted as if they were the only
perpetrators of child sexual abuse in communities. This is inaccurate and has
resulted in unfair shaming, and consequent further disempowerment, of
Aboriginal men as a whole”.[34]
1.39
Although some of the factors bearing on Indigenous men's health are
similar to those affecting non-indigenous men, including risk-taking behaviour,
injury, road trauma, alcohol and other drug consumption (including cigarette
smoking) and eating habits leading to obesity, the health status of Indigenous
men is not a 'worst case' example of the state of men's health in Australia
generally but is to a large extent the product of factors relating to the
destruction of traditional societies and cultures, the breakdown of traditional
social roles and alienation from, and disempowerment by, the Australian
mainstream which are distinctly different from the experience of men in the
wider society. Indigenous health requires a separate and complementary approach.
It is inextricably linked, "...not just [to] the physical well-being of an
individual but... to the social, emotional and cultural well-being of the whole
Community".[35]
1.40
Thus the committee believes that it requires a distinct approach and
therefore supports the recommendation of the Aboriginal Torres Strait Islander Social
Justice Commissioner in his submission to the committee that:
...a national Aboriginal and Torres Strait Islander men’s
health strategy is developed and integrated with a national plan of action
towards achieving Aboriginal and Torres Strait Islander health equality by
2030.[36]
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