Prognosis: Steady Improvement

By Anastasia Toufexis

But the nation's health-care system still lags behind the West's

Japan began to modernize its medicine along Western lines more than a century ago. Despite intensive efforts and some impressive successes, the nation remains underdeveloped by Western standards: its system is loosely regulated and the quality of its care is uneven.

"It's the wild, wild West of medicine," says Seth Goldsmith, professor of public health at the University of Massachusetts at Amherst and author of a forthcoming book on Japanese hospitals.

Health care in Japan is founded on family doctors, generalists who make up about 40% of the nation's 163,000 physicians. They run small clinics, usually out of their homes, treating people for minor ailments. Swamped with work and barred from practicing in hospitals, which are controlled by specialists, many of these doctors are unable to keep up with advances in the field. Unlike the American Medical Association, the more casually organized Japan Medical Association makes little effort to oversee or upgrade the quality of health care.

Most family doctors double as pharmacists. That dual role was officially sanctioned more than 100 years ago, when druggists were scarce; it continues today even though Japan also has more than 120,000 pharmacists. One of the most severe criticisms of Japanese medicine made by Westerners is that family doctors overprescribe. An American scholar who recently consulted a Japanese doctor for a mildly sprained ankle came away with a muscle relaxant, an anti-inflammatory drug, a stomach powder to ease the side effects of the drugs, and a foot plaster. In the U.S., he probably would have been told to stay off the foot for a while and take a few aspirin.

Patients with serious symptoms are sent by the local doctor to see specialists in a hospital; they, too, are often not as rigorously trained and supervised as their American counterparts. "There is no licensing system or qualification test as a specialist," says Dr. Yasuyuki Hosoda, a leading heart surgeon who practices at Tokyo's Toranomon Hospital. Hosoda spent six years as a resident and researcher at the Cleveland Clinic and worked for ten years at the Borgess Medical Center in Kalamazoo, Mich.

Although Japanese hospitals are sometimes endowed with the latest hightech equipment, they often lack the trained personnel to use it. Japan has 2,500 computerized axial tomography (CAT) scanners, sophisticated X-ray devices that reveal detailed cross-sectional views of the body. Yet there are only 1,500 radiologists in the country to handle the machines. By contrast, the U.S. has about 2,800 CAT scanners, but more than 12,000 specialists are qualified to use them.

Most Japanese hospitals, especially the private ones, amounting to 80% of the nation's 9,224, are old and inadequate. St. Luke's International Hospital in Tokyo is jammed daily by more than 1,500 outpatients, who crowd the hallways for hours. Three ophthalmologists work simultaneously in the one examining room, while waiting patients stand by and watch. There is a stock Japanese complaint about visiting a hospital: "A three-hour wait for a three-minute exam."

The ill who are admitted to a hospital know enough to bring their own chopsticks, towels and soap and not to expect amenities. Example: a woman recently checked into a large, state-run hospital in Tokyo to have a thyroid tumor removed. She was able to get a semiprivate room. The sheets were changed only once a week and the bath and toilet were down the hall. Her sharpest recollection: "I hated to go to the bathroom. Scores of cockroaches were clustered there at night." Still, she said, "the care was excellent."

The Japanese accept crowded hospitals in part because the system has improved during the past few decades. Before World War II, the family doctor would even keep a patient in a makeshift ward that was part of his house or clinic. Indeed, the Japanese do not complain a great deal about medical care in general. They rarely challenge the authority of their physicians by asking for a second opinion or questioning a diagnosis. Says Louise Shimizu, an American who teaches childbirth preparation classes in Tokyo: "It is always a struggle to get information. You cannot build up good relations with doctors."

The Japanese put up with such highhanded treatment largely because of the revered place that a white-coated doctor, a figure of authority, has long held in the culture. The physicians' incomes reflect their prestige. The typical family doctor working in his small, poorly equipped clinic makes about $67,000 a year, while a lawyer earns $31,000 and a university professor $29,000. In addition, although their income is taxed, doctors make thousands more on the side from tips that are discreetly passed on by patients. After her operation, the thyroid patient delivered a box of candy with five 10,000 yen bills ($215) hidden at the bottom. Says she: "I was told that's what everyone does."

But if the doctors are doing well, the rest of the country's medical system has serious financial problems.

Hospitals are in particular trouble.

Because the government strictly limits how much they may charge (the minimum price per day is $36, vs. $99 in the U.S.), hospital administrators face a catch-22 situation. To meet their expenses, they are forced to take in more and more patients, which only increases expensive and lamentable overcrowding. Institutions that buy costly equipment often find it impossible to balance their books. Forty-three hospitals went bankrupt in 1982, double the number two years before. Says Dr. Kinori Kosaka, director of Toranomon Hospital: "Better medical treatment requires updated medical facilities, excellent doctors, nurses and technicians. But we can't charge extra. That is why it is so difficult to run a good hospital today."

The country's network of company-and state-backed insurance programs assures treatment to virtually everyone; wage earners contribute as little as $5.20 a month to plans that provide lavish benefits. Critics complain that patients overuse the system for such woes as hangovers and general fatigue. Another factor that runs up the costs to the state is the high salaries of doctors, supplemented by their income from filling out prescriptions.

Still, Japan spends only 5.07% of its gross national product, or $53.6 billion, on health care, in contrast with 10.5% in the U.S. The main difference: the more sophisticated treatment offered in

America. In the future, the Japanese figure is expected to rise because of the improving longevity statistics. In the past 25 years, the life expectancy of Japanese women has been raised from 68 to 80 years, and of men from 64 to 74. At the same time, infant mortality has dropped. Only seven of every 1,000 babies die before age one, compared with 77 a quarter-century ago.* The statistics reflect improvements in care and the socialized program that offers treatment to all. As a result, Japan's medical system must begin to cope with illnesses that occur more frequently in an aging population and that are very costly to treat.

Twenty-five years ago, the nation's top killer was stroke. Today stroke is second to cancer, which causes one out of every five deaths, the same rate as in the U.S. Only a few hospitals offer the full array of radiation, surgery and drug treatments for cancer that is available in America, but these institutions are comparable to the best in the U.S. Says Dr. Keiichi Suemasu of Japan's National Cancer Center Hospital in Tokyo: "We are very competitive when it comes to cancer treatment of any organ. As for stomach and lung cancer, we feel we are a step ahead of America." Japan also recently launched a ten-year anticancer research effort.

Largely because a more westernized diet has replaced traditional meals of rice and fish with foods heavy in animal protein and fats, heart disease has become the nation's third leading cause of death. However, the Japanese lag behind the U.S. in treating heart ailments because surgeons still lack experience. Only 1,200 coronary bypass operations were performed in Japan last year, compared with 160,000 in the U.S.

Japan also trails the U.S. in preventive medicine. There are no public health-education campaigns aimed at lowering such heart disease risk factors as cholesterol, smoking and high blood pressure. But magazines and newspapers are beginning to discuss such matters, and Japanese men and women, young and old, have become increasingly health-conscious. Many exercise regularly. Others are modifying their eating habits in fashions all too familiar to Westerners, drinking diet soda and low-calorie beer and using low-salt sauces on their food.

In addition to coping with an aging population, Japan faces another challenge. Says Surgeon Hosoda: "The real problem now is what kind of medical care you can get when you are still in your 40s and 50s and one day are struck by a heart attack or any other killer disease. We need a lot of work on quality medicine." In this phase of health care, foreign experts like Massachusetts' Goldsmith believe that the Japanese are far behind the West. Still, few doubt that they will eventually catch up. --ByAnastasia Toufexis.

Reported by Yuki Ishikawa/Tokyo

*In the U.S., life expectancy is 78 years for women and 70 years for men. Eleven of every 1,000 American babies die in their first year.

With reporting by Yuki Ishikawa This file is automatically generated by a robot program, so viewer discretion is required.