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Women and heart disease
Women a n d heart disease Dr Dorothy Broom
ABSTRACT: - This paper was presented at a meeting of the Australian Capital Territory Chapter of the Royal College of Nursing, Australia on May 12, 1994. It explores issues of gender in relation to heart disease which have led to misconceptions about the mortality and morbidity of the disease in women and which may retard diagnosis in women and delay effective treatment. Research on men has become the norm and the possibility that women may respond to the same disease differently has been largely ignored.
INTRODUCTION I suspect some of you are a little puzzled by my choice of topic. Why women and heart d i s e a s e , of all t h i n g s ? Why would somebody who was involved in women's health w a n t to talk about heart disease? There are two answers to that question. The honest answer is that last year's National Heart Foundation theme for Heart Week was "Women and heart disease." Because I was asked to launch that Heart Week, I was forced to become acquainted with the facts about women and heart disease, and doing so c h a n g e d my t h i n k i n g on the topic. Perhaps I can do the same for some of you. But equally important to me - and equally honest, I'm glad to say - is that thinking about women and heart disease has changed my thinking about women and health and, more broadly, about gender and health. I would be doubly pleased to achieve that for some of you as well, b u t together those amount to an ambitious agenda. Let's see h o w far we can go in c o n s i d e r i n g the question, "What's special about women and heart disease?"
Dr Dorothy Broom is a research fellow at the National Centre for Epidemiology and Population Health at the Australian National University.
There are several ways of approaching this question. One is to assemble the statistics about cardiovascular morbidity and mortality suffered by women. The National Heart Foundation has done a great deal of that w o r k , and you can obtain from the Foundation many excellent publications that supply details, so I review them only briefly. Everyone knows that cardiovascular disease is a disease of public health importance; by some measures, the most important. Most people probably also know that in the last two and a half decades, death rates from
COUUEOIAN VOLUME 2 (1) JANUARY 1995
16
cardiovascular disease have been falling. And I suspect that, whatever we know of the statistics, we tend to think of CVD as a male problem. In most age groups, many more men than women suffer from heart disease, and premature mortality from heart disease is m u c h more common a m o n g men than w o m e n . But, serious as they are, m e n ' s morbidity and mortality statistics are not the whole story. Heart disease is the major killer of women as well as men. Half of all deaths a m o n g A u s t r a l i a n w o m e n are from cardiovascular disease, and about a third of those deaths arc considered premature. In a year, about 10,000 heart attacks occur among w o m e n b e t w e e n 20 and 70 years of age. More than half of all w o m e n over age 65 have high blood pressure, and other risk factors follow a similar p a t t e r n . The e x c e p t i o n is s m o k i n g , w h i c h is m o r e common among younger women than in the g e n e r a t i o n s of their m o t h e r s and grandmothers. Because smoking doubles the risk of h e a r t attack and s t r o k e , the popularity of smoking among young women is alarming. Smoking in combination with the use of oral contraceptives multiplies the risk 10 times.
BEYOND THE STATISTICS These statistics alone would provide ample reason for interest in our question. There are, however, other dimensions. Despite the fact that it is the major killer of women, only very recently has serious attention been t u r n e d to cardiovascular disease a m o n g women. Men's disproportionately higher i n c i d e n c e of m o r b i d i t y and p r e m a t u r e mortality from heart disease produced an impression among lay people and doctors ^ V RpYAl. CQLUE0E OF NURSING. AUSTRALIA^
alike that heart disease happened only to m e n . This s t e r e o t y p e of h e a r t d i s e a s e retarded the recognition of the significance of the p r o b l e m a m o n g w o m e n , and may h a v e c o n t r i b u t e d to the sense in s o m e quarters that a focus on women and heart disease is somehow extraordinary, a kind of extravagance. T h e r e m a y be i m m e d i a t e serious consequences of the stereotyped image of heart disease. Recent American, British and Australian research suggests that cardiovascular symptoms are liable to be investigated less thoroughly and treated less a g g r e s s i v e l y in w o m e n t h a n in m e n . Apparently the discrepancy is not explained by differences in the average ages at which women and men become ill. The failure to pursue symptoms vigorously would be an u n d e r s t a n d a b l e result of a w i d e s p r e a d though incorrect - belief that women don't get heart disease. Such a belief might make doctors less likely to suspect heart disease in a woman, and less likely to take it seriously when it occurs. It may also promote a belief among women and their families that heart disease isn't a women's health problem and t h e r e f o r e t h a t the risk factors a r e n ' t important to women. A related and equally disturbing element is the neglect of women in medical research g e n e r a l l y , i n c l u d i n g r e s e a r c h on h e a r t disease. In medical research, men and male animals have been the main or only subjects of m o s t s t u d i e s of d i s e a s e , d i a g n o s t i c procedures, management, therapy and prevention. Sometimes, when women were included, the results derived from w o m e n w e r e d i s c a r d e d b e c a u s e they d i d n o t conform to the pattern based on results from m e n . The c o n s e q u e n c e is that we often k n o w little or n o t h i n g a b o u t h o w s o m e disorders can manifest themselves differently in women and men, how risk factors may vary, or h o w the sexes m a y differ in their r e s p o n s e to t h e r a p e u t i c interventions. The present confusion over dietary advice to women regarding intake of fats is an e x a m p l e of, and an i m p o r t a n t question raised belatedly because of, an assumption that findings relevant to men w o u l d be r e l e v a n t to e v e r y o n e . T h i s a s s u m p t i o n in t u r n r e s t s on a d e e p c o n v i c t i o n t h a t the n o r m a l b o d y is n o t subject to such aberrations as h o r m o n a l cycling, pregnancy, lactation or menopause, t,
*9tyu> soitadK ogi^taft
a n d t h a t it is t h e r e f o r e a p p r o p r i a t e to exclude such aberrant bodies from medical r e s e a r c h on the g r o u n d s t h a t t h e y 'contaminate' the results with 'extraneous' variation. I must stress that I am not accusing doctors a n d r e s e a r c h e r s of sexism - that is, of a prejudice against women or any intention to treat them less effectively or to ignore their h e a l t h care - a l t h o u g h sexism m a y be present in some instances. On the contrary, it is perfectly possible - indeed it is more likely - for the processes I identify to prevail in the absence of any anti-woman feelings or attitudes, but the results can still be harmful to women. We are just now beginning to explore the p o s s i b i l i t y t h a t the ' s a m e ' d i s e a s e m a y manifest somewhat differently in w o m e n t h a n in m e n . AIDS is an e x a m p l e : the pattern of the 'typical' AIDS case has arisen from observations of men, because men are the majority of HIV-positive people in the d e v e l o p e d w e s t a l t h o u g h , in the w o r l d overall, w o m e n are equally likely to be infected. T h e m o d e l t h u s d e r i v e d is s u s p e c t e d of r e t a r d i n g the d i a g n o s i s in women and consequently delaying effective treatment. It is also possible that optimum management of some conditions may sometimes differ between the sexes. The very factors that have justified women's exclusion from most medical research raise important questions about whether therapeutic regimens developed and tested on men will be safe and effective for women. Women diabetics have suspected that doses of insulin vary in effectiveness at different t i m e s in the m e n s t r u a l cycle, and they have sought largely unsuccessfully - doctors who would c o o p e r a t e in an e x p l o r a t i o n of s u c h v a r i a t i o n . It h a s also b e e n f o u n d t h a t damage from alcohol occurs more rapidly a m o n g w o m e n t h a n men because of sex differences in the metabolism of specific chemicals. O n e m i g h t ask w h e t h e r analogous processes may be relevant to the m a n a g e m e n t of h e a r t d i s e a s e . Are the p r o t o c o l s d e v i s e d by a n d for m e n completely appropriate for women and, if not, what modifications might improve the care of women with cardiovascular disease? Women have not been completely neglected in the picture of heart disease, however. We t j j g g g U ^ N VQUyM£%M JAN«AR£«9£
have had a place, and it is in the home. Until r e c e n t l y , w o m a n ' s m a i n role w a s as an u n p a i d c a r e g i v e r for a sick m a n , or especially as the u n p a i d m a n a g e r of the m a n ' s risk factors. Several i l l n e s s prevention campaigns designed to change men's dietary risk factors have been aimed not at promoting behavioural change in men but at inducing guilt and behavioural change among women, who were held responsible for men's eating. Indeed many advertisers do the same thing (recall 'Feed the Man Meat', 'You Ought to be Congratulated' or 'Good on ya, Mum', all messages designed n o t to i m p r o v e w o m e n ' s h e a l t h b u t to induce women to help others eat differently). The TV ads in a NSW North Coast health p r o m o t i o n c a m p a i g n of the early 1980s supply a vivid example. In one commercial, a husband and young children are shown in a large glass beaker in the kitchen, to which the wife/mother is cheerfully adding large doses of fat, emptying her frypan to refill it once more as she prepares yet another meal consisting almost entirely of high-cholesterol foods a n d d r o w n i n g her i n n o c e n t a n d protesting family in the excess fat. This representation is superficial, unhelpful and i n s u l t i n g to w o m e n a n d m e n a l i k e . A l t h o u g h I am n o t a w a r e of s i m i l a r representations in the more recent past, it is a c a u t i o n a r y lesson to p e o p l e in h e a l t h promotion. A more respectful a p p r o a c h would have uncovered many women who were painfully aware of their h u s b a n d ' s risky e a t i n g p a t t e r n s a n d e a g e r for constructive help in facilitating positive c h a n g e s . R e p r e s e n t i n g w o m e n as the ignorant p e r p e t r a t o r s of their h u s b a n d s ' (and c h i l d r e n ' s ) ill h e a l t h d i d n ' t h e l p women, and representing men as the childlike v i c t i m s of w o m e n ' s i g n o r a n c e did n o t h i n g to e n c o u r a g e m e n to take responsibility for their own health.
concentrating on men, a little attention to women isn't too much to ask. But there is more to it than that. The omission of women arises from an o v e r a l l failure to t a k e gender - masculinity as well as femininity seriously. The concentration on men is not an honest and explicit affirmation of the m a s c u l i n e ; it is an u n n a m e d a n d u n a c k n o w l e d g e d p l a c i n g of m e n at t h e c e n t r e . That is, it is a focus on m a l e s m a s q u e r a d i n g as attention to h u m a n i t y . Because this focus is not forthright, it is blind to its e x c l u s i o n of w o m e n a n d c a n n o t acknowledge the masculinity of its subject matter.
A HAZARD TO MEN?
Until recently, the medical establishment has i g n o r e d the relevance of m a s c u l i n i t y to health, just as it has ignored the relevance of femininity, and ignoring gender is probably as hazardous to men as to women. It is, I believe, one of the crucial elements that p r e v e n t e d for so long recognition of the w a y s m a s c u l i n i t y c o n t r i b u t e s to h e a r t disease risk factors. Smoking, for example, w a s for s e v e r a l d e c a d e s m a i n l y a m a l e a c t i v i t y ; i n d e e d , it w a s a m e a n s of confirming and displaying certain forms of masculinity, a fact not lost on advertisers. 'Quit' programs might have been more effective more quickly if they had attended to the g e n d e r (not to m e n t i o n class) i m p l i c a t i o n s of s m o k i n g a n d h e n c e of q u i t t i n g . The specific implications may c h a n g e w i t h t i m e , b u t the r e l e v a n c e of gender persists. Tobacco marketers have been much quicker than the health sector to identify and capitalise on the potential of gender to mobilise new markets for their p r o d u c t s . Belatedly, as the incidence of smoking among young women has increased, health promoters have noticed that smoking has different social meanings and symbolic power among different sectors of the p o p u l a t i o n , a n d s o m e of t h o s e differences are gendered.
That last example connects neatly with what may seem the m o s t u n a n t i c i p a t e d consequence of the failure to take women seriously: I think it has been bad for men as well as for women. Consequently, I believe that attention to women and heart disease will also benefit men's health. To do that we must return to the question: what is special a b o u t w o m e n and h e a r t disease? Some p e o p l e m a y t h i n k t h a t s i m p l e e q u i t y is answer enough. After all the y e a r s
The effort to promote dietary change and exercise must also take gender seriously if it is to be effective. Alcohol consumption and drunkenness have been socially accepted for men, and almost requisite in some circles of adolescent and young adult men. Specific foods and styles of food p r e p a r a t i o n are associated with masculinity and, if men are to eat a h e a l t h i e r diet, the s y m b o l i c c o n n o t a t i o n s of food m a y h a v e to be considered. We might learn a lot from the
effective initiatives of gay men in eroticising safe sex. They have transformed prevention into a positive and pleasurable part of gay masculinity. By contrast, the heart disease prevention message has been largely a dour lesson in asceticism and denial, including denial of certain forms of masculine selfexpression and pleasure. If a man suggests that "doing these things won't actually make you live longer ... it'll just seem longer," nobody should be surprised.
appropriately. If, on consideration, gender appears to have relatively little bearing on some particular illnesses, well and good. This brief discussion has suggested that gender has important implications for many aspects of heart disease, and that the focus for t h i s y e a r ' s H e a r t Week is far from premature. I a p p l a u d the Heart F o u n d a t i o n ' s focus on w o m e n and heart disease, which is timely and welcome to all w o m e n a n d to the m e n w h o care a b o u t them.
CONCLUSIONS Heart disease seems a far cry from what we h a v e b e e n e n c o u r a g e d to think of as 'women's health issues'. Reproductive and gynaecological health are now accepted as b e i n g a b o u t w o m e n ' s h e a l t h , j u s t as testicular cancer and impotence are accepted as men's health problems. But I have been arguing that this narrow understanding of the relationship between gender and disease w o n ' t d o . H e a r t d i s e a s e is as m u c h a women's health issue as breast cancer, and it ought to be as much a men's health issue as prostate disease. The sexed body does not become neutered simply because the organ in question occurs in both male and female bodies, or because the disease in question occurs in women and men both. A woman is not just a case of heart disease, a man is n o t j u s t a h e a r t attack. I g n o r i n g t h e relevance of gender does not diminish its relevance; it just makes it more difficult to c o n s i d e r the r e l e v a n c e of gender thoughtfully and respond to it
The slogan for last year's Heart Week was 'Heart disease doesn't care what sex you are'. Maybe heart disease doesn't but social i n s t i t u t i o n s d o , a n d it is a b o u t time we started taking that fact seriously in health care.
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ABSTRACT: - This paper was presented at a meeting of the Australian Capital Territory Chapter of the Royal College of Nursing, Australia on May 12, 1994. It explores issues of gender in relation to heart disease which have led to misconceptions about the mortality and morbidity of the disease in women and which may retard diagnosis in women and delay effective treatment. Research on men has become the norm and the possibility that women may respond to the same disease differently has been largely ignored.
INTRODUCTION I suspect some of you are a little puzzled by my choice of topic. Why women and heart d i s e a s e , of all t h i n g s ? Why would somebody who was involved in women's health w a n t to talk about heart disease? There are two answers to that question. The honest answer is that last year's National Heart Foundation theme for Heart Week was "Women and heart disease." Because I was asked to launch that Heart Week, I was forced to become acquainted with the facts about women and heart disease, and doing so c h a n g e d my t h i n k i n g on the topic. Perhaps I can do the same for some of you. But equally important to me - and equally honest, I'm glad to say - is that thinking about women and heart disease has changed my thinking about women and health and, more broadly, about gender and health. I would be doubly pleased to achieve that for some of you as well, b u t together those amount to an ambitious agenda. Let's see h o w far we can go in c o n s i d e r i n g the question, "What's special about women and heart disease?"
Dr Dorothy Broom is a research fellow at the National Centre for Epidemiology and Population Health at the Australian National University.
There are several ways of approaching this question. One is to assemble the statistics about cardiovascular morbidity and mortality suffered by women. The National Heart Foundation has done a great deal of that w o r k , and you can obtain from the Foundation many excellent publications that supply details, so I review them only briefly. Everyone knows that cardiovascular disease is a disease of public health importance; by some measures, the most important. Most people probably also know that in the last two and a half decades, death rates from
COUUEOIAN VOLUME 2 (1) JANUARY 1995
16
cardiovascular disease have been falling. And I suspect that, whatever we know of the statistics, we tend to think of CVD as a male problem. In most age groups, many more men than women suffer from heart disease, and premature mortality from heart disease is m u c h more common a m o n g men than w o m e n . But, serious as they are, m e n ' s morbidity and mortality statistics are not the whole story. Heart disease is the major killer of women as well as men. Half of all deaths a m o n g A u s t r a l i a n w o m e n are from cardiovascular disease, and about a third of those deaths arc considered premature. In a year, about 10,000 heart attacks occur among w o m e n b e t w e e n 20 and 70 years of age. More than half of all w o m e n over age 65 have high blood pressure, and other risk factors follow a similar p a t t e r n . The e x c e p t i o n is s m o k i n g , w h i c h is m o r e common among younger women than in the g e n e r a t i o n s of their m o t h e r s and grandmothers. Because smoking doubles the risk of h e a r t attack and s t r o k e , the popularity of smoking among young women is alarming. Smoking in combination with the use of oral contraceptives multiplies the risk 10 times.
BEYOND THE STATISTICS These statistics alone would provide ample reason for interest in our question. There are, however, other dimensions. Despite the fact that it is the major killer of women, only very recently has serious attention been t u r n e d to cardiovascular disease a m o n g women. Men's disproportionately higher i n c i d e n c e of m o r b i d i t y and p r e m a t u r e mortality from heart disease produced an impression among lay people and doctors ^ V RpYAl. CQLUE0E OF NURSING. AUSTRALIA^
alike that heart disease happened only to m e n . This s t e r e o t y p e of h e a r t d i s e a s e retarded the recognition of the significance of the p r o b l e m a m o n g w o m e n , and may h a v e c o n t r i b u t e d to the sense in s o m e quarters that a focus on women and heart disease is somehow extraordinary, a kind of extravagance. T h e r e m a y be i m m e d i a t e serious consequences of the stereotyped image of heart disease. Recent American, British and Australian research suggests that cardiovascular symptoms are liable to be investigated less thoroughly and treated less a g g r e s s i v e l y in w o m e n t h a n in m e n . Apparently the discrepancy is not explained by differences in the average ages at which women and men become ill. The failure to pursue symptoms vigorously would be an u n d e r s t a n d a b l e result of a w i d e s p r e a d though incorrect - belief that women don't get heart disease. Such a belief might make doctors less likely to suspect heart disease in a woman, and less likely to take it seriously when it occurs. It may also promote a belief among women and their families that heart disease isn't a women's health problem and t h e r e f o r e t h a t the risk factors a r e n ' t important to women. A related and equally disturbing element is the neglect of women in medical research g e n e r a l l y , i n c l u d i n g r e s e a r c h on h e a r t disease. In medical research, men and male animals have been the main or only subjects of m o s t s t u d i e s of d i s e a s e , d i a g n o s t i c procedures, management, therapy and prevention. Sometimes, when women were included, the results derived from w o m e n w e r e d i s c a r d e d b e c a u s e they d i d n o t conform to the pattern based on results from m e n . The c o n s e q u e n c e is that we often k n o w little or n o t h i n g a b o u t h o w s o m e disorders can manifest themselves differently in women and men, how risk factors may vary, or h o w the sexes m a y differ in their r e s p o n s e to t h e r a p e u t i c interventions. The present confusion over dietary advice to women regarding intake of fats is an e x a m p l e of, and an i m p o r t a n t question raised belatedly because of, an assumption that findings relevant to men w o u l d be r e l e v a n t to e v e r y o n e . T h i s a s s u m p t i o n in t u r n r e s t s on a d e e p c o n v i c t i o n t h a t the n o r m a l b o d y is n o t subject to such aberrations as h o r m o n a l cycling, pregnancy, lactation or menopause, t,
*9tyu> soitadK ogi^taft
a n d t h a t it is t h e r e f o r e a p p r o p r i a t e to exclude such aberrant bodies from medical r e s e a r c h on the g r o u n d s t h a t t h e y 'contaminate' the results with 'extraneous' variation. I must stress that I am not accusing doctors a n d r e s e a r c h e r s of sexism - that is, of a prejudice against women or any intention to treat them less effectively or to ignore their h e a l t h care - a l t h o u g h sexism m a y be present in some instances. On the contrary, it is perfectly possible - indeed it is more likely - for the processes I identify to prevail in the absence of any anti-woman feelings or attitudes, but the results can still be harmful to women. We are just now beginning to explore the p o s s i b i l i t y t h a t the ' s a m e ' d i s e a s e m a y manifest somewhat differently in w o m e n t h a n in m e n . AIDS is an e x a m p l e : the pattern of the 'typical' AIDS case has arisen from observations of men, because men are the majority of HIV-positive people in the d e v e l o p e d w e s t a l t h o u g h , in the w o r l d overall, w o m e n are equally likely to be infected. T h e m o d e l t h u s d e r i v e d is s u s p e c t e d of r e t a r d i n g the d i a g n o s i s in women and consequently delaying effective treatment. It is also possible that optimum management of some conditions may sometimes differ between the sexes. The very factors that have justified women's exclusion from most medical research raise important questions about whether therapeutic regimens developed and tested on men will be safe and effective for women. Women diabetics have suspected that doses of insulin vary in effectiveness at different t i m e s in the m e n s t r u a l cycle, and they have sought largely unsuccessfully - doctors who would c o o p e r a t e in an e x p l o r a t i o n of s u c h v a r i a t i o n . It h a s also b e e n f o u n d t h a t damage from alcohol occurs more rapidly a m o n g w o m e n t h a n men because of sex differences in the metabolism of specific chemicals. O n e m i g h t ask w h e t h e r analogous processes may be relevant to the m a n a g e m e n t of h e a r t d i s e a s e . Are the p r o t o c o l s d e v i s e d by a n d for m e n completely appropriate for women and, if not, what modifications might improve the care of women with cardiovascular disease? Women have not been completely neglected in the picture of heart disease, however. We t j j g g g U ^ N VQUyM£%M JAN«AR£«9£
have had a place, and it is in the home. Until r e c e n t l y , w o m a n ' s m a i n role w a s as an u n p a i d c a r e g i v e r for a sick m a n , or especially as the u n p a i d m a n a g e r of the m a n ' s risk factors. Several i l l n e s s prevention campaigns designed to change men's dietary risk factors have been aimed not at promoting behavioural change in men but at inducing guilt and behavioural change among women, who were held responsible for men's eating. Indeed many advertisers do the same thing (recall 'Feed the Man Meat', 'You Ought to be Congratulated' or 'Good on ya, Mum', all messages designed n o t to i m p r o v e w o m e n ' s h e a l t h b u t to induce women to help others eat differently). The TV ads in a NSW North Coast health p r o m o t i o n c a m p a i g n of the early 1980s supply a vivid example. In one commercial, a husband and young children are shown in a large glass beaker in the kitchen, to which the wife/mother is cheerfully adding large doses of fat, emptying her frypan to refill it once more as she prepares yet another meal consisting almost entirely of high-cholesterol foods a n d d r o w n i n g her i n n o c e n t a n d protesting family in the excess fat. This representation is superficial, unhelpful and i n s u l t i n g to w o m e n a n d m e n a l i k e . A l t h o u g h I am n o t a w a r e of s i m i l a r representations in the more recent past, it is a c a u t i o n a r y lesson to p e o p l e in h e a l t h promotion. A more respectful a p p r o a c h would have uncovered many women who were painfully aware of their h u s b a n d ' s risky e a t i n g p a t t e r n s a n d e a g e r for constructive help in facilitating positive c h a n g e s . R e p r e s e n t i n g w o m e n as the ignorant p e r p e t r a t o r s of their h u s b a n d s ' (and c h i l d r e n ' s ) ill h e a l t h d i d n ' t h e l p women, and representing men as the childlike v i c t i m s of w o m e n ' s i g n o r a n c e did n o t h i n g to e n c o u r a g e m e n to take responsibility for their own health.
concentrating on men, a little attention to women isn't too much to ask. But there is more to it than that. The omission of women arises from an o v e r a l l failure to t a k e gender - masculinity as well as femininity seriously. The concentration on men is not an honest and explicit affirmation of the m a s c u l i n e ; it is an u n n a m e d a n d u n a c k n o w l e d g e d p l a c i n g of m e n at t h e c e n t r e . That is, it is a focus on m a l e s m a s q u e r a d i n g as attention to h u m a n i t y . Because this focus is not forthright, it is blind to its e x c l u s i o n of w o m e n a n d c a n n o t acknowledge the masculinity of its subject matter.
A HAZARD TO MEN?
Until recently, the medical establishment has i g n o r e d the relevance of m a s c u l i n i t y to health, just as it has ignored the relevance of femininity, and ignoring gender is probably as hazardous to men as to women. It is, I believe, one of the crucial elements that p r e v e n t e d for so long recognition of the w a y s m a s c u l i n i t y c o n t r i b u t e s to h e a r t disease risk factors. Smoking, for example, w a s for s e v e r a l d e c a d e s m a i n l y a m a l e a c t i v i t y ; i n d e e d , it w a s a m e a n s of confirming and displaying certain forms of masculinity, a fact not lost on advertisers. 'Quit' programs might have been more effective more quickly if they had attended to the g e n d e r (not to m e n t i o n class) i m p l i c a t i o n s of s m o k i n g a n d h e n c e of q u i t t i n g . The specific implications may c h a n g e w i t h t i m e , b u t the r e l e v a n c e of gender persists. Tobacco marketers have been much quicker than the health sector to identify and capitalise on the potential of gender to mobilise new markets for their p r o d u c t s . Belatedly, as the incidence of smoking among young women has increased, health promoters have noticed that smoking has different social meanings and symbolic power among different sectors of the p o p u l a t i o n , a n d s o m e of t h o s e differences are gendered.
That last example connects neatly with what may seem the m o s t u n a n t i c i p a t e d consequence of the failure to take women seriously: I think it has been bad for men as well as for women. Consequently, I believe that attention to women and heart disease will also benefit men's health. To do that we must return to the question: what is special a b o u t w o m e n and h e a r t disease? Some p e o p l e m a y t h i n k t h a t s i m p l e e q u i t y is answer enough. After all the y e a r s
The effort to promote dietary change and exercise must also take gender seriously if it is to be effective. Alcohol consumption and drunkenness have been socially accepted for men, and almost requisite in some circles of adolescent and young adult men. Specific foods and styles of food p r e p a r a t i o n are associated with masculinity and, if men are to eat a h e a l t h i e r diet, the s y m b o l i c c o n n o t a t i o n s of food m a y h a v e to be considered. We might learn a lot from the
effective initiatives of gay men in eroticising safe sex. They have transformed prevention into a positive and pleasurable part of gay masculinity. By contrast, the heart disease prevention message has been largely a dour lesson in asceticism and denial, including denial of certain forms of masculine selfexpression and pleasure. If a man suggests that "doing these things won't actually make you live longer ... it'll just seem longer," nobody should be surprised.
appropriately. If, on consideration, gender appears to have relatively little bearing on some particular illnesses, well and good. This brief discussion has suggested that gender has important implications for many aspects of heart disease, and that the focus for t h i s y e a r ' s H e a r t Week is far from premature. I a p p l a u d the Heart F o u n d a t i o n ' s focus on w o m e n and heart disease, which is timely and welcome to all w o m e n a n d to the m e n w h o care a b o u t them.
CONCLUSIONS Heart disease seems a far cry from what we h a v e b e e n e n c o u r a g e d to think of as 'women's health issues'. Reproductive and gynaecological health are now accepted as b e i n g a b o u t w o m e n ' s h e a l t h , j u s t as testicular cancer and impotence are accepted as men's health problems. But I have been arguing that this narrow understanding of the relationship between gender and disease w o n ' t d o . H e a r t d i s e a s e is as m u c h a women's health issue as breast cancer, and it ought to be as much a men's health issue as prostate disease. The sexed body does not become neutered simply because the organ in question occurs in both male and female bodies, or because the disease in question occurs in women and men both. A woman is not just a case of heart disease, a man is n o t j u s t a h e a r t attack. I g n o r i n g t h e relevance of gender does not diminish its relevance; it just makes it more difficult to c o n s i d e r the r e l e v a n c e of gender thoughtfully and respond to it
The slogan for last year's Heart Week was 'Heart disease doesn't care what sex you are'. Maybe heart disease doesn't but social i n s t i t u t i o n s d o , a n d it is a b o u t time we started taking that fact seriously in health care.
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