This month, I am writing from Paris as part of a meeting on medical communications in Geneva. In traveling, I have given some thought to different cultural and environmental variables that affect men's health globally. Numerous French anthropologists have long been interested in the role of culture in shaping human behavior and health. Marcel Mauss, founder of the Institute of Ethnology of the University of Paris, studied human societies as total systems, self-regulating and adaptive to changing circumstances in ways designed to preserve the integrity of the system. Mauss exerted considerable influence over such disparate figures as Claude Levi-Strauss in France and Bronislaw Malinowski and A.R. Radcliffe-Brown in England. These early anthropologists pointed out the health promoting properties of traditional cultures in which there were few of the stressors that increase male mortality today and their work inspired much of the artistic and creative counter-culture that thrived in Paris in the first half of the 1900s.

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However it is not until recent years that anthropologists have pulled together bio-cultural data to develop solid theories on the anthropology of men's health. The key discovery of anthropologists on men's health focuses on the greater risk of men for dying from a variety of causes and the bio-cultural drivers of this tendency. A recent study by Kruger and Nesse (2004) provides the basis for this review drawing on pioneering cultural and bio-behavioral research in 20 countries. By better understanding the anthropology of men's health, we can move towards a more holistic, less pharmacologically based, approach to male health problems.

Kruger and Nesse (2004) note that the discrepancy between male and female mortality rates, recognized since at least 1750 (Kalben, 2000), has been explained by an array of biological and behavioral causes (Hazzard, 1990; Kraemer, 2000). In species where females make a greater parental investment, they tend to be more discriminating in mate choice, so the reproductive success of males depends largely on their ability to compete for mating opportunities (Trivers, 1972), either by winning fights with other males or by presenting displays preferred by females (Darwin, 1871). The fitness benefits of these outcomes tend to increase the prevalence of genes that promote male risk-taking and competitive ability at the expense of decreased investment in repair capacity and disease prevention (Daly and Wilson, 1978). This is the evolutionary reason why females live longer on average in most animal species (Hazzard, 1990).

Compared to women, men tend to have greater height and weight, more upper-body strength, higher metabolic rates, higher juvenile mortality, later sexual maturity, and shorter life-spans (Cronin, 1991). The role of sexual selection is supported by the high correlation between excess male mortality and sexual size dimorphism across mammalian taxa, after controlling for the effects of phylogeny (Promislow, 1992). Some increased risk results directly from the increased vulnerability of male structural, physiological, endocrinological, and immunological systems, especially lower resistance to infection, injury, stress and degenerative diseases (Folstad and Karter, 1992; Hazzard, 1990). Male mammals are also more likely than females to have parasites (Moore, 2002), both because of the immunosuppressive effects of testosterone and because their bodies are simply larger (Folstad and Karter, 1992). Infection or parasites kill twice as many men as women in developed countries, four times as many in undeveloped countries (Owens, 2002). Hamilton and Zuk (1982) have proposed that females are sensitive to physiological cues reflecting parasite loads in potential male mates, with the exemplar being female birds that prefer brightly colored males. Men are also more susceptible than women to mortality stemming from cold winter months. (Rau and Doblhammer, 2003).

Kruger and Nesse also note that sexual selection helps to explain some differences in behavioral tendencies, including risk-taking, competitiveness, and sensitivity to hierarchy (Cronin, 1991). Greater male than female variation in reproductive success means that risk-taking has higher payoffs for males as they compete for resources, social status, and mates (Daly and Wilson, 1985).

Special selection pressures faced by females may also have increased sex differences in the tendency for engaging in risky behaviors. The costs of risk-taking tend to be higher for women because offspring survival depends more on maternal than paternal care and defense (Campbell, 1999). This notion fits quite well with the recent recognition of sex differences in behavioral responses to stress. Rather than the "fight or flight" behavior that may characterize male behavioral reactions to adverse circumstances, the female behavioral pattern is thought to resemble a "tend-and-befriend" response where nurturant tending activities protect and reduce distress in oneself and offspring and safety and befriending activities create and maintain social networks facilitating this process (Taylor, Klein, Lewis, Gruenewald, Gurung, Updegraff, 2000).

The tendency for males to be less cautious is thought to account for much of the sex difference in rates of violence and the use of alcohol or illicit drugs (Kraemer, 2000) according to Kruger and Nesse. Accidents are the fourth leading cause of death for men in the USA, but the seventh for women (Anderson, 2001). The substantially higher rates of fatal and non-fatal accidents for boys has been partially attributed to a pattern of poor motor and cognitive regulation, leading to a misjudgment of risk (Kraemer, 2000). Epidemiologists are starting to recognize the evolutionary significance of disproportionate male risk-taking in their recommendations for intervention programs (Nell, 2003). Suicide rates for young men in several Western nations are now several times that of young women (McClure, 2000). Social expectations for males to be tough, and discouragement of the expression of emotions such as anxiety and shame may amplify the tendency to take risks (Doyle, 2001; Kraemer, 2000). Some excess male mortality may also result from preferential medical assistance to females in life-threatening situations (Moynihan, 1998).

Higher rates of health adverse behaviors such as smoking, drinking, and working in hazardous occupations contribute to excess male mortality (Hazzard, 1986). The recent dramatic declines in male mortality from lung cancer and stroke are due in part to decreases in male smoking rates (Brennan and Bray, 2002). Smoking rates have increased for women (Pampel, 2002), a factor which may narrow the sex difference in lung cancer and stroke mortality. Males are more likely to die from chronic liver disease and cirrhosis than females, most likely as a result of higher rates of alcohol consumption (Zhang, Sasaki, and Kesteloot, 1995). In industrialized countries, the epidemic of coronary heart disease following several decades of increased consumption of dietary fats, has a greater toll on men than women (Lawlor, Ebrahim, and Smith, 2001).

Kruger and Nesse then go on to note that historical changes in human environments have significantly changed mortality patterns. These influences include: the increased spread of infectious diseases through increasing population size, mobility, and the domestication of animals (Diamond, 1997); public health measures such as improved sanitation and vaccination (McKeown, 1979); the development of antibiotics; the emergence of scientific medicine; the increased availability and consumption of fatty foods, alcohol, tobacco, and other drugs (Eaton, et al., 2002); and the widespread availability of automobiles and lethal weapons. These changes have resulted in both the recent dramatic decline in mortality from infectious diseases (Cutler and Meara, 2001) and the increasing prominence of mortality from causes directly or indirectly influenced by behavior, most of which disproportionately affect men. The decline in maternal mortality has also dramatically decreased the female mortality rate and increased the divergence from the male mortality rate; between 1935 and 1956 maternal mortality dropped from 582 to 40 deaths per 100,000 live births in the USA (Guyer, 2000).

Women's health has also been adversely affected by changes from cultural modernization. Increasing caloric intake and consumption of dietary fats has led to earlier menarche (Eaton and Eaton III, 1999), and women in modern societies experience several times more menstrual cycles than women in natural fertility populations (Eaton et al., 1994; Strassman, 1997, 1999). The increase in women's exposure to estrogen is likely responsible for increased rates of ovarian and breast cancers (Eaton et al., 1994; Strassman, 1999).