Bad medicine

Though Michael Moore's 2007 polemic Sicko was aimed at the US health care system, the documentary maker may do well to train his sights on Japan's medical establishment, if there's ever a sequel.

As a system in absolute, wheezing-andgasping disarray, the national medical system maintains an affable, problem-free face. The national health insurance plan guarantees inexpensive medical treatment for all; constant glances to Western medicine for inspiration assures Japanese patients the most up-to-date medical equipment and treatment techniques; small, family-run ‘neighborhood clinics' offer citizens in distress easy, (if loosely regulated) access to treatment. In the early ‘90s, then- US President Bill Clinton spoke glowingly of the local health care system; then-First Lady Hillary Clinton opined that that "Japanese medical care system is maintained by the saint-like self-sacrifice of medical workers."

"Saint-like self-sacrifice" aside, whistling through gritted teeth only fools people far enough away not to see the pained facial expression: as far as the Japanese health care system goes, things are bad, so bad that some fairly massive reformations are needed to prevent the industry from falling into the debt-laden, resource-free abyss it currently seems headed for.

The nation loves its doctors. In 2004, nearly 76 years after his death in Africa researching yellow fever, Japan celebrated the life and work of Fukushima doctor and bacteriologist Hideyo Noguchi with a place on the ¥1,000 note. Doctors are lionized in manga and dramas like Blackjack and the extremely earnest Team Medical Dragon; real-life ‘genius' surgeons like Kami no Te (‘God-Hands') neurosurgeon Takanori Fukushima are profiled lovingly on TV; and in an era of low-wage haken (parttime) work everywhere, a career in the medi- cal profession still has something of an aura of greatness. For all of that, however, rafts of employed doctors are fleeing the industry, and too few students are coming through to replace them.

Japanese doctors are, without a doubt, some of the most overworked medical specialists in the world; an Organization for Economic Cooperation and Development report noted that, at 8,400 patients a year, Japanese doctors saw 3.5 times the OECD average of 2,200 patients annually. "It's become the norm for doctors to work 36 hours straight, which is emotionally and physically exhausting," Hyogo Brain and Heart Centre vice director Teishi Kajiya told the AFP earlier this year. "We never know when one of us might collapse."

The reasons for this are severalfold, though interconnected. The much-lamented low birthrate has decreased the number of incom- ing doctors (and the patients they have to care for). The lack of patients has led to a lack of revenue. The lack of revenue (and mounting prefectural debt) has led to hospital closures, and stagnant salaries. The stagnant salaries have led to less and less students wishing to become doctors, which in turn leads to remaining doctors working "normal" 36-hour shifts, which leads to students opting for cushier, better-paying jobs in less-stressful fields ...

Doctors working 36-hour shifts are bad enough. Consider further the meager number of doctors on duty at most times in most area hospitals (most barely meet a minimum of only three on-duty doctors to handle all incom- ing patients; regular medical standards quote three doctors for every emergency patient).

It is problematic, to put it mildly. "The shortage of doctors does not only mean that there is no doctor in the community,"Kosei- kai Kurihashi Hospital Vice-President Dr. Honda Hiroshi lamented on a recent NHK program. "Because the number of doctors is not enough, one doctor should play multiple roles as surgeon, chemo-therapist, palliative therapist and emergency doctor and others. This causes serious negative effects on the quality and safety of medical services." (It's 3am in the hospital; is that man in the white jacket a heart specialist? He is now!)

Understandably, the threat of litigation looms large for medical practitioners, who are increasingly wary of helping patients in disciplines they have little training in. Extre- mely regrettably, many hospitals are curr- ently doing the equivalent of the cross-arm "NO" sign when too many emergency patients come a' knocking.

In a hideous closure to last year's denial- of-service horror stories, an 89-year-old Osaka Prefecture woman died December 26 after her ambulance was refused admi- ssion at more than two dozen hospitals. Following a bout of sickness, the woman's family called for an ambu- lance early the previous morning. The ambulance arrived, but was forced to spend two hours contacting a total of 30 hospitals before the patient was eventually admitted to the Osaka Minami Medical Center in Kawachinagano. By then, however, her heart had stopped; she was even- tually resuscitated at the hospital, only to die the next morning.

This followed similar stories from last August (nine hospitals refusing a pregnant woman, who would later miscarry after her ambulance crashed), and in 2006 (where a mother-to-be died after being rejected by 20 hospitals); to say nothing of regular emergency cases, a report from the Fire and Disaster Management Agency that in 2006, a total of 667 expectant mothers were turned away from at least three hospitals while transported by ambu- lance. "The reality is that we've been forced to reduce emergency treatment to a portion of our patients since there are too few doctors," said Kajiya, whose estimated that his own hospital had turned down more than 100 patients in the past two and a half years. "It simply can't be helped."

Health, Labor and Welfare Minister Yoichi Masuzoe – taking over from former minister Hakuo Yanagisawa, whose baffling 2007 women-as-"birth-giving-machines" comment sealed his fate but good – has vowed to improve the system. Monetary enhance- ments (or ‘bribes', one can call them) are being used to lure young doctors back to rural areas; the government has pegged ¥150 billion to help get the industry out of debt and make things more attractive for potential new doctors.

The simplest (and, most likely, effective) fix, however, is already in the works. Though the visa obstacles faced by foreign doctors hoping to work in Japan are still largely insurmountable, measures are underway to help bring in a number of nurses and caregivers from Japan's neighboring countries. Under economic partnership agreements with Indonesia and the Phili- ppines, Japan will accept a certain number of trainee nurses from each country. The trainees are slated to take part in six months of Japanese language training, then commit to on-the-job training that will, ostensibly, help them pass the national nursing exami- nation they are required to take within three years in order to stay in the country.

The response to date, however, has been a rousing lack of enthusiasm. According to survey results released by the Kyushu Uni- versity Asia Center earlier this year, less than half (46%) of Japan's large hospitals would consider adding even licensed foreign nurses to their staff. The same survey found that 62% of the hospitals were unwilling to accept unlicensed trainee nurses for on-the-job training, citing language prob- lems, support difficulties and, quite unfor- tunately, the possible unwillingness of their patients to be treated by a non-Japanese.

All things considered, however, the hos- pitals, and their patients, may not have much of a choice in another decade or so, as more and more industries – and the nation in general – find themselves in the same dilemma. In emergencies, after all, one has find help where it's available.

Text: Jeff Lo • Photos: KS