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.
11 August, 2000
(originally published on Journal of disability and medico-pedagogy Vol.2.2000:p9-12)