Health in Transition
Gender-related social changes in society have the potential to reach deep into the interiors of the body and change traditional health profiles. The current article begins by considering the reducing ‘life expectancy gap’ between women and men in many western countries, changing patterns in the major causes of death, namely circulatory disease and cancer, and 0111 ways that men and women assess their own health during their lifetimes. It then considers the interpretations that researchers and other commentators have made of these patterns.
Changes In Life Expectancy
The longer average life expectancy of western women compared to men now tends to be taken for granted. However, it has not always existed, and there are indications that it may not hold true for the future. Modern statistical records go back only to the mid-eighteenth century. But reconstructed data from the early seventeenth century suggest that male and female mortality differed very little in most European countries; if anything, there appears to have been a slight male advantage (Gjonça et al. 2005). The now familiar female advantage began towards the end of the nineteenth century and was well established by the early 1900s. The historical shift from ‘male to female advantage’ was associated with changes in women’s circumstances. Reductions in deaths in childbirth are often referred to in explanation, but women actually were more likely to die in earlier times from the common ‘killer diseases’, such as tuberculosis, scarlet fever, typhus and typhoid fever. These diseases also affected men, of course, but grinding agricultural work, chronic exhaustion from maintaining the family and the anaemia and malnutrition that resulted from an unequal share of food meant that women were less resistant to infection (Gjonça et al. 2005; Shorter 1982). Referring specifically to England, Sheila Ryan Johansson (1996) explains that the economic marginalisation of women was particularly marked in rural areas, as paid employment in the agrarian sector declined alongside the enclosure movement and technological change and jobs got increasingly scarce. She proposes that, as women’s economic value declined, families may have found it more prudent to invest in the health of males. Industrialisation and urbanisation freed many women from the damaging effects of rural life. Of course, this does not mean to say that the experience of health and illness was the same for men and women during their lives or that there were no major differences in health between rich and poor, for men and women alike. Harriet Martineau (1861) drew attention to the needless suffering for women in occupations such as needle worker (blindness, spinal disease) or governess (perpetual fever of mind and wear and tear on nerves). But it would seem that, as far as life expectancy is concerned, the problems that arose in the wake of industrialisation affected men as much as women (Gjonça et al. 2005).
The hundred or so years from roughly the 1880s to around the 1970s were characterised by what now appears to have been a distinct period of gradually increasing female ‘longevity advantage’ in much of the West. Although this evolved differently in different countries, statistics for the UK, the US, Australia and Canada can be used to illustrate this trend. Thus in England and Wales, the number of ‘extra’ years, on average, that a female might expect at birth to live, compared to a male, rose from around 2 years for those born in 1841, to 3.6 years for those born in 1910, to 4.4 years for those born in 1950, to a peak of 6.9 years for those born in 1969 (ONS 2007; Yuen 2005). In the US, females born in 1900 could expect to live, on average, 2 years longer than their male counterparts; this rose to 5.5 years for those born in 1950, to reach a sizeable 7.6 years for those born in 1970 (NCHS (National Centre for Health Statistics) 2004). The longevity advantage grew from 3.6 years for Australian females, and from about 3 years for Canadian females who were born at the start of the twentieth century, to a projected 7.0 and 7.1 years respectively for those born in the early 1980s (AIHW (Australian Institute of Health and Welfare) 2006; Statistics Canada 2001).To point to this ‘longevity advantage’ is not to claim that women (or men for that matter) were in good health during their lifetimes. During the early decades of the twentieth century many people lacked access to the health care that they needed (as is still the case today), something that was particularly the case for women. As Helen Jones discusses, ‘the plight of many single women without employment and a man to support them financially at a time when there was no free health services, was dire’. One of the most telling accounts of this is Margery Spring Rice’s study, Working-class Wives, Their Health and Conditions
The Reducing Gap
The late 1960s and early 1970s appear to have marked a historical peak, as the female longevity ‘advantage’ began to be chipped away during the last quarter of the twentieth century. It should be emphasised that life expectancy/projected life expectancy at birth continues to grow for both males and for females, but the gap between them has been reducing. Between 1969 and 2007 the gap reduced from 6.3 to 4 years in the UK. Many other low-mortality Anglophone and European countries have similar patterns. Here we can see that both males and females have gained over the period 1970 to 2002, and that this has occurred at each selected point in the life course (birth, age 45 and age 65). But alongside this, we see a reducing female/male gap. Thus, at all ages, the differences are higher in 1970 than in 2002. This narrowing gap is related to larger ‘male gains’ at all ages. Other countries show different trends. For example, Hungary has seen an increasing gap between male and female life expectancy (from 7.2 years in 1980 to 8.4 years in 2002). Here both males and females have gained years, but females have gained more years than males (Gjonça et al. 2005). This pattern also appears to pertain to Taiwan (Lu 2007). The gap has also increased in the Russian Federation (from 11.6 years in 1980 to 13.2 years in 2002), but in this instance, both males and females have lost years over the period, with men losing more than women (Gjonça et al. 2005). Even though intuitively we would have expected the transition to have been more traumatic for women, given threats to formerly full employment, generally speaking the massive changes in Eastern Europe following the revolutions of the late 1980s and early 1990s have negatively impacted more on the health of men than that of women (Chenet 2000). As a number of researchers have discussed, the rise in alcohol use, particularly among ‘blue collar’ young men, has had a lethal effect on longevity (see, for example, Cockerham 2000; Payne 2006). These international comparisons are instructive because they draw our attention to the extreme sensitivity 011 of health status to social change, often over a relatively short period, and to the variable impacts of such change on men and women and on different age and socio-economic groups.
Returning to Low-Mortality Anglophone
Although age-standardised death rates fell by about half for men and women in England and Wales between 1950 and 2004, there were significant differences in the timing of changes. Between 1950 and 1969, death rates for males under the age of seventy-five fell by 7 per cent and for their female counterparts by 23 per cent. But in the period since then, male rates have fallen by 53 per cent and female rates by 45 per cent (Baker et al. 2006). Most of the improvement for men has come after 1980. Similarly data for Canada show that the age-standardised death rate declined by twice as much for males (8 per cent) as for females (4 per cent) between 1990 and 1997 (Statistics Canada 2001). Although these changes may seem small, they are highly significant historically, since some suggest that they may eventually culminate in the end of the female longevity advantage (e.g. Connolly 2002). Generally speaking, healthy life expectancy falls as life expectancy increases, reflecting the burden of illness that often accompanies ageing, especially old age (ONS 2007). So although on average women still live longer than men, their ‘extra years’ generally are not spent in good health. And as men’s life expectancy increases, we might expect them to follow suit. It is interesting, therefore, to observe that research from the Netherlands has found that men’s overall life expectancy not only grew more than women’s between 1989 and 2000, but was accompanied by greater gains in healthy life expectancy (Perenboom et al. 2005). Bird and Rieker (2008) report a similar trend for the US. However, it is too soon to tell whether this signals a more general gap in healthy life expectancy favouring men.
Major Causes of Death
The major causes of death in affluent western societies are circulatory disease (including heart disease and stroke) and cancer. Although men start and end with higher rates, the decrease in deaths from circulatory disease generally and cardio-vascular disease (CVD) in particular since the 1970s has been less pronounced among women than men. For example, the age-standardised death rate for circulatory disease for British men was 6,900 per million in 1971, reducing to 2,600 per million by 2005. The equivalent figures for women were 4,300 per million and 1,700 per million (ONS 2007). For coronary heart disease specifically, the decline in deaths has been slower for younger ages and, again, especially among women (Petersen et al. 2005). Cancer is the second most common cause of death for British men and women. Although overall mortality rates have changed relatively little over the last thirty or so years in the UK, male deaths peaked in the mid1980s at 2,900 per million and then fell to 2,200 per million by 2005. In contrast, female death rates peaked in the late 1980s, at 1,900 per million and then gradually fell to 1,600 per million by 2005 (ONS 2007). These overall rates conceal variations in trends for different kinds of cancer. Most notable in this respect is lung cancer. Lung cancer is far more common in men, for whom it has been the major cancer death since the 1940s. For women, breast cancer mortality was significantly higher than lung cancer mortality until it peaked in the late 1980s and lung cancer ‘caught up’, to the point that they are now about the same (Griffiths and Brock 2003). The timing of peaks and troughs in lung cancer incidence is quite different for British men and women. For men, both incidence and mortality rose enormously from the mid-twentieth century through to the early 1980s and thereafter began to fall, with a decrease of around 40 per cent between the mid-1970s and 2001. Incidence and mortality for women meanwhile has lagged about twenty years behind and plateaued as recently as the mid-1990s, with an increase of about 80 per cent over the same period (ONS 2006a; ONS 2007). In the US, lung cancer accounted for only 3 per cent of all female cancer deaths in 1950; by 2000 this had risen to 25 per cent (DHHS (Department of Health and Human Services) 2001).
These trends are germane to the current discussion for two reasons. First, and in simplified terms, while men are still ‘worse off’ than women, the incidence of these major diseases, and mortality due to them, seem to be improving at a faster pace for men than for women, thereby contributing to their overall ‘catch up’ in life expectancy and reduction in the ‘longevity gap’. Second, CVD and many cancers are believed to be associated with so-called ‘lifestyle’ factors and ‘lifestyle changes’. Much of the cancer burden worldwide, for example, can be attributed to the ‘tobacco epidemic’ (Vineis et al. 2004). Here the life course is important because of the cumulative effects of social circumstances in early life for later health. Age cohorts are also important, because people born around the same time are subject to similar environmental and lifestyle influences. The complex aetiology of many major diseases such as heart disease and many cancers makes it difficult to draw one-to-one associations with social factors. Alcohol consumption above daily recommended rates, and especially ‘binge drinking’, is indirectly associated with CHD (Unal et al. 2004). Despite what we might be led to believe from the moral panic over ‘young women’s drinking’, cross-nationally, men still consume considerably more alcohol than women (Bird and Rieker 2008; ONS 2007; Payne 2006). To take the UK as an example, in 2005, just over one-third of men and one-fifth of women reported exceeding the recommended daily amount of alcohol in 2005 (ONS 2007).A total of 30 per cent of young men aged 16–24 had engaged in binge drinking (defined as at least twice he recommended daily amounts) in the week before interview, compared to 22 per cent of girls in the same age range (ONS 2007). Among men, there appears to be little variation by social class, although for women, higher levels of drinking seem to be associated with higher social class, at least as measured by occupation (ONS 2007; Waterson 2000). Recognition of this has no doubt fuelled concerns over an association between women’s movement into the higher echelons of the workforce and ‘bad health behaviours’. However, although males generally consume more alcohol than females, the percentage of adults consuming more than the recommend weekly level in Britain has remained more or less stable among men since the mid-1990s, but increased by over 50 per cent among women (General Household Survey cited by Petersen et al. 2005). By way of further illustration, although by international comparison levels of alcohol consumption are relatively low as a whole in Sweden, consumption has been rising.4 Here, too, men still drink more than women, but there has been ‘convergence between sexes, at least in urban areas’ (Helmersson Bergmark 2004). Alcohol-related death rates have increased significantly in the UK and elsewhere in recent years. The UK, for example, saw a rise from 6.9 to 12.9 per 100,000 population between 1991 and 2005. However two thirds of this increase was attributable to male deaths with the gap between males and females widening over the period (ONS 2006c). There has been a distinct rise in mortality from chronic liver disease and cirrhosis among both English men and women from the early 1990s. Although female rates remain lower than male rates, they have risen more sharply and are currently above the average of the original fifteen European Union (EU) member states (DoH (Department of Health) 2007). There is evidence that women are more biologically vulnerable to health damage from alcohol: in addition to having different body mass, men and women metabolise alcohol differently, so that women reach higher blood alcohol levels than men while consuming similar weight-adjusted amounts of alcohol (Bird and Rieker 2008; Waterson 2000).
Self-Reports of Health
Age at death is a relatively robust indicator and historical data enable us reliably to review trends over time. While we would expect a relationship between mortality and morbidity in terms of the major causes of death that have been discussed, this may tell us relatively little about the overall state of a person’s health during their lifetime. It is very difficult to track morbidity (or illness) patterns over time, since any observed changes could reflect changing thresholds of ‘what counts’ as illness and changes in symptom reporting. This would be confounded by any changes in how men and women (and different subgroups of men and women) think about and act on symptoms. So data are not strictly comparable (Payne 2006). With these significant caveats in mind, at the present time at least, male/female morbidity differences in adulthood appear to be relatively small (Payne 2006). When one looks internationally and also at different studies within countries, the figures are inconsistent: in some contexts women seem to report slightly poorer health; in others there is little or no difference (Payne 2006); and in others still, men report their health to be worse. To take a specific illustration, data for self-assessed health, longstanding illness and acute sickness collected annually for England show gradual and slight increases in reports of ill health on all measures for both men and women between 1993 and 2003. At each time point, ill health inclines modestly towards women, but the overall picture is more of similarity than difference (DoH 2004). Data from Australia on self-assessed health for 1995 and 2001 also show minimal differences; if anything, there are better ratings in some age groups among women in 2001 (AIHW 2004). The picture is, of course, complicated for different age groups and for some specific conditions. For example, a much larger proportion of older women suffer from musculoskeletal conditions such as arthritis and rheumatism than men (see, for example, GHS (General Household Survey) 2004). It is possible that a series of urban myths have formed around women’s ‘excess’ morbidity (Macintyre et al. 1999) whereby researchers have been blinkered in the study of morbidity patterns by the search for difference in relation to the sex (biology)/(social) gender distinction.
Social Class and Ethnicity
Patterns of health and illness in contemporary western societies are highly complex and therefore defy easy summary, particularly when we bear in mind that health status is about far more than just being a woman or a man, that is, when we take into account factors such as age, ethnicity and social class. However, it is important to point out that the splintering of the bi-polar social script has meant not only new patterns of equality and inequality between women and men but also new patterns of inequality between women. Thus as Sylvia Walby (1997) remarks: to a significant extent women are polarising between those, typically younger, educated and employed, who engage in new patterns of gender relations somewhat convergent with those of men, and those, particularly disadvantaged women, typically older and less educated, who built their life trajectories around patterns of private patriarchy. These new patterns are intertwined with diversities and inequalities generated by social divisions including class, ethnicity and region. There are limitations in using conventional statistical measures of socioeconomic status to capture women’s experience (Bartley 2004). However, data often show marked health differences within women (although they are often less strong than those among men). To take Britain as an example, although mortality rates have been declining, social class differences (measured by occupation) retain a strong grip. Thus for the period 1997– 2001, the life expectancy of women in occupational class V (unskilled) was 77.6 years, compared to 82.2 years for women in class I (professional) (ONS n.d). Age-standardised all-cause mortality ratios of classes IV and V : I and II (per 100,000 person years) for women were 1.69 in 1986–92 and 1.41 in 1997–99 (White et al. 2003; for a wider discussion, see Graham 2000). Differences in health also vary by ethnicity, with many minority ethnic groups (but not all) reporting worse health than the ‘general population’. For example, data for England show that, while 44 per cent of black Caribbean and 44 per cent of Irish women reported a long-standing illness in 2004, only 24 per cent of Chinese and black African women did so (Sproston and Mindell, cited in Field and Blakemore 2007).
The association of the narrowing ‘longevity gap’ with growing societal affluence explains its concentration in high-income, low-mortality Anglophone and European countries and also prompts commentators to find explanations for the trend in the changes in employment patterns, in family structures and in the apparent convergence in the ‘lifestyles’ of men and women that these countries have experienced. It therefore is not surprising that a broadly conceived ‘convergence thesis’ has been adopted by social scientists. Thus Mel Bartley writes that: we might guess that as the home and work situations of women and men become more similar (as women become more likely to have fulltime jobs of similar status to men, and as work and marriage and children are combined in more similar ways, any remaining health differences between men and women may disappear. More generally, Ingrid Waldron dubs this the ‘women’s emancipation thesis’, or the view that ‘the changing roles of women and a general liberalisation of norms concerning women’s behaviour have resulted in decreasing gender differences in mortality’ (2000). Others place their emphasis on changes among men. Thus Jacques Vallin and colleagues (2001) refer to men cutting back on ‘certain harmful habits which were previously markedly male in nature (alcohol and tobacco consumption, for instance)’, whereas women are taking them up (though not to the same extent) (2001). They also draw attention to factors such as reduced male exposure to risks due to safety improvements on the roads and at work, and to men ‘beginning to copy women in their attitude to health’, such as making more frequent use of health services (although, again, women’s use generally remains higher).
While these authors draw attention to positive change in men’s lives, there is also a propensity to cast men as victims buffeted by the winds of rapid social change but also subject to the heavy drag of traditional patriarchy. There is some merit in this argument, particularly when attention is drawn to the difficulties experienced by sub-groups of men, such as young working-class men who are suffering from high levels of unemployment (McDowell 2003). But this ‘crisis discourse’ also harbours difficulties, because, as Stephen Whitehead relates, it polarises debate ‘into one of competition for health resources between women and men, while also enflaming the “moral panic” and ensuing backlash against feminism and women’s issues generally’ (2002). This is particularly evident when researchers foreground women’s ‘advantages’ (such as longer life expectancy, greater use of health services and so on) in order to establish men as the disadvantaged (see, for example, Meryn 2004; White and Holmes 2006). Even more problematic is the wider literature that castigates women for the sorrows of men as it filters into discussion of health. Harrison G. Pope and co-authors, for example, draw an association between what they see as a growing preoccupation among men of all ages with their bodies, or what they call ‘the Adonis complex’, and anxiety and depression. Such an association may well exist – suicide rates are, for example, much higher in males than females.5 But the concerning point is their conclusion that the reason why men are left with ‘primarily their bodies as the defining source of masculinity’ is the ‘growing equality between women and men in many aspects of life’ (Pope et al. 2000). Wider support for this thesis is found in the ‘backlash’ literature written by men and women alike, which berates feminists for failing to acknowledge women’s new advantage and for failing to appreciate the problems of men (see Coward 2000; Jones 2002). Combined with the depictions of individual women making (misguided) choices, that is, as having failed in their ‘own emancipation,’ it is a fairly short step to the conclusion that women are liable not only for their own ‘downfall’ but also for that of men (and, on occasion, for society as a whole).
It has been argued that the old shackles of the binary social script, which positioned women and men as opposites, have been superseded by a more flexible social system or, as I have put it earlier, by slippery silken ties that nonetheless bind. The new fabric of life for women is laced with contradictions (a point that applies to men too) with implications for their health. This is not to imply that things were totally clear cut in the past, but rather that the change is a matter of degree, although the scale is large. Thus we have seen that in low-mortality and Anglophone countries, women’s advantage in life expectancy is being chipped away. It is ironic, to say the least, if it is the case that women were more protected by the binary divides of the ‘old single system’. As Penny Kane (1994) proposed some time ago, theoretically there are three possible explanations for the reducing male/female gap in life expectancy: it could be due to improvements for men; there could be a deterioration or plateauing for women; or both of these trends could be taking place simultaneously. The latter explanation has the greater validity. Thus, men are indeed ‘catching up’, but it has to be remembered alongside this that, at least on average, women’s life expectancy is not decreasing. However, there is very clear evidence of deterioration in some causes of death, with the exponential rise in the prevalence of lung cancer and lung cancer mortality among women being the obvious example. But drawing on the arguments of Fred Pampel, this cannot in any simple or easy sense be attributed to women’s ‘independence’. Using data from several countries, Pampel shows that it is not so much how ‘egalitarian’ a country is, in terms of women’s ‘emancipation’, that accounts for levels of smoking but where a country stands in terms of the diffusion of the smoking epidemic that seems to matter. Thus, ‘the longer the history of smoking in a nation’, ‘the more alike the smoking of men and women is’ (Pampel 2001; see also Pampel 2002). There have been sharp increases in liver disease and deaths from cirrhosis of the liver among women in recent years, but it is still the case that incidence is higher among men. Heart disease is the major cause of death for both men and women, but women’s rates remain lower than men’s. As noted above, there are also significant differences among women (and among men), such as those related to social class. Moreover, people typically do not present with a neatly packaged profile of health ‘risks’ or ‘benefits’ in the ways that they live their lives (Bird and Rieker 2008). Thus, in Britain, women in poorer socio-economic circumstances tend to smoke more than their better-off counterparts, but the better off in their turn tend to be the consumers of ‘excessive’ amounts of alcohol.
The weft and weave of the fabric of life is finally complicated by the knotty issue of how men and women feel about the state of their own health, which, in terms of general assessments, often seems more similar than different but varies in relation to specific symptoms and conditions (Annandale and Field 2007). The way that I have discussed health has been self-evidently limited. The difficulty, of course, is that health is multifaceted. As sociologists of health have been arguing for some time, the ways that individuals think about their health, its relationship to their identity, and how they interpret symptoms and take actions in relation to their health is complicated enough (Blaxter 2004; Herzlich 1973; James and Hockey 2007). Identifying why it is socially patterned in particular ways adds an even greater challenge, and it has been possible to touch upon only some aspects of this here. In the place of the convergence narrative, I propose that these complex and shifting patterns of health and illness can be interpreted though the lens of the multiple positioning of women in relation to what I have called the ‘new single system’ of patriarchal capitalism (although it has to be appreciated that this too is a constructed narrative in its own terms). In some ways this position shares the view of Ingrid Waldron that ‘recent trends in gender differences in behaviour have been influenced by the interacting effects of fundamental aspects of traditional gender roles and the contemporary context’ and that this has led to a diversity of experience (2000). But it differs from this by emphasising, among other things, the systematically driven nature of these complex shifts. Through the optic of the ‘new single system’ we can appreciate that the old balance of power has indeed changed; that the rigid orthodoxies of the past are breaking down and being reconfigured in new, more complex ways with implications for health, and that these changes are systematic in form. At the level of the social economy, the operation of the ‘new single system’ is discernible in juxtapositions of diversity and binary difference that co-exist and necessarily feed off each other. Reading social reality in this way assumes the mantle of political critique not only by widening the scope of what we see but by starting from a different place in what we see (Hennessy 2000). However, it is essential to also be aware that these ideologies are tapestries woven out of contrary impulses, which themselves resist a final suturing. As Teresa Ebert writes of what she terms late capitalist patriarchy, the effect is not an organic, homogenous, unified whole, but rather an over-determined ‘totality in process, a self-divided, multiple arena of social struggle’ (1993). Although it appears – to borrow an image from J. K. Gibson-Graham (1996) – that our lives are ‘dripping with’ what I have termed a ‘new single system’ of patriarchal capitalism; that is, unitary, singular and total, juxtapositions of difference and diversity are historically specific ideological effects that generate liberatory as well as oppressive life spaces. These spaces can never be pristine and sharply bounded.
Rather, they are inescapably muddied and conflicted. I conceptualise these as the ‘conflicted spaces’ of the ‘single system’ of patriarchal capitalism. The data presented above are rather sterile, aggregated snapshots of undistinguishable individuals with particular diseases, or who died, or are projected to die, at particular ages. Genetic and biological influences notwithstanding, they inevitably mask the fundamentally dynamic nature of ‘health status’ as it is shaped by the circumstances of our lives. Much of what happens to us and the decisions we take in our daily lives affects our health in one way or another, although we are generally unaware of, unable or unwilling to fathom exactly how at the time (Bird and Rieker 2008) As we have seen, the eddies of the ‘new single system’ generate heavily conflicted milieu – spaces for those things that are beneficial and for those things that are detrimental to health (or both – cigarette smoking, for example, may help with short-term stress while undermining longer term well-being). As Stephanie Genz discusses more generally, women’s use of ‘different dimensions of agency’ slip between ‘feminised agency and patriarchal recuperation’ (2006). Hybridity is the reality of our lives as we ‘buy into standardized femininities while also seeking to resignify their meanings’. It is our lived or embodied experience within the ‘conflicted spaces’ of the ‘new single system’ that requires our attention 0111 in relation to health.