Study on Okinawa’s Development Experience in Public Health and Medical Sector December 2000 Institute for International Cooperation Japan International Cooperation Agency I I C Ｊ Ｒ 00-56 PREFACE Recent years have seen a new emphasis on "people-oriented development" through aid in the social development field. Cooperation in the public health and medical sector is becoming increasingly important within this context because of its contributions to physical well-being, which is the basis from which all human activities proceed. Nonetheless, infectious diseases that were long ago eradicated in developed countries are still rampant in developing countries, as are HIV/AIDS and other new diseases. Even those diseases that can be prevented or treated claim precious lives on a daily basis because of inappropriate education and medical care. The government of developing countries, donors, NGOs, and other organizations continue to work to rectify this situation and improve the health care levels of people in developing countries. Japan, as one of the world's leading donor countries, is expected both to improve the quality of its own aid and to take a leadership role in this sector. To help us in this effort, we referred to the history of health and medical care in postwar Okinawa Prefecture. Okinawa's experiences during postwar reconstruction contain many lessons that can be put to use in improving the quality of aid made available to developing countries. In the times immediately following World War II, the people in Okinawa were constantly threatened with contagion and disease due to a lack of medical facilities and personnel, including doctors. Okinawa's subtropical climate combined with its insular geography meant that a long and strenuous effort had to be made in order to reach current levels of public health. This report reviews the valuable experience and expertise gained by Okinawa as its government and people joined forces to overcome this situation. As was stated above, health and medical care are becoming more prominent components of aid, and this study, which systematizes Okinawa's local health care development experiences while examining the potential for international cooperation based on these experiences, is indeed both timely and welcome. The study was chaired by Mr. Seisho Higa, Director of the Chuou Health Center in Okinawa who has many years of experience and deep insight into public health and medical care in the prefecture. The study committee included, as members and advisers, many doctors, nurses and local government officials who played important roles in improving public health levels in postwar Okinawa. On behalf of JICA, I would like to express my sincerest gratitude to the chairperson, study committee, advisers, and others involved for their earnest efforts in completing this study. Finally, it is our sincere hope that this report will contribute to the improvement of public health and medical care in developing countries. We also hope that it will be an impetus for deeper relations between JICA and the people of Okinawa Prefecture as well as for the expansion of the circle of international cooperation. December 2000 Keiichi Kato Managing Director IFIC, JICA FOREWORD Seisho Higa Chairperson Director, Chuou Health Center, Okinawa Prefecture 1. Introduction This report contains the findings of a study committee that worked for approximately one year beginning in early 1999 under a commission from the JICA. The study committee had four primary objectives: (1) To systematize the experiences of Okinawa in local public health and medical care and to put them into a form that can be used as a development aid manual; (2) To conduct a detailed study of the international cooperation resources available in Okinawa Prefecture, discuss the potential for international cooperation by the government and people of Okinawa, and to provide recommendations in this regard; (3) To translate the resulting report into English for use in training programs; (4) To introduce a wide spectrum of the public in Okinawa and elsewhere about the prefecture’s history on public health and medical care and the international contributions Okinawa has made to date. Our study of international public health care cooperation by Okinawa rests upon several assumptions: 1) That cooperation will build upon the prefecture’s experiences since the war; 2) That cooperation will focus on primary health care; 3) That programs will be suited to the facilities, equipment, and manpower currently available within the prefecture; 4) That attention will be given to the accumulation of international cooperation experiences within the prefecture; 5) That attention will be given to the involvement of younger generations in the prefecture; and 6) That the prefecture will be able to provide feedback, supervision, and advice even after training programs are completed. The study committee evaluated and analyzed the approaches and expertise created and accumulated by Okinawa Prefecture in the field of public health care based on the assumptions that application to international cooperation had great potential. This was also based upon the idea that there are self- evident differences between the international cooperation conducted at the central level and the prefectural level, and that the prefecture should concentrate on the training of mid-level health care staff. In the course of this study, we gained further confidence that the subtropical climate, insular geography, and postwar historical experiences of Okinawa are unique within Japan and it can provide valuable reference points for the difficulties encountered by developing countries. However, while experience and expertise can be accumulated, they tend to gradually disappear over time or to change their form and nature. The study committee was keenly aware of the need for constant efforts to transmit Okinawa’s experiences and expertise from one generation to the next. It was indeed timely to contextualize and reevaluate the health care organizations, technologies, and systems that developed out of the creativity and innovation of postwar Okinawa. This is useful in aid for developing countries, and is also an asset and a legacy for the people of Okinawa. As we reviewed individual projects and entered the summarization process, the passion and enthusiasm exhibited by people working in the health care field, and the unity that was seen between governments and citizens emerged. There was more than just government policy behind the programs of the U.S. Military Government, the U.S. Civil Administration, and the Japanese government; the efforts of people played major role. We became aware of not only systems and programs, but of the individual medical professionals with the sense of duty and pride that they brought to their work—the physicians who sacrificed themselves to improve public health at a time when few medical professionals were available; the public health care nurses who accepted assignments on outlying islands and in remote villages, where they went door-to-door providing maternal and child health care and treating tuberculosis patients; the medical servicemen who protected the lives of people living on remote islands. Thanks to their efforts and the combined efforts of local residents, the Ryukyu government, the Japanese government and the U.S. Civil Administration, Okinawa was successful in eliminating such endemic diseases as malaria and filaria, as well as hookworm and other parasites. Reading between the lines of this report, you will see that the passion and effort of those involved were the keys to success for projects in development aid. The study committee had time limitations, and it is uncertain whether we achieved all of our objectives, but we hope that people involved in international cooperation will find within this report directions that can be taken in primary health care activities in developing countries, and that this report will contribute in some way to the improvement of public health care in developing countries. 2. Structure of the report Chapter 1 describes the status of health care in developing countries, the issues faced, and the efforts made by Japan. Many developing countries continue to suffer from inferior health care environments, and it is urgent that health care cooperation be provided. Indeed, this should be seen as a global problem. Chapter 2 describes what is happening in Okinawa today. In addition to brief summaries of Okinawa’s geographical and climate characteristics, economy, and health indices, this chapter also contains statistical information on the number of health care workers and descriptions of current health care institutions and government systems. Chapter 3 describes the health care system that was painstakingly built by Okinawa Prefecture after the war. The chapter takes a topic-by-topic look at the history of health care in the prefecture and the activities of physicians, nurses, and health administrators as they fought to overcome disease with extremely deficient medical resources. This chapter was written by people who are involved first hand in health care in Okinawa: prefectural government administrators, employees of major hospitals, public health center personnel, nurses, university professors, and NGO members. Chapter 4 contains an outline of the health and medical institutions in Okinawa and a description of the international cooperation in which they have engaged thus far. This final chapter provides basic information for future studies