Health, Illness, and Medical Care in Japan CONTRIBUTORS CHRISTIE W. KIEFER University of California, San Francisco MARGARET LOCK McGill University SUSAN ORPETT LONG John Carroll University EDWARD NORBECK Rice University DAVID K. REYNOLDS ToDo Institute and Health Center Pacific NANCY R. ROSENBERGER Emory University WILLIAM E. STESLICKE University of South Florida This book is based on a conference sponsored by the Joint Com- mittee on Japanese Studies of the American Council of Learned Societies and the Social Science Research Council. Health, Illness, and Medical Care in Japan Cultural and Social Dimensions Edited by Edward Norbeck and Margaret Lock Open Access edition funded by the National Endowment for the Humanities / Andrew W. Mellon Foundation Humanities Open Book Program. Licensed under the terms of Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 In- ternational (CC BY-NC-ND 4.0), which permits readers to freely download and share the work in print or electronic format for non-commercial purposes, so long as credit is given to the author. Derivative works and commercial uses require per- mission from the publisher. For details, see https://creativecommons.org/licenses/by-nc-nd/4.0/. The Cre- ative Commons license described above does not apply to any material that is separately copyrighted. Open Access ISBNs: 9780824880767 (PDF) 9780824880774 (EPUB) This version created: 17 May, 2019 Please visit www.hawaiiopen.org for more Open Access works from University of Hawai‘i Press. © 1987 University of Hawaii Press All rights reserved To the memory of Bill Lebra CONTENTS Dedication vi Foreword ROBERT J. SMITH viii Acknowledgments xi Introduction: Health and Medical Care as Cultural and Social Phenomena MARGARET LOCK xii The Japanese State of Health: A Political-Economic Perspective WILLIAM E. STESLICKE 1 Health Care Providers: Technology, Policy, and Professional Dominance SUSAN ORPETT LONG 48 Care of the Aged in Japan CHRISTIE W. KIEFER 71 Japanese Models of Psychotherapy DAVID K. REYNOLDS 93 Protests of a Good Wife and Wise Mother: The Medicalization of Distress in Japan MARGARET LOCK 115 Productivity, Sexuality, and Ideologies of Menopausal Problems in Japan NANCY R. ROSENBERGER 145 Notes 177 Contributors 188 vii FOREWORD In my file of miscellaneous materials there is a color repro- duction of a painting that epitomizes the common view of the relationship between modern biomedicine and the indigenous medical systems it has encountered. Identified only as taken from a 1930s Soviet publication, Paint ings by Yakut Artists, it shows an interior scene. On a platform bed, covered by an animal skin throw, lies a woman with oriental features and long black hair. In a dark corner near the foot of the bed stand a small boy and an old man whose features register anxiety and resignation, respectively. At the back of the room, looking out sternly from under a fur-lined parka, is a man who seems to be the patient’s husband. For patient she is. Standing full center is the sturdy figure of a woman in the process of re- moving a heavy fur outercoat to reveal her gleaming white nurse’s uniform. She stands, obviously having been brought to the house by the husband, purposefully and powerfully delin- eated, looking toward the patient. Her features are Caucasian, her short hair, light brown. She is placed between the bed and a dark figure of a man whose posture suggests that he has been pushed aside. His features, like those of all the family members, are oriental, his long hair, jet black. Clad in full regalia and holding a skin drum and stick, he has been thrust into semi- darkness. The painting, by one A. N. Ossipov, is entitled The Expulsion of the Shaman. It might well have been subtitled “Su- perstition Eclipsed by the Light of Reason.” Readers of the contributions to this volume will soon dis- cover that the allegory so carefully worked out by the Soviet artist could hardly be less appropriate to the contemporary Japanese medical scene. In one way or another every essay reveals how consistently and thoroughly interwoven are the several systems by means of which the Japanese define health and the ways in which illness can be treated. Modern bio- viii FOREWORD medical scientific practice was in fact built on the existing structure of the practice of what is loosely called “Chinese med- icine.” The Meiji government, in the late nineteenth century, did indeed sponsor the establishment of Western biomedical science, as the Soviet government was to do in its turn, but in Japan no move was made to stamp out the indigenous system already in place. The authorities controlled its practice, to be sure, but a pluralistic system has flourished for over a century. Over the years a degree of integration has taken place so that the recent boom in the use of herbal medicines is traceable in part to its promotion by Japan’s great pharmaceutical houses. Thus, the Japanese—ever concerned with health and given to equating illness with disorder—enjoy the benefits of medical pluralism and increasingly exploit its diversity. There is yet another major emphasis in these essays that greatly aids our understanding of how such systems work. In Japan, as in most—perhaps all—other societies today, the pro- fessionally given definitions of health, illness, and therapy are all in important ways shaped by social and cultural beliefs concerning the body, the concept of the self and identity, and the relationship of the individual to society. Folk or popular medical knowledge and assumptions are deeply implicated in the professional biomedical definitions of proper health main- tenance, symptoms of illness, and effective treatment of them. We would expect to find such cultural influences in, say, the psychotherapies, but the authors show similar interweaving of social and cultural factors in what are usually seen as purely technical medical decisions such as length of hospital stay, degree of intrusiveness of treatment, and analysis of the origins of the multiplying syndromes so widely reported in the Japanese press. That such decisions are strongly influenced by the notion that the primary responsibility for health and the successful treatment of illness rests squarely on the individual and members of the immediate social group—particularly the family—is only one of the many findings reported here that re- veals how society and culture figure in the operation of seem- ingly autonomous technical domains. What is true for Japan is equally true for other societies where indigenous medical systems are fused with biomedicine. If these papers successfully defend that proposition, as I believe they do, then we are in the authors’ debt for giving us one more example of the essential failure of the convergence model of modernization. That model holds that we are all tending in the same direction and says, in effect, that the expulsion of the ix FOREWORD shaman by the nurse is the inevitable outcome of the clash of medical systems in all societies. If the argument were valid, the Japanese medical scene by rights ought to be far less variegated and complex than it is after more than a century of full-scale adoption of alien biomedical teaching and practice. What has happened instead is the establishment of a pluralistic medical system strongly grounded in Japanese conceptions of the nature of men and women, the sources of their physical and psychologi- cal well-being, and the treatable causes of ill-health and dis- order. Insofar as these considerations are socially and culturally specific, the resulting medical system is identifiably Japanese. To the degree that all medical systems are incorporative rather than exclusive, the contributions to this volume clearly signal the necessity to look more closely at our own. Robert J. Smith Cornell University x ACKNOWLEDGMENTS An expression of hearty thanks is due to the Social Science Research Council, the moving spirit in the preparation of this volume. The council provided the original inspiration and the funds for a planning meeting on themes relating to Japanese health and illness that was organized by Edward Norbeck and held at Rice University. Several pertinent topics were selected as especially suitable for further elaboration and presentation as papers at the American Anthropological Association Meeting held in Chicago in November 1983. The contents of this volume, revised versions of the papers given at that meeting, have ben- efited from the critical discussion given by George DeVos and Michael Reich at the panel presentation and by editing from Edward Norbeck. The authors would also like to thank the several anonymous referees for their helpful comments and the University of Hawaii Press for a magnificent job of editing and production. xi Introduction: Health and Medical Care as Cultural and Social Phenomena MARGARET LOCK If human beings could be improved like oxen, I suppose it would be possible after some years for the Japanese to boast physiques as powerful as the Westerners’, to be strong, free from illness, and economical human beings, any one of whom can do the work of three men of today. But I wonder if in that case the qualities of the special inborn character of the Japanese people would still exist. I doubt it somehow. —Masaoka Shiki, Bokujū itteki (A drop of ink), 1901 The comparative study of health and illness has proved to be, in recent years, a rich source for the cross-fertilization of ideas among the social sciences. This, in turn, has led to some new conceptualizations about how best to go about conducting re- search and interpreting data. Several factors have contributed to the emergence of an interdisciplinary approach to the analysis of health care. Over the past thirty years, and with increasing vigor of late, the sub- discipline known as the sociology of knowledge, drawing pri- marily on philosophical theory and often using the small-sample ethnographic methods of anthropology, has developed a rig- orous critique of the notion that the scientific method is a value- free endeavor.