key: cord-0720767-84rc2osv
authors: Baker, Peter; White, Alan; Morgan, Rosemary
title: Men's health: COVID-19 pandemic highlights need for overdue policy action
date: 2020-06-18
journal: Lancet
DOI: 10.1016/s0140-6736(20)31303-9
sha: f0d03e0e67862b0dc53a9f9625e7590f1ca9033e
doc_id: 720767
cord_uid: 84rc2osv

nan

The COVID-19 pandemic is shining a cruel light on the state of men's health globally. In 38 out of 43 countries for which provisional data were available, as of June 10, 2020, more men than women have died from COVID-19 despite a similar number of confirmed cases in each sex. 1 In several countries, including the Netherlands, Dominican Republic, and Spain, about twice as many men as women have died from COVID-19. 1 International Men's Health Week on June 15-21 is an opportune time to focus attention on this issue and the need for a new and systematic approach to improve the health of men generally.

Men and women are differentially affected by COVID-19. Although more men are dying from COVID-19, women are also substantially impacted by the disease. 2 Their role as health workers and carers puts them at risk of infection, they have paid a heavy price economically and in terms of increased domestic burdens, and they have been even more likely than usual to experience domestic violence during lockdown. 2,3 An equal role for women in global health leadership is required to ensure that their needs are included in policy. 4 The differential harmful effects of the pandemic on gender and racial minorities must also be recognised. 5, 6 COVID-19 shows how sex and gender differences are differentially impacting on men. 7 Men's lower immune responses combined with gendered practices and behaviours related to masculinity, including smoking and drinking, engaging less in preventive public health measures such as mask-wearing or handwashing, and delayed health-care seeking, could contribute to men's vulnerability to COVID-19. 8 The higher prevalence of pre-existing comorbidities in men than in women, such as cardiovascular disease, diabetes, and hypertension, is also likely to be a factor in men's susceptibility to severe COVID-19. 9 These conditions, and others, have long been responsible Men's health: COVID-19 pandemic highlights need for overdue policy action the effect of the total number of adverse events would have been more precise and therefore easier to interpret.

Taken together, the results of the HALT-IT trial should change clinical practice. As administered in HALT-IT, tranexamic acid is unlikely to benefit adults with severe gastrointestinal bleeding and there can be adverse events using this higher dose. Although the adverse events might be lower with a lower dose, it is unlikely that a lower dose will have any beneficial effects on bleeding, including rebleeding events, and the need for additional invasive procedures.

HALT-IT highlights the importance of rigorous testing of interventions in randomised trials, including the balance between benefit and harm in different subgroups of patients, in this case in patients with different sources of bleeding. The beneficial effects of tranexamic acid observed in patients with bleeding after trauma 4 or childbirth 5 cannot be extrapolated to those with severe bleeding from the gastrointestinal tract. Informed by the HALT-IT trial, routine use of tranexamic acid in adults with severe gastrointestinal bleeding should be halted. for men's excess burden of premature and avoidable mortality, 10 which is also affected by the historical neglect of men's health at the policy level, globally, nationally, and locally. 11 For policy makers, men's health has been a problem hiding in plain sight. An analysis of 35 national health policies in the WHO European Region member states, for example, found that the term "men's health" appeared once. 10 A WHO and UNAIDS review of national policies on health, HIV, sexual and reproductive health, and mental health in 14 countries in eastern and southern Africa found that the health of men and boys was well addressed in the health policy of only one country, eSwatini. 12 Global Action on Men's Health's new report, From the Margins to the Mainstream, 13 examines why men's health has been overlooked. Although gender has generally been a marginal issue in health policy, where it has been addressed, it has often been incorrectly conflated with women. Other factors include inadequate awareness and knowledge among policy makers of men's health issues and the absence of political will to push men's health issues onto policy agendas. Also relevant are the lack of sex-disaggregated health data and the paucity of research into the economic costs of men's poor health.

Thankfully, there has been some progress. The WHO European Region published a men's health strategy for its 53 member states in 2018. Four countries-Australia, Brazil, Iran, and Ireland-have national men's health policies that seek to promote optimum health and wellbeing for men, with a particular focus on health equity between different population groups of men. 14 These national policies are integrated with existing policies, adopt a social determinants approach, work from a strengths-based perspective, and support men to take increased responsibility for their own health. At the local level, the provincial government of Quebec in Canada has in place a Ministerial Action Plan on Men's Health and Wellbeing that focuses on the development of promotion and prevention strategies and adapting services to improve access and better meet the needs of men. 15 Men's health needs have also been included in some specific health policy areas-eg, more than 30 countries include boys among the intended recipients of their national human papillomavirus vaccination programmes.

New opportunities are opening for further action. Evidence about how to deliver health services, including health promotion, that meet men's needs more effectively is more widely available. It is increasingly well understood by WHO and others that the Sustainable Development Goal (SDG) of reducing premature mortality from non-communicable diseases (NCDs) would be more quickly achieved if the disproportionate burden of many NCDs among men was reduced. 16 There is a much better understanding of, and interest in, the role of male gender norms in determining men's health outcomes. 17 The cost-effectiveness of tackling the poor state of men's health is also becoming clearer. 18 Any developments in men's health policy must be located within a framework that embraces a commitment to gender equality and that does not see supporting men's health and women's health as a binary choice. 19 An equity-based approach is needed to ensure that men in disadvantaged and at-risk groups with the worst health outcomes, such as men of colour, gay, bisexual, and transgender men, or men who are homeless or in prison, benefit most. Policies that are aligned with existing public health priorities, such as the SDGs, or that reduce the burden on health systems and costs, are more likely to achieve traction with policy makers.

COVID-19 has shown that action is needed to address the gendered nature of the pandemic as well as pre-existing health inequities. This action must be supported and driven by policy-if not now, when? PB is the Director of Global Action on Men's Health (GAMH), is the author of the GAMH report From the Margins to the Mainstream, and receives fees from the charity. AW is a patron of The Men's Health Forum (Great Britain), is a member of GAMH, and was an unpaid adviser on the GAMH report. RM was not involved in contributing to the GAMH report and has received grants from the US National Institute for Health Research for research on gender and influenza and from the Canadian Institute for Health Research for research on COVID-19 and gender. Human rights scrutiny in the COVID-19 pandemic has largely focused on limitations of individual freedoms to protect public health, yet it is essential to look at the broader relevance of realising human rights to promote public health in the COVID-19 response.

The human right to the enjoyment of the highest attainable standard of physical and mental health provides binding normative guidance for health-care systems, broader social responses, and global solidarity. As recognised in the International Covenant on Economic, Social and Cultural Rights, the right to health requires that states take steps for the "prevention, treatment and control of epidemic, endemic, occupational and other diseases" and to assure "medical service and medical attention in the event of sickness". 1 The right to health requires that health goods, services, and facilities are available in adequate numbers; accessible on a financial, geographical, and non-discriminatory basis; acceptable, including culturally appropriate and respectful of gender and medical ethics; and of good quality. 2 However, many states have faced difficulties in ensuring the availability and accessibility of COVID-19related health coverage, leading to shortages in essential medical care, including diagnostic tests, ventilators, and oxygen, and in personal protective equipment for health-care workers and other front-line staff. 3 In some countries, austerity measures, structural adjustment programmes, and user fees have rendered essential services inaccessible for some vulnerable populations. 4 Implementation of the right to health through health systems requires that treatment is based on medical evidence; that testing and care are not withheld on the basis of disability, age, or inability to pay; and that states devote maximum resources to health care and recovery. 5 In providing this care in the context of COVID-19, these emergency responses must guard against interruptions to other essential health-care services, including sexual and reproductive health care, antiretrovirals for people living with HIV, immunisation campaigns, and communitybased care and support, including mental health care. [6] [7] [8] Undertaking immediate and progressive steps to prevent the rising public health threat of COVID-19, states must additionally "take measures to prevent, or at least to mitigate" the impact of the disease, drawing these measures from "the best available scientific evidence to protect public health", as reflected in the guidance from WHO. 9 Even as states limit individual freedoms to address this public health emergency-assuring that such limitations are reasonable, proportionate, nondiscriminatory, and grounded in law 10 -it is crucial to consider the population-level impacts of the disease and give special attention to the disproportionate risks faced by marginalised and disadvantaged populations. 3 Lessons learned from the HIV response highlight the importance of engaging and prioritising-and not further marginalisingthese populations in disease prevention responses. 11 Beyond the health system, social determinants of health, including adequate housing, safe drinking water and sanitation, food, social security, and protection from violence, are central elements of the right to health and The right to health must guide responses to COVID- 19 

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