journal of men's health
Volume 5, Issue 3 , Pages 184-188, September 2008

Poverty and men's health

  • April M.W. Young, PhD

      Affiliations

    • Collins Center for Public Policy, Miami, Florida, USA
    • Corresponding Author InformationCorresponding author.
    • ,
  • Siegfried Meryn, MD

      Affiliations

    • International Society for Men's Health, Vienna, Austria
    • ,
  • Henrie M. Treadwell, PhD

      Affiliations

    • Community Voices, National Center for Primary Care, Atlanta, Georgia, USA

Article Outline

 

The role of poverty in distinguishing the health outcomes of poor men from those of their more-privileged male counterparts is worthy of the world's concern, and certainly warrants the consideration of our men's health field. Poor men's relatively constrained access to care, their environmental exposures, and their behavioral and attitudinal risk factors add up to a consistent and pronounced health jeopardy. This manifests as high morbidity and elevated levels of mortality. A good deal of attention has been paid to the disparities between men and women in terms of life expectancy, experiences of illness, treatment approaches, and the nature of health discourse. So, we know well the ways in which health phenomena are gendered. However, we have yet to adequately consider how health within the male sex tracks our landscapes of economic privilege and disadvantage in communities throughout the world – how men's health is classed, so to speak. This scant notice of health disparities among men has rendered invisible many nations’ remarkably vulnerable populations of poor men.

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Poor men at risk 

Data suggest that the health of poor men around the world is in particular jeopardy, with high rates of illness, injury, disability, and premature death. In Latin American and Caribbean countries, for instance, there are strong associations between income and mortality risk. The probability of dying between 15 and 59 years of age is almost invariably at least double, occasionally nearly triple, for poor men compared to non-poor men [1]. Links between socioeconomic status and lung cancer risk among men have been affirmed by studies from Canada, Sweden, and New Zealand [2], [3], [4]. Findings in six European countries during 4-year periods in the early 1980s and 1990s indicate persistent socioeconomic inequalities in stroke mortality and ischemic heart disease [5].

The prevalence of seriously health-averse behaviors among poor men accounts for much excess morbidity and mortality. The World Health Organization points to tobacco as the world's single largest cause of preventable death, killing one third to one half of all users. Worldwide, 36% of men smoke tobacco [6]. In India, 42% of men smoke. In 2003, the prevalence of tobacco smoking among Russian men aged 15 years and older was 56.7%. In China, the rate of smoking among men well exceeds half at 57.4%. The documented higher prevalence of tobacco use among poorer classes suggests that, again in this instance, poor men are at the greatest risk of illness and death.

Similarly, health-compromising patterns of alcohol consumption are noted to occur among populations of poor men. Male mortality due to alcohol-related causes is remarkable in Russia, for example. Pronounced socioeconomic differences have been noted in alcohol-related death in Russia, and, perhaps quite predictably, unemployment is a strong correlate of heavy consumption [7], [8], [9].

Given the excessive rates of smoking among men, notable tendencies to dangerous alcohol consumption, and the particularly class-laden nature of these phenomena, the strategic and programmatic approach to smoking cessation and prevention of alcohol abuse and dependency must be male-specific and customized to target the socioeconomic strata at greatest risk from these behaviors. The approaches should be further elaborated to appropriately address particular cultural contexts.

Hazards in the social and physical environments that poor men often inhabit also contribute to negative health outcomes. Labor-related displacement and migration [10], pollution and substandard living conditions [11], state-sponsored conflict and violent civil strife [12], and dangerous and under-regulated employment are realities in the lives of poor men, in nation after nation, that systematically undermine well-being.

Lack of access to health care, disparate treatment experiences, and inadequate health-seeking behaviors further disadvantage poor men. Aboriginal and Torres Strait Islander men in Australia have a lower average life expectancy than all Australian men – 59 years compared to 76 years [13]. Perhaps predictably, men in Australia under-utilize health services [14]. U.S. researchers found that Hispanic men were less likely to receive colorectal cancer screening, cardiovascular risk factor screening, and vaccinations, while Black men consistently received worse care for end-stage renal disease [15]. Examining a number of studies and findings, one researcher concluded, in a compelling editorial, that controlling for prognostic factors there were no racial differences in treatment response to traditional lung cancer chemotherapy, radiation therapy, and surgery. However, compared to whites, a remarkable proportion of African Americans with lung cancer do not receive potential curative treatments and optimal therapies [16]. Swedish researchers found that socioeconomic disadvantage and the perception of discrimination relate independently to the likelihood of refraining from seeking medical services [17].

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Poverty's health risks magnified 

While there are common health issues affecting poor and marginalized men globally, there are, at the same time, national and regional inflections in mortality and morbidity among poor and marginalized men that are important to note. These variations often follow predictable courses, tracking the intricate social fault lines that divide and sub-divide the privileged in communities from their less-well-off counterparts. In addition to socioeconomic status, such inflections in the health jeopardy poor men face can result from racial and ethnic discrimination [18], dynamics associated with immigration status [19], and intolerance based on sexual orientation [20]. These phenomena further pattern health outcomes within the category of poor men, in some instances compounding the jeopardy associated with already-marginal status.

In general, data examining the relationships between poverty and other social phenomena exerting influence on men's health are limited. However, an exception is race and ethnicity. A number of studies have documented racial and ethnic groups’ subjection to excess mortality and morbidity. The layered and constellation-like nature of the relevant issues can often make causality and clear correlation difficult to establish. However, cross-nation comparative analyses revealing consistencies in the issues at play strongly suggest race and ethnicity are indeed noteworthy social influences on the health of the world's poor men.

For instance, examining data from 12 countries with various growth rates, national income, and population, researchers found economic disparity correlated with race and ethnicity throughout, along with a striking similarity in its manifestation [21]. Because of the enduring significance of race and ethnicity in countries such as the U.S., having lower-class status and being of color are often closely linked, and it is difficult to separate the two issues. While overall mortality and morbidity rates have improved in the U.S., men of color are still more likely to die of cardiovascular disease, diabetes, and cancer than their white counterparts. Life expectancy for African American men is 69.5 years, for Hispanic men it is 73.7 years, and for Native American men it is 66.1 years. For men of color, the life expectancy figures are an average of 7.8% lower than the 75.7-year lifetime a white man in the U.S. can anticipate.

In a longitudinal study of coronary heart disease incidence in Puerto Rican men, researchers concluded that skin color – relative darkness or lightness – may be capturing dynamics in the social environment that influence mortality risk. While they found no association between skin color and cardiovascular disease, skin color did predict higher all-cause mortality among urban-dwelling men. Dark-skinned men living in urban areas in Puerto Rico have a higher risk of death than their lighter-skinned counterparts. Another notable finding was that dark-skinned Puerto Rican men were less educated than light-skinned men [22].

These data suggest that other categories of social marginality, in addition to poverty, warrant identification, analysis, and monitoring to account for disparities in health among various groups of men.

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Consistency across health systems 

Data also suggest that health disparities between privileged and poor men are manifest in some measure across nations – even within those with near-universal health coverage and broad social safety nets. Despite the availability of resources in the health systems of wealthier nations, socially marginalized people fare less well than their better-situated counterparts. Those who are poorer; racially, ethnically, linguistically different; have different sexual orientations – who are marginalized in their countries – have worse health status.

The U.S., for example, has the world's highest per capita health expenditures [23], but poor and working-poor men, in particular, have no state provision for preventive and primary health care. In Sweden, one of the world's model health care systems, African immigrants with HIV have higher morbidity rates and die sooner than native Swedes who are HIV-positive [19]. Arguably, the power of marginalizing forces – racism, classism, xenophobia, linguistic discrimination – restricts the benevolent reach of universal health care.

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Incarceration: a global emergency 

Incarceration is a phenomenon of growing influence in so many countries, and is arguably one of the most systematically crippling forces in poor communities worldwide. The existence of data is uneven, but in many countries incarceration and health disparities follow similar tracks along the social fault lines. Just as the poor are more likely to suffer negative health outcomes, socioeconomically disadvantaged persons have a greater likelihood of incarceration.

While incarceration of women is increasing in several nations, imprisonment is a particularly deleterious part of the experience of social and economic marginalization for men in many countries. In correctional settings and facilities of detention, the well-being of already-marginalized men is further jeopardized by exposure to a range of physiological and psychological risks that increase the likelihood of poor health outcomes. Those detained in correctional settings are frequently subject to communicable infections, injury by violence, sexual trauma, and to under-regulated clinical trials. Facilities’ adherence to correctional health care standards is a matter of ongoing uncertainty and controversy around the world.

Additionally, psychological torment is a pervasive health risk inmates face. They are subjected to extreme custodial interventions such as ‘close management,’ i.e., solitary confinement; injurious chemical, electrical, and manual control techniques; strip searches and invasive body cavity searches; and documented physical torture in many countries.

Strong evidence from many nations shows that it is socially marginalized men who have the greatest likelihood of incarceration. More than one-third of Italy's prison inmates are foreigners, and the nation's apprehension about its growing Romanian immigrant population would seem to be reflected in their disproportionate representation – nearly 6% – among Italy's incarcerated [24]. In the U.S., correctional populations are less-educated than the general population. The rate of failure to complete high school or its equivalent is more than double (40%) among U.S. prisoners compared to the general population (18%) [25].

Once they are incarcerated, men's jeopardies continue to predict poor health outcomes inside correctional facilities. U.S. prisoners who were homeless in the year before their arrest and who had received government assistance are more likely to report current medical problems than those who had not been homeless or who had not received government assistance [26]. Data show a higher prevalence of HIV, hepatitis B virus, hepatitis C virus, and syphilis among both prison inmates and officers in Ghana compared to the country's general population. The findings led that study's authors to affirm that prisons are high-risk environments for blood-borne and sexually transmitted infections [27]. A study of injection drug users in Bangkok yielded the conclusion that incarceration is related by multiple pathways to the incidence of HIV infection among them [28].

Even after release from correctional facilities, the particular jeopardy of marginalized men remains in the form of sharply elevated risks of mortality. Elevated mortality was noted among a sample of male French prison releasees [29]. The French study findings resonate with U.S. evidence. A Washington State study found that newly released prisoners were 12.7 times as likely to die in the 2 weeks following their release compared to other state residents in the same demographic groups [30].

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The way forward: jmh Social Determinants Section 

As yet, specific data are scarce that would allow us to precisely address many of the most pressing questions about how the world's poor men are faring health-wise. However, indications gathered from a range of sources and phenomena suggest a troubling predicament: that male subjection to excess morbidity and mortality is magnified in poverty, even as poverty renders health structures and notions elusive.

A structured research agenda and targeted resources are needed to address poor men's invisibility. An evidence-based, coherent critique can then inform a disciplinary movement within the men's health field.

The new jmh Social Determinants Section, headed by Section Editor Dr Henrie M. Treadwell, signals the importance of disparities and the relevance of issues of power to health outcomes in the men's health field. As international policy organizations emphasize maternal and child health, it is imperative that the field of men's health call attention to the concerns of the world's poor men. In this endeavor, as in others, the Social Determinants Section will cultivate a global approach, emphasizing cross-national comparative analysis. Social Determinants will develop a body of work through the jmh and cultivate an analytic perspective on disparate health outcomes produced by categories and experiences of marginalization, gender differences, and many of the issues associated with access and health systems.

The new section is based on the critical premise that overall improvement in health outcomes within and across nations requires male-specific interventions targeted particularly to those men abiding at lower social echelons in communities. Also, effectively serving poor men will have broad discursive and programmatic benefits. The challenges they pose will yield insight into the nature of health vulnerability generally and unaddressed, un-articulated health needs.

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References 

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PII: S1875-6867(08)00145-0

doi:10.1016/j.jomh.2008.07.001

journal of men's health
Volume 5, Issue 3 , Pages 184-188, September 2008

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