Men's health in proportion 2: the God Doctor

You will remember that in a recent post I looked at a crowd of 100,000 men in one of the world’s largest football stadiums, and asked what they’d all eventually die of. The surprising answer was that around a fifth of them would die from heart disease and stroke, less than a 20th of them would die from prostate cancer, and around 40% of them would die from dozens and dozens of less common conditions that we rarely think about when it comes to men’s health.

Photo credit: Dieter Drescher / Foter.com / CC BY-NC-ND

Let’s take another look at this crowd, this time from the perspective of a psychic doctor who has the power to see one year into the future. Let’s call him the God Doctor (some believe he exists). When he looks down on the football crowd at a game being played in May, he can see who is going to be diagnosed with a new condition before the following May.

What he’ll find is this. Out of the crowd of 100,000 men:

• 500 (that's one in 200) will be told they have heart disease

• 250 will have a heart attack

• 180 will have a stroke

• 105 will be told they have prostate cancer 

• 58 will be told they have lung cancer

• 58 will be told they have bowel cancer

(The figures aren’t exact, because sadly disease incidence figures aren’t easily comparable, but it provides a rough idea).

You may look at such statistics, as I do, and draw some simple conclusions. You may say...

“Getting to grips with how I can avoid disease/keep alive, isn’t simple.”

“If I’m going to live by the law of averages on what’s going to kill me, then I’m going to concentrate on reducing my risk of stroke and heart disease. If I exercise properly, eat a varied diet and stop smoking, I’ll definitely be reducing my risk of conditions that definitely kill a lot of men – heart disease and stroke.”

“If I do that, it’s very likely that I’ll reduce my risk of all those other conditions, like many cancers, where smoking, diet and exercise may play a part.” All good thinking so far. Entirely sensible.

But then you might think some more about these statistics and the statistics about mortality in the previous post and start to get confused. With prostate cancer, for example, it looks as if there’s a reasonable chance of me getting it, but much less of a chance of me dying from it. And you might start to wonder whether statistics can be used from many perspectives, according to what message you want to give the public.

Most of all, your confusion might result in one big question. What about me? It’s all very well having these averages for populations, but what if you’re my age, with my parents, in my country, with my background? What if some diseases actually hold more fears for you: should that be ignored?

Good point. I’d like to talk about that some more, because in this age of “personalised medicine”, we’re absolutely rubbish at personalising information to make it useful. More in another post.

Mental disintegration: the unacceptable face of cricket

Well done then, Australian cricketer David Warner. There you are sporting your Movember moustache, supposedly declaring your allegiance to the cause of men’s health, supporting men who are struggling with physical and mental health problems.

And then, after the Aussies paste England in the first Ashes test match, you gleefully declare that the performance of England cricketer Jonathan Trott was “poor and weak” and that he had “scared eyes”. You promise him there will be more “sledging” (the cricketing art of heaping abuse on batsmen with the aim of causing “mental disintegration” – a term coined by one Australian captain ). 

“Disrespectful” is how the cricketing community has condemned Warner’s words. For those who care about mental health, the condemnation should be stronger – particularly after the news that Jonathan Trott has now had to withdraw from the Ashes tour “because of a long-standing stress-related condition”.

In some machismo circles, it is seen as a necessary part of being a competitive male that you should put those down who can be labelled weak or mentally frail.  In school, such behaviour is called bullying.

Can it have any long-term effect? You bet. More and more studies are showing that bullying leads to mental health problems. A study published in one of the most respected psychiatric journals this year found that victims of bullying were nearly five times as likely to have anxiety and panic attacks than those who weren’t bullied.

It’s pretty clear that David Warner’s comments didn’t cause Trott’s stress-related problems, but they didn’t help. Anyone who really wanted to help the cause of men’s health wouldn’t be attempting to cause mental disintegration. Perhaps David Warner needs to be told that nearly 10% of premature male deaths are the result of suicide, self-harm and accidents. 

Hairs come easy. Actions don’t. 

Men's health in proportion: the football ground

Welcome to the Nou Camp stadium. It’s the Champions League final 2015 between Manchester United and Chelsea. The ground is massive – it has a 100,000 capacity. Today it’s full at the seams with a crowd is entirely made up of British men and boys – of all ages from five to 90. The women have something better to do.

Let’s look at this crowd of men, with the eye of an all-seeing God who can look into the future. And let’s bear in mind that this is an unusual crowd, because as it represents a cross-section of the entire British male population – one in six is over the age of 65. Quite a few will be there in wheelchairs.

The God view of the crowd 

Out of that enormous crowd of 100,000 men, 847 will die in the coming year. Nearly half of them over the age of 80.  

What will they die of? I’ve scrawled over the nice picture of the Nou Camp to give you a general idea (below) but here are the figures (based on data from National Statistics).

136 of them will die of heart disease (16.1% of the deaths)

61 of them will die of lung cancer (7.2%) 

52 of them will die of a stroke (6.1%)

49 will die of respiratory disease (5.8%) 

43 will die of dementia (5.1%) 

39 will die of influenza and pneumonia (4.7%)

40 will die of accidents, suicide and self harm (4.7%)

34 will die of prostate cancer (4.1%) 

27 will die of bowel cancer (3.2%) 

Picture: Oh-Barcelona.com/Foter.com/CC BY

You’ll be wondering what all the others died of. Other types of cancers, liver disease, and dozens of other conditions that affect a smaller number of men across all age ranges.

What does this show? Well, it shows first of all that people die, even if they’ve just been to the football. You’re not “unlucky”, you’re just human. You’re part of the football crowd.

What else does it show? It shows that an awful lot of men die of heart disease, and not that many from “male specific” conditions like prostate cancer.

It’s one way of getting our health, and the things we should worry about, in proportion. There are others... coming soon.

Getting health in proportion: the No I'm Not Lost Effect

So you’re a practical, generally responsible chap – most of us are. You’re concerned about your health, in a vague sort of way. Most of us are. You don’t want to die, you don’t want to burden to your family, you don’t want to be useless. Most of us don’t.

But you also find the whole health thing a bit of a pain. You’re fed up with everyone telling you to start doing this, and stop doing that. You frankly don’t want to spend your life at the doctor’s surgery: it seems dull, dependent, confusing and might confront you with something that makes your life more complicated than it already is. 

This is what I call the No I’m Not Lost Effect. It’s a cliché, but still perfectly true, that most men would rather have their toenails pulled out with molegrips than stop the car and ask someone for directions if they’re lost. The invention of satnav may have saved men a haranging from women passengers only too willing to acknowledge failure to passers by, but the problem persists in health. 

"For God's sake Amanda, don't ask that man
for directions!"

Men want to find their own way when it comes to keeping healthy. We’d rather do our own own groundwork, find ways of doing things that fit our own lives, decide our own routes and not have to stick what some so-called “expert” says is the proper way.

There’s another cliché about men which is relevant: that we can’t multitask. We like to focus on one thing at a time. The truth is that it is impossible for the average male to absorb, assimilate and implement all the health information fired at us by doctors, health education campaigns, or the media. There’s just too much – or even if there isn’t too much, it seems too much. We don’t want our brains cluttered with stuff which may or may not be relevant to us. 

Clearly, ignoring the opinions of others and concentrating on one thing at a time has its hazards. But I don’t think it’s stupid. I’d say it has its advantages.

What if we built on men's need to control and focus?  Men need to be helped to work out for ourselves what we’re most likely to die of – doctors could do more to help us do that. Because frankly we’re currently being told to worry about too many things that will never, ever effect us.

Each of us will die of something nasty: a single condition. Before that happens, it is possible we will be affected by anything between none (if we’re very lucky) and 20 (if we’re very unlucky) potentially serious conditions. Some of the conditions we get will be completely unpredictable – against the odds and possibly obscure – so there’s little point in trying to predict them. 

But some, and particularly the ones we are likely to die of, are much more predictable.  This is either because of our family history, or because simple statistics reveal how common they are in men.

As a society, we’re very bad at helping men get things into proportion in this way. I’ll be trying to help in posts that follow.

Men and women: one size doesn't fit all

So which is the sneezier gender? New research from the American College of Allergy, Asthma and Immunology shows that women are more at risk from allergies, asthma and other diseases that affect the body’s immune system.

The researcher, Renata Engler, has also found that the pattern of which gender is most susceptible to allergies changes over time – in childhood, it’s boys who suffer more.

Why is such research important? Because it joins a growing body of evidence that men and women have radical differences when it comes to physiology and health. For example,  it’s only in the past decade that doctors have begun to realise that heart attacks manifest themselves very differently in women than men. Women are less likely to get classic chest pain, and more likely to have indigestion-like symptoms.

It's increasingly clear that lumping everyone together in terms of typical symptoms, likely diagnoses, optimal treatments is not only unhelpful, but also potentially dangerous. In this supposed age of personalised medicine, one size won’t fit all. Which is particularly obvious (if you stop to think about it) when it comes to big hulking men and less than big and hulking women. 

Episode 7: Admission

The world gradually congealed into view. Drake was looking at a fluorescent light on a polystyrene tiled ceiling. Around him were curtains and above him stood a man with a benign smile on his face, wearing white.

“Where am I?” asked Drake.

“In the Hospital” said the man.

Drake was confused. “What do you want with me?”

“Well, we don’t want anything, apart from to make you well.”

Drake was trying to work out how he could be in a hospital, when he was clearly in a reeling ship. The room was swaying and he felt sick. Altogether he felt extremely strange, disconnected, and he didn’t like the look of the man in white now bending over and looking into his eyes. 

“Whose side are you on?” Drake demanded, but his words seemed slow and delayed. He tried to focus: the face had something of Kolotov about it.

The man looked puzzled, and then impatient.

“Look, you’re here because you had a nasty turn. We want to make sure you’re alright so we’re running a few checks. Now just relax, and we’ll soon have you as right as rain.”

You must be joking, thought Drake, and leapt out of the bed. Except he didn’t. He couldn’t. His legs didn’t move at all. He tried to heave himself over the bed rail with his arms, but the man in white stood in his way.

“I’m afraid you don’t have use of your legs at the moment,” said the man in white. “We’re not quite sure what’s happened yet, but it’s possible you’ve had some kind of small stroke, so we’re running some tests.”

Drake tried to think back. What was the last thing he remembered? He’d gone to see Dr Sixsmith, stormed out of the surgery, driven home... That’s right. Mrs Drake was out – she’d left a note to say she was meeting a friend in town. He’d gone to start packing for his trip to Zagreb and then... that was where his memory ended. He must have lost consciousness then.

“I’m going to leave you in the capable hands of nurse Cooper now,” said the man in white. He drew back the curtain and called to the other side of the room. “Nurse Cooper, will you attend to Bed Number 6”?

Movember: a response from the Head HonchMo

Last week I talked to Movember’s Head Honcho Paul Villanti. He’d seen my earlier blog posts, raising questions about Movember’s aims and transparency. 

What he said clarified some of the muddy waters surrounding Movember, although some areas remain opaque. He acknowledged that there had been mistakes, and that the organisation had not always been clear in communicating what it aimed to achieve. 

In particular, he made clear that:

• Movember never set out to transform men’s health in its broadest sense
• Movember will finally be considering moving into UK mental health projects next year
• Movember has some regrets about some of the men’s health advice it has put out in the past.

About Paul Villanti

Paul Villanti has a say in every aspect of Movember, overseeing its investments in health initiatives globally. He is not one of the charity’s original founders, but joined from a business background four years after Movember was established in 2003. Today he is Executive Director of Programmes, and a member of the Board, the Global Scientific Committee and the Global Leadership Team. He is also Director of Movember Europe, a Director on the Boards of the Prostate Cancer Foundation (USA) and Prostate Cancer Canada and is an Associate Director of Prostate Cancer UK.

That’s a lot of responsibility. 

The prostate question

I asked Paul Villanti about Movember’s focus on prostate cancer, even though the disease accounts for only 3% of premature male death in the UK. In some countries with lower male life expectancy the disease hardly features as a problem at all. “Changing the face of men’s health” surely involves tackling more than that?

He said that from the start Movember had been “results-focused”. 

“In deciding the areas to invest in, we’ve challenged ourselves to make a significant impact on men’s lives,” he said. “Strategically the decision was made a long time ago that we wanted to focus on areas where we could make a significant impact on men’s lives rather than having a Santa Claus strategy where you sprinkle a bit of money everywhere but actually not make much of a difference.” 

In the long-term, he said, Movember was all about building strong partnerships with specific organisations across many sectors, he said, and if funds allowed it wanted to expand beyond core areas: prostate cancer, testicular cancer and mental health. 

“I don’t think there’s any organisation in the world capable of solving all the problems in men’s health,” he said. “I fully accept that we aren’t tackling every men’s health issue, and I think it’s really important to be transparent about what we do raise funds for.”  

The initial decision to focus on prostate cancer was driven by the fact that investment in this field had been historically very low. There are complex and pressing issues to be resolved, such as the need for effective screening and overtreatment. “It is expected to be the most common cancer by 2030. It is a significant challenge facing men and under-invested in in every country,” said Villanti. 

The expertise question

So what research and professional expertise informs Movember’s decision-making and health advice? The Movember Board, which decides strategy, is dominated by Australian businessmen and Movember’s founders, and has only one representative with any health expertise (in prostate cancer). Its Global Scientific Committee is almost exclusively prostate cancer experts.

Villanti explained that in each country, programmes are decided on and overseen by panels of national experts in particular fields (for example mental health). These groups, he said, do not feature on the Movember website but are working behind the scenes. I asked him what expertise informs Movember’s decisions on a higher strategic level to help change men’s health. Villanti assured me that there are a large number of experts that guide strategic direction, and then moved the subject back to the specifics of programme development again. 

The mental health question

In this blog I’ve pointed to my concern that Movember UK donated no money to mental health projects in the UK in 2011 and 2012, even though its website claims it raises “vital funds and awareness for prostate cancer and testicular cancer and mental health”. 

Paul Villanti reassured me that in March 2014, the Movember Board will be looking at ways to “expand investment” in the UK beyond prostate and testicular cancer. 

“We had always planned to review our options at this stage,” he said. It will be engaging independent experts in men’s health to inform this process, and will seek advice from mental health groups. “We expect the advice we get to inform the process,” he said. 

The health awareness question

I explained to Paul Villanti my reservations about Movember’s much-vaunted “awareness and education” work in the UK, which seems to consist entirely of hoping men will talk more about their health as a result of growing moustaches. There’s little evidence that talking about health, or going to the doctor for check-ups, will result in men living longer, I pointed out.

He acknowledged that there is much we don’t know about men’s health behaviour. However, it is clear that men have lower levels of health literacy than women, and this results in poor health outcomes, he said. “Step one obviously is to increase their levels of education and awareness, and the Movember campaign is respected across prostate cancer and mental health because it uses the unorthodox concept of using fun to increase men’s awareness of the risks they face, try and educate them and encourage them to take action when they’re sick.”

The screening advice question

Over the past two years, doctors in the UK and elsewhere have criticised Movember’s health education advice. Until late last year, its website advised men over the age of 50 to get a PSA test – even though the test is very contentious because of the dangers of over-diagnosis and incorrect diagnosis. 

Until last month, its website advice on colon screening and aortic aneurysm was at odds with NHS recommendations. The website still said that prostate screening at age 40 was “reasonable” and its information on mental health problems suggested they went no wider than depression. 

Villanti told me that Movember hadn’t recommended the PSA test since 2011 – it had instead encouraged conversations about screening with GPs. But he acknowledged that its attempts to take a global position on men’s health last year – including a recommendation on its website last year that men should have an annual health check and specific checks at different stages of their lives – had not succeeded.

“With the benefit of hindsight, there were a number of weaknesses with that approach which we have taken on board,” he said. Much of the advice Movember put on its website had been based on information from the Australian College of General Practitioners and other Australian health bodies. “What we realised was that there are major disparities in what professional health bodies say from country to country. To us, that seemed incredible: it’s supposed to be based on the best evidence out there. We can’t understand why one country recommends one thing, and another recommends another approach.” 

He emphasised that the organisation did have serious concerns about over-diagnosis and over-treatment, and the problem was being investigated in various Movember programmes. I told Villanti that his concern about over-treatment was not reflected in the messages that Movember pushes out.

“One of my big frustrations is that we don’t know at a population level how bad some of these issues are, and how different treatment modalities relate to poor outcomes, so we are investing in a national cancer registry in Australia. We see that as a powerful vehicle for improving the quality of treatment, and we’re hoping to do something similar in the UK.”

With Movember now in full flow, and millions already donated by members of the public, it’s surely right that those who oversee it are kept on their toes – something that, up until now, hasn’t been done in the media. We all love the story of how Movember grew from small beginnings, but it isn’t the only story. 

It’s good that Paul Villanti is prepared to respond to comment and concerns, and I hope that there are messages the organisation will take on board, because it has too good an opportunity to waste.

Movember needs to be more open about its strategy – even if that makes it appear more limited in its scope than it would like.

Movember needs to draw in a wider range of evidence and expertise when setting strategies and goals, and providing health advice.

Movember needs to be global in outlook, as well as activity – not taking Australia as a template for what the rest of the world needs.

Most of all, Movember needs to step up its game. It started as a group of Aussie blokes in a pub with an idea to change the world and the skills to bring it off, but with very little understanding of health or its global dimensions. Mistakes are bound to happen as long as Movember’s tight-knit structures and decision-making continue to reflect that historic and naive starting point.

Forgotten gurus: George R Sims

In this, the first week of Movember, let’s celebrate a true guru of male hair growth: George R Sims, journalist, dramatist, novelist, social reformer, gambler, sportsman, bulldog breeder and inventor of Tatcho hair restorer. 

Sims made a fortune from his diverse activities, and became a Victorian celebrity. By 1898 he earned £150,000 a year. Late in his career, he invented a hair tonic to prevent “inevitable” loss of hair, and the money continued to flow in. The bad news is that it didn’t do anything to improve his own receding hairline, and he lost virtually all the money he made through gambling.

In 1902, the British Medical Journal published an analysis of the content of Tatcho. It turned out to be mainly borax, glycerine, formaldehyde, alcohol, colouring and perfume: more cleaning product than growth-promoter. 

But as this 1909 advertisement shows, that didn’t stop Tatcho continuing to be a cultural phenomenon: “It will bring back the hair of your youth, make a new being of you, and give you a new grip upon life,” said the eternally reassuring advertisements. In an age when hair equalled vigour, men wanted to believe. And who knows, many may indeed have felt more confident in themselves having this slimy, semi-caustic blackening on their heads.