hiroshima to fukushima and covid-19

HIROSHIMA TO FUKUSHIMA AND

COVID-19:

A HISTORY OF JAPANESE HEALTHCARE

TOMOKO Y. STEEN, PH.D.

GEORGETOWN UNIVERSITY

MEDICAL CENTER

ACKNOWLEDGEMENT

The statements included in this

presentation are all based on my own

knowledge and research and do not reflect

or represent organizations that I am

affiliated with.

Japan’s healthcare system is shaped by a unique and complex history…

A JAPANESE NURSE PORTRAYED AS A 現代美人 (MODERN BEAUTY), PREPARES AN INJECTION FOR A PATIENT, CA. 1910

NATIONAL LIBRARY OF MEDICINE

HEALTH INSURANCE AND

QUALITY OF HEALTHCARE

UNIVERSAL HEALTH CARE AROUND THE WORLD

https://vignette.wikia.nocookie.net/liberapedia/images/9/94/Health.png/r

evision/latest?cb=20090404062422

JAPANESE HEALTH CARE: HEALTH

INSURANCE

• Since 1961 Japan has provided universal health

coverage, which allows access to preventive, curative

and rehabilitative services at an affordable cost.

• All residents of Japan (including non-citizens who have

establish residency in Japan) are required by the law to

have health insurance coverage.

• People without insurance through employers (“social

insurance”) can participate in a national health

insurance program administered by local governments.

JAPANESE HEALTH INSURANCE

The Japan’s statutory health insurance system (SHIS)

has two types of mandatory insurance and cover

98.3%; remaining 1.7% covered by the Public Social

Assistance Program.

1) employment-based plans (59% of the population)

2) residence-based insurance plans, which include:

a) Citizen Health Insurance plans for unemployed

or freelance individuals age 74 and under

(27% of the population).

b) Health Insurance for the Elderly plans, which

automatically cover all adults age 75 and older

(12.7% of the population).

*Low income category: disposable income $23,458

https://www.mhlw.go.jp/bunya/ir

youhoken/iryouhoken01/dl/01_e

ng.pdf

https://www.commonwealthfund.

org/international-health-policy-

center/countries/japan

http://www.ipss.go.jp/s-

info/e/ssj2014/006.html

COMPREHENSIVE MEDICINE

• Everyone is entitled to quality healthcare and is required to have a

health insurance.

• Costs of medical equipment and drug are strictly regulated by

Japanese government .

• Each of Japan’s prefectures (47) and regions has its own residence-

based insurance plan. There are more than 1,400 employment-

based plans.

• Doctors are assign to rural areas: formerly recent national medical

school graduates were required to spend time working in rural areas

for the first few years. (No longer required.)

• Each medical school now has a special category for educating

doctors to work in rural areas for 6-7 years after graduation--free

tuition.

• Federal and local governments agree on strategies to improve health

care in rural areas through telemedicine since 2007-telemedicine (D

to D or D to P), and other arrangements.

https://www.jmir.org/2020/1/e13649/

• Patients are free to select physicians or facilities of

their choice and cannot be denied coverage.

• Hospitals, by law, must be run as non-profits and be

managed by physicians.

• For-profit corporations are not allowed to own or

operate hospitals. Clinics must be owned and

operated by physicians.

JAPANESE HEALTH CARE: PATIENTS’

RIGHTS

• Brain and heart surgery: unique techniques are

developed

• Plastic and orthopedic surgery: techniques to fit its

population

• Pharmacy: combined use of western and Kampo

medicine

• Educational Programs on integrative and

complementary medicine at top medical schools

• Federal licensing (doctors, dentists, pharmacists)

rather than prefectural or regional license —

standards are high and consistent

JAPANESE HEALTH CARE:

SPECIALIZATION AND LICENSING

JAPANESE HEALTHCARE: INTEGRATION

Survey on the Current State of

Kampo Prescription Frequencies

by physicians.

Data retrieved from: 2011 Japan Kampo

Medicine Manufacturers Association

HISTORY OF MEDICINE IN JAPAN

UP TO THE MODERN PERIOD: (5TH CENTURY THROUGH 1868)

1. Traditional Kampo Medicine learned from China

2. Introduction of Dutch/German Medicine

ORIGIN OF KAMPO MEDICINEIN JAPAN

TRADITIONAL MEDICINE: KAMPO (漢方)

• Herbal medicine is introduced from China in

the 5th and 6th Century

• An independent Japanese school of Kampo was

established in the 1500s

• A shift to western medicine occurs toward the end

of the 1700s

• Prohibition of the use of Kampo during the early

modern period -- late 1800s

• Recent revival of Kampo medicine as mainstream

treatment

INTRODUCTION OF WESTERN-STYLE MEDICINE

• From Mid-1500s: Introduction of western medicine

from Portugal, Holland and Spain (Jesuit

Missionaries)

• Between 1639-1854: Japanese borders are closed

(sakoku鎖国). However, Nagasaki city remained

open to Holland, Portugal and China.

• Western medicine is introduced by Engelbert

Kaempfer, German naturalist and physician (1690-

1692) and by Philipp Franz von Balthasar Siebold

(German physician) during his stay in Nagasaki

(1823-1829).

WESTERN STYLE MEDICAL EDUCATION

• 1774 Kaitaishinsho 解体新書 Tāheru

Anatomia–first Japanese translation of

an anatomy book by Hiraga Gennai 平賀

源内

• 1854 First medical school was

established in Nagasaki - 長崎医学伝習

所（Nagasaki School of Medicine)

MODERN PERIOD:MEIJI RESTORATION,

SINO-JAPANESE WAR TO WWII (1868-1945)

3. Active introduction of German Medicine:

Study Abroad programs in Germany

4. Biological & Chemical weapons research

5. Atomic Bombs dropped on Hiroshima and

Nagasaki

MEIJI RESTORATION: MODERN JAPAN AND SCIENCE POLICY FROM 1868

• Wakon yosai (和魂洋才）—introduction of western talents (science, technology, medicine and other studies) while maintaining Japanese spirit

• Study abroad programs in Germany, France, England and the US

• Foreign teachers in Japan お抱え外国人講師

• Establishment of imperial universities 帝国大学

• Establishment of research institutes 理研

• Promotion of industries and innovation 殖産興業

• Industrial revolution 産業革命

WAR MEDICINE DURING WWII(WATER PURIFICATION UNIT 731)

• Epidemic prevention

• Bio-weapons development

• Human experiments

• Large-scale operations from Northern China to

Southeast Asia

ATOMIC BOMBS WERE DROPPED IN HIROSHIMA AND NAGASAKI

• First large-scale civilian casualties caused by nuclear

weapons

• Long terms effects of radiation

• Atomic Bomb Casualty Commission (ABCC) was

established – Life Span Studies & Children of

Atomic Bombs

• New health coverage, atomic bomb notebook

(Gembaku techo), Atomic Bomb Survivors

Support Law (hibakusha hogo hou被爆者保護法)

established by Japanese government (1957,

1968, 1994)

Atomic bombing of Hiroshima, OSTI.gov

POST WAR(1945-1989)

6. Allied Occupation Period

7. Industrial Growth Period

(高度成長期）

8. Pollution sickness (公害）

ALLIED OCCUPATION PERIOD

• Health reform under occupation - new

health policy

• Margaret Sanger’s visit: Abortion was

considered a eugenics act in the 1880s,

and then in 1931 as a women’s right. It

became legal in 1948, one of the first

countries to legalize abortion, but called

“Protection of Eugenics Act” 優生保護法

POST-OCCUPATION ECONOMIC GROWTH: ADVANCEMENT OF SCIENCE, TECHNOLOGY AND MEDICINE

• Scientists and doctors accepted

Fulbright Scholarships to study abroad

in the US & Europe

• Kōdo seicyo ki (高度成長期） -

high industrial development period

• 1910-1970: Itai-itai disease (Cadmium): Toyama 1955

• 1961: Yokkaichi asthma (Sulfur dioxide and nitrogen

dioxide): Yokkaichi-city in Mie 1972

• 1932-68: Minamata disease I (Mercury)

Chisso Chemical Factory in Kumamoto 1956

• 1964-65: Minamata disease II (Mercury) – Showa

Electric Works in Niigata 1965

______________________________

Citizen’s group pressured politicians to establish policies

for industrial regulation and factory safety

ECONOMIC GROWTH AND POLLUTION DISEASES

Drug Hazards 薬害

• The rapid development of pharmaceutical

industries and related companies resulted in

drug hazards

• 1956-62 Thalidomide: Birth defects

• 1980 Green Cross: HIV-tainted blood

products

• Citizen’s group pressured the Ministry of Public

Health to enact regulations薬事法/薬機法

(Pharmaceutical Affairs Law) 1874, 1917, 1960,

1973, 1985, 1997, 2014, 2019

• New regulations for clinical trials, quality control,

marketing and import (including cosmetics)

POST MODERN JAPAN(1990 – PRESENT)

9. The Lost Decade

10. Adaptation of European R&D Systems: Gender

Equality

11. An Aging Society

12. Disaster Medicine:

a. Great East Japan Earthquake and Fukushima

Nuclear Accident

b. Covid 19 (SARS-CoV-2) Management

JAPAN’S LOST DECADE AND MEDICAL COSTS

The Japanese Economy

“The unseen casualties of Japan’s lost

decades suffer in silence Politicians

who engage younger voters are few, so

the disgruntled stay unheard.“

in Financial Times By Sahoko Kaji

https://www.ft.com/content/042a592e-c283-11e4-

ad89-00144feab7de

Healthcare Expenditure/OECD, 2006

R&D BUDGET

• Social Principles of Human-Centric

Artificial Intelligence(AI)

• Moonshot Research and Development

Program

• Cross-Ministerial Strategic Innovation

Promotion Program

https://www8.cao.go.jp/cstp/english/

COUNCIL FOR SCIENCE,

TECHNOLOGY AND INNOVATION

ADVANCED TECHNOLOGY

• Cancer treatments

• Infectious diseases

• Public health & Immunization

• Drug development

• Organ transplants

• Regenerative medicine - aging

• AI and Robotics - aging, work force shortage

SHINYA YAMANAKA RECEIVES NOBEL PRIZE

The 2012 Nobel Prize in Physiology and

Medicine resulted in a large government funding

shift from all other basic research to iPS and

applied research/clinical research

TASUKU HINJO RECEIVESNOBEL PRIZE

The 2018 Nobel Prize in Physiology and Medicine

shared with James P. Allison "for their discovery of

cancer therapy by inhibition of negative immune

regulation.“

R&D BUDGET

• Cancer Immunotherapy

• iPS cell

• Nanotechnology

• Drug discovery

TECHNOLOGY TRANSFERS AND INTERNATIONAL SUPPORT

• R&D grants for developing countries

• Introduction of new technologies: technology

transfers

• Accepting science students from developing

countries to national universities and research

institutes - JST, JSPS

WOMEN IN SCIENCE & MEDICINE: POLICY

BENEFIT AND PROTECTIONS FOR WOMEN IN SCIENCE

• Women study abroad, 1871-73

• Reliable childcare by universities and

research facilities since 1940

• Equal opportunity laws: pay equality

established in 1985

After 2000,

• Flexibilities for research grant

• Post childcare grants for women scientists

• Partial/full parental leave with job security

GENDER EQUALITY BUREAU, CABINET OFFICE JST, JSPS

HTTP://WWW.GENDER.GO.JP/ENGLISH_CONTENTS/ABOUT_DANJO/WHITEPAPER/INDEX.HTML

AGING AND SUSTAINABLE MEDICINE

“JAPAN: SUPER-AGING SOCIETY PREPARING FOR THE FUTURE.”

The Gerontologist, Volume 51, Issue

4, August 2011, Pages 425–

432https://doi.org/10.1093/geront/

gnr067

NATIONAL CENTER FOR GERIATRICS AND GERONTOLOGY

Our mission is to dedicate ourselves to the

promotion of the physical and mental health of the

elderly, so that they can achieve life-long

independence, and the improvement of the health

and welfare of the people and society.

SUSTAINABLE HEALTH POLICY FOR AGING POPULATIONS

• Distance medicine

• Visiting nurse

• Assignment of younger doctors to

• rural areas

• AI and Robotics

• Need of geriatrics and holistic approach

DISASTER MANAGEMENT: SCIENCE AND HEALTH POLICY

DISASTER MANAGEMENT: SCIENCE & HEALTH POLICY

Fukushima Nuclear Accident

• Previously organized committee was not

contacted at the time of disaster

• No horizontal communication or agreement

among ministries

• Industry monopolies

• No centralized system of regulation such as

NRC in the US

FUKUSHIMA NUCLEAR ACCIDENT

Why does Japan have lower death rates from Covid19?

• Public Health: Controlling the amount of

virus circulating

• High subscription to mask wearing since

1918 pandemic flu

• Common practice of gargling

• Policy: Universal health care: preventive

care and early diagnostics

• Government Science Team: Contact tracing

and cluster managements since 2009

• Public Attitudes: Public compliance with

government orders

https://covid19japan.com/

• Key Preventive Measures started early (in March)

“Avoid Three Cs”:

• Closed spaces with poor ventilation

• Crowded places with many people

• Close contact settings such as face-to-face

conversations.

• Potential previous exposure to corona viruses

• Lower obesity rates

• More specialized and accurate testing zt the local

public health office (although less testing than

Korea or Taiwan)

Outbreak

Monitoring

Map 10/4/2020

Japan’s Low Death Rate…

2020 Annual Meeting ThemeUse of Emerging Technologies for Disaster Managements:

Cases of Nuclear Disaster and the COVID-19 Pandemic

Sponsored by

Biomedical Science Policy and Advocacy Program at Georgetown & DTRA

https://nssregistration.wixsite.com/nov2020

Annual Nuclear Security Summit at GeorgetownNovember 16th-18th, 2020

DO YOU HAVE ANY QUESTIONS?

CONTACT ME AT: TYS8@GEORGETOWN.EDU