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Chapter 1 the History of Public Health and Medical Services Chapter 1 The History of Public Health and Medical Services In order to understand the general condition of population of Japan was estimated at 35 million. public health and medical services in Japan, we will With subsequent establishment of a capitalist first review changes in population demographics, society and economic development came an birth and mortality rates, and disease prevalence. increase in population, exceeding 64 million by the We will then introduce the history of Japan’s year 1930 (see Figure 1-1). initiatives in the field of public health and medical Following the end of the Second World War, services from the Meiji Era (1868~) to the present with the return of soldiers and civilians from day, to gain an overview of what initiatives were overseas, and natural increase due to the first Baby conducted in each phase. Boom in the 3 years from 1947 to 1949, the population increased by roughly 10 million people, reaching 83.2 million in 1950. Since 1950, the 1. Demographics: Population, Birth and population growth rate has been stable at roughly Mortality Rate, Disease Prevalence 1% per year. Since 1970, a reduced birth rate and increased 1-1 Population Change life expectancy have led to a rapid aging of the As of October 1, 2002, the total population of Japanese population. In 1970, the elderly population Japan was 127,430,000, making it the 7th most (population aged 65 years old and over) exceeded populous nation in the world. In the late 1800’s, 7% of the total population, meeting the UN corresponding to the early Meiji Era, the definition of an “aging society.” Life expectancy Figure 1-1 Trends in Total Population and Population Demographics Population (millions) (%) 140 80 120 70 100 60 Total population 0 ~ 14 years 80 15 ~ 64 years 50 ~ 65 years 60 Actual Estimated 30 40 20 20 10 0 0 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050 Year Source: Complied by the author on the basis of data from the National Institute of Population and Social Security Research. 11 Japan’s Experience in Public Health and Medical Systems has subsequently continued to increase, and a 1-2 Birth and Mortality Rate tendency to marry later or to remain unmarried Until around 1870 (early Meiji Era), both the has further reduced the birth rate. As of April birth rate and mortality rate were high in Japan, a 2002, the proportion of elderly was 18.3% of the period of “high fertility and mortality” (see Figure total population, considerably greater than the 1-2). While mortality rate subsequently declined, proportion of children (aged under 14 years) of the birth rate tended to rise until around 1910, and 14.3%. As a result of the long term reduction in then went into a gradual decline. This was the the birth rate, the Japanese population is expected period of “high fertility but low mortality.”1 to reach a peak in 2006, and subsequently decline After the chaos of the Second World War, the (estimates as of January 2002). first post-war Baby Boom saw the birth rate soar, Figure 1-2 Trends in Birth Rate and Mortality Rate High fertility, Low fertility low mortality and mortality 40 Birth rate 35 Death rate 30 25 20 15 10 Commencement 5 of modern statistics Birth rates and death (per 1,000) 0 1870 1880 1890 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 Year Source: Compiled by the author on the basis of data from the National Institute of Population and Social Security Research. Figure 1-3 Trends in Main Causes of Death 350 TB 300 Malignant neoplasia (cancer) Heart disease (excluding hypertension) 250 Cerebrovascular disease (stroke) Pneumonia 200 150 100 Death rate (per 100,000) 50 0 1920 1925 1930 1935 1940 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 Year Source: Compiled by the author on the basis of data from Ministry of Health, Labour and Welfare 1 Ato, Makoto (2000) Gendai Jinko-gaku [Modern Demography], Nihon Hyoron-sha. 12 Chapter 1 The History of Public Health and Medical Services reaching at its peak of 2.7 million births per year. disease prevalence in terms of changes in the main However, the birth rate fell dramatically after 1949, causes of death (mortality rates per 100,000), we see and declined most precipitously during the period that pneumonia was the number one cause of death 1949~1957. The main reason for this decline was the until the end of the Meiji Era, and then tuberculosis Eugenic Protection Law of 1948 (now the Mother’s became the number one cause. This situation Body Protection Law), that allowed induced continued until 1951. In 1951, tuberculosis was abortion under certain conditions. In 1955, the replaced as the leading cause of death by number of reported induced abortions had reached “cerebrovascular disease (stroke),” followed by 1.17 million, a figure to rival the 1.73 million births “malignant neoplasia (cancer)” as the second and recorded in the same year. The mortality rate also “pneumonia, etc.” as the third. declined markedly during the same period. This brought together what remain today the The birth rate has continued to decline from three leading causes of death. It can be said that at 1973 until the present day. On the other hand, the this time the major causes of death changed from mortality rate began a gradual but steady increase infectious diseases to lifestyle-related diseases. from the late 1980’s, as a result of the aging Since the late 1960’s, cerebrovascular disease population. With both the birth rate and the (stroke) has steadily declined, whereas heart mortality rate at low levels, the period after 1960 disease has increased as a cause of death. Malignant has been called that of “low fertility and mortality.” neoplasia (cancer) increased steadily throughout the post-war period, becoming the number one 1-3 The Structure of Disease Prevalence cause of death in 1981, and has subsequently If we examine changes in the structure of continued to increase (see Figure 1-3)3. Table 1-1 Classification of the Phases in Public Health and Medical Systems in Japan Phase I Phase II Phase III Phase IV Phase V 1868~1919 1920~1945 1946~1960 1961~1979 1980~present Period Acute infectious diseases Chronic infectious Restructuring the health Expanding medical Challenge of an aging control diseases control and administration services society formation of maternal and child health services • Acute infectious • Chronic infectious • Postwar acute • Lifestyle-related • Low birth rate and diseases diseases infectious diseases diseases aging population • Maternal and child • Chronic infectious • Traffic accidents Main health diseases • Environmental Issues • Maternal and child pollution health • Occupational health • Sanitation • Establishment of a • Initiation of a • Restructure of the • Universal health • Effective and efficient centrally directed community-based health administration insurance coverage distribution of epidemic prevention approach to public • Community-based • Expansion of medical medical institutions systems health, centered on health approach to services and personnel Initiatives • Collation of statistics public health nurses public health • National movement • Radical reform of the demanding better social security system public health and • Promotion of new medical services community-based public health Source: compiled by the author. 3 Causes of death were classified in accordance with the WHO criteria, but major modifications to these criteria in 1995 (set in 1979) mean that caution is required in making comparison of data from before and after 1995. 13 Japan’s Experience in Public Health and Medical Systems 2. The History of Public Health and Environmental pollution from the flourishing heavy Medical Services4 chemical industry at this time became a major social In this study, we examined changes in public problem. Lifestyle-related diseases replaced health and medical services in Japan since the infectious diseases as the major health challenge Meiji Era (1868~1912), dividing this period into during this period. five phases, looking at both the principal Phase V “Challenge of an Aging Society” is challenges in each phase and the main initiatives the period in which we need to make drastic taken to meet those challenges (see Table 1-1).5 reforms in the health care and medical system to We will briefly outline the characteristics of each meet the challenges caused by a rapidly aging phase. population. In the midst of large scale restructuring Phase I “Acute Infectious Diseases Control” of the social security system, the provision of health was the period in which Western medicine was care and medical services is also undergoing re- introduced to Japan as part of its modernization, examination. This is a period when the providing and acute infectious diseases were the greatest system of community-based service is also being challenge. reinforced in the health care field in the Phase II “Chronic Infectious Disease Control decentralization of many governmental activities. and Formation of Maternal and Child Health We will now provide an overview of the Services” was the period when, in accordance with characteristics of Japan’s initiatives in the field of the Kenpei-Kenmin (Healthy Soldier, Healthy public health and medical services for each phase. People) concept, public health services were strengthened to combat chronic infectious diseases 2-1 Phase I: Acute Infectious Disease Control and to improve maternal and child health. The (1868~1919) basic structure of the public health system of today was established during this phase. [The Birth of a Modern Nation] Phase III “Restructuring the Health In 1868, Japan ended a 250 year period of Administration” was the period in which the isolationism and the Bakuhan-taisei (Shogunate administration of public health and medical services and domain system, feudal system comprising the was restructured as part of the recovery from the Shogun and the lords of each domain).
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