Northern Ireland Forum

for

Political Dialogue

~~~~~~~~~

MEN'S HEALTH IN NORTHERN IRELAND

- An Examination by Standing Committee 'C'

(Health Issues)

~~~~~~~~~

Presented to the Northern Ireland Forum for Political Dialogue

on 13 February 1998

Note

DRAFT REPORTS

This report has been prepared by Standing Committee C for

the consideration of the Northern Ireland Forum for

Political Dialogue. Until adopted by the Forum in

accordance with its Rules, this report may not be reproduced

in whole or in part or used for broadcast purposes.

ACKNOWLEDGEMENT

The Committee is indebted to those organisations and individuals who

willingly gave of their time and expertise to assist it in its efforts to come to

grips with this important new area of interest.

This report is theirs as much as anyone's and we are most grateful for their

valued participation and co-operation.

CONTENTS

INTRODUCTION TO REPORT

Section Page

1. BACKGROUND 1

2. MEN'S HEALTH 2

3. WHY MEN'S HEALTH? 3

4. EVIDENCE 4

5. STRUCTURE OF REPORT 5

FINDINGS

6. INTRODUCTION 6

7. NATURE OF THE PROBLEM - OVERVIEW 8

8. DRUGS: Introduction 11

Heroin 12

Enforcement 13

Powder Drugs 14

Illicit Drug Use 15

Alcohol and Tobacco 16

General 17

Shaftesbury Square Hospital 17

Treatment Provision 18

Recommendations 21

9. SEXUALLY TRANSMITTED DISEASES:

Introduction 23

Spread of HIV 24

Pregnancy and Abortion 25

Recommendations 26

CONTENTS

(Cont'd)

Section Page

10. SUICIDES: Introduction 27

Risk Profiles 28

Recommendations 32

11. GENERAL: MAIN CAUSES OF DEATH 33

Potential Years of Life 34

Life Expectancy and Disease Prevention 34

Accidents 35

Conditioning 35

Tobacco 36

Exercise 36

Men Only 37

Rectal Examination 37

Workplace Clinics 38

Unemployment 38

Deprivation 39

Recommendations 40

12. MEN: SOME OTHER ISSUES 41

Recommendations 44

13. SUMMARY OF RECOMMENDATIONS AND

CONCLUSIONS 46

LIST OF TABLES

Page

EXTERNAL CAUSES OF MALE DEATHS 10

DRUG TAKING IN NORTHERN IRELAND 20

LIFE EXPECTANCY THIS CENTURY 43

APPENDICES

Appendix A Committee Membership

Appendix B Record of Committee Visit to Shaftesbury Square

Hospital

Appendix C Record of Committee Visit to Shankill's Men's Centre

Appendix D Compendium of Oral Evidence

Appendix E Remit of Committee

Appendix F Bibliography

1

INTRODUCTION TO REPORT

1. Background

1.1 This is the fourth report of Standing Committee C (Health Issues) of

the Northern Ireland Forum for Political Dialogue. It follows a

well-established pattern whereby the Committee takes evidence on a

subject of public concern and relates its findings in documentary

form.

1.2 The subject matter of this report differs in character from the earlier

reports which addressed topical matters that were already at the

centre of the health care stage within the Province or were otherwise

prominent. These reports involved the sifting of evidence, analyses

and the taking of positions.

1.3 This report is about a subject that does not yet have the public profile

it merits and yet it directly affects nearly half the population and

indirectly affects the remainder. It is about a subject that deserves to

become prominent, and part of its function is to raise public, political

and professional awareness, and to see that in this, the era of

'equality', it is accorded a much deserved and overdue equality of

treatment in the minds and, most importantly, in the actions of all

concerned.

2

1.4 Such equality does not have to be argued for. It is there to be

realised. Its absence is evident through ignorance and neglect

principally on the part of men in relation to their own health.

1.5 This is not a report that is brim full of statistics though the expert

witnesses and the written evidence yield enough of these. No, the

argument at this stage is not about precision in figurework but about

the recognition of a new concept, and the subsequent doing of

something about it. In any event there is no dispute as to the facts

among the various witnesses who were drawn from the statutory,

voluntary and academic sectors.

1.6 The report's focus is on men's health but it is of a very general nature

and includes sections that go somewhat wider than the generic title

implies. The reason for this is simply that, quite naturally, some

issues which affect men also affect women. Nevertheless the

essence of the report is men's health in the way that the centre of a

target is the bull's eye and one is part of the other.

2. Men's Health

2.1 The report is about men's health or, more aptly, their poor health. It

was prepared with the great encouragement and involvement of

everyone in Committee C - men and women. It is a matter that

affects the health needs of the whole community of Northern Ireland

and it falls within the broad remit, established on 26 July 1996, on

health issues that the Committee enjoys within the Forum.

3

2.2 Men's health has in the past not been seen as a subject that was

politically correct. It is a concept that has only emerged onto the

healthcare stage in the last 3 to 4 years and was first raised by the

Committee in its report on the Health Service endorsed by the Forum

on 26 April 1997.

2.3 Just as women's issues are increasingly the concern of everyone, if

only because in the end they affect everyone, in all kinds of ways; so

it is with Men's Health, and this report most assuredly does not carry

the stamp of MEN ONLY.

3. Why Men's Health

3.1 There is no shortage of material for the Committee to attend to in the

field of public health. Men's health was never at the forefront of this.

However, it gradually began to dawn on the Committee through the

taking of evidence on other subjects, notably on cancer care, that

whilst there were resources and a focus in relation to women's health

there was no corresponding interest in or effort on the health issues

that are important to the well-being of men. It is about men's health,

it is not about taking away anything in terms of resources from any

other area of health.

3.2 This report is much more about raising awareness and making minor

adjustments. It is also about sowing seeds and putting into place a

strategy, at modest cost, that will lead in a very gradual way to a

4

necessary equalisation of prevention, care and treatment for men.

The question is one of realising that these needs exist and of

providing an effective vehicle for their delivery.

4. Evidence

4.1 Having identified the subject as an area on which it would like to hear

more the Committee took some preliminary or introductory evidence

with a view to exploring the benefits of tackling this new area. This

was given by Dr Ian Banks who is a regular contributor on the

subject to the Belfast Telegraph, and Men's Health Magazine. He has

written a number of books and has done television work on the

subject.

4.2 As well as being an acknowledged authority on Men's Health Dr

Banks is a practising general practitioner in a rural area. He chairs the

Men's Health Forum of the British Medical Association (BMA) and

the Royal College of Nursing (RCN).

4.3 Members were impressed with the initial session and a definite

programme of evidence-taking evolved out of this with sessions with

the Samaritans; Youth Action; an expert from the Royal Victoria

Hospital on Sexually Transmitted Diseases (STDs); a research

psychologist from QUB; office-holders of the BMA in Northern

Ireland; members of the Chest, Heart & Stroke Association; the Head

of the RUC Drugs Squad; and a psychiatrist working with drug and

alcohol abusers in Belfast.

5

4.4 Finally, evidence was given by a doctor and a senior administrator

from the Department of Health and Social Services.

4.5 The Committee decided to supplement conventional evidence-taking

with two outside visits - one to Shaftesbury Square Hospital - an

addiction centre - and the second to the Men's Centre on the

Shankill Road.

4.6 All of the above is documented and appears in the compendium of

evidence at the end of this volume.

5. Structure of the Report

5.1 The body of the report - its anatomy if you like - which follows next,

consists of a series of findings which are to do with the nature of the

main health problems facing men in Northern Ireland and to some

extent the background to these. The material comes from written

and oral evidence taken and also from the growing amount of

literature on the matter. A Summary of Recommendations follows

this and supporting documentation is annexed.

5.2 It is important here to add a cautionary note on our literature search.

We make no claims that this is in any way exhaustive. However we

believe that it is both impractical and unnecessary to delve into

ever-more detail in a report that is general in scope and introductory

in purpose.

6

7

6. FINDINGS

Introduction

6.1 A question some people might pose is why get involved in this

obscure subject when there are so many other big issues that could

be dealt with within the Committee remit. The answer to this

question is that this is a cinderella (or more accurately cinder-fella)

subject that does not deserve to be obscure. Any light-heartedness in

the answer should not be seen as detracting from the seriousness of

the subject: it only serves to illustrate the point and indeed the level of

general ignorance there is in this area. The facts are these:

Studies have shown (and this is not restricted to Northern

Ireland) that being born male is a distinct disadvantage with

respect to health and life expectancy. Baby boys are more

frequent victims of sudden infant death syndrome (cot death) and

more male children around the age of 5 are killed in accidents

than females. This shows that even at that young age the male

tendency to 'risk taking' is becoming apparent.

Society is today concerned with equality - rightly and properly

so, although the means of achieving this are always going to be

open to debate and this report makes no comment on this. What

could be more unequal than premature death where the equalities

in life are denied in the most absolute and final way?

8

The average life expectancy of a man is only 72 years compared

with 79 for a women. Indeed in the more senior age group

women outnumber men 4:1 and yet 200 years ago men lived

longer than women. Indeed this was also the case in Northern

Ireland up to the end of the last century. There are explanations

for this, some more speculative than others, but it does at least

suggest that there may be scope for improvements and there may

not be a purely genetic predisposition for men to die earlier than

women.

At present men are indisputably far more likely to die prematurely

before reaching old age than women. They fall victim to strokes,

heart disease and cancers.

More women than men have skin cancer and yet more men die

of the disease.

We were told that 12% of the population have raised blood

pressure. This particularly applies to men but only 1 in 6 will

have their hypertension detected.

Men are not as free as women to discuss their health 'in an

accessible way' and it is very probable that the impact of health

promotion in the past was much greater on women than men.

Women for instance see their doctors twice as often as do men.

9

The rates of suicides for males is much higher than for females.

It is much too high for everyone but since we are here talking

about men's health it is useful to draw the comparison to

underline the point. It is particularly high for young males.

Men are more susceptible to drug and alcohol abuse.

42% of young men's deaths are caused by accidents.

45% of male deaths are caused by external factors (see analysis

at the end of this section).

6.2 All of the above serves to illustrate that men's health is a valid subject

for study and one that should concern all of the species. The record

of questioning in the evidence sessions will show that this was

certainly the case in Committee.

7. Nature of the Problem - Overview

7.1 'Men's Health' has been seen as something that is basically not

'politically correct' and it has not been recognised as an area of wide

interest. All this is now changing however and it is due in no small

measure to the efforts of Sir Kenneth Calman, the Chief Medical

Officer at the Department of Health, that it is moving up the Health

agenda. Before this it appeared only as a very general target within a

large number of targets within the Health of the Nation.

10

7.2 Northern Ireland has some of the worst health statistics in the whole

of Europe and this is particularly true in relation to Men's Health.

7.3 Some organisations, such as Youth Action from which we took

evidence, are beginning to realise that after 20 years of giving priority

to working with women a lop-sidedness may have developed and the

stage has been reached where some corrective is needed to the

direction of effort. There was the feeling that "women have, over the

last 25 years, been very good at putting forward their case. Men are

learning a lot from the feminist movement and from working with

young women". The Committee was also told that in 1998 for

example there will be more females employed in Northern Ireland

than males.

7.4 Societal changes, undoubtedly, have an impact on the health and

well-being of individuals. The extent of this is hard to gauge but we

were also told that "men are not free to discuss their health in as an

accessible way as women are and they do not visit their GPs as

often" and that "we need to provide a service that caters effectively

and sensitively for men in a way that allows them to discuss their

health freely and set personal goals".

7.5 Other evidence suggests that 80% of men only attend their GP

surgeries when their partner tells them and that women on the other

hand go "spontaneously", "early" and "opportunistically".

11

7.6 It is surely time to begin to dig beneath the surface for more detail on

all of this and at least come up with some of the right questions even

if the answers take a little longer.

12

Percentage of Deaths

Attributed to External Factors

FACTOR % OF DEATHS

Tobacco 19

Poor diet/exercise 14

patterns

Alcohol 5

Microbial agents 4

Toxic agents 3

TOTAL 45

13

8. Drugs

Introduction

8.1 The Health Committee was asked in the Forum (RoD 24.1.97) to look

at the Drugs issue. It has not been possible to prepare and consider a

full scale report on this single issue but the Committee is glad to be

able to have done something in this area under the wider and related

topic of men's health. We well realise the limitations of that

something in terms of scope and balance etc, but because of the

many pressures upon the Committee's time it will not be possible to

re-visit the issue in any greater depth in what remains of the Forum's

life-span.

8.2 During the past five years there has been a serious and frightening

deterioration in the drugs situation in Northern Ireland. There are far

more drugs available in every town and village. It is an area in which

nominal religious affiliation plays no part - the problem

comprehensively crosses the divide. The main considerations for the

dealer are those of any legitimate business coupled of course with the

added problems which impinge on criminal activity. Those who deal

in these drugs have no interest in the welfare of their clients

whatsoever.

8.3 People taking drugs are much younger than ever before and it is quite

common for people of 12 and 13 to be involved (probably in the

taking of Cannabis. LSD, Ecstasy and Amphetamine are the drugs of

14

choice for many - a huge proportion of the under-25s are taking far

more of these drugs.

8.4 Surveys show that 42% of 15-16 year olds admit to having used a

drug at some stage; 18% admit to using drugs regularly. (Source:

WHO funded study by HPA of school children in NI in 1994. It

should therefore be noted that these figures are conservative.)

8.5 One of the attractions of drugs for some young people is their price.

The total cost often compares favourably with an evening's

entertainment in, for example, a pub.

Heroin

8.6 Heroin is a drug about which we should be concerned. However to

put its use into some context it is estimated that around 100 young

people use this in Northern Ireland whereas there are 8,000 users in

Dublin alone. Heroin is a very dangerous drug; it is addictive and

leads people to neglect themselves. It is easy to overdose on and

because of the difficulties in knowing purity levels deaths from

injecting due to overdose are very common. Regular users have high

levels of dependence and cannot stop using the drug without help.

8.7 It has to be said for the future though that heroin is beginning to take

a hold in the province. Two kilos of heroin are consumed in

Stranraer (population 17,000) each month and Stranraer is closer to

15

Larne, with which it has an excellent linkage, than are many towns of

a similar or larger size in the province.

8.8 Northern Ireland does not have an injecting culture at present but

with the growth in heroin this will change. Needle sharing will lead to

in increase in hepatitis and possibly AIDS.

8.9 It must be remembered that certain viruses Hepatitis B and C and HIV

are spread quite easily by injecting-drug misuse.

8.10 Doctors prescribe substitutes for heroin, normally this is the drug

methadone. The difficulty with this is that methadone is more

addictive than heroin and therefore harder for the individual to defeat.

This form of prescribing is not warranted in Northern Ireland

because of the relatively small scale of the heroin problem here at

present.

Enforcement

8.11 The RUC Drugs Squad and Customs and Excise are the two key

enforcement agencies. They have an important role in preventing all

forms of illicit drugs coming into this country.

8.12 Law enforcement is very important in relation to drugs. We are

assured that the Drugs Squad has all the resources it requires at this

moment in time in its fight against drugs.

16

8.13 During 1997 drug seizures reached record levels. This is in some

ways a worrying fact because it points to a growing Northern Ireland

market in drugs. Seizure of cannabis and amphetamine both showed

a three-fold increase on the previous year. LSD has increased

phenomenally with seizures of 135,000 kilos dwarfing the previous

year's figure of 8,000 kilos. Arrests point to greater numbers taking

drugs and the emergence of a more complex drugs scene.

8.14 The Drugs Squad does a lot of work in towns in mainland UK

because of the configuration of dealing networks. A working

knowledge is necessary of the drugs situation in areas such as

Manchester, Liverpool, Bolton and Blackpool.

Powder Drugs

8.15 There has been an increase in the use of powder drugs in the

province - amphetamine (speed), cocaine and heroin. Amphetamine

causes people to be very active and to feel energetic. Purity levels of

some of these drugs varies greatly and there are clear dangers at both

extremes.

8.16 Ecstasy, the 'E' tablet is the fourth most commonly used drug in

Northern Ireland. It does not incline people towards violence and is

thus known as the 'love drug'. It causes brain damage in animals in

equivalent doses to those used by young people at raves or dances. It

is possible that brain damage could occur in almost a whole

generation because of this. Some people get used to taking Ecstasy

17

and become very anxious at the thought of giving this up - they may

need a lot of help to successfully kick the habit.

8.17 There have been two deaths in the province associated with Ecstasy.

While under the influence of this drug the individuals were not able to

look after their own welfare.

8.19 These various drugs affect the central nervous system and they are

taken by people to bring about a state of mind that is conducive to

their enjoying themselves. When drugs take effect it is difficult for

those who have taken them to take care of themselves and instead of

taking one drug, increasingly, drug users are resorting to a cocktail.

Illicit Drug Use

8.20 There is growing police concern about interference with drinks in

licensed premises. This activity whereby drugs are added to

alcoholic or soft drinks can take place when patrons leave the table

for any reason. The victim, who later comes under the influence of

the 'Mickey Finn', becomes very frightened and vulnerable as the

drug takes hold.

8.21 The RUC are clear that all terrorist organisations in Northern Ireland

are deeply involved in drug trafficking. The depth of involvement is

on the increase. Part of the reason for this is almost certainly due to

the success of the Anti-Racketeering Squad, set up in 1982, in

closing off funds to these organisations from other sources.

18

8.22 A further difficulty is that when prisoners are released - often people

who had been sentenced because of the last three decades of unrest -

they are unable to get work and consequently feel impelled to move in

on the drugs scene.

8.23 It is thought wise when dealing with a drug problem to also tackle it

at local level. District Councils and others should take an interest in

the problem in their own communities. They can liaise with the

police and they have certain powers than can help combat the

trafficking of drugs on grounds that are not designed specifically for

the combating of illicit drug-taking, for example, on health and safety

and fire prevention grounds or in the granting of occasional licences.

Councils need to let the owners of licensed premises know that

abusive drugs in their establishments will not be permitted.

8.24 There have over the years been suggestions from some quarters that

certain drugs should be de-criminalised but we have heard no expert

evidence that would favour this.

Alcohol and Tobacco

8.25 The numbers of young people who have no qualms about taking

substances illegally must be a matter of great concern to everyone.

8.26 The legal drugs - alcohol and tobacco - have caused incalculably

more harm to physical and mental health and to society than those

19

that are illicit. The volume of work at Shaftesbury Square Hospital is

3:1 in favour of alcohol. Most cases seen at the hospital are of the

severest kind.

8.27 Alcohol consumption has steadily increased and is now double what it

was 50 years ago. Examples of the harm associated with heavy

alcohol intake include physical ill-health, psychological ill-health,

public disorder, crime, family disputes, road traffic accidents (it used

to be considered macho to drink and drive) and employment

problems.

8.28 All of the other addictive drugs used are more frequently by males

than females. However it must be borne in mind that in Northern

Ireland all other addictive drugs cause less than 2% of the deaths that

can be attributed directly to alcohol.

General

8.29 Males easily predominate in the world of drug trafficking. Also there

is a male predomination so far as abusers are concerned and this

would not be unexpected. However drug trafficking and the abuse of

drugs are most assuredly a problem for all of society and particularly

for all our young people. These are our future and middle-class

parents especially, must take to heart the real possibility that they are

not immune. If all parents do not remain alive to the dangers they

may find their families joining the statistics. Some statistics which

20

illustrate the scale of drug taking in the province are given in the table

following this section.

Shaftesbury Square Hospital

8.30 The Committee visited Shaftesbury Square Hospital on

5 November 1997 following an evidence session with the Resident

Consultant Psychiatrist at the establishment Dr Diana Patterson. The

hospital exists to work in partnership with people who have problems

of addiction, providing:

health education and support

a caring partnership for addicts

encouragement to addicts and abusers to take personal

responsibility

a point of contact and co-ordination

an assessment of individual patient needs

We were impressed with the services we saw at this hospital as

representative of the addiction services available across the province.

In view of the evidence we have taken from the police there can be

little doubt that such services, unfortunately, have a fairly certain

future.

Treatment Provision

21

8.31 Each of the Health and Social Services Board has provision for

treatment of drug misuse. The Eastern Health and Social Services

Board has two centres and the other Board has one each. The

centres were originally set up for the treatment of alcoholism and

have had their roles expanded to encompass the treatment of drug

misuse. There is no specific funding in Northern Ireland for the

treatment of drug addiction.

8.32 In 1996 the Government launched a package of measures aimed at

tackling drugs misuse. The Northern Ireland Drugs Campaign

co-ordinates the work of the Police, Customs and Excise, the

Northern Ireland Prison Service, The Probation Board, The Health

Promotion Agency (HPA), DHSS and DENI, and the Statistics and

Research Agency.

8.33 The comprehensive measures include an HPA-led Public Information

Campaign which aims to discourage experimentation among young

people and raise general awareness; the running of video-based

training sessions in schools and the provision of funds to enable the

schools to buy in supporting materials; the distribution of a handbook

for professionals and the provision of a Directory of Services for

those working in the field; the establishment of a co-ordination

network based on the H&SS Boards; and the initiation of a research

strategy and programme.

22

Percentage of Males and Females who have ever used certain drugs

Male Female

Amphetamines

Cannabis

Ecstasy

LSD/Acid

Magic Mushrooms

Tranquillizers

Amyl/Butyl/Nitrate

Glue/Solvents/Petrol etc

9.5

26

6.3

7

11.3

5.3

13.5

6.4

3.1

9.5

2

1.9

1.2

9.5

3.2

1.7

Source: NI Omnibus Survey

23

RECOMMENDATIONS

We feel that there needs to be a greater awareness of the

dangers that can arise resulting from interference with drinks

in public houses. Patrons need to be aware of these dangers and

publicans and proprietors have a special though onerous

responsibility here. This is an issue which requires greater

publicity and agencies should consider how best to tackle this

problem.

We were given evidence from the BMA that a reduction in legal

alcohol limits would save lives. We welcome the moves being

made in England to lower the legal alcohol limit there and

recommend that the position in Northern Ireland be kept in line

with this.

We commend and support the Northern Ireland Drugs

Campaign and would ask that the efforts in this area be

sustained.

The area of prisoner releases and their reintegration into

society is something to which the authorities will need to give

some thought. It is not just a question of enforcement or

education, prisoners need help to reintegrate into society and if

they are turning to crime on release then the present

24

arrangements for their re-introduction into society are not

working (the evidence given was that they were getting involved

in the drugs scene). And here we appreciate that we move from

health to criminal justice and its aftercare but in this case the

two are inseparable. We ask for a co-ordinated response from

all of the statutory agencies and we do so through the medium

of DHSS and Mr Worthington the Minister for Public Health in

Northern Ireland.

25

9. Sexually Transmitted Diseases

Introduction

9.1 People are generally unaware that Sexually Transmitted Diseases

(STDs) are one of the major world-wide public health problems and

that they are as old as humanity itself. The World Health

Organisation estimates that there are in excess of 300 million new

infections of these annually. The scale of HIV, the most serious

sexually transmitted disease world-wide, has reached epidemic

proportions and contrary to popular belief 75% of cases have been

transmitted heterosexually.

9.2 Locally the provision of services to combat sexually transmitted

diseases is centred at the Royal Victoria Hospital. The service in

Northern Ireland is based on 4 sites.

9.3 Sexually transmitted diseases are mainly diseases of young people.

The main risks of acquiring them are well recognised and arise from

sexual behaviour.

9.4 The evidence in this case given mainly by Dr Maw details a number

of sexually transmitted diseases and some of the problems associated

with them. Some are much more prevalent than others. Some

diseases such as gonorrhoea and syphilis have been largely

eradicated.

26

9.5 The most feared of the STDs is of course HIV and in Northern

Ireland to date 222 cases have been identified. A scientifically based

survey shows that the problem is increasing.

Spread of HIV

9.6 In Northern Ireland two-thirds of those who are HIV infected are

homosexual males. The disease is principally to be found in young

men with the major attacks occurring a decade or so after infection.

9.7 There are now a larger proportion of gay men remaining in Northern

Ireland and it is likely that this will increase the incidence of HIV here.

Additionally there is a growing heterosexual spread.

9.8 There are a number of innovative treatments now available for HIV.

Some of these have been called 'Lazarus drugs' because of their

success in treating HIV in its advanced state. Therapy is expensive

although other interventions for other diseases can be much more

expensive. Prevention is as always best and this can be affected by

various means ranging from the use of condoms through a reduction

in sexual partners to abstinence. The bottom line requirement in

relation to STDs is to have a programme of effective health and

sex education.

Pregnancy and Abortion

27

9.9 The abortion and the unwanted pregnancy rates are growing. We

were advised that basic education in these matters has to start early in

a child's life - even before secondary school. If this is so then it will

have to be handled carefully and sensitively and with maximum

parental understanding and co-operation. Some people take the view

that if you educate people about sexual matters you encourage them

to have sex at an early stage. Others argue that this is one of the few

aspects of human endeavour and life in which education is positively

discouraged and that to take such a position is the very antithesis of

education itself. Whatever the truth of the matter, and perhaps there

is no absolute black and white in this case, it is a difficult area in

Northern Ireland and at this time we make no specific

recommendation, not least because we have not taken sufficient

evidence to enable us to definitively do so. We are however

committed to taking further evidence on the question of abortion but

this falls outside the scope of this report.

28

RECOMMENDATIONS

We are concerned at the poor resources in the area of

genito-urinary medicine in Northern Ireland and would call on

the Department here to implement the guidelines on resources

that have been applied in England and Wales. Additionally

there would seem to be a need for the provision of adequate

psycho-sexual support services that will allow patients to be

referred on to further specialist services.

The bottom line requirement in relation to Sexually

Transmitted Diseases is to have a programme of effective

health and sex education.

29

10. Suicides

Introduction

10.1 Annually in Northern Ireland in excess of 100,000 people seen by

their general practitioners are diagnosed as mentally ill. Over 11,000

will be referred for specialist treatment of some kind. Mental health

difficulties can particularly affect males and are not limited in their

consequences to the individual; they also affect family and friends

and suicide is without question much more common among men.

10.2 Suicide is a complex area that is not well understood. Prediction is

extremely difficult. From the late 1970s to the mid-1980s there was

a sharp increase in suicides (male and female) but the rise for male

suicides has been steeper. One of the main sources of data is death

certificates.

10.3 A study in the Greater Dublin area in the 1970s indicated that the

suicide rate was 117% under-represented. We were given evidence

to suggest that suicide rates would always be under-estimated.

10.4 Evidence was given that suggests that it might be possible to make

some improvements in the process of classification of deaths in the

Office of the Registrar General. The indications are that the true level

of suicides may be being masked.

30

10.5 For every female who takes her life by suicide 3 times as many males

do so and for young males the rate is much higher

Risk Profiles

10.6 The profile of those at risk shows a very clear association with their

mental state. There may be a psychosis (a severe form of mental

disorder where the individual experiences hallucinations, delusions

etc, perhaps where he is being told to kill himself). If psychotics are

not successfully treated with medication they could be at risk.

Psychosis is an indicator of suicide risk and depressed mood is

probably one of the best indicators.

10.7 People at particular risk often have a history of more than 4 years of

living alone as a single, divorced, widowed or unemployed person or

as a person whose status has in some way suddenly changed.

10.8 Unemployment is a major pre-disposing factor in the case of suicide.

As unemployment rose in Edinburgh in the 1970s so too did the

suicide rate which reached epidemic proportions with a 10-fold

increase.

10.9 In the United States the term 'Hopelessness' entered the vocabulary of

the psychiatrist when it became clear that doctors were seeing

patients who displayed none of the classic suicide risk factors. They

were not depressed, unemployed or suffering from severe mental

disorder - they quite simply appeared to have lost hope. It is clear

31

that if someone communicates suicidal ideas he (or she) should be

considered a high risk.

10.10 It is believed also that the more intelligent a person is the more likely

he may be to take his own life. The more risk factors that are

present in a particular case the greater the likelihood of a tragic

outcome.

10.11 Evidence was given that 15% of all individuals who suffer from

depression will kill themselves. 18% of alcoholics kill themselves

(alcohol, it must be remembered, is a depressant). 10% of

schizophrenics eventually kill themselves and 1:100 of the population

is schizophrenic. Schizophrenia is the most severe mental illness and

it can take a number of different forms.

10.12 Suicides are twice the rate in rural areas that they are in urban areas.

This is a reversal of the position of 20 years ago. Rural employment

will decrease over the next few years and rural life is often very

isolated. Farmers are coming under increasing financial pressure

with many farms no longer viable. All of this, it is believed, leads to

an increased risk and because of the pathology of suicide the full

effects of the BSE crisis have yet to be felt.

10.13 People who are at a particularly high risk are members of the security

forces. These have a ready means to their own destruction.

Following them those mainly at risk range from labourers, through

the unemployed, farmers (who often also have access to firearms

etc) and health service personnel. In modern western countries

32

constant change has brought with it a most phenomenal amount of

pressure for the individual. The indicators show that those at risk

will be young males between the ages of 20-34 who live alone and

who are unmarried, separated or divorced.

10.14 Without going into details of the methods here it is the case that male

suicides tend to be of a more violent nature. Studies have shown that

a person who is intent on taking his or her life will ultimately do so.

However there are many people who have had suicidal thoughts and

urges and who are given space at the critical point through timely

help.

10.15 People are not most at risk when they are in the depths of depression

or when they are having to wrestle with a crisis. The risks come as

they begin to come out of depression and recover the ability to act.

10.16 Voluntary work in this area of endeavour is carried out by the

Samaritans. This is a nation-wide organisation which was set up in

London 1953 by Rev Chad Varah, a Church of England cleric with a

scientific training. Varah did some research on the incidence of

suicide and para-suicide (attempted suicide) and concluded that there

was a need for a voluntary body to provide ready access to people at

times of crisis who were suicidal, desperate or despairing. Branches

were subsequently set up all over the UK and there are now 8

branches in Northern Ireland. The Samaritans provide a 24 hour

confidential service staffed by unpaid volunteers.

33

10.17 In 1996 there were over 115,000 contacts with members in Northern

Ireland. Of that number 8,276 people were prepared to discuss

suicidal thoughts and feelings. Interestingly, calls to the Samaritans

are nearly equal for males and females yet the suicide rate among

males runs much higher. This raises a number of questions but the

ethos of confidentiality that applies within the Samaritans organisation

militates against a deeper analysis, although it is possible that the

organisation itself, resources permitting, could do its own analysis.

10.18 We are aware, from sources other than evidence given, that the

Samaritans are also involved in a schools-based programme to defeat

depression.

34

RECOMMENDATIONS

We recommend that the Registrar General should review the

classification of deaths in his office with a view to improving the

accuracy and utility of the information he produces on causes of

death. He should consult with health and other professionals as

well as academics who work in the field as part of this exercise.

It appears to the Committee that it would be easier to catalogue

the occurrence of suicide in Northern Ireland if Coroners'

Courts were able to return a definitive verdict. This is an issue

which crosses government Departments but we address it to the

Minister for Public Health and ask that he consider it and that

he involves colleagues in the ministerial team in looking at the

possibilities and in taking them forward.

We fully support the schools-based Defeat Depression

Campaign.

35

11. General

Main Causes of Death

11.1 The main causes of death are heart disease, cerebro-vascular disease

(strokes etc) and cancer. These are followed by respiratory disease,

accidents, injuries and poisonings.

11.2 A decrease in cigarette smoking would help to make a huge impact on

the number of strokes (as it would in other areas of ill-health).

11.3 We do not know how many strokes occur in Northern Ireland

because there is no stroke register. A recent estimate of the numbers

suggest that the annual figure may now be as high as 4,500. Of

these, approximately one-third recovers, one-third die and one-third

will be left disabled.

11.4 An analysis of the external factors which affect health shows that

alcohol, infectious agents and poisons account collectively for nearly

half the deaths in Northern Ireland. Much of this relates to what has

been described as behavioural choices. For example the smoking of

tobacco, the consumption of alcohol, the food that we eat and the

taking of exercise are often all a matter of choice.

36

Potential Years of Life

11.5 Premature deaths are often described statistically by epidemiologists

in terms of potential years of life lost. We know that potentially we

can expect a man in Northern Ireland, on average, to live until he is

72 years. If, for example, a young male dies at 20 then 52 potential

years of life, using the average figures, are lost. The total such loss

in any given year is the accumulation of these statistics in that year.

Figures for males depending on the cause are often markedly higher

than for females and this is especially pronounced in the case of road

traffic accidents, homicides and suicides.

Life Expectancy and Disease Prevention

11.6 There has been a huge improvement in male life expectancy this

century ranging from 47 years at the turn of the century to 72 years

in 1995. There are a number of reasons for this but foremost among

them has been the emphasis placed on disease prevention

(immunisation in particular but also on housing and nutrition). It is

also interesting to know that male life expectancy was higher than

female life expectancy (marginally) at the turn of the century.

Average life expectancy levels within the UK are higher than for

Northern Ireland but interestingly, at the same time, the differential

between males and females is lower. This shows that Northern

Ireland is relatively worse than the UK average in terms of life

expectancy for men on two counts. A tabulation of Northern Ireland

Life Expectancy at Birth and at 65 is shown at the end of this section.

37

Accidents

11.7 Accidents are also a major cause of death and injury due mainly to

home and road traffic accidents (accounting for 40% of all

accidents). There are estimated to cost in the region of £400m

annually. The vast majority of accidents are preventable and the

importance of prevention generally has recently been dramatically

underlined by a Public Accounts Committee report on the treatment

of heart disease.

11.8 Ongoing work on prevention of road accidents is being undertaken by

a cross-departmental working group, the Road Safety Review Group.

11.9 Home safety is a more difficult area. A recent strategy document

prepared by RoSPA which focuses on ways of improving

preventative services is being looked at by the Department.

11.10 It is useful to observe that there has been a much needed shift away

from the emphasis on mortality figures in relation to accidents -

clearly these are only the tip of the iceberg.

Conditioning

11.11 In Northern Ireland we have one of the highest death rates in the

world for coronary heart disease. We were told in evidence that it is

94% higher than the average for the European Union. Even if the real

38

percentage were only half this figure the difference would still be

quite staggering.

11.12 Health is an area in which genetics plays a very important part but

thankfully that is far from the end of the story. The way in which

we are brought up is also of a high importance, some would say of

paramount importance. Men are conditioned through early childhood,

through the media and society and general into a macho way of

thinking. This conditioning may well be the source of many of their

health problems.

11.12 Such conditioning extends through adulthood with many men having

minimal contact with children because "they go to work in the

morning when it is dark and the kids are still in bed, and they come

home in the evening when the kids are getting ready to go to bed".

Tobacco

11.13 Tobacco is responsible for 3,000 deaths annually in the province and

half of those who smoke ultimately die of their habit. If a man of 50

begins to smoke he increases his risk of heart attack three-fold. It

has been shown that if young people can be kept away from the habit

to the age of 20 the odds are excellent that they will not become

lifelong smokers. There is no shortage of evidence against tobacco:

what is lacking and has been lacking for a very long time is the

political will to face the problem.

39

Exercise

11.14 There may be a need to encourage men to look after certain aspects

of their health - for example to look after their weight and blood

pressure.

11.15 We know that exercise is linked to success in weight control and that

trying to lose weight without exercising is counter-productive. Some

42% of males in Northern Ireland are overweight and 10% are obese.

Men Only

11.16 There are a number of diseases that affect men only. These are

principally to do with the sexual organs, eg testicular cancer and

prostate cancer. The latter is second only to lung cancer in the

number of cancer deaths accounted for in males. It is a serious

public health problem and as yet there is no evidence to show

whether or not early detection and treatment improves survival rates.

Rectal Examination

11.17 Evidence was given to the Committee on the problems associated

with men submitting themselves to a rectal examination. This is

perhaps not a particularly nice thing to discuss. But it is not a

question of taste and the Committee makes no apology in tacking this

issue.

40

11.18 A rectal examination apparently (and unsurprisingly) is something that

is resisted by patients and avoided by general practitioners and yet

90% of the tumours in cases of colo-rectal cancers are 'within reach

of a gloved finger'. Major studies in America show that early

diagnosis makes a massive difference and in that country they have

succeeded in getting men to accept that such an examination is

perfectly normal.

41

Workplace Clinics

11.19 One of the things that has been shown to be effective in generating

the interest of males in their health is where clinics are located in the

workplace. Clinics that is, not in the relatively narrow sense of

occupational health but clinics that deal with all health issues. Men

will take an interest in their health if a service such as this is delivered

in the workplace. The payback for a management investing in these

services is a reduction in sickness absence. An excellent example

locally of the system in action is the scheme operated by Du Pont in

Londonderry which has won a national (UK) award for its work.

Dr Porter has led Du Pont (Europe) in this endeavour.

11.20 These schemes are of course all very well for the larger companies

but small companies could not afford them. However alternatives to

such schemes are offered by a number of organisations including the

City Hospital and charities such as the Chest, Heart and Stroke

Association. It appears that bringing health into the workplace as an

issue works particularly well for men.

Unemployment

11.21 Unemployment brings health problems particularly among men as the

proportion of male employment in the workforce decreases. It brings

many challenges to males who have been used to being a

'breadwinner' for their families and is a risk factor associated with

42

mental ill-health and suicide. It often is a component of social

deprivation. Here, the role of early diagnosis is important.

Deprivation

11.22 There is a well-established link between social deprivation and

ill-health and it has also been suggested that societies that are less

equal may have poor overall health on average than those that are

more equal.

11.23 Taken as a whole the Northern Ireland population is more

disadvantaged than other parts of the United Kingdom and the

proportion of long-term unemployed - and this is particularly acute in

the case of males - has been consistently higher and household

incomes are lower.

11.24 The standard of health within Northern Ireland by whatever measures

used is among the lowest the UK. Morbidity and mortality rates, and

levels of disability are all markedly higher than in better regions of the

UK. Social deprivation brought about by a number of factors needs

to be tackled and this is particularly true of the scourge of

unemployment and in this case of male unemployment in particular.

11.25 A GP-led programme of preventative health consisting of periodic

screening check-ups of patients in high risk groups might prove

helpful.

43

RECOMMENDATIONS

In dealing with some of the huge public health issues,

professionals need to work alongside business, the voluntary

sector (including community organisations) and local councils.

The public needs to know the dangers posed by elements of

their lifestyle. They need to be able to make necessary

adjustments and to get help in doing so.

A good relationship with a caring and listening adult is crucial to

the health and well-being of male children and adolescents .

The Committee recommends that a Government ban on tobacco

sponsorship and advertising should be introduced as soon as

possible. An attack on the devastating effects of tobacco

smoking on the health of the nation must be begun sooner

rather than later.

The Committee recommends that the Department seriously

consider the establishment of a stroke register within the

province so that the full scale and consequences of the stroke

problem can be monitored and tackled.

44

12. Men - Some Other Issues

12.1 In Northern Ireland 25% of young people are unemployed. From the

limited research that exists we believe many young males are

under-achieving at school. Those who do succeed in getting to

grammar school can come under pressure from their peers and drop

out. There is here an issue of disadvantage where youths make their

way into, what is for them, a post-education world where they are

almost unemployable. In time this leads to depression and dark

thoughts. The challenge in many ways must be recognised - young

men blow things out of proportion and this can lead to tragic

consequences.

12.2 They are often risk-takers - they steal cars, they drive recklessly and

without seat-belts and they eat snack foods. There is also a growing

feeling in parts of the feminist movement (a broad church) that

women can bring up children of any particular union without male

involvement. There is, as they see it, no role for a father.

12.3 Of course the rights of the young must be put in context. Older

people have rights too and society needs a better integration that

facilitates mutual respect and support and leads to higher self esteem

for all its members.

12.4 During this investigation the Committee took the opportunity to visit

the Shankill Men's Health Project - an initiative that is unique in

Northern Ireland although there are other Men's Centres throughout

45

the UK. These provide an opportunity for men to take charge of their

lives and share their struggles for greater health.

46

Northern Ireland: Expectation of Life

at Birth and at 65 Years of Age

(1900-1995)

Expectation of Life

At Birth At age 65 years

Period Male Female Male Female

1900-02

1925-27

1950-52

1975-77

1980-82

1985-87

1991-93

1993-95

47.1

55.4

65.5

67.5

69.3

70.6

72.5

72.7

46.7

56.1

68.8

73.8

75.7

76.7

78.4

78.3

10.5

11.9

12.1

11.8

12.4

12.8

13.7

14.0

10.4

12.7

13.5

15.3

16.1

16.6

17.6

17.6

47

RECOMMENDATIONS

12.5 Some of the issues above are patently not confined to just health and

well-being. The problems are massive and apply to all modern

western democratic societies in the late 20th century. Social

integration can be influenced by government policies and we

recommend that the government take stock of this problem in a

structured way and that efforts be brought to bear to ensure

that the problems and difficulties of young men are better

anticipated and prepared for before they actually become young

men, and that when they do reach that level, they enter a more

welcoming adult world. This is a tall order for anyone - a

problem of society no less - and we can do no more than point in

a general direction. We do however support social and health

education in schools.

The Committee recommends that a publicly-funded Men's

Health Forum be established in Northern Ireland. Men's Health

is a vast area of concern in which the province is already well

behind the rest of the country both in the understanding of it

and in coming to grips with it. Indeed it is almost as if it has

been invisible. This Forum could be modelled on similar fora in

the UK, and would consist of professionals, public

representatives (representatives of the NI Forum and of the

District Councils etc) voluntary and community groups

concerned with Men's Health and statutory agencies. We would

48

suggest that someone of the standing of Dr Ian Banks in this

area be asked to take this initiative forward. If Dr Banks

himself can be involved at least at the early stages this would be

a great asset.

The Committee recommends that Men's Health be treated as a

specific policy issue by DHSS which should move quickly in

establishing and funding a Forum of the kind described above.

We welcome the current Youth Services Review which we

believe will recommend organised and much needed support for

school leavers through to the age of twenty-five. This we are

convinced will benefit not only young men but in the long run

society as a whole.

49

13. SUMMARY OF RECOMMENDATIONS AND CONCLUSIONS

13.1 We feel that there needs to be a greater awareness of the

dangers that can arise resulting from interference with drinks

in public houses. Patrons need to be aware of these dangers and

publicans and proprietors have a special though onerous

responsibility here. This is an issue which requires greater

publicity and agencies should consider how best to tackle this

problem.

13.2 We were given evidence from the BMA that a reduction in legal

alcohol limits would save lives. We welcome the moves being

made in England to lower the legal alcohol limit there and

recommend that the position in Northern Ireland be kept in line

with this.

13.3 We commend and support the Northern Ireland Drugs

Campaign and would ask that the efforts in this area be

sustained.

13.4 The area of prisoner releases and their reintegration into

society is something to which the authorities will need to give

some thought. It is not just a question of enforcement or

education, prisoners need help to reintegrate into society and if

they are turning to crime on release then the present

50

arrangements for their re-introduction into society are not

working (the evidence given was that they were getting involved

in the drugs scene). And here we appreciate that we move from

health to criminal justice and its aftercare but in this case the

two are inseparable. We ask for a co-ordinated response from

all of the statutory agencies and we do so through the medium

of DHSS and Mr Worthington the Minister for Public Health in

Northern Ireland.

13.5 We recommend that the Registrar General should review the

classification of deaths in his office with a view to improving the

accuracy and utility of the information he produces on causes of

death. He should consult with health and other professionals as

well as academics who work in the field as part of this exercise.

13.6 It appears to the Committee that it would be easier to catalogue

the occurrence of suicide in Northern Ireland if Coroners'

Courts were able to return a definitive verdict. This is an issue

which crosses government Departments but we address it to the

Minister for Public Health and ask that he consider it and that

he involves colleagues in the ministerial team in looking at the

possibilities and in taking them forward.

13.7 We fully support the schools-based Defeat Depression

Campaign.

51

13.8 We are concerned at the poor resources in the area of

genito-urinary medicine in Northern Ireland and would call on

the Department here to implement the guidelines on resources

that have been applied in England and Wales. Additionally

there would seem to be a need for the provision of adequate

psycho-sexual support services that will allow patients to be

referred on to further specialisms.

13.9 The bottom line requirement in relation to Sexually

Transmitted Diseases is to have a programme of effective

health and sex education.

13.10 In dealing with some of the huge public health issues,

professionals need to work alongside business, the voluntary

sector (including community organisations) and local councils.

The public needs to know the dangers posed by elements of

their lifestyle. They need to be able to make necessary

adjustments and to get help in doing so.

13.11 A good relationship with a caring and listening adult is crucial to

the health and well-being of male children and adolescents .

13.12 The Committee recommends that a Government ban on tobacco

sponsorship and advertising should be introduced as soon as

possible. An attack on the devastating affects of tobacco

52

smoking on the health of the nation must be begun sooner

rather than later.

13.13 The Committee recommends that the Department seriously

consider the establishment of a stroke register within the

province so that the full scale and consequences of the stroke

problem can be monitored and tackled.

13.14 We recommend that the government take stock of the

problems of social integration in a structured way and that

efforts be brought to bear to ensure that the problems and

difficulties of young men are better anticipated and prepared for

before they actually become young men, and that when they do

reach that level, they enter a more welcoming adult world. This

is a tall order for anyone - a problem of society no less - and we

can do no more than point in a general direction. We do

however support social and health education in schools.

13.15 The Committee recommends that a publicly-funded Men's

Health Forum be established in Northern Ireland. Men's Health

is a vast area of concern in which the province is already well

behind the rest of the country both in the understanding of it,

and in coming to grips with. Indeed it is almost as if it has been

invisible. This Forum could be modelled on similar fora in the

UK, and would consist of professionals, public representatives

(representatives of the NI Forum and of the District Councils

53

etc) voluntary and community groups concerned with Men's

Health and statutory agencies. We would suggest that someone

of the standing of Dr Ian Banks in this area be asked to take

this initiative forward. If Dr Banks himself can be involved at

least at the early stages this would be a great asset.

13.16 The Committee recommends that Men's Health be treated as a

specific policy issue by DHSS which should move quickly in

establishing and funding a Forum of the kind described above.

13.17 We welcome the current Youth Services Review which we

believe will recommend organised and much needed support for

school leavers through to the age of twenty-five. This we are

convinced will benefit not only young men but in the long run

society as a whole.

54

APPENDICES

55

APPENDIX A

Committee Membership

60

APPENDIX A

STANDING COMMITTEE 'C'

(HEALTH ISSUES)

Committee Members who attended the Evidence Sessions on Men's

Health

Mrs M Beattie DUP

Mr C Calvert DUP

Mr G Campbell DUP

Mr S Foster UUP

Mr S Gardiner UUP

Mr P King UUP

Mrs M Marshall Alliance*

Mrs J Parkes DUP

Ms G Rice Alliance*

Mr T Robinson UUP

Mr H Smyth PUP

Dr J Wilde Women's Coalition*

* Attend Committee on behalf of the Party under Rule 14(4)(a)

Note: Labour was not represented on the Committee during the

course of this investigation. This does not imply any

withdrawal on their part from the general activities of

Committee C.

61

APPENDIX E

REMIT: The Forum has set up a number of Committees. The

Committee to deal with HEALTH ISSUES is among

these.

DESIGNATION: STANDING COMMITTEE C

TERMS OF REFERENCE: To examine the health needs of the community in

Northern Ireland with particular reference to health care

administration; acute hospital services, community care

services and access by the rural community and report

to the Forum.

62

APPENDIX F

~ BIBLIOGRAPHY ~

1. BANKS, I Get Fit With Brittas - BBC Education - 1997

2. BANKS, I A Guide to Men's Health - The Trouble with

Men

BBC Education - 1996

3. BANKS, I Ask Dr Ian about Men's Health - Blackstaff

1997

4. BANKS, I The Good Patient Guide - BBC 1997

5. BANKS, I Young Men's Health - A Youth Work Concern

-

Youth Action - 1996

6. BRADFORD, N Men's Health Matters - The Complete A-Z of

Male Health Part 2 - Vermillion - 1995

7. BRADFORD, N Men's Health Matters - The Complete A-Z of

Male Health Part 2 - Vermillion - 1995

8. BREWER, S The Complete Book of Men's Health -

Exercise, Irritable Bowel, Impotence, Sex

Drive, Sports Nutrition, Blood Pressure, Heart

Disease, Diet, Alcohol, Baldness, Prostrate,

Cholesterol, Sperm Count, Fatigue, Ageing -

Vols 1 and 2

9. CARROLL, S The Which Guide to Men's Health - The

Essential Health and Fitness Manual for Men

and those who care about them - Which Books

- 1995

10. CARRUTHERS, M Male Menopause - Restoring Vitality and

Virility - Harper Vollins - 1996

65

11. HARLAND, K Young Men Talking - Voices from Belfast -

Youth Action - 1996

12. LLOYD, T Men's Health Review prepared on behalf of the

Men's Health Forum - sponsored by an educational

grant from Merck Sharp & Dohme Ltd

13. SNASHALL, D ABC of Work Related Disorders - BMJ

Publishing Group - 1997

66

• Men's Health in Northern Ireland: An Examination by Standing Committee C (introduced on 1998-02-13 10:03:00 - CREATE_FROM - e838121) [This document] [view current proposal at this moment]
  • Adopt report on Men's Health (introduced on 1998-02-13 10:03:00 - PROCEDURE - e838122) [view current proposal at this moment]
    • None (introduced on 1998-02-13 10:03:00 - ADOPT_PROPOSAL - e838133) [view current proposal at this moment]
  • None (introduced on 1998-02-13 10:03:00 - DEBATE_PROPOSAL - e838123) [view current proposal at this moment]
  • None (introduced on 1998-02-13 10:03:00 - DEBATE_PROPOSAL - e838125) [view current proposal at this moment]
  • None (introduced on 1998-02-13 10:03:00 - DEBATE_PROPOSAL - e838126) [view current proposal at this moment]
  • None (introduced on 1998-02-13 10:03:00 - DEBATE_PROPOSAL - e838127) [view current proposal at this moment]
  • None (introduced on 1998-02-13 10:03:00 - DEBATE_PROPOSAL - e838128) [view current proposal at this moment]
  • None (introduced on 1998-02-13 10:03:00 - DEBATE_PROPOSAL - e838129) [view current proposal at this moment]
  • None (introduced on 1998-02-13 10:03:00 - DEBATE_PROPOSAL - e838132) [view current proposal at this moment]
  • None (introduced on 1998-02-13 10:03:00 - ADOPT_PROPOSAL - e838134) [view current proposal at this moment]