Anthony DISTEFANO*, Takeshi MATSUISHI**
*University of California, Los Angeles(UCLA), School of Public Health
**Yokohama National University, Faculty of Education and Human Sciences, Department of Special Education
As a student in the master's program at the
University of California, Los Angeles (UCLA)
School of Public Health, it is required of
me to participate in 200 hours of field studies.
Instead of staying in California like most
of my classmates, I saw this as an opportunity
to study the overall organization and activities
of the Japanese public health system, and
therefore sought to secure an internship
in Japan. Fortunately, I came across the
homepage of Dr. Takeshi Matsuishi's laboratory
in the Department of Special Education at
Yokohama National University. I was very
excited that after applying, I was accepted
as a scholarship recipient and invited to
conduct my internship with Dr. Matsuishi.
The following is a brief summary of what
I learned and of my experiences during my
5-week stay in July/August, 2000.
My first week in Japan consisted mainly of
visiting each of the four agencies at which
I would be based in ensuing weeks. I was
given tours of facilities and introduced
to people who would be responsible for my
training.
Kamakura, seat of the military government
during the 12th-14th centuries, is a fairly
small city in Kanagawa Prefecture, about
30 minutes by train from Yokohama. It was
there that I spent the second week of my
internship at a local public health center.
These facilities, more precisely translated
as health promotion and welfare offices,
are the first line of defense in Japan's
community healthcare scheme. Their functions
span a wide range of public health concerns.
The Kamakura center comprised 4 departments:
1. Health Promotion and Welfare- Maternal-child
health promotion; nutrition; dental health
promotion; prevention of so-called lifestyle
diseases (e.g. cardiovascular disease); welfare
care for the elderly; welfare assistance
(monetary); insurance care and assistance
for the elderly.
2. Health Promotion and Prevention- Prevention
of infectious diseases and/or diseases that
are difficult to diagnose and treat; mental
health promotion; healthcare for survivors
of atomic bomb(s); care for senile dementia;
HIV/AIDS prevention; general health consultation
and counseling.
3. Environmental Hygiene- Guidance for facilities
on how to comply with Japanese environmental
hygiene laws; similar guidance for drugs/pharmaceuticals;
water purification and disposal; testing
of household items and home-safety consultation.
4. Food Hygiene- Guidance for facilities
on how to comply with Japanese food hygiene
laws.
Whereas larger cities like Yokohama have
as many as 18 public health centers, one
for each ward, the Kamakura facility is responsible
for a larger, less densely populated geographical
area, including Kamakura City, Zushi City,
the town of Hayama, Yokosuka City, and Miura
City. People from all of these places go
to the Kamakura center for various health
screenings and consultations. In general,
the staff conveyed to me that currently,
Japan's most serious public health concerns
are the rapid aging of its population, the
subsequent increase in utilization of health
services, and the associated rise in health
expenditures.
For week 3, I was based at the Yokohama branch
Healthcare Management Center for Nippon Telephone
and Telegraph (NTT), Japan's largest telecommunications
company. The purpose of my internship at
NTT was to get a look at a component of healthcare
that is uniquely Japanese, the corporate
health management system. The Yokohama center's
service area encompasses all of eastern Japan
and the northern island of Hokkaido. It is
staffed by 3 physicians, 12 public health
nurses, 1 registered nurses. The center
is typical among larger corporations in Japan.
It serves only the employees of NTT, and
has various responsibilities, including regular
medical examinations, health consultations,
education for branch offices on occupational/industrial
hygiene, and case (disease) management. An
outpatient clinic was also once in operation,
but has been discontinued.
It is standard practice in Japan for company
employees to have one physical examinations
per year. The results of the lab tests, which
are conducted at clinics and hospitals in
the employees' local areas, are sent to the
healthcare management center for analysis.
If an employee or his/her supervisor believes
that a health problem is serious, a consultation
at the healthcare management center may be
indicated. One consultation that I observed
ended in an employee being diagnosed with
a form of schizophrenia. As serious as his
condition is, however, I was told that NTT
would continue to employ the man. The company
adheres to a rapidly declining Japanese tradition
of employing workers for life. Such a case
would surely be unusual in the United States.
I accompanied the senior physician of the
center to a branch office of NTT-ME, an NTT
subsidiary, where he conducted health counseling
with select employees. The consultations
tended to emphasize preventive medical advice,
including recommendations for diet and exercise.
I also had the opportunity to sit in on a
meeting of the company's Occupational Health
and Safety Committee, which is responsible
for assuring that the company complies with
Japanese laws concerning the workplace environment.
They also sponsor campaigns to promote safer
driving habits. These experiences collectively
gave me an idea of how large corporations
in Japan take a very active role in both
the maintenance of a safe workplace and in
managing the healthcare of their employees.
Mental health was the focus of week 4, during
which I observed the functioning of the Yokohama
City Comprehensive Healthcare and Medical
Treatment Center. Although the facility deals
mostly with mental health issues, there is
no mention of this in its name. The center's
facilities include day care for patients
with senile dementia, day and night care
for those with mental disabilities, and various
imaging equipment for tests ordered by doctors
in the area. The staff of the center's general
consultation office explained to me Japan's
new Insurance for the Care and Assistance
for the Elderly. This new insurance plan,
which went into effect 4/1/00, was created
in response to the aging of the nation's
population. In Yokohama City, persons 65
years of age and over currently make up 13.5%
of the population. This proportion is expected
to increase to 17.5% by 2010. Obviously,
with increasing numbers of elderly people
will come an increase in the prevalence of
senile dementia, including Alzheimer's disease.
I had the chance, on two separate days, to
observe the day care programs for senile
dementia patients and was impressed by the
organization and warmth of care provided.
There was a 1:4 ratio of staff to patients,
and the former treated the latter with more
respect than I have observed on occasion
in the United States. I also spent two days
learning about the day care and dormitory-style
night care programs available for people
with mental disorders. The most common diagnosis
of patients in this section of the center
was schizophrenia. I was pleased to find
that a few of them spoke excellent English
and were eager for me to join in their activities,
which included sports, various arts and crafts,
and prevocational skills training in printing.
Adjacent to the Comprehensive Healthcare
and Medical Treatment Center, is the Yokohama
Rehabilitation Center, where I spent the
final week of my internship. Founded in 1987,
the center is divided into 6 major departments:
1. Information and Counseling Service- Integration
of medical and social services; handles new
clients and decides their needs and the available
services in and outside the center.
2. Medical Department- Medical services in
the medical ward; medical evaluation and
consultation to other divisions in the center;
physical therapy; occupational therapy; speech/language
and hearing therapy, psychotherapy.
3. Pediatric Habilitation- Medical services
for physically and mentally impaired children;
facilities for continuous therapeutic exercise,
psychotherapy, and nursing on a day-service
basis.
4. Social and Vocational Rehabilitation Department-
Social skills training; prevocational training;
vocational consultation.
5. Community Rehabilitation Service Department-
Outreach rehabilitation programs for home-bound,
physically disabled people.
6. Rehabilitation Engineering Division- Provides
prosthetics and orthotics, technical aids,
and house remodeling services.
The Rehabilitation Center has a close relationship
with local hospitals, clinics, child health
centers and particularly pubic health centers,
all of which refer patients who require specific
treatment. More than half of the clients
are under 18 years of age. What I found most
unique among the center's programs was the
Community Rehabilitation Service Department's
outreach rehabilitation service. A surprising
\1,500,000 (about $15,000) in home remodeling,
to allow for more independent living of disabled
people, is covered by a Yokohama City fund.
Additional money is also available for the
installation of specific devices in the home.
Patients from both the Comprehensive Healthcare
and Treatment center and the Rehabilitation
Center utilize the impressive facilities
of the Yokohama Rapport Sports and Cultural
Center for the Disabled, which is connected
to both buildings. The Sports Center includes
a large gymnasium, a fitness room, a bowling
alley, and a swimming pool. All areas are
used for physical and occupational therapy
in addition to organized team activities
for clients of various disabilities.
My general impression of community health
in Japan can really only be my impressions
of how it functions in Kanagawa Prefecture.
It is my understanding that this prefecture,
and Yokohama, in particular, are quite progressive
in their organization of public health compared
with other areas of Japan. If that is true,
I may have been given what is not the typical
example of the Japanese system. Whether that
is the case or not, however, Kanagawa seems
to have a well-established yet continuously
evolving collaboration among public agencies
that contribute to the maintenance of public
health.
I would like to express my gratitude to Dr.
Matsuishi for his invitation and his guidance
throughout my internship and to the dozens
of staff members who took time out of their
busy schedules to show a foreign student
the intricate workings of their facilities.
Yokohama, Japan
11 August, 2000
(originally published on Journal of disability and medico-pedagogy Vol.2.2000:p9-12)
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