Thursday, 7 November 2013

Movember: a response from the Head HonchMo

Last week I talked to Movember’s Head Honcho Paul Villanti. He’d seen my earlier blog posts, raising questions about Movember’s aims and transparency. 
What he said clarified some of the muddy waters surrounding Movember, although some areas remain opaque. He acknowledged that there had been mistakes, and that the organisation had not always been clear in communicating what it aimed to achieve. 
In particular, he made clear that:
  • Movember never set out to transform men’s health in its broadest sense
  • Movember will finally be considering moving into UK mental health projects next year
  • Movember has some regrets about some of the men’s health advice it has put out in the past.

About Paul Villanti

Paul Villanti has a say in every aspect of Movember, overseeing its investments in health initiatives globally. He is not one of the charity’s original founders, but joined from a business background four years after Movember was established in 2003. Today he is Executive Director of Programmes, and a member of the Board, the Global Scientific Committee and the Global Leadership Team. He is also Director of Movember Europe, a Director on the Boards of the Prostate Cancer Foundation (USA) and Prostate Cancer Canada and is an Associate Director of Prostate Cancer UK.
That’s a lot of responsibility. 

The prostate question

I asked Paul Villanti about Movember’s focus on prostate cancer, even though the disease accounts for only 3% of premature male death in the UK. In some countries with lower male life expectancy the disease hardly features as a problem at all. “Changing the face of men’s health” surely involves tackling more than that?
He said that from the start Movember had been “results-focused”. 
“In deciding the areas to invest in, we’ve challenged ourselves to make a significant impact on men’s lives,” he said. “Strategically the decision was made a long time ago that we wanted to focus on areas where we could make a significant impact on men’s lives rather than having a Santa Claus strategy where you sprinkle a bit of money everywhere but actually not make much of a difference.” 
In the long-term, he said, Movember was all about building strong partnerships with specific organisations across many sectors, he said, and if funds allowed it wanted to expand beyond core areas: prostate cancer, testicular cancer and mental health. 
“I don’t think there’s any organisation in the world capable of solving all the problems in men’s health,” he said. “I fully accept that we aren’t tackling every men’s health issue, and I think it’s really important to be transparent about what we do raise funds for.”  
The initial decision to focus on prostate cancer was driven by the fact that investment in this field had been historically very low. There are complex and pressing issues to be resolved, such as the need for effective screening and overtreatment. “It is expected to be the most common cancer by 2030. It is a significant challenge facing men and under-invested in in every country,” said Villanti. 

The expertise question

So what research and professional expertise informs Movember’s decision-making and health advice? The Movember Board, which decides strategy, is dominated by Australian businessmen and Movember’s founders, and has only one representative with any health expertise (in prostate cancer). Its Global Scientific Committee is almost exclusively prostate cancer experts.
Villanti explained that in each country, programmes are decided on and overseen by panels of national experts in particular fields (for example mental health). These groups, he said, do not feature on the Movember website but are working behind the scenes. I asked him what expertise informs Movember’s decisions on a higher strategic level to help change men’s health. Villanti assured me that there are a large number of experts that guide strategic direction, and then moved the subject back to the specifics of programme development again. 

The mental health question

In this blog I’ve pointed to my concern that Movember UK donated no money to mental health projects in the UK in 2011 and 2012, even though its website claims it raises “vital funds and awareness for prostate cancer and testicular cancer and mental health”. 
Paul Villanti reassured me that in March 2014, the Movember Board will be looking at ways to “expand investment” in the UK beyond prostate and testicular cancer. 
“We had always planned to review our options at this stage,” he said. It will be engaging independent experts in men’s health to inform this process, and will seek advice from mental health groups. “We expect the advice we get to inform the process,” he said. 

The health awareness question

I explained to Paul Villanti my reservations about Movember’s much-vaunted “awareness and education” work in the UK, which seems to consist entirely of hoping men will talk more about their health as a result of growing moustaches. There’s little evidence that talking about health, or going to the doctor for check-ups, will result in men living longer, I pointed out.
He acknowledged that there is much we don’t know about men’s health behaviour. However, it is clear that men have lower levels of health literacy than women, and this results in poor health outcomes, he said. “Step one obviously is to increase their levels of education and awareness, and the Movember campaign is respected across prostate cancer and mental health because it uses the unorthodox concept of using fun to increase men’s awareness of the risks they face, try and educate them and encourage them to take action when they’re sick.”

The screening advice question

Over the past two years, doctors in the UK and elsewhere have criticised Movember’s health education advice. Until late last year, its website advised men over the age of 50 to get a PSA test – even though the test is very contentious because of the dangers of over-diagnosis and incorrect diagnosis. 
Until last month, its website advice on colon screening and aortic aneurysm was at odds with NHS recommendations. The website still said that prostate screening at age 40 was “reasonable” and its information on mental health problems suggested they went no wider than depression. 
Villanti told me that Movember hadn’t recommended the PSA test since 2011 – it had instead encouraged conversations about screening with GPs. But he acknowledged that its attempts to take a global position on men’s health last year – including a recommendation on its website last year that men should have an annual health check and specific checks at different stages of their lives – had not succeeded.
“With the benefit of hindsight, there were a number of weaknesses with that approach which we have taken on board,” he said. Much of the advice Movember put on its website had been based on information from the Australian College of General Practitioners and other Australian health bodies. “What we realised was that there are major disparities in what professional health bodies say from country to country. To us, that seemed incredible: it’s supposed to be based on the best evidence out there. We can’t understand why one country recommends one thing, and another recommends another approach.” 
He emphasised that the organisation did have serious concerns about over-diagnosis and over-treatment, and the problem was being investigated in various Movember programmes. I told Villanti that his concern about over-treatment was not reflected in the messages that Movember pushes out.
“One of my big frustrations is that we don’t know at a population level how bad some of these issues are, and how different treatment modalities relate to poor outcomes, so we are investing in a national cancer registry in Australia. We see that as a powerful vehicle for improving the quality of treatment, and we’re hoping to do something similar in the UK.”

With Movember now in full flow, and millions already donated by members of the public, it’s surely right that those who oversee it are kept on their toes – something that, up until now, hasn’t been done in the media. We all love the story of how Movember grew from small beginnings, but it isn’t the only story. 
It’s good that Paul Villanti is prepared to respond to comment and concerns, and I hope that there are messages the organisation will take on board, because it has too good an opportunity to waste.
Movember needs to be more open about its strategy – even if that makes it appear more limited in its scope than it would like.
Movember needs to draw in a wider range of evidence and expertise when setting strategies and goals, and providing health advice.
Movember needs to be global in outlook, as well as activity – not taking Australia as a template for what the rest of the world needs.
Most of all, Movember needs to step up its game. It started as a group of Aussie blokes in a pub with an idea to change the world and the skills to bring it off, but with very little understanding of health or its global dimensions. Mistakes are bound to happen as long as Movember’s tight-knit structures and decision-making continue to reflect that historic and naive starting point.