Introduction: Health and Medical Care as Cultural and Social Phenomena
If human beings could be improved like oxen, I suppose it would be possible after some years for the Japanese to boast physiques as powerful as the Westerners’, to be strong, free from illness, and economical human beings, any one of whom can do the work of three men of today. But I wonder if in that case the qualities of the special inborn character of the Japanese people would still exist. I doubt it somehow.
—Masaoka Shiki, Bokujū itteki (A drop of ink), 1901
The comparative study of health and illness has proved to be, in recent years, a rich source for the cross-fertilization of ideas among the social sciences. This, in turn, has led to some new conceptualizations about how best to go about conducting research and interpreting data.
Several factors have contributed to the emergence of an interdisciplinary approach to the analysis of health care. Over the past thirty years, and with increasing vigor of late, the subdiscipline known as the sociology of knowledge, drawing primarily on philosophical theory and often using the small-sample ethnographic methods of anthropology, has developed a rigorous critique of the notion that the scientific method is a value-free endeavor. The way has been opened for the analysis of biomedicine as a cultural product, and the sociologist Freidson was one of the first to undertake such a study. Since the publication of Freidson’s Profession of Medicine in 1970, numerous critical studies representing a range of perspectives have appeared. Navarro’s presentation (1976) of the Marxist view of the links between capitalism and biomedicine and Illich’s well-known book (1976) focusing on the shortcomings of the medical profession itself are two examples; a third is McKeown’s sober and carefully researched study (1976) attributing improved health in late 2nineteenth and early twentieth-century Europe mainly to improved nutritional status and public health measures and not to services provided by the medical profession. It is not altogether surprising that, concurrent with these developments, a flood of popular interest in alternative and exotic health care systems emerged, an interest partially fueled by the research of anthropologists into comparative medical systems and in which Asian medicine figured prominently (see, for example, Kleinman 1979; Leslie 1976; Lock 1980).
Many researchers who wish to account adequately for the generation of medical knowledge and the institutionalization and practice of medicine, whether in a nonliterate or a complex society, have gradually come to see that most of the traditional, discipline-confined approaches used in the social sciences are too narrow. The work of both the physician and the shaman is invariably modified by political forces. The “popular” cultural construction of ideas about the cosmos and the relationship of people to nature and the spirit world as well as ideas about birth, death, gender, human anatomy, physiology, nutrition, body boundaries, social identity, the nature of emotions, normality and abnormality, early socialization, and so on, all contribute to shared ideas in any one medical tradition. Members participating in any tradition, whether they are ordinary people or professionals, help to sustain and change these ideas.
“Professional” beliefs about health, preventive medicine, and etiology of illnesses and their nosology and therapy, all of which form the corpus of esoteric medical knowledge, including biomedicine, are everywhere partially structured by popular medical knowledge (Helman 1978; Hahn and Gaines 1985) and are the product of a particular historical, institutional, and political setting. This situation is made more complex because in most parts of the world today societies have been exposed to at least one and often two major, literate medical traditions, the ideas of which have been superimposed, often over the course of hundreds of years, upon an indigenous nonliterate medical tradition. A state of pluralism is normal but is rarely explicitly recognized as such by members of a society. It is only the fastidious historian or anthropologist who takes the trouble to tease out the origins of various medical ideas.
Thus, medically related conceptions are embedded in a mesh of cultural concepts, what Peter Worsley (1982) has called a “metamedical” framework. Isolation and study of components such as a “medical system” or “tradition,” a hospital, a clinic, or a healing session, are artificially bounded units superimposed by the social scientist who undertakes 3the analysis. It is, of course, necessary to create some sort of controllable units in order to collect and analyze data. It is also essential, however, that preconceived notions about the complete separation of, for example, biomedical knowledge and religious or political beliefs or biomedical practice and ritual or magic be carefully scrutinized and not assumed a priori as natural and inevitable.
The Study of Health and Illness in Japan
We have come a considerable distance from the first publication by a Westerner of what could be loosely classified as a study into health care in Japan. In the thirties a large part of a Ciba symposium on bathing was devoted to the therapeutic nature of Japanese baths (Martin 1939). Since that time various ethnographies have recorded a great deal of information that contributes both to our understanding of contemporary behavior in connection with health and illness and to our knowledge about the metamedical framework in Japan (see Beardsley, Hall, and Ward 1959; Embree 1939; Norbeck 1954; Smith 1978). Research focusing on religious beliefs, such as that by Smith (1974), Lebra (1976b), and Yoshida (1967), has been particularly important in this respect. Contributions by psychological anthropologists and psychiatrists (Caudill 1976; DeVos 1973; Doi 1973; Doi 1986) have also been invaluable in laying the groundwork for a culturally informed analysis of Japanese medical ideas. The work of scholars such as Nakane (1970) and Fukutake (1980) on social organization in Japan provides important points of departure for an analysis of the institutionalized health care system.
The collection of writings in this volume represents only a portion of the recent social science research on health, illness, and healing in Japan. The vast literature on epidemiology and on quantitative approaches to the analysis of the Japanese health care complex (see, for example, Ikegami 1980; Munakata 1986; Yamamoto 1978; Yamamoto and Ohmura 1975), though not represented in this collection, is referred to in many of the essays in this volume, especially that by William Steslicke. There is also a literature produced mainly by medical professionals but also by some social scientists that has a direct bearing on applied medical care and that focuses largely on the encounter between health care professionals and patients (see, for example, Ikemi et al. 1980). This topic is not dealt with here because, rather than remaining within the narrow scientific perspective almost invariably adopted in modern medical and 4epidemiological circles, the contributors to this volume have undertaken studies of rather than in medicine and its related realms. In other words, despite the fact that one of us, David Reynolds, is both a trained social scientist and a medical practitioner, we have retained in the studies that follow a perspective that is separate and analytical rather than one that is primarily applied. Even within this perspective, however, the topics are necessarily limited, and extremely important areas are left unexamined in this particular volume, including contemporary religious beliefs and practices and their relationship to healing (Davis 1980; Lebra 1982; Yoshida 1984); connections between indigenous categories of thought and current health beliefs and practices (Lock 1982b; Ohnuki-Tierney 1984); ideas about contraception and reproduction (Coleman 1983); suicide (Iga et al. 1978; Iga 1986); industrial pollution and related problems (McKean 1981; Reich 1984); the “culture,” social organization, and education of health care personnel (Long 1980, 1984, 1986); the traditional literate medical tradition (Lock 1980); and historical studies on health-related issues (Smith 1977).
What is unusual about this collection of essays is that a broad range of topics relating to health and illness are addressed in a number of ways by one political scientist and five anthropologists, none of whom are limited by the theories of their own disciplines but who draw upon all of the social sciences to a greater or lesser degree in an attempt to portray some fragments of the extraordinarily complex picture that is modern Japan.
The topic chosen teaches us about an aspect of Japanese culture that has not been well documented until recently. In so doing, many of the critical dilemmas and paradoxes that plague the society as it proceeds apace with industrial expansion and economic growth are exposed through a new lens. These studies in health and illness reveal from a unique vantage point the way in which the process of modernization has become encoded into and expressed through the body, at times to its benefit but at other times to its detriment.
The Health Care Complex
William Steslicke, in his overview of the Japanese health care system, contrasts what he terms the “health miracle” (the remarkable improvements in life expectancy and infant mortality) with costs to health (diseases caused by environmental pollution and the increased incidence of heart disease and cancer, among many other problems). Steslicke points 5out that the Japanese, like people of other industrial nations, have become “health care consumers,” who expect and demand the ready availability of high-technology professionalized medical services. While local family practitioners, acupuncturists, and practitioners of massage remain fully occupied, nevertheless, a great demand is placed on large centrally located hospitals. It is not unusual to see people queuing up at the entrances of hospital outpatient departments beginning at six o’clock in the morning in order to be among the first patients to be seen when the doors open at nine. Most women, for example, now prefer to give birth in hospitals where use is made of technology such as fetal monitors, leading to a decline in the use of obstetrician/gynecologists who run their own small, private clinics. This trend, combined with an increased use of contraception and hence a reduction in the abortion rate, has caused some of these private practitioners to go out of business (Lock 1987).
Susan Long and William Steslicke both stress the power of the Japanese government in shaping the implementation of medical care, a situation that makes Japan more comparable with European countries or Canada than with the United States. Steslicke, who has done more than anyone over the years to describe and analyze for the English-speaking audience the intricacies of the Japanese medical care complex, summarizes the system thus: the bulk of medical care is provided by the “private sector,” where the delivery of services is highly competitive leading to redundancy in some areas. The average length of stay in hospitals is 38.3 days as opposed to 8 days in the United States. Steslicke suggests that this can be explained in part by the fact that hospitals are not separated into acute and chronic care facilities, as they are in North America. Other factors implicated by Steslicke are the structure of health insurance plans in Japan, which allows for more generous hospital stays, and cultural ideas about the importance of nurturance and rest during illness (see also Lebra 1976a; Lock 1980; Kiefer, this volume).
One feature of the Japanese medical system that creates chronic policy problems is the combining of a predominately private, fee-for-service, physician-centered system of care with a compulsory health insurance system (Abe 1985; Steslicke 1982a). Although the health insurance system is universal, many people do not use it and are covered instead by private policies not only for illness but for health-related benefits such as retirement funding. These private policies, which are offered to employees of large businesses, provide much better coverage than do the 6government-managed plans to which owners and employees of small businesses and poorer members of society such as the elderly and unemployed tend to belong. This two-tiered system is often the target of policy reform but so far with little success (Steslicke 1982c).
The “closed-staff” system in Japanese hospitals that are organized as self-contained units limits the possibility for referrals and for liaison work. This system also encourages each hospital to be comprehensive and in competition with other hospitals for acquisition of the latest technology, with the result that the quality of care may vary widely (Niki 1985). This same system contributes to poor coordination and continuity of services from primary to specialized care, little concern with rehabilitation and prevention, and inadequate regional health care planning. In an attempt to rectify some of the shortcomings of the closed-staff system, certain well-publicized experimental projects have been undertaken. Two of these are described by Christie Kiefer in this volume. Other projects designed in part to provide possible models for large-scale changes in the future include the 35-year-old primary health care experiment run out of Saku hospital in Nagano prefecture (Abrams 1979; Nishirai 1983), a community health experiment being conducted seventy kilometers north of Tokyo (Miyasaka 1971), and the much more recent privately funded Life Planning Center, founded by a Tokyo physician and created to increase public awareness of preventive health care.
Steslicke also points out that although most Japanese physicians are trained as specialists, by far the majority of them work as general practitioners operating their own small private practice. It is widely recognized that a fee-for-service system encourages aggressive medical practice. A carefully controlled study published in 1976 demonstrated how an annual increase in the rate of appendectomy in Japan (up to three times that of England) was directly correlated to the institution of the fee-for-service system (Yoshida and Yoshida 1976).
One of the most controversial features of the system is that physicians are permitted to both dispense and prescribe drugs, a situation that is clearly linked with excessive use of medication in Japan (Abe 1985). Herbal medication has recently been introduced into the picture; one or two drug companies have begun to promote attractively packaged traditional herbal medication among physicians, who are now legally able to receive reimbursement for its prescription. It is reported that over two-thirds of all Japanese physicians prescribe herbal medication at times, some with great frequency (Nikkei Medical 1981). This means that traditional medicine 7 has entered the world of big business, a change that has enormous implications for both modern and traditional medicinal practice (Lock 1984b; and see Long, this volume).
Steslicke’s chapter describes the ongoing efforts at cost containment in the health care system today, the roles of the various government agencies in this process, and the complex relationship of these agencies to the medical profession and to the “health care industry” composed primarily of drug companies and manufacturers of medical technology. He points out that policymakers in future will have to face up to a much more demanding Japanese public, a public that has a growing sense of entitlement to good care. He also predicts that the health of the public will increasingly be pitted against the interests of those officials in government who are concerned more with fiscal than physical health, and that the Japan Medical Association, at present undergoing a period of reorganization, could be a wild card in the delicate process of reform.
The Process of Medicalization
The topic of medicalization comes up in all but one of the contributions to this volume. Early studies on the process of medicalization (mostly in the United States and Britain) tended to emphasize the role of the medical profession, which some critics believe actively creates a market for its services principally by redefining certain behaviors and problems as diseases (Freidson 1970; Zola 1978).
There have been four critical lines of thought in the past few years that have broadened our understanding of the process of medicalization. The first proposes that the practice of medicine is a reflection of the organization and values of society at large and that members of the medical profession are themselves members of particular cultures, societies, and political systems. Related to this is the second point, graphically illustrated in Susan Long’s chapter in this volume, that professional interests and power are seriously curtailed by government intervention, the interests of which are often at odds with those of the profession.
Third, the medical profession is not a uniform, hegemonic institution; rather, it is made up of a variety of interest groups that form, to some extent, independent bases of power. In Japan there are constant tensions between national and regional medical organizations. Tensions also exist among speciality groups and between clinicians and researchers, salaried hospital-based and private practitioners, rural and urban practitioners, 8and M.D.s practicing traditional medicine and those practicing biomedicine. In characteristic Japanese fashion, factions form behind each of these interest groups and become enmeshed in a web of conflicting and competing interests. This leads to a very complex situation, which has not yet received sufficient analytic attention, although Susan Long’s work has consistently made some important contributions in this respect.
The final point to be noted in connection with the process of medicalization is that there has to be a cooperative public willing to visit physicians, sit in waiting rooms, and stay in hospital beds. Probably every Westerner who has observed the implementation of medical care in Japan has been struck by how readily the Japanese public makes use of health care facilities, physicians, and medication (a topic that, though statistically documented [Okino 1978], awaits fuller analysis). What also strikes an outsider is the extreme time pressure that physicians work under (on average, three minutes per patient), due largely to the structure of payment for their work. The payment structure also encourages physicians to focus on physical interventions, since they are reimbursed only for the procedures they perform. These factors, along with various cultural reasons of long historical tradition (Lock 1980; Ohnuki-Tierney 1984; Kiefer, this volume), produce a strong tendency for interactions between physicians and patients to be focused upon the physical body and the furnishing of treatment for it. Environmental, social, and psychological origins of illness tend to go unexamined in the offices of both physicians and traditional medical practitioners. This brings us fully into the purvue of medical anthropology and the cultural analysis of health and illness, which I will examine next in order to bring us back to the question of medicalization.
The Cultural Construction of Health and Illness
A recent flood of work in medical anthropology and sociology, some of which is inspired by Foucault (1973, 1979), has begun to question persistently the naive assumption that the body physical, because of its constitution from cells, molecules, and liquids, should be exempt from cultural analysis (Armstrong 1983; Bourdieu 1977; Comaroff 1985; Douglas 1970; Turner 1984). Contemporary research sets out to demonstrate that the body is socially and culturally produced and historically situated: it is both a part of nature and society but, at the same time, a representation of the way that nature and society are conceived. In order to understand 9how this is achieved in any given society, it is necessary to examine historical and contemporary cosmologies, ideas about the concept of self and the relationship of self and society, the “location” of the emotions in the physical body, the language of emotions, forms of expression of pain and discomfort and the meanings that are attributed to them, and ideas about body boundaries. An understanding of the nature of social relationships is also obviously crucial, as is an awareness of the culturally accepted means of expressing dissent and the use of the body as a symbolic medium for this purpose.
We are fortunate that so much literature is already available on many of these topics in Japan due to the rich tradition of Buddhist studies as well as psychological, psychoanalytic, and cultural anthropology. If concepts such as nurturance, loss, dependency, responsibility, and so on, are incorporated into the analysis, as is the case in the chapters by Reynolds and Kiefer in this volume, then continuities between the physical body, its cultural construction, and the larger social context become apparent.
The work of Caudill and Doi (1963) from more than twenty years ago produced significant results using this kind of approach. They demonstrated, among other things, how, because of cultural ideas about nonexposure of “real self” (honne), it is extremely difficult for Japanese patients to discuss their feelings with medical professionals. DeVos and Wagatsuma (1959) used the Thematic Apperception Test to show an association between introjected guilt and a concern about illness and death. They contrasted this situation with Hallowell’s research with the Saulteaux, where sorcery is linked to the incidence of illness. (More recent studies over the past twenty years have shown a decline in the frequency of guilt feelings and suicidal ideation in association with illness in Japan [Shinfuku et al. 1973].) Lebra’s studies (1974, 1976a, 1982) into religious groups and healing in Japan have consistently demonstrated that, in addition to paying attention to cognitive constructs, it is important to understand the symbolic presentation of self through the use of nonverbal communication in order to better understand the transactions that take place in healing ceremonies and between patients and their families. Reynolds (1976, 1980, 1981) in his portrayals of Japanese indigenous psychotherapeutic systems has given us a rich picture of a society that cultivates self-responsibility for the incidence of illnesses and that is disposed toward the use of techniques of introspection in psychotherapeutic healing. In a recent article Susan and Bruce Long (1982) use a symbolic interactionist approach to examine why Japanese physicians 10deem it unethical to reveal a “death sentence” of cancer. They discuss the way in which patients and family members immerse themselves in “proper” role behavior in order to collude with the physician in hiding the diagnosis.
One of the important contributions that Ohnuki-Tierney’s research (1984) into Japanese medicine makes is to demonstrate that, by taking as the boundaries for our analyses the demarcations between medical systems as they are perceived by the Japanese themselves (which also happen to be the categories which make “common sense” to Western social scientists), we have often failed to show some very important features common to all types of Japanese health care. At the level of institutionalization there are indeed clear demarcations between folk, traditional literate, and biomedical systems of medicine (Lock 1982a; Long, this volume), but using a cultural and structural (in the Levi-Straussian sense of the term) analysis, it is possible to demonstrate, as does Ohnuki-Tierney, that there are certain concepts and values, such as those based upon ideas of purity and impurity, for example, that surface in a wide range of religious and medical settings, including modern hospitals. Doi’s analysis (1986) of concepts such as ura “inside” and omote “outside” is also applicable in any setting. Although there is institutionalization and tolerance of pluralism (albeit with demarcations that weight distribution of power clearly in favor of the biomedical system today), at the level of the metamedical context made manifest in medical knowledge and practice, there is surprising consistency across many institutionalized boundaries.
In his chapter Reynolds points out some common features of all contemporary Japanese psychotherapeutic systems. The first is “specification,” in which patients at intake interviews are required to give precise descriptions of self and symptoms. In his earlier work Reynolds discussed how many Japanese psychiatric patients tend to suffer from being overly focused upon themselves (this tendency is usually linked to Doi’s  famous discussion of the concept of amae). Because of this exaggerated self-focus, a second psychotherapeutic feature, “dissolving” self-focus, is central to most therapies in Japan. This is often accomplished by the use of techniques of introspection, just one example of “doing something” that is part of virtually all psychotherapies in Japan. Reynolds stresses that a large amount of time is spent in reflecting upon and restructuring relationships to authority figures, including that with the therapist if necessary (see also Tatara 1982). In conclusion he states that therapy always commences with an acceptance of the client as a worthy person. 11Reynolds’ discussion is particularly important because in it he also points out the differences in the therapies that he discusses. In a complex society such as Japan’s, argues Reynolds, patients bring a variety of values and expectations to therapy, and he shows how there is flexibility and choice available to both therapists and patients.
In examining the plight of the elderly in modern Japan, Christie Kiefer examines political, economic, social, and cultural aspects of the problem. Using the key concept of responsibility toward family members, Kiefer analyzes the role played by women in looking after their elderly kin. He draws on the work of Caudill (1962), Doi (1973), and Lebra (1976a), who have all emphasized the passive helplessness (amae) manifested so often in social relationships in Japan and the caretaking response that it elicits (amayakasu). The concepts of amae and amayakasu surface yet again in the behavior of the elderly and in their care. Kiefer demonstrates how these values contribute negatively (to a Western mind) to the condition of the elderly, encouraging the elderly to remain bedridden and offering no incentive for provision of rehabilitative services for them. Kiefer does not limit his analysis to cultural factors, however. He also points out the economic and political reasons for the continued encouragement of care for the elderly in their own homes as well as the negative historical associations on the part of both families and physicians in connection with nursing homes and the power of the medical profession in blocking the development of good nursing and paraprofessional services. Kiefer is careful to show that, though each of these factors can and should be analyzed in terms of the interests of powerful groups, they must also be viewed as partially the product of cultural values that the elite share with the vast majority of ordinary people. (For other recent studies on the elderly in Japan see articles by Steslicke, J. Campbell, Lock, Goldsmith, and R. Campbell, all in Pacific Affairs 1984.)
The first Western study on medical ethics in Japan was published in 1985. It should come as no surprise in light of the above discussion and the following essays, that the author of this study found consensus and deference to authority characteristic of the Japanese approach to ethical issues in health care (Feldman 1985). In this most recent field of medical activity there is a tendency among Western scholars to assume that ethically informed medical decisions are value free. However, this illustration from Japan demonstrates how, as with every other aspect of medical care, cultural patterning is inevitable. 12
Changing Symptom Patterns and the Epidemiology of Illness
The present volume does not suggest any reasons for, nor does it more than superficially discuss, the changing incidence of physical disease in Japan (see Steslicke, this volume, table 6). This is a topic worthy of serious interdisciplinary analysis, particularly in light of the findings by Marmot and Syme (1976) in their fifteen-year study of the incidence of coronary heart disease in Japanese Americans. After controlling for all the usual “hard” variables associated with the incidence of CHD, Marmot and Syme reach the conclusion that a large proportion of the variance must be explained by retention of traditional values during the process of acculturation after migration. The hasty abandonment of traditional values is associated, they find, with an increased risk of CHD (see also Cohen et al. 1979). These findings have been born out by studies in other cultural settings (see Scotch 1963, for example), and it would be interesting to undertake similar studies inside Japan itself.
Reynolds, in his contribution to this volume, discusses the way in which psychiatric symptoms have changed over the past forty years, including a decrease in neurotic complaints associated with a fear of blushing, taijinkyofushō (often regarded as a culture-bound syndrome [Tanaka-Matsumi 1979]). He cites an increase in neurotic depression and phobias in connection with eye contact and suggests some cultural reasons for these changes.
One of the major problems that arises in the assessment of psychiatric symptoms is the question of standardization in diagnostic techniques. Japan continues to provide a stern challenge to attempts to create a diagnostic system that is universally valid, and the problems of applying the American Psychiatric Association’s latest classificatory system, DSM-III, are amply demonstrated by Honda (1983). It is not surprising that there is difficulty in standardizing psychiatric diagnosis, given the fact that the “mechanism” of the production of emotion is thought to be different in Japan than elsewhere (Tsunoda 1979); that language partially structures the means of expressing emotion (Beeman 1985); that the emotional “center” of the body in Japan was traditionally, at least, the abdomen (hara) and not the heart (Lock 1980); that, for example, Japanese tend to associate feelings of depression (yūutsu) with rain, clouds, and the dark, whereas Americans usually associate such feelings with despair and loneliness (Tanaka-Matsumi and Marsella 1976); and that there is repeated evidence, comparatively speaking, of a tendency to somatize (express through physical symptoms) rather than to verbalize 13about emotional states (Lock 1980, and this volume; Marsella 1980; Ohara 1973; Ohnuki-Tierney 1984; Shinfuku et al. 1973; Yoshimita, Kawano, and Takayama 1971).
Added to the complications that arise because of the cultural construction of emotion is the question of differential use and availability of mental health facilities. Mental illness is highly stigmatizing in Japan even today, whereas to consult with an ordinary physician about nonspecific functional complaints and to receive medication is completely acceptable. Relatively speaking, much greater use is made in Japan of medication and hospitalization for psychiatric problems than of psychotherapeutic methods (Ikegami 1980). These factors lead Western psychiatrists to believe that there is probably an underdiagnosis of problems such as depression, largely because general practitioners and internists (not only in Japan but throughout the world) do not easily recognize and diagnose depressive illnesses (Katon, Ries, and Kleinman 1984).
One other very important factor to note in the management of psychiatric illness is that diagnosis is a social process, the result of a negotiation between the presentation of symptoms by a patient and their assessment by a physician. Since physicians are as much a product of their cultures as are patients, it should not be surprising to find that there is considerable cross-cultural variation in psychiatric diagnosis. Marsella and his colleagues who work on the ongoing World Health Organization’s multicenter study of depressive disorder (which includes Japan) conclude that, while the so-called core symptoms of depressive disorder can be found in many cultures, the full range of manifestations of depressive syndrome as it is conceived in the West is not universal. They stress that one cannot ignore the complex ways in which the incidence, experience of, and therapy for depression are culturally constructed. They caution that it is necessary first of all to distinguish clearly between prevalence and incidence studies, between normal and clinical populations, and between conceptualizations about feeling depressed and the actual manifestation and diagnosis of depressive syndrome (Marsella et al. 1985). The enormous difficulties in measurement of this disorder should not be underestimated, and further culturally informed research in Japan should produce invaluable data.
Social and Political Uses of Illness States
In the opening of her chapter on the social uses of menopause, Nancy Rosenberger emphasizes that there are many Japans, that it is not the 14uniform culture that is so often portrayed by both Japanese and foreign researchers. For some time Japanese researchers have been interested in the effect of regional climate and dietary variations on the incidence of disease (Oiso 1975). Educational and occupational differences are also important, and the continued occurrence of fox, badger, snake, and dog possession in specific geographical regions among less well educated people is one obvious example of this phenomenon (Yoshida 1967, 1972, 1984). A recent survey and cultural study of menopause in Japan used three subsamples: housewives, women employed in factories, and those running farms (Lock 1986a). Although little variation was found in the incidence of menopausal symptomatology (it was remarkably low in all three subsamples), both this study and Rosenberger’s work presented in this volume graphically demonstrate how the social construction of menopause varies according to educational and occupational status. These recent studies of menopause raise further cautionary notes in the study of health and illness cross-culturally that lead us back to the problem of medicalization.
Menopause is a life-cycle transition that has become highly medicalized of late in the West. Important reasons for this are the aggressive marketing of estrogen replacement therapy and its adoption by gynecologists in their belief that it is an effective cure for symptomatology at menopause, which has been redefined in the medical literature as a “deficiency disease” (McCrea 1983). Physicians feel justified in their belief by the results they obtain when using estrogen replacement therapy with clinical populations in the West. Moreover, because they believe that biological changes at menopause are universal, they do not question the assumption that such treatment is also universally appropriate.
Lock’s survey shows that Japanese women do not suffer to anything like the same degree from the symptoms that are commonly associated with menopause in the West, and recent research from other cultures has produced similar findings (Beyene 1986). This means that further comparative research is needed in order to unravel the various causal possibilities. Could these differences be accounted for by genetic, dietary, or climatic variation? Or are they differences due largely to the cultural interpretation of symptoms? Or does the fact that the problem is highly medicalized in the West and is much less so in Japan account for most of the difference? Or, and I am inclined to settle for this last possibility, are all three factors important? Whatever the answer, the findings raise for scrutiny assumptions made by medical professionals about the biological 15basis of menopause. These assumptions are being adopted at a rapid rate by Japanese gynecologists, although instead of citing the “hot flash” as the most frequently reported symptom, Japanese gynecologists resort to their early exposure to German medical knowledge and cite an imbalance of the autonomic nervous system as the biggest issue (Lock 1986a). We are beginning, therefore, to expose in the examination of menopause some of the same problems encountered by researchers working on depression.
The research of Rosenberger and Lock raises another crucial issue: the difference between actual symptomatology and the way in which ideas about events related to the body are subjected to shared cultural stereotypes of what should or is likely to happen. Rosenberger cites previous work to show that manipulation of the sick role is not uncommon in Japan, and her chapter here is an excellent study of how expectations about the experience of menopause are used in culturally appropriate ways by three samples of Japanese women. The meanings of menopause are interpreted in dramatically different styles in the three contexts and reflect regional differences in expected social roles as well as some of the changes that women’s roles in general are undergoing in Japan today.
Symbolic use of the body is central to the Rosenberger and Lock chapters, but while Rosenberger focuses more on family dynamics and the changing roles of women, Lock surveys some of the historical and contemporary means of expressing protest and then analyzes the somatization of distress as one widely used form of dissent in Japan today (see also Ikemi and Ikemi 1982). She goes on to discuss the way in which the somatized problems of women are managed in various clinical settings and makes extensive use of popular literature written by medical practitioners to illustrate the argument.
In common with all of the other contributors to this book, Lock demonstrates a great variation in the expression and management of medically related problems, albeit within certain ubiquitous cultural limitations. In the case of the medicalization of distress resulting from problems in which social precursors are heavily implicated, it is suggested that, while much contemporary medicalization acts to reduce psychosocial problems to the neutral terrain of the physical body, some of it may indeed serve to break down a little of the isolation that women experience in modern Japan. Hence medicalization may facilitate an ability to reinterpret the origins of distress as a social rather than a biological problem. We see some signs of this with the recent surge of interest in counseling 16 and self-help groups, although naturally these groups also reflect shared Japanese values and do not function quite like their counterparts in the West (Lock n.d.).
The problems of women are not the only ones being medicalized. The press, popular medical literature, and government documents are rife with concern about “stress” and the reported increase of mental and physical illnesses thought to be associated with modernization, especially urbanization and the rise of the nuclear family. In addition to the numerous syndromes and neuroses associated exclusively with women, there are daily newspaper reports about “salary-man syndrome,” “maladjustment-to-the-job syndrome,” “school-refusal syndrome,” parent abuse by children, bullying in school, and so on. Some authors write about the “pathological family” (Higuchi 1980).
What needs careful investigation is how these problems are used by people in power in both government and medical settings and by the media for their own ends. The statistics published on, for example, school-refusal syndrome show that the problem, although it clearly exists and is perhaps on the increase, is nevertheless still much smaller than anything that would cause ripples in North America (Monbushō 1983). The touting of glib articles on the latest syndrome has become part of the internal cultural debate (nihonjinron) on where the nation is heading and which values should be cultivated for success in the postindustrial age (Lock n.d.). Certainly many people are suffering both psychologically and physically as a result of the enormous pressure imposed upon them by the stringent requirements of the Japanese labor and educational system. Certainly many women, because of discrimination in employment and culturally inscribed values about the continued necessity of total dedication to maternal nurturance in an era of small families, are suffering from the opposite problem: a diminished social role. However, with some notable exceptions (Yuzawa 1980) very little work has yet been done to distinguish the causes and incidence of genuine modern malaise from the poorly authenticated allegations of social disintegration that are perpetrated by partisan and powerful groups. It is disheartening that virtually without exception official and popular literature places the blame for all kinds of suffering firmly back onto the modern Japanese family, the “thinness” of its relationships and its lack of moral and tenacious fiber (Lock 1986b; Iino 1980; Sasaki 1983; Monbushō 1983). The larger social contradictions and impasses, many of which are raised in this volume and are perhaps expressed most poignantly in Kiefer’s discussion 17of the plight of the elderly and their female caretakers, remain relatively unquestioned and unexamined.
There is a call by the present Japanese government for a return to more traditional values, and in particular for a cultivation of something equivalent to the ie, the traditional Japanese household, where the young, the chronically sick, and the elderly would be fully taken care of. This is part of a plan for the “Japanese Welfare State” (McCormack 1986) and designed to avoid some of the pitfalls of what has been labeled the “English Disease” (see Steslicke, this volume). The creation of a modern version of the ie would, of course, if effective, relieve the government of the financial burden of improving and installing a range of health-related facilities. On the other hand, with urbanization, the existence of the nuclear family (which is unlikely to be replaced by a traditional extended family once again, despite attempts to do so), and the increasing desire of many middle-class women to participate seriously in the work force, the creation of a modern ie seems unrealistic. The absorption of the social side effects of urbanization, economic expansion, and technological progress by the family, in particular by an employed housewife living in an urban, nuclear household, is totally unrealistic. One cannot have one’s tofu and eat it too. It remains to be seen how Japan will deal with the impasse it now seems to have reached after a period of incredibly rapid social change. I agree with Long in that I do not foresee a convergence with Western models for managing the problems of the modern world. On the contrary, I think that Japan is bent on creating its own specific, contextually relevant answers to these problems and that it will, therefore, continue to provide us with a rich source for the contrasting analysis of problems of all kinds, including those related to health and illness.
The essays that follow are designed to offer insights into several specific theoretical issues. They demonstrate, first, the importance of grounding studies of the body, health, and illness in rich empirical data and of analyzing that data from the perspective of each one of the social sciences. They are therefore an attempt to fill the lacuna that has arisen between “grand theory” such as that created, for example, by Foucault, Habermas, and Lacan, and highly descriptive microanalyses (Crews 1986). Second, the essays function, as does almost all social science done by both Japanese and Western scholars on Japan, to place similar studies done on the West in perspective and to show up some of the limitations of research designed without the benefits of cross-cultural insights. At 18the same time, some of the methods of dealing with problems of health and illness in Japan may provide insights for Western policymakers and practitioners. Third, the findings presented in these papers have important implications for developing countries, since they indicate some of the problems that are likely to arise in situations of rapid social change. Most especially they illustrate how biomedicine, when it is exported, does not simply alight in a vacuum and that it must be integrated into already existing beliefs and practices. The essays also illustrate some of the paradoxical outcomes that arise as the result of the application of modern medical technology.
In conclusion, it must be noted that it is unfortunate that no contributions to this volume have been made by Japanese researchers, an unavoidable result of the exigencies of current funding in the social sciences. We look forward to being involved with our Japanese colleagues in future conferences and publications. In the meantime, we welcome their comments and criticisms and hope that this volume may provide some incentive for a pooling of our knowledge and methodological inclinations.
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