HIROSHIMA TO FUKUSHIMA AND COVID-19:

A HISTORY OF JAPANESE HEALTHCARE

TOMOKO Y. STEEN, PH.D. GEORGETOWN UNIVERSITY MEDICAL CENTER The statements included in this presentation are all based on my own ACKNOWLEDGEMENT 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 • Since 1961 Japan has provided universal health coverage, which allows access to preventive, curative and rehabilitative services at an affordable cost. JAPANESE HEALTH • All residents of Japan (including non-citizens who have CARE: HEALTH establish residency in Japan) are required by the law to INSURANCE 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. https://www.mhlw.go.jp/bunya/ir 1) employment-based plans (59% of the population) youhoken/iryouhoken01/dl/01_e 2) residence-based insurance plans, which include: ng.pdf a) Citizen Health Insurance plans for unemployed https://www.commonwealthfund. or freelance individuals age 74 and under org/international-health-policy- (27% of the population). center/countries/japan b) Health Insurance for the Elderly plans, which http://www.ipss.go.jp/s- automatically cover all adults age 75 and older info/e/ssj2014/006.html (12.7% of the population). *Low income category: disposable income $23,458

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. JAPANESE HEALTH • Hospitals, by law, must be run as non-profits and be CARE: PATIENTS’ managed by physicians. RIGHTS • For-profit corporations are not allowed to own or operate hospitals. Clinics must be owned and operated by physicians. • Brain and heart surgery: unique techniques are developed • Plastic and orthopedic surgery: techniques to fit its population JAPANESE HEALTH • Pharmacy: combined use of western and Kampo CARE: medicine SPECIALIZATION AND LICENSING • 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 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 1. Traditional Kampo Medicine learned from China UP TO THE MODERN PERIOD: (5TH CENTURY THROUGH 1868) 2. Introduction of Dutch/German Medicine ORIGIN OF KAMPO MEDICINE IN 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) 3. Active introduction of German Medicine: Study Abroad programs in Germany MODERN PERIOD: MEIJI RESTORATION, 4. Biological & Chemical weapons research SINO-JAPANESE WAR TO WWII (1868-1945) 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 6. Allied Occupation Period

POST WAR 7. Industrial Growth Period (1945-1989) (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 ECONOMIC GROWTH AND POLLUTION DISEASES

• 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 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) 9. The Lost Decade

10. Adaptation of European R&D Systems: Gender Equality POST MODERN JAPAN (1990 – PRESENT) 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 COUNCIL FOR SCIENCE, TECHNOLOGY AND INNOVATION

• 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/ 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 RECEIVES NOBEL 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 Japan’s Low Death Rate…

• Key Preventive Measures started early (in March) “Avoid Three Cs”: • Closed spaces with poor ventilation Outbreak • Crowded places with many people Monitoring • Close contact settings such as face-to-face conversations. Map • Potential previous exposure to corona viruses 10/4/2020 • Lower obesity rates • More specialized and accurate testing zt the local public health office (although less testing than Korea or Taiwan)

https://covid19japan.com/ Annual Nuclear Security Summit at Georgetown November 16th-18th, 2020 2020 Annual Meeting Theme Use 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 DO YOU HAVE ANY QUESTIONS?

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