What Ails Japan

Statistically, Japanese medicine has much to boast about. Physicians are as numerous as in most Western countries, and life expectancy, at 73 years, is among the highest in the world (the U.S. figure is 71). Credit for this longevity, however, belongs more to diet and innate strength than to professional health care, for Japanese medicine is sick.

In a country noted for personal cleanliness, most hospitals are cramped and dirty. Emergency care is deficient in both quality and quantity. While Japanese technology and industry are flexible, high-energy enterprises, the medical establishment is rigidly oldfashioned, and specialized treatment is difficult to obtain. "Medicine is the forgotten aspect of our rapid progress," laments Dr. Hiroshi Kuroiwa, a gifted young surgeon who has recently returned to Tokyo after three years of specialty training in the U.S. "Things would be different if our medical system had been exposed to the same foreign competition as our business."

The ordinary Japanese has only one consolation for the mediocre care he receives: an elaborate medical insurance system pays most of the bills.

The problem starts with the medical schools. Training emphasizes research rather than clinical practice. Schools are overcrowded, curriculums out of date, and students discontented to the point of periodic open rebellion. Dr. Taro Takemi, the outspoken president of the Japan Medical Association, damns the schools vehemently: "Today," he says, "they provide neither decent research nor decent clinical training."

If the new graduate wants to specialize, he can expect no more than $300 a month on the staff of a government or university hospital. More typically, he borrows money to buy the minimum of necessary equipment, opens his own office and starts a general practice. He treats as many patients as he can in his "clinic" and holds on to them as long as possible. If he puts a seriously ill patient into a general hospital, the physician almost invariably loses all contact with him--and all income from the case. Of the country's 6,800 general hospitals, only about 50 allow a G.P. to obtain staff privileges and retain charge of his patients.

Whether in a big city or small town, the country's 69,000 private clinics are remarkably alike. In Tokyo, Dr. Takeshi Ito (not his real name), an internist who calls himself a child specialist, owns and runs a one-room clinic with a cubbyhole dispensary. Ito sees about 60 patients during each long clinic day, visiting a few bedridden patients at home in the afternoon. At night, relaxing with his hi-fi and a bottle of Scotch, Ito wonders aloud whether he can call himself "a true disciple of this noble science of medicine." He provides his own answer: "I often feel so ashamed of myself for doing what I do as a physician that I hate being called one. But what can I do? I have to keep myself and my family fed."

Like most of his colleagues, he denounces the point system by which the government determines how much a doctor shall be paid for services performed and medicines dispensed. Some doctors, he says, have long since "sold their souls to Mephistopheles and turned into nothing but point getters." Under the most representative of Japan's five insurance plans, the individual pays 6.9% of his income into the fund, and his employer matches this amount. On his first visit to the doctor the patient pays 200 yen (67-c-) out of his own pocket; the insurance company adds 27-c-. After that, everything is on the plan. For the second visit, a doctor is paid only about 16-c-. If he gives an injection, he earns eleven points, or 37-c-. An appendectomy pulls in 1,290 points, or $43.

The schedules allow relatively few points for a prescription, many for the medicine itself--hence the pressure for the doctor to do his own dispensing and the temptation to overprescribe. Doctors buy drugs at a discount of up to 60%; retailing them is the biggest single source of income for the average private physician. Dr. Shogo Yoda, 65, head of the Yamanashi chapter of the Japan Medical Association, notes that Japanese are inclined to develop a strong personal relationship with an individual physician, instead of seeking a specialist when they need one. A Tokyo schoolteacher, Takehiko Osawa, 41, is an example: he suffers from chronic asthma, for which he is being treated by his family doctor--a gynecologist. To Osawa, it was natural to go to him: "I trust him."

Japanese trust higher authority generally, including the health authorities who maintain the cumbersome, ill-balanced point system and the Japan Medical Association. Many J.M.A. members oppose hospital improvements because better hospitals would draw patronage from their private clinics. Until such conflicts can be reconciled, technologically advanced Japan will remain a medically underdeveloped nation.

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