Why is men's health and well-being policy not implemented in Australia?

In Australia during the 1990s there was considerable public discourse about men's health and well-being. Generally this discourse has constructed men as a single category and described men's health as problematic. The Australian Commonwealth Government and some states responded to the discourse of men and their health by beginning men's health and well-being policy processes. Despite significant policy writing activity there has been very limited government program development or budget allocation. In other words policy implementation has been modest. This paper explores reasons for Australian governments' inability to implement men's health and well-being policies relatively systematically.

Key Words: men's health, men's health policy, Australian governments

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There has been remarkably little discussion in the Australian men's health literature about policy and related program development, or about appropriate political action that would generate programs for populations of men. This is an important issue to address because, in recent years, epidemiologists have produced vast quantities of data that suggest that in many ways, men's health outcomes (e.g., morbidity, injury and death) are significantly poorer than women's (Mathers, 1996; National Health Strategy [NHS], 1992). However, such data do not explain why the differences exist, nor do they explain what can be done, if anything, to improve men's health outcomes through public policy. Some men and women who support men's health initiatives have studied the data but so far have not created the policies that would lead to comprehensive and publicly directed interventions for the betterment of men's health. If there is a compelling case for men's health, why do policy endeavours falter prior to implementation?

This paper discusses the impediments to Australian men's health and well-being policies being implemented. This is useful because it is important to know what the difficulties are in moving from policy formulation to policy implementation when arguing for men and their health, especially in relation to the activities of the state. For those who believe that men's health and well-being requires state intervention, astute strategising and an understanding of the complex and changing policy climate are required.

In the following discussion it is accepted that men's health is significantly socially constructed, meaning that masculine values and practices, as well as men's location in social structures and environments, influence their health outcomes. The expectation is that men in Australia, for example, do not cry. Dominant discourses and practices suggest men are rational, separate individuals who are tough and competitive and exercise "power over" (Smith, 1996; West, 1996). Men embody these values, but also construct social environments conducive to them (workplaces, sporting arenas, workplaces, etc.). In this paper it is also proposed that men as a sex/gender have no legitimate claims on the state for special or additional men's health and well-being programs. State interventions ought to be targeted only toward men who have the poorest health outcomes, who are in the lowest one or two quintiles of the male population measured by income, education, and occupational prestige (NHS, 1992). Yet if the health and well-being of those who experience poor health outcomes is to improve, men generally will need to come to understand the dynamics of the social conditions that cause men, especially poor men, to have poor health, and will have to act to change some masculine values and practices that are implicated in poor health outcomes. Also if men's health policies and programs are to be successful, there need to be widespread government initiated processes of consultation.

MEN'S HEALTH POLICY IN AUSTRALIA

In Australia, there are four broad issues that, at least until now, have precluded the movement of coherent, bureaucratically processed policies into accepted government policy with clearly established budgets and broad political legitimacy. These issues are associated with medical dominance, the lack of a men's social movement, the Australian political and policy climate, and aspects of Australian men's culture.

MEDICAL DOMINANCE

AN ENTRENCHED BIOLOGICAL FRAMEWORK

Medical dominance is entrenched in the popular medical media discourse around "health." This discourse continues to assert the predominance of individual bodily pathologies rather than uncover the social processes implicated in varying health outcomes across various populations. The random distribution of germs, genes, and accidents is assumed, although the random distribution of morbidities in the current men's health discourse is gender-specific. Some conditions randomly afflict men as a population, while some different conditions randomly afflict women. Thus, so a common argument runs, if women suffer from breast cancer, and there has been a response by governments to provide breast screening services, then men suffer from prostate cancer and also require screening programs. It is all a matter of balance (Broom, 1995; Broom, 1999; Wadham, 1997). Such a simple and inherently competitive view of health and policy motivation fails to acknowledge the data and fails to recognise the complex social structural determinants that impinge on health for differing populations of men, as well as varying populations of women (Connell, 2000; Wadham, 1997).

This widely held, simple, biologised view about random distributions of medical afflictions is in contrast to the socially constructed explanations of health and gender evident in all the Australian policy documents on men's health and well-being. The centrality of the individual pathologised body, subject to medical treatment facilitated by medical insurance, has been reinscribed by a range of policies (for example, hospital funding, private medical insurance, pharmaceutical cost containment and rural medical service distribution) during the period of the current Australian government.

This clash between social constructionist policies and entrenched medical and biologised frameworks of understanding health, continually reinscribed through media stories, has no doubt contributed to the stalling of men's health and well-being policy implementation.

THE PREVALENCE OF MEDICAL EVIDENCE-BASED DISCOURSE

What men's health policy formulation has in Australia, that the development of women's health policy had less of, is epidemiological data (for example, Abraham, d'Espaignet & Stevenson, 1995; AIHW, 2001; CDHHCS, 1993-94; Glover & Tennant, 1999; Harrison & Cripps, 1994; Harrison & Dolinis, 1995; Mathers, 1994a, 1994b; NHS, 1992). These data have allowed health experts to identify health outcome differences on a great range of morbidity measures. Mortality data have also been compared over a range of populations. This data flow has been possible because of the increased power of computers, and these national and state databases have been more accessible for men's health policy development and politics from the mid nineties on. Women had access to less powerful data sets in the mid eighties, when they were establishing their health needs and subsequently making claims upon the state.

Such data are essential to sound policy development and for the provocation of public debate and academic theory building. However, the uses to which the data sets have been put in popular media discourse, and by some politically active men, have been as the basis for claims to further medical access for men.

While accumulating and publishing such data are necessary, there has been little movement beyond. Masculinist political interests have not demanded or provided qualitative alternatives to this quantitative amassing. Academic men have not worked through existing gender studies departments (established by feminist women) in order to uncover the lived experiences of men, in particular men on the social margins. For example, the South Australian men's health and well-being policy processes facilitated data-gathering through public consultations that explored men's experience of health and well-being. The data have since lain dormant. There has been no stimulus for major research projects, like the Women's Health Australia project (Women's Health Australia, 2002), that would seek to determine men's understandings of health, and health relationships. As indicated by the research agenda (CDHAC, 1998), the relationships between risk, violence, masculinities, class, and injury, in particular, need exploring, uncovering and clarifying.

The objectives of the discarded National Men's Health Policy (draft) include "Initiatives and services directed at men which are evidence based ... for which standards have been set and best practice identified and promulgated" (CDHSH, 1996, p. 43). Such standards and practices were medically formulated and emerged from "problems" located in epidemiological data.

Such medical, evidence-based requirements sit uneasily in social constructionist understandings of men's health, which generally Australian men's health policy documents support. Accumulating data and targeting programs to appropriate (sub)populations are laudable and commonplace in Australian health policy. However, the risk is that medical practitioners and their patients assume this is a complete framework for planning services that produce optimal outcomes.

Invoking evidence-based research in a predominantly medical discourse appears to obviate the need for further analysis. In other words, "show me the numbers and we will know where to put the money for programs." More far-reaching and deeply rooted analysis and theory-making are no longer required. If men who have inadequate income and little education, on the evidence provided, carry a disproportionate burden of morbidity and early mortality, evidence-based medicine will show that they require medical education and medical treatment. However, it may be that guaranteed income, safer work environments, adequate housing, opportunities for re-skilling, and skills for community living are required, rather than individualised curative medical interventions.

Australian feminists have established evidence-based measurements for programs, as gender has been recognised as a significant variable in establishing a variety of life chances, including health chances. This has gained political and policy leverage for women. However, the evidence has been taken up in women's political activities and contextualised and theorised in association with women's lived experience. In relation to the development of the Australian Women's Health policy, Grey (1998) writes that, "estimates have it that representatives of over a million women from diverse backgrounds and from all parts of the country had been consulted" (p. 108). Feminist women were also well placed in bureaucracies to move the issues into policy and programs (Grey, 1998), and academic journals reporting findings using a variety of feminist social research techniques grew.

The discourse of evidence-based medicine in men's health and well-being policy documents obfuscates the need for further work beyond the data sets. To date in Australia, academic work has given little foundation and impetus to assist policy bureaucrats, and grassroots political activity has failed to create a policy crisis, which creates visibility for apparent health and well-being needs of men.

In short, it seems unlikely that the common appeals made for medical, evidence-based men's health policy will change the hegemonic masculine values and related structures (Connell, 1995) that shape and maintain the great differences in morbidity and mortality between the most healthy 20% of men and the least healthy 20% of men (Mathers, 1994a, 1996; Moller, 1995; NHS, 1992). Hegemonic masculinity exalts and reinscribes the dominant masculine values and practices, while subordinating and marginalising other forms of masculinities that may provide more positive health and social justice outcomes. A medically and individualised evidence-based focus alone will not illuminate, for example, power in men's and women's relationships, nor uncover the health issues in men's lived experiences. An analysis that does not analyse and find a curriculum for reworking hegemonic masculinity will mean that women's and children's, as well as other men's, health and well-being will continue to suffer through violence and other risk ventures (Connell, 2000).

The problem for men's health advocates who want to move beyond reforming medical practice, or who see the need to move beyond the study of data, becomes clearer with an assessment of the social and political context that gave rise to the women's movement and the women's health movement. The importance of a broader contextual analysis and a broader social movement that paves the way for different understandings and for new policy directions has been alluded to above.

SOCIAL MOVEMENTS

MEN'S HEALTH LACKS A SUSTAINING SOCIAL MOVEMENT

Successful women's health policy and programs emerged in Australia in the 1970s and 1980s, when women mobilised through a national and international women's social and political movement. The women's movement focussed on a lack of social equality between men and women and examined power differences in gendered relationships. Women developed a broad political analysis and advocated programs based on their needs that found substantial public acceptance. They organised in many strategic sites, only one of which was health.

Women's social and political mobilisation developed in Australia mostly during a period of socially reformist commonwealth and state governments. They worked for changed values and practices in the health care system, which favoured women taking responsibility for their health and for the containment of male medical power and its associated technologies. Changes were strengthened when women pursuing feminist objectives became established in bureaucracies and service delivery organisations (CDCSH, 1989; Grey, 1998; Palmer & Short, 1996; Sawer, 1990, 1991; Sawer & Simms, 1993; van Acker, 2001).

Men's health policy advocates lack such a broad, sustaining social movement with an underlying coherent social justice ideology. Unable to draw sustenance from a social movement, much men's health lobbying appears to be based on a simple liberal democratic argument, "If women have ... then men should have .... "Lacking a social movement's impetus, where men's health has been embraced it has tended to be medically, technologically, and individualistically curative, and privately provided (for example, impotence drugs, weight loss clinics, and cholesterol-lowering drugs). Men's health political activity, as modest as it has been, has not worked toward social change, but has tended simply to demand more medicine or better individual support.

Men's health advocates who look to women's achievements and make claims on behalf of men and their health in parallel, or as a mirror reflection, need to note that these are different times in social, political, and economic terms. Australian men are not involved in a national and international men's social movement that seeks to win patronage from the state and thus to acquire budgets for programs. More is needed than simple appeals to equality so that men can share the gains that women have won through social and political activities over more than three decades.

Is A MEN'S HEALTH SOCIAL MOVEMENT LIKELY?

The prospects in Australia for generating a men's social movement that might pursue changes to men's health and well-being by drawing on the widespread problematisations of it appear poor. In a discussion of the prospects for new social movements, Frankel (1992) is pessimistic. He believes economic liberalism so dominates policy and political debate that it leaves little scope for the development of social movements. Despite analysis that seeks to understand the reasons for their demise, leaders of aspiring movements appear unable to develop continuing commitment from their adherents. In addition, Frankel (1992-1993) argues, when the Australian Labor Party was in government, it successfully corporatised the activities of social movements (feminists and Greens for example) by employing leaders as consultants, as well as by offering special-purpose grants (see, for example, Auer, 1990). Frankel also asserts that post-modernist theory predominates, and thus "big idea" social reform movements appear inappropriate or unfashionable.

Connell (1995, 1997), on the other hand, acknowledges that there have been attempts to develop, in Australia and elsewhere, a Men's Liberation Movement in imitation of the Women's Liberation Movement. Some men have aspired to lay the foundation for a broader social movement that has sought to involve men in gendered issues. Under the banner of men's liberation, men have explored issues of gender in their own lives, published magazines, organised demonstrations, provided child care at feminist conferences, run violence prevention programs, and so on (Connell, 1995). However, quoting Tolson, Connell writes that men "were imperialists in a rebellion of slaves" (p. 235). The problem for a men's liberation movement is that liberation movements gain strength from the need for social reform and the creation of social justice, expressed and acted on by those who are oppressed (by sex, by ethnicity, by social class, by geographical location, etc.). Men generally cannot create solidarity around opposing the interests that they share and defend by virtue of sex/gender (Connell 1995). The prospects for an energising social movement geared to sponsoring men's health activism and achieving health policy outcomes appears poor (Connell, 1995).

While there exists a range of theoretical positions about the possibilities for social movements to shift public policy (Della Porta & Diani, 1999), especially in times dominated by economically liberal political rationalities, men's gendered position in western societies appears to undercut the possibilities for social movement solidarity needed to generate changed policy directions. In Australia, men have not unified to put pressure on governments in order to move policies to programs.

MEN'S HEALTH AS MASCULINIST POLITICS

Not only are the prospects for generating a men's social movement currently poor, but Connell (1995, 1997) argues that the structure of gender politics means more specific and directed men's politics of reform and social justice are problematic. Attempts to activate men around particular men's issues (rather than as potential contributors to a broader social movement) have been unstable and subject to appropriation by gurus and entrepreneurs who have been able to promote a certain kind of masculinist, generally individualised, therapeutic focus, rather than adopting an agenda of social reform (Connell, 1995).

The hype in Australia around the impotence-relieving pill Viagra[R] is a recent manifestation of these individualising and therapeutic tendencies. Another example is the South Australian government's partnership with a multi-national drug company to fund a caravan staffed by nurses that visits shopping malls throughout the state. The services offered are exclusively for men and are provided under the banner of a men's health tune-up. The caravan decorations and staff clothing approximate the style of a racing car pit crew. Blood pressure and cholesterol levels are measured, and where necessary, referrals are made to general medical practitioners.

It is difficult to identify any coherent and astute masculinist political activity that is stimulating demand for relevant men's health and well-being policies in Australia that adhere to the social (re)constructionist views of the policy writers. Rather, curative medicine continues to colonise new territories, and by so doing crowds out argument for more gendered and socially structured analyses of health outcomes.

GAY MEN AND MEN'S COALITIONS

The only time that a predominantly men's health policy has been established on recent Australian health agendas has been through HIV/AIDS policies and programs. Gay men were able to mobilise and to play excellent politics (McCamish & Najman, 1995). Also, gay men have minority status and may identify with gay issues. Many gay men report experiences of being oppressed by a homophobic and heterosexist society. Experiences of oppression and minority status may lead to sufficient solidarity that can, in turn, generate effective political energy. In addition, gay men more than other men and women, initially at least, were perceived to have the most exposure to HIV/AIDS.

Other men with poor health chances may not feel so imminently threatened, nor might they have the resources to gather together. In this sense gay men's health, which was sustained by the gay men's liberation social movement cannot stand as a hopeful model for impetus for improvements to men's health generally, as there are fewer possibilities for solidarity.

Further, for many heterosexual men, engaging in discussion or programs about men's health renders suspect their heterosexist masculinity. In Australia, because of gay men's prominent advocacy in relation to men and issues of HIV/AIDS, men's health in popular discourse is often seen as a territory populated by gay men. It is thus tainted territory in dominant discourses of heterosexual masculinity. If many heterosexual men are to engage in men's health discussion and programs, then they will first need to feel comfortable sharing a broad men's health agenda with gay men, or men's health will have to be differently badged. To date, coalitions of gay and other men in Australia have not been notable in pursuing men's health and well-being agendas. Gay men's policy implementation successes have not provided a foundation for broader men's health and well-being political actions.

THE AUSTRALIAN POLITICAL AND POLICY CLIMATE

There are some men with interests in particular forms of masculinities who are more active in shaping political agendas (Carey, 1996; Edgar, 1997; Connell, 1995, 1997; Flood, 1997; Lindgard & Mills, 1997; Mac an Ghaill & Haywood, 1997; McLean, 1996; Pease, 1997; White, 1996). The question is whether or not there is enough energy and astute political strategising in masculinist political interest groups to move men's health and well-being, as well as other men's agendas, forward in terms of policy and program development. Related to this is the question about whether or not the policy directions pushed will be both socially transformatory and just.

In South Australia, for example, masculine political interests were not significant in driving policy formulation. Rather, the motivation for the men's health policy work came from the state health bureaucracy, from feminist women in the bureaucracy, and from women in state conservative politics. The health bureaucracy had produced a range of population health policies (women's, youth, aged, rural, people with disabilities, Aboriginal etc.) and, in a sense, a study of men as a population just had to be "done." There was a certain media-driven, bureaucratic inevitability in this.

Feminist women working in women's health initially pushed the agenda of a population health policy for men. Some pressure also emerged from women in the conservative Liberal Party but this appears not to have been sustained. Perhaps a chance was seen to test some political waters for electoral gain, rather than to work toward a transformation of health-threatening gendered behaviours and environments, especially for men on the social margins.

The media discourse in Australia about men's health gained impetus from about 1994, and this publicity established men's health discourses, giving some impetus to men's health policy work. In 1996, a National Men's Health Policy (CDHSH, 1996) was drafted after a national round of consultations. The process was halted in 1997, shortly after the current socially conservative Commonwealth government came to power. Since then there have been small budget allocations to men's health initiatives, such as support for the four National Men's Health Conferences, the establishment of a national men's health database, and the development of a Men's Health Research Agenda (CDHAC, 1998).

Four of Australia's six state governments and one of Australia's two territory governments ran policy processes between 1995 and 2002 and produced detailed written policy statements. However, neither major political party has entered a national election campaign promoting a men's health policy, although short election policy statements have been published. A minor party, the socially liberal Australian Democrats, has been most consistent in producing men's health statements during election campaigns.

INSIGNIFICANT OUTCOMES FOR AUSTRALIAN MEN'S HEALTH POLICIES

While bureaucratically developed and government-approved policy processes and statements vary, there are three outstanding features to all Australian men's health and well-being policy documents (Luck, Bamford, & Williamson, 2000). First, all policies at the national or state level take a social constructionist point of view. Second, all men's health policies focus directly on particular populations of men, who are known to have very poor health outcomes relative to middle and upper class men, or men in the highest quintiles of education and income. Men, as a category, are disaggregated, and men defined as poor on a range of indices are targeted. Thirdly, while the Commonwealth government began a consultative process for its draft Men's Health Policy (CDHSH, 1996), since then there has been only one statewide (in South Australia) consultative process for men's health, unlike the thorough national process run for the National Women's Health Policy (CDCSH, 1989; Grey, 1998). No findings from widespread public consultations supplemented by academic research are available.

Government policy processes have not led directly to programs. Explanations for the stalling need to be found and appropriate strategies debated for policy enthusiasm to be turned into comprehensive budgeted programs. Luck et al.'s (2000, p. 171) observation that "Australian policy development at national level has encouraged greater ownership of the issues (than in the United Kingdom) amongst males" suggests paltry policy development in the U.K., rather than significant achievements in Australia.

There has been significant activity in Australia that has claimed men's health and well-being as a label. Papers at Australia's four National Men's Health Conferences report a wide range of activities from discussions of doctor/male patient interaction to health promotion activities run through community health centres (Curtin University, 1997; University of Western Sydney, 2001). However, these activities aimed at repairing aspects of some men's health are not assessed against Australian or state data or comprehensive strategic plans. Nor do they stem from systematic and comprehensive commonwealth or state government processes, but they are decentered, to small health service agencies. They rely on short-term funding, which usually takes the form of a budget reorientation, and they are agency-specific.

Australian governments appear to appease small and local men's health lobbies with modest grants that offer limited health services to men such as health information services (Men's Information Health Resource Centre [MIHRC], 2001) and dedicated telephone lines (Mensline Australia, 2002). It is difficult to imagine the establishment of a network of men's community health centres or a publicly funded national program for men that checks heart health or screens for prostate cancer. It seems improbable that governments will develop major, publicly funded programs that target those populations of men whose health on a variety of indicators is most impaired. It also appears unlikely in an age of social conservatism that comprehensive government men's health policies will be involved in social (re)construction in order to address the major policy issues identified to date.

PRESSURE ON AUSTRALIAN HEALTH BUDGETS

In Australia, this is a period of neo-liberal political rationality (Beeson & Firth, 1998; Dean, 1999) in which there is argument about industrial relations reform, privatisation of government agencies, corporate restructuring, and individualising responsibilities. It is an age of appeals to the market that is to regulate and to distribute. It is not an age when dominant political discourse argues for interventions in favour of the social, the community, or in favour of health and well-being, as opposed to curative medicine (Baum & Murray, 1999). These are not the times of the socially or environmentally interventionist state (Jamrozik, 2001).

Men's health activists are seeking to change the health agenda in Australia at a time when the health budget is under considerable pressure. The aged are increasing in number and proportion of the population; medical technology is more complex, more expensive, and more used; pharmaceutical budgets continue to grow; and doctor numbers and hospital admissions are comparatively high (Budget, 2002). Such cost pressures exist in a time when containment of public expenditures is constructed as a public virtue and when major Australian political parties argue about changing the tax mix, but are committed to no overall tax increase. If men are to make claims on the state through men's health policies and programs, what other interest groups will lose portions of their budget allocations?

If men's health is to capture a budget for programs, it will need to be drawn from other sectors of public expenditure (housing, transport, education, etc.), or gained from a reorientation of health service delivery programs away from medicine and its institutions. Reorienting health budgets away from medical practice in Australia has proven to be very difficult and currently runs at only five percent of all health expenditures (Choice, 1997; Duckett, 2000). Is it possible for men's health advocates to wrestle successfully the curative medicine lobby and the perceived needs of a growing number of older Australians, during a period of restraint?

AUSTRALIAN MEN'S CULTURE

MASCULINITY AT THE HEART

At the heart of Australian men's health and well-being policy work is the idea of masculinity or masculinities. Connell defines hegemonic masculinity as gender practice that guarantees, or takes for granted, the dominance and authority of men and the subordination of women (1995).

The Draft National Men's Health Policy Paper takes on the idea of hegemonic masculinity, and also notes the existence of a range of Australian masculinities.

   Research (and common sense) points to the fact that there are a
   range of masculinities which change over time, although some are
   more dominant than others. This is further influenced by issues
   such as cultural background, sexual orientation, geographic location
   and socioeconomic status.

   While issues of socialisation and risk taking are likely to be
   contentious and cause considerable debate, it would appear that a
   national men's health policy needs to accept this is an important
   area of inquiry and action.... Consideration must also be given to
   structural factors. (CDHSH, 1996, pp. 6-7)

The South Australian Men's Health Policy Background Paper states:

   Some groups of men have a greater advantage and access to privileges
   than other groups of men. This is determined by factors such
   as wealth and income, housing, education and geographical location
   and discrimination based on beliefs about ethnicity, race, sexuality,
   ability, religious affiliation and age.

   These differences are in mm associated with differences in
   opportunity and access to resources. The result is different
   health and well being outcomes amongst men. (DHS, 2000, p. 2)

Given that Australian men's health and well-being policy documents locate masculinities as central, what kinds of policy options are possible? Masculinities lead to particular attitudes, values and behaviours which compromise good health outcomes for sub-populations of men, but also lead to men being over-represented in environments which are particularly dangerous. Men predominantly construct and regulate public environments, building into them masculine assumptions. It is also usually men who organise work schedules and who construct work environments or especially dangerous environments like roads, farms and mines (Harrison & Cripps, 1994).

If masculine cultural values and practices, as well as locations in social structures, are what lead many men to have poor health outcomes on some morbidity, injury, and death indices (usually associated with risk-taking), then it is men's practices of masculinities that must change, as well as some men's position in the social structures. In other words, many men's risk behaviours, as well as some attitudes, values, occupations, and income levels need to change (NHS, 1992). It is difficult to envisage Australian governments of any persuasion being active in critiquing masculinities (rather than simply condemning men's violence and drug taking), and intervening in innovative ways in social structures to promote the welfare of men who are located on the social margins.

Given that hegemonic masculinity is a cultural norm, aspects of masculine expression are often not unmasked and critiqued, and such characteristics may be considered to be an aspect of the human condition. Men's anger and aggression, for example, may be considered a natural part of life, rather than a socially constructed aspect of much masculine practice.

Australian masculinities and the relatively impaired health outcomes to which they contribute for many men with lower socio-economic status may well be challenged in the market place of popular ideas and to some extent in the media. However, the dominant discourse seems to be increasingly hyper-masculinised, competitive, and accepting of inequalities. In the realms of public policy generally, and health policy in particular, it seems quite improbable that political leaders will welcome policy that would overtly challenge dominant values such as individual toughness, independence, endurance, competitiveness, and the exercising of masculine power over others. Australia's male political elites are in most cases thoroughly embedded in the values of the hyper-masculine, and are thus unlikely to champion policies that make problematic the acceptance of hegemonic masculinity.

If the modest energy around men's health issues is to be translated into more tangible policy outcomes in Australia, and possibly in other nations, the following directions are recommended. Advocates need to be in partnerships, rather than in competition with, others who understand health as gendered in important ways. For example, in Australia, gay men have been astute strategists in winning research budgets and have been successful in developing and running budgeted programs, which have changed gay men's sexual practices, so that health outcomes have improved. Much can be learned about strategic policy development and behavioural change from these experiences.

Further, men's health advocates and health professionals need to work respectfully with populations of men who experience poor health outcomes as a result of risk and violence, in order to understand the dynamics of these practices and to establish purposeful paths of change. These issues are thoroughly canvassed in the Research Agenda and Background Report (CDHAC, 1998). Men's health advocates would also do well to incorporate their activities into public or population health organisations, while academic advocates would do well to engage with gendered health research projects, where the foundations of gendered research are already laid.

CONCLUSION

In this paper, I have noted that, in Australia, since 1995, there has been media attention that has constructed men and their health as problematic. Policy writing activity around the broad idea of men's health and well-being has been undertaken in a range of locations.

The policy writing activity across state and commonwealth governments has achieved a broad consensus around three core issues. First, in order to understand men's health and well-being, a social constructionist view of gender and health needs to be adopted. Second, policy and programs ought to focus on men in the lowest one or two quintiles of populations, measured by income, education, and employment. Finally, widespread consultation is necessary in order to refine understanding of health and well-being issues while concurrently building policy legitimacy.

Despite men's health and well-being being described as a "media marvel" (Wadham, 1997), and despite the policy writing activity and broad consensus on key policy issues, there has been little movement from policy to programs, and initial optimism among many for tangible policy outcomes has begun to fade. In this paper I have sought to document impediments to men's health and well-being policy implementation.

In brief, the major impediments can be grouped under four headings. On the one hand policy development has argued that some men's relatively poor outcomes on morbidity and mortality measures derive from social dynamics rather than biological determinants. However this understanding is not congruent with medically dominant ideas about what counts as evidence and challenges established biologised understandings about the distribution of germs, genes, and accidents that lead to poor health outcomes.

Policy may also have failed to be transformed into budgeted programs because there has not been a men's health and well-being social movement to create energy for the project and through which political strategising could take place. It is also apparent that the conditions for creating and sustaining a men's social movement differ from the social context that gave rise to a women's movement that addressed women's health in relatively well-funded programs. Men's gendered positions in society mean that the creating of coalitions of interest in order to create political change is unlikely.

Current neo-liberal political rationalities and Australian political discourse around health (curative medicine) and budgets further reduce options for those who advocate men's health and well-being programs.

During the period in which men's health and well-being in Australia has been discussed, little evidence can be garnered that points to men engaging in political activity that is likely to move the men's health agenda forward.

Uncovering the social processes by which Australian masculinities contribute to poor health outcomes for men with low socio-economic status appears to be a remote possibility at this time. Until this occurs, the health chances of Indigenous men, men in prisons, men with low levels of education, many rural young men, and men who are either unattached or marginally attached to the labour force will remain very poor compared with those who enjoy the bulk of the benefits of Australian hegemonic masculinity.

The author acknowledges the contributions of three anonymous reviewers. This paper is significantly improved thanks to their helpful critiques.

NOTE

(1.) This paper grew out of my involvement in Australian men's health and well-being policy work. I was an independent Chair of the South Australian Men's Health and Well-Being policy processes from 1995 to 2001, a process undertaken within the South Australian Department of Human Services at the behest of the responsible Ministers.

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Correspondence concerning this article should be addressed to Peter Lumb, School of Social Work and Social Policy, University of South Australia, St. Bernards Road, Magill 5072. Australia. Electronic mail: [e-mail].

PETER LUMB

University of South Australia