Health Care Providers: Technology, Policy, and Professional Dominance
Susan Orpett Long
Japanese patients have a wide range of options for obtaining treatment for illness. They may consult a religious specialist or participate in the group therapy of the “new religions.” If they prefer a secular cure, they may turn to an herbalist or other folk healer, a specialist in moxibustion or acupuncture, a physician, nurse, or pharmacist. They may elect to treat themselves with home remedies or with over-the-counter medications of natural or synthetic varieties; or, they may do nothing at all. In the broad sense in which most medical anthropologists conceive of a health care system, Japanese health care providers include the shaman, the operator of a hot springs bath, and the dentist.
Yet anyone familiar with modern Japanese society will immediately recognize that all healers are not equal, Biomedicine, introduced by the Portuguese and Spanish in the sixteenth century, has come to occupy a special position in the Japanese health care system. Its legal status, access to governmental and private resources for research and clinical care, and cooptation of certain roles and therapies from traditional medicine all clearly reflect biomedicine’s structural dominance.1 Moreover, within biomedicine there are numerous functionaries, but all are subservient legally and in practice to physicians.
This situation raises three questions: How did biomedical physicians come to dominate the Japanese health care system? What is the nature of that dominance? Will it continue as medicine and society change? I deal with these questions by tracing changes in relations among health providers in two periods. I first consider the introduction of European medicine and the development, through the Tokugawa period (1600–1867), of a corps of biomedical physicians and their relation to the Meiji government’s 67 decision in 1868 to promote biomedicine officially. Second, I focus on the period after World War II, which, in parallel to Japan’s rapid economic growth, has been characterized by a tremendous expansion of biomedicine and its personnel.
My discussion revolves around two variables, technology and policy. In this context, technology refers to the physical material and techniques applied to the human body for purposes of preventing or curing illness; it does not include the equally important but more abstract aspects of healing such as healer-patient relations or symbolic interpretations of the technology. Although Japan has indigenous medical technology, major technological change has been introduced from other societies, first from China and later from Europe and America. By policy, I mean the plans, decisions, and actions of the central government that affect medical technology and health care providers. Although my original hypothesis was that new technology would result in changing patterns of relationships among healers, I now conclude that the relation is much more complex. As medical sociologist Eliot Freidson (1970, 72) has asserted: “A profession attains and maintains its position by virtue of the protection and patronage of some elite segment of society which has been persuaded that there is some special value in its work. Its position is thus secured by the political and economic influence of the elite which sponsors it.”
In the case of Japan, I suggest that the government played and continues to play the role Freidson describes. Government decisions, based on the availability of a certain technology, structure the relationships among health care providers, while at the same time helping to adapt the technology to Japan’s specific sociocultural environment.
The Introduction of European Medicine
Medical historians (especially those writing in English) have tended to view the introduction of European medicine as resulting in a dichotomy between “traditional” and “modern” techniques and practices. In the words of one: “The two systems of medicine that came into confrontation were fundamentally divergent. For a millennium, the Japanese practiced traditional medicine, which was completely nonscientific” (Bowers 1980, 157). Accordingly, the decision of the Meiji government to legitimate and support biomedicine becomes, for some, a “triumph” of European “scientific” technology (see, for example, Seaman, who titled his 1906 book The Real Triumph of Japan). 68
Aside from the question of just how scientific sixteenth and seventeenth-century European or Japanese medicine was, the Japanese scene to which European medicine was introduced was far from a unified, static, or unprofessional medical system. Although secular Chinese-style (kampō) physicians were established alongside religious specialists as the official health care providers as early as the eighth century, subsequent centuries saw a decline in their influence as Buddhist priest-doctors and folk healers combined the Chinese technology with local custom and practical need. In the fifteenth and sixteenth centuries, however, Neo-Confucian medical theory and practice brought about a revitalization of Chinese-style medicine in Japan, and an elite of secular physicians emerged who served government officials, samurai, and townspeople. The Neo-Confucian influence was systemized and formalized in the sixteenth century by Manase Dōsan into a school known as the goseiha.
Even among the elite secular physicians of the Tokugawa period, however, a variety of approaches and methods existed. Another school, the kohōha, arose in the seventeenth century and advocated, in opposition to the Neo-Confucians, a return to the classical Chinese medical literature. This school represented a more empirical and simplified practice of medicine which eventually, Otsuka (1976) claims, “Japanized” goseiha medicine.2 Each of these schools had notable followers who published medical books and offered their own versions of Chinese medical theory; it is not clear how these affected the practice of most secular doctors. We do know that medical knowledge was obtained in a variety of ways: by attaching oneself formally to a teacher, by studying the classical medical texts (if one were already a Confucian scholar), by independent study, and by unlettered apprenticeship (Fuse 1979, 114). The goseiha and kohōha movements were undoubtedly most influential in the first and second types of education. We also know that there was no national system of registration and licensure for all physicians, although some official schools did certify their graduates.3 Many practiced an eclectic medicine, deriving theory and technique from both goseiha and kohōha, and also from practical experience. (For a discussion of explicit combining by individual scholar-physicians, see Okazaki 1976, 151–152.) Lock (1980, 57) believes that goseiha medicine was emphasized in the Kansai region, whereas schools in Kyushu and Edo taught kohōha and Western medicine. Writing about the history of medicine in Kyoto, however, Moritani (1978, 100–124) emphasizes the development and practice of kohōha and some eclectic schools there. The writings of physicians of both 69schools, as well as of those using eclectic approaches, were published and available. This, coupled with the fact that patients might try physicians from various schools until they found a successful treatment,4 leads me to believe that the practitioners were not as far apart in what they actually did as their theoretical classification might lead us to expect.
Although there were undoubtedly strong teacher-pupil loyalties and competition among the various approaches, it is my contention that the overall tone of Tokugawa medicine, at least until the nineteenth century, was one of openness to new ideas, growing empiricism, and syncretism, paralleling trends in eighteenth-century Japanese Confucianism (Craig 1965, 156). Thus, as European medical techniques were gradually introduced, they presented only one more set of options that could be utilized in combination with other technology. In fact, the Japanese scholars and doctors who studied European medicine generally approached it pragmatically. They expressed greatest interest in European surgical technology (methods, medications, etc.), especially in surgery and ophthalmology. Lock (1980, 57) claims that even those drawn to Western surgical technology continued to rely on the Chinese system for internal medicine.5 Specialists adopted European techniques and established their own “schools” in surgery and ophthalmology (Okazaki 1976, 154). Manase Dōsan, the leader of the goseiha movement, was himself influenced by Western medicine and even converted to Christianity in the 1560s or 1570s (Okazaki 1976, 104).
The Official Adoption of Biomedicine
If Western medicine, when first introduced to Japan, added to rather than threatened the existing repertoire of technology, what happened in the last part of the Tokugawa period to polarize Japan’s doctors into Western and kampō groups by the latter part of the nineteenth century?
First, new technology continued to be brought to Japan. Most authors point to the translation of a German anatomy book, Anatomische tabellen (Kaitai shinsho), in 1774 as a turning point in the history of Japanese medicine. Sugita Genpaku and his cotranslators were impressed, after witnessing the dissection of an executed criminal, with the superiority of the book’s illustrations over those found in Chinese texts and became determined to make this information available to Japanese doctors and scholars. With the translation of this book, Western medicine was presented as an alternative to the Chinese interpretations, not as a supplement. 70 Moreover, in the last part of the eighteenth century, interest turned toward Western internal medicine, and its drugs were increasingly imported. Most indigenous medications consisted of the crude drug boiled or steeped in hot water (infusions and decoctions, while alcohol-based fluid extracts and aromatics were avoided), which accorded with Japanese tradition (Okazaki 1976, 180). Otsuka notes that when the first work on Western internal medicine was published in 1793 it contained a preface by a famous physician-official; this preface was removed from the second edition, “probably because younger practitioners of kampō and Rampō6 stood against such a cooperative—or, from another point of view, conciliatory—attitude” (Otsuka 1976, 333). The greatest change in technology may have been the introduction of public health measures to combat contagious disease, particularly the introduction of the live smallpox vaccination in 1824 and 1849 (see Otsuka 1976, 334).
These technological innovations were only indirectly responsible for the later dominance of biomedical physicians, however. The intermediate step was the obtaining of government sponsorship. From 1739, when the government sent two scholar-officials to Nagasaki to study Dutch, the attitude of government might be characterized as active tolerance of Western medicine. This was the beginning of the avid translation of Dutch scientific books, although it is unlikely that at this point many outside the intelligentsia were affected. By the first half of the nineteenth century, doctors who had studied with the Dutch at Nagasaki established their own private medical schools, and biomedicine was included in the curriculum of at least some official han schools. Philipp Franz Balthasar Von Siebold, a physician from a prominent German medical family, served from 1823 to 1828 at the Dutch station. He received permission to see patients in Nagasaki rather than being restricted to Dejima (the island where all foreigners were required at that time to reside) and later built a medical school on the outskirts of Nagasaki, where he gave clinical lectures on internal medicine as well as surgery.
There was as yet no organized opposition on the part of the Chinese-style practitioners, although by the 1840s a number of practicing physicians identified themselves as “Western medical” specialists (Moritani 1978, 125). However, the ailing economic and social position of the Edo government did provide the opportunity for one last display of power for at least one school, the Taki, that combined elements of kohōha and 71goseiha (Okazaki 1976, 151). The Taki family had come to control the government’s Medical Bureau and served as personal physicians to the shogun. When the government decided that, in order to bolster its own position, it was necessary to rid itself of foreign influence,7 the Takis took advantage of the new policy to strengthen their own control over medical theory and practice. The government outlawed the use of Dutch words in advertising medicines, restricted publication of Dutch books, supervised their importation and sale, and subjected all publications of Dutch medical translations to the censorship of the Taki-controlled Medical Bureau. Medical books published between 1840 and 1853 were those that supported the Takis’ own approach (Sugaya 1976, 4; Kawakami 1977, 90).
Dutch medicine nevertheless continued to be practiced. The decision to end the 200-year-old closed-country (sakoku) system and reopen Japan in the face of Western pressure in the 1850s caused a complete turn around in the official attitude toward foreign technology. The government was now convinced that the only way to remain sovereign was to adopt foreign technology, particularly military technology. The internal warfare that characterized the end of the Tokugawa and early Meiji periods intensified an interest in surgical treatment. In 1857 the Edo government requested that the Dutch send a military surgeon to train Japanese physicians; as a result, J. L. C. Pompe van Meedervort was allowed to establish a school in Nagasaki with a full biomedical curriculum, including instruction in the basic sciences. Moreover, an official government physician, Matsumoto Ryōjun, requested and received permission to study there and assist in setting up the new school, despite the fact that restrictions of foreign study remained in effect (Bowers 1970, 178).
The new government policy toward foreign technology also allowed official support of public health measures such as vaccinations. In 1858 Dutch-style doctors in Edo established the Vaccination Institute as a private institution funded by subscription. “Although it used the name ‘Vaccination Institute,’ it served at the same time to promote Western medicine” (Kawakami 1977, 88). Within several years the institute received a government subsidy (Bowers 1970, 195). The government also decided to support a surgical hospital in Edo (Fuse 1979, 133) as well as Pompe’s medical school, laboratories, and hospital in Nagasaki. Several authors (for example, Okazaki 1976, 213; Bowers 1970, 189) see a direct relation between Pompe’s efforts in controlling a cholera epidemic and 72his receiving government funds, which had been requested several years previously. The final blow to the power of the Chinese-style doctors came in 1858 when they failed to cure the ailing shogun. Dutch-style physicians were then called in to serve as court physicians, providing de facto recognition of the change in governmental attitude.
Thus, the Tokugawa government, ten years before the Meiji Restoration, had already adopted a policy of promoting biomedicine. The positive attitude toward Western biomedicine was partly a response to Western technology as it was displayed by European and American military might in the 1850s. It was also in many ways a continuation of a trend of growing interest in biomedical technology as it was gradually introduced and proven useful in the Japanese context. Chinese-style physicians such as the Takis did not react until they were sufficiently threatened by government interest in and support of biomedicine.
The Meiji government took the final steps in assuring the dominant position of biomedicine. The government decided to support biomedical education and research institutes based on the German system;8 it founded public biomedical hospitals and began a national system of physician licensure. Proclamations of 1875 and 1883 restricted the practice of Chinese-style medicine to those holding biomedical degrees, thus subordinating kampō to the biomedical system. Practitioners of massage and acupuncture had to be licensed as well, and their practice was limited by law so that they were no threat to physicians. It was in this period that the term kampō first came to be used, thus indicating the polarization of biomedicine and Chinese-style medicine. In reaction, kampō physicians organized themselves for purposes of education and research and for political reasons. From the second session of the newly established Diet (1891), the kampō physicians’ association tried to legislate changes in licensure and registration. A bill was finally brought to a vote in 1895 and defeated. Over 63 percent of Japanese doctors at this time still had no training in biomedicine (Fuse 1979, 146).9
How was it that biomedicine had such strong support in government circles? One factor was the infatuation of Meiji leaders with Western technology in general. Medicine was a small but highly visible part of their dramatic effort to modernize quickly and so avoid colonization. Biomedicine as a social institution also gained strength in part through interbureaucratic rivalries and rivalry between the Diet and the bureaucracy (see Bartholomew 1982). The effect was that “Meiji doctors, ordered by the government to discard traditional medical practices and 73ideas and switch to Western medicine, without regard for the ruin of kampō physicians, became an intelligensia, an elite bearing one part of the burden of national prosperity” (Fuse 1979, 211).
A second factor was that many of the people who played leadership roles in and out of the government had studied at the Tokugawa-period schools of Dutch learning, receiving instruction directly from the foreigners at Nagasaki and later from their followers in Edo, Kyoto, and Osaka.10 As students of Dutch learning, they not only favored adoption of Western technology, but had developed intense loyalties to teachers and classmates.
There were, however, important continuities in the nature of medical practice from the Tokugawa to the Meiji period. Although the government insisted on westernization, as in the previous period, an elite of physicians received public support, whereas most of the system remained private as in Tokugawa times. Payment for medications prescribed by physicians continued to be the responsibility of patients or their families. Medicine in both Tokugawa and Meiji Japan was a full-time male occupation, and a practitioner in both periods could earn a living through relatively autonomous medical practice (Fuse 1979; Bartholomew 1982). Furthermore, Bartholomew’s research on the formation of the Meiji scientific community shows that the social class background of medical practitioners in the early Meiji period was similar to that of recruits in the last half of the Tokugawa period. In his sample of 189 scientists, 101 had physician-fathers and 75 of these were kampō physicians (1980, 69). Bartholomew concludes that:
When the sons of Chinese-style physicians realized the possibilities of careers in modern chemistry or biomedical science, they entered those fields as circumstances allowed with little or no thought to their intellectual incompatibility with Chinese-style medicine. The modern biomedical science tradition in particular developed rapidly in post-Restoration Japan precisely because it was able to exploit not only the presence of Chinese medicine but because it could build on its institutional patterns—autonomy, occupational base, rigorous training and certification programs—which had already come into existence during the Tokugawa period. (1980, 72)
Medicine, now limited to biomedicine, must have been an attractive career in the Meiji period, even more so than today. It meant, for the practitioner, financial security and prestige as a healer and as a “modern”; it also afforded opportunities for a high level of intellectual attainment 74 and, for a few, study abroad, a university position, or government employment. Rather than having to organize to fight for a favored role in the new society, biomedical physicians were selected by the government for sponsorship; it was not until 1875 that for academic and political purposes, the first organization for biomedical physicians was founded. Prefectural governments encouraged the formation of medical associations from 1886 on as a way of influencing individual physicians (Kawakami 1977, 231–232). Various specialty groups and academic medical societies were also founded in the latter part of the Meiji period. The Japan Medical Association (Dai Nippon Ikai), with membership limited to licensed practitioners, was founded in 1893 in the midst of the Diet debate about licensure for Chinese-style doctors.
Professional Organization Today
Although great progress has been made since the 1920s in universalizing access to care and in developing indirect methods of payment, the structure of the medical profession has changed little from Meiji or even Tokugawa times. Meiji prohibitions against practicing kampō without a biomedical license remain in effect. The recent “kampō boom” of popular interest in herbal medications, which has been sparked or encouraged by biomedical pharmaceutical companies, has not been to the benefit of kampō. The result of the “boom” has been the inclusion of some kampō medications among those eligible for insurance reimbursement, and thus their widespread use and misuse by biomedical physicians with little knowledge of kampō theory or practice (Lock 1984). In order to become licensed, practitioners of massage and acupuncture must complete prescribed courses of study structurally similar to those of biomedical paraprofessional workers such as nurses. Thus, despite the negative publicity about synthetic drugs and their prescribers, the “kampō boom” has, if anything, only further subordinated kampō to biomedicine.
The government continues to directly support only a minority of physicians. For the most part, the system still relies on “machi-isha” private practitioners of the common people, as in Tokugawa times. Although less than half of Japanese physicians are in private practice, these private practitioners account for over 90 percent of primary care clinics and 75 percent of hospitals (Hashimoto 1978a, 23).
Professors, assistant professors, and lecturers at the prestigious national university medical schools, administrative and staff doctors at nationally 75 supported hospitals, as well as a small number of physicians engaged in full-time research constitute the national government-employed group. This group has counterparts at prefectural and local levels, but with somewhat less prestige. These salaried physicians may historically be most similar to the retained doctors of the Tokugawa government and daimyo. Unlike the Meiji professors, who spent the majority of their time seeing private patients, probably in order to support themselves (see Bartholomew n.d.), contemporary public hospital and university physicians rarely establish their own private practices or spend more than a small amount of their time on professional pursuits outside of the hospital or university that is their major employer.
Salaried doctors may be divided into various groups. Some are employed by the Ministry of Education, some by the Ministry of Health and Welfare, and some by prefectural and local governments. A salaried physician may be a clinician or a researcher or, as is most common in university settings, may fill both roles. Physicians are also divided by their specialities within biomedicine. Overall, the interests and organizations of salaried doctors differ from those of private practitioners.
As entrepreneurs, private practitioners must concern themselves to a greater extent than do their salaried counterparts with satisfying their patients’ expectations. In order to be paid they must deal with the demands and the red tape of the complex insurance system. As in any business, they need to pay their employees and other overhead costs. These physicians have specialty and interest groups that provide mutual support at the local level. Nationally, their common interests are represented by the Japan Medical Association.11
The media and the public in Japan view the JMA as a powerful influence on the government. It attempts to influence policy mainly through the bureaucracy, having formal representation on a number of advisory boards such as the Social Security System Council, the Medical Fee Payment Fund, and the Social Insurance Council. It lobbies for favorable policy decisions and has even sponsored nationwide work stoppages. The JMA also attempts to influence policy indirectly through support of physicians or other sympathetic candidates for political office and through “public education” campaigns (Steslicke 1973).
On the other hand, pressures directed in the reverse direction, at individual practitioners, constitute an equally significant aspect of government-physician relations. I have already pointed out that biomedical physicians’ groups were formed in the Meiji period at the encouragement 76 of the government. In 1961, despite opposition to various aspects of the program from many private practitioners and the JMA, the government established a universal insurance system. Opposition from business and labor has foiled JMA attempts since then to unify and rationalize this system.
Private practitioners, through the JMA, are given some voice in determining legal regulations governing their practices and in fixing the insurance reimbursement schedule on which their livelihood depends, but they are far from having the power to determine policy. As long as it cannot, or will not, nationalize the medical system fully, the government must be willing to keep private physicians relatively satisfied. But although the government must accommodate private practitioners, it is not willing to withdraw its control. Private as well as salaried physicians must bow to overall government policy that determines to a large extent the nature of their work and their daily routines. The financial structure of the system virtually eliminates the practice of preventive medicine or patient education and encourages physicians to see large numbers of patients (whose visits are consequently brief) and the dispensing of large amounts of medication. As the intermediary between government and private practitioner, the JMA can, by vetoing clinic locations, refusing to file insurance forms, and so on, at the local level, make practice difficult or impossible for private practitioners who oppose it (Nomura 1976). It thus has a role in enforcing government policy as well as in shaping it.
Physician Dominance in an Age of High-Technology Medicine
The spectacular growth of the field of medicine (and the medicalization of many aspects of society) experienced in the United States since World War II has had its counterpart in Japan. Kawakami (1977, 525) notes that the technological revolution in medicine has meant new synthetic Pharmaceuticals, the development of antibiotics, progress in surgery, and reliance on clinical laboratory tests and X rays. He suggests that these new elements of biomedicine have created changes in hospital construction and management, particularly the inclusion of a central laboratory and changes in surgical facilities. The new technology increasingly replaces the one-to-one doctor-patient relationship with medical care provided by a health care team.
As in the United States, costs have also risen dramatically. As the Japanese government concentrated on policies of high economic growth in 77the 1950s and 1960s, some attention was given to public health, particularly to the eradication of tuberculosis and other infectious diseases. The government pieced together a complex universal insurance program, which went into effect in 1961. However, as late as 1970, only 3.32 percent of Japan’s GNP was spent on medical care; the government came under increasing attack in the late 1960s and 1970s for neglecting social services and for actually promoting medical problems such as pollution-related disease through its high-growth policy. In 1973 a program for medical care for the elderly went into effect and a program of catastrophic insurance began. By 1980 the cost of medical care constituted over 5 percent of Japan’s GNP, although the government’s share of that cost remained fairly constant between the mid-1960s and 1980 (see table 1).
The changes in medical technology have created new roles for health workers. In addition to the physicians, nurses, and pharmacists found before World War II, there are now nutritionists, speech therapists, artificial limb technicians, physical therapists, cytology technicians, medical photographers, and clinical engineers. Endoscopic technicians have their own professional organization of 71,000 members (Byōin 1981). Physicists also work with radiologists, and audiologists help otolaryngologists.
Table 1. Japanese Medical Costs as Percentage of GNP
|Year||GNP||Direct Public Expense as Percentage of Medical Costs|
Sources: Ministry of Health and Welfare statistics from Kōsei Tōkei Kyōkai 1982, 248, 249) and Nihon Ishikai (1977, 395).
* 1966 figure. 78
Not only has the variety of health providers increased, but the number of health workers has risen dramatically both in absolute terms and relative to population size (see table 2). Only among midwives has a decrease occurred, a result of physicians taking over prenatal and childbirth care. Moreover, there seems to be a trend toward an increasing proportion of health providers employed by hospitals. In 1970, 37 percent of physicians worked as salaried employees; by 1980 this figure had increased to 48 percent (Nihon Ishikai 1977, 396; Kōsei Tōkei Kyōkai 1982, 210). Among nurses, the proportion of hospital-employed has risen for registered nurses and for nurse-midwives (as opposed to private practice for the latter) and has decreased slightly for practical nurses (Kōseishō 1982, 2–7). The great increase among technicians reflects occupations which are hospital based: 72 percent for X ray and radiology, 83 percent for laboratory (as opposed to physicians, public health nurses, or pharmacists) (statistics from Kōsei Tōkei Kyōkai 1982, 210–214).
The increase in the variety and numbers of biomedical health workers suggests that major changes are occurring in relations among health providers and, as medicine has become more bureaucratic, between providers and patients. Some writers expect that paramedical workers will become more assertive and that the dominance of physicians will be lessened. They claim that medical education does not provide physicians with the knowledge of how to utilize the new technology (Tani 1973, 103), and physicians thus become more dependent upon the technicians they are supposed to supervise (Ishihara 1981). Paramedicals, operating through medical labor unions organized after World War II, have demanded better wages and working conditions (the most noticeable instance was in I960, during a nationwide hospital strike) (see Kawakami 1977, 525–529).
Table 2. Increase in Health Care Workers
|1960||1970||Increase from 1960||1980||Increase from 1970|
Public health nurse
X-ray and radiology technician
Total population in 1,000 persons
Sources: Ministry of Health and Welfare statistics from Hashimoto (1978b, 534) and Kōsei Tōkei Kyōkai (1982, 210).
a 1965 figure.
b 1978 figure. 79
Despite the trends of change discussed above, including the creation and aggressiveness of medical labor unions, several factors mitigate against any substantial alteration in the physicians’ role of dominance in the medical system. All of these factors may be traced, at least in part, to the government’s sponsorship of their dominance. The most obvious example is that laws relating to paramedical workers (including practitioners of acupuncture and massage) state explicitly that the medical activities of these workers are limited to those under the direction or direct orders of physicians. Judging from the comments of an official of the Ministry of Health and Welfare, these limitations are interpreted quite literally. When asked about the best personnel to deal with new medical technology, this official discussed the need to treat each case separately according to the medical knowledge and skill required for it. As far as hearing tests, artificial dialysis, pacemakers, and the like are concerned, “at the present time, all of these techniques can be considered most appropriately performed by a physician or a nurse assisting him” (Byōin 1981, 757). Although the ministry recognizes that its conservative policies are detrimental to both the development of an adequate supply and the quality of paramedical workers, it remains unwilling to grant them greater autonomy. Hashimoto Masami, former head of the Department of Public Health Practice within the Ministry of Health and Welfare, expressed the ministry’s ambivalent attitude.
It is apparent that recent trends and changing patterns in health caused by rapid changes in socio-economic and socio-biological conditions require the development of various new types of health personnel.
Under the present situation in Japan, however, … well planned governmental efforts for the improvement of the education and training methods and the social status of these health personnel should be promoted. The strengthening and effective training of teaching staff, the establishment of continuing education systems, a deepening understanding with the medical professions on the problem seem to be important. At the same time, selected new types of health disciplines must be developed cautiously. (Hashimoto 1978b, 538)
Deference shown to physicians by paramedical workers may be traced in part to the influence of Japanese patterns of interpersonal behavior. Expectations surrounding male-female interaction are important. Over 90 percent of physicians are men, women doctors being concentrated in a few specialties such as opthalmology and pediatrics. By contrast, women usually fill subordinate roles. Fifty-five percent of pharmacists and 97 80percent of nurses are women (Kōseishō 1982, 10–11; Kōsei Tōkei Kyōkai 1982, 211, 212). Behavior patterns from outside the work setting, such as those between husbands and wives, may easily be transferred to the medical context (Long 1984).
The length and type of education most paramedical workers require differ greatly from the training of physicians in medical school and postgraduate programs. Most nurses and many other paramedical workers receive their training at special vocational schools that are generally considered inferior to college and university programs in terms of faculties, facilities, and educational curricula. A few occupations, such as pharmacy, require baccalaureate degrees, but most require only graduation from junior colleges. Although the government cannot dictate the ways in which sex roles and educational attainment should affect social status or interpersonal relations, the perpetuation of the social gap between physicians and other health workers must be considered an indirect result of government educational and licensing requirements, laws relating to working conditions, and wage structure.
Physician dominance is also indirectly maintained through laws regulating hospital organization. Prewar hospitals were characterized by what Ishihara (1981) calls “vertical” organization, in which a paramedical worker was attached to one or another specialty department headed by a physician. During the postwar occupation, the Allied forces attempted to democratize the medical system by creating the “horizontal” organization found in American hospitals, in which pharmacy, nursing service, laboratory, and so on each have a separate administrative unit with a nonphysician head. This reform did not take hold in most university hospitals in Japan. Private hospitals, which the government had in the past encouraged to proliferate, remain under the firm control of their entrepreneurial physician founders. Even in the large public hospitals where there is “horizontal” organization, the official structure appears to have had little impact at the behavioral level, and paramedical workers continue to believe they are working for a specialty department or for a doctor. Legally, a hospital director must be a physician, so that even in the most horizontal of structures, paramedical departments remain subordinate.
A final policy maintaining the physicians’ dominance of the medical system has been the government’s attempt to increase the physician-to-population ratio to 150 per 100,000 population by 1985 (the 1980 ratio was 141 per 100,000 population [Kōsei Tōkei Kyōkai 1982, 214]). The 81government thus promoted the establishment of numerous new medical schools (mostly private) in the 1960s and 1970s, many of which are considered inferior to the public (especially national) university medical schools. This expansion has raised total annual enrollment at all medical schools from 2,840 students in 1960 to 8,260 students in 1980 (Kōsei Tōkei Kyōkai 1982, 215).
This policy has several consequences. First, by greatly expanding the size of the occupational group, it makes physicians less of an elite group vis-à-vis other interest groups attempting to influence policy. Theoretically, if all the new graduates were to go into private practice, competition for patients would increase and incomes of physicians would decline. But within the public medical system, ironically, the effect has been to maintain the positions of those in power. Large numbers of young physicians in university and public sector hospitals mean that more experienced doctors can delegate tasks to them (as apprentices) rather than having to rely on paramedicals. Even though Japanese physicians are highly specialized in their medical training and practice, because of their large numbers many of them will remain generalists in both tasks and responsibilities. Young doctors often perform work that in the United States would be assigned to nurses (for example, history taking in outpatient clinics) and laboratory personnel, thus reducing the effect of the shortage of paramedical workers.
Large numbers of young doctors also strengthen the ikyoku system (see Long 1980, 112–123, 158–160), the “feudal” hierarchy of doctors under a single departmental professor that has been a feature of biomedical education and research since the Meiji government decided to adopt many aspects of the German model of Western medicine. In this system, a young physician relies on his professor for introductions to employment opportunities. In exchange for some loss of autonomy in these decisions, the young doctor, by maintaining good relations with his professor, assures receptivity to referrals of private patients, access to new developments in his field, and sometimes access to research facilities, any of which might help to advance his career. The professor, for his part, needs to cultivate good relations with administrator-physicians at hospitals and with private practitioners in the area to obtain political and financial support, including employment for the young doctors in his department.
During the war years the government decided to increase rapidly the number of physicians and so promoted shortened courses at local governmental 82 and private medical schools. When the war ended, many young doctors turned to the university medical departments for further education and for help in obtaining employment, thus fostering the continuation of the hierarchy they had known earlier. Despite attempts to democratize medical schools after World War II, this hierarchic system was particularly strong in the 1950s and 1960s.
Several changes began to threaten the ikyoku system in the 1960s. Although the system was the target of a revolt by medical students and interns in the late sixties, the success of the revolt seems to have stemmed from socioeconomic and technical changes rather than mere protest against the educational system. Although the number of physicians had increased, government policy, especially the establishment of the universal insurance system, had created a relative shortage. Hospitals competed for physicians, approaching them directly rather than through their professors and offering higher salaries than in the past. At the same time, specialized, high-technology medicine made general private practice more expensive and less prestigious, and thus a less desirable career option while higher hospital salaries created a financially viable alternative, thus somewhat relieving the physician shortage in public hospitals. For both of these reasons hospital employment became a viable alternative.
In recent years, as economic growth has slowed, so also has the increase in the number of hospital beds (Kōsei Tōkei Kyōkai 1982, 204). The need for expensive equipment and changes in tax laws have made it more difficult to enter private practice, as has pressure from local medical associations. Thus, an increase in young physicians comes at a time of changing employment and career opportunities. This circumstance seems to have the effect of restrengthening the power of professors, administrator-physicians, and others who are at the top of the medical hierarchy.
By examining the Japanese medical system in two periods, I have attempted to explore and explain the relationship between technological change and professional dominance. The introduction of Western medicine, which occurred gradually over a period of three hundred years, culminated in 1868 with the government’s declaration of support for a German-style medical system. This declaration reflects what Lee (1982) 83calls the “structural superiority” that Western medicine had achieved. Inroads were also made in expanding its “functional strength‚” the distribution and utilization of Western medicine so as to increase its impact on the society as a whole. Unlike Lee’s Chinese examples, however, these changes did not come about through professional organization in Japan; rather, the government sponsored such changes in the course of promoting its own interests. It was not, therefore, the introduction of biomedical technology itself that brought about the dominance of biomedical physicians. Certainly, that technology had first to be made available (by, among other things, overcoming the language barrier) and then shown to be effective. But there were other factors of equal importance in determining government policy, in particular, the economic and social weakness of the late Tokugawa government and the threat to Japanese sovereignty posed by the European military powers. Technology plus politics determined the shape of the Meiji medical system.
In the period since World War II, biomedicine’s functional strength was assured by economic growth (see Lee 1982) and the establishment of a universal health insurance system. As a result of worldwide trends in biomedicine, technological innovations have occurred at a rapid rate, and the Japanese government has pursued a policy of supporting what I call “high-technology medicine.” Such technology could curb the dominance of the system by physicians who are unable to control the technology and who, as a result, become only one part of a more specialized division of labor in a bureaucratic setting. However, while accepting or even encouraging technological change, the government has been cautious about altering the social structure of the medical system. Its policies have maintained the subordinate status of paramedical workers and the power of physicians in high-level university and hospital positions. Thus, while in the earlier period technological change led to sociocultural change through government support, more recent changes in the nature of medical technology have had only limited impact in this regard.
The circumstances described above have several implications for our broader understanding of the relationship between technological and sociocultural change. First, it appears that there is no direct relationship in which technology determines social structure. In neither of the periods I have discussed did the Japanese government create policy merely in reaction to changes in available medical technology. Rather, it investigated the technology, studied its possible consequences, and attempted to direct the speed of its introduction and to control its use. Thus, to understand 84 the Japanese medical scene, we need microlevel political and sociological studies that treat government officials and professionals as well as patients as active decision makers. Such research would clarify the abstract concepts of “government” and “profession” by revealing the relationships among individuals with different areas of expertise and the procedures by which they make decisions. This would lead to a fuller understanding of the specific conditions under which technical change will lead to changes in social structure.
The second implication of this study is that the result of decision making cannot be viewed as blind copying, of which the Japanese have often been accused. The Japanese version of biomedicine today has certainly been greatly influenced by the seventeenth and eighteenth-century Dutch, nineteenth-century German, and twentieth-century American medical systems that served as its models. But from the beginning, when Japanese physicians concentrated on European surgical techniques, the “borrowing” was selective. Bartholomew (1974) points to several important differences between Meiji medicine and its German model. Despite the similarity in the technology of biomedicine in Japan and the United States today, there are notable differences in the structure of their systems, in the organization of their medical professions, and in relations among their health care workers. Differences, as Ben-David has written of scientific activity in general, do not arise because social values determine the content (here, technology) of science. But two types of conditions influence differences in the nature of scientific activity: “the changing constellation of social values and interests among populations as a whole which channeled the motivation of people to support, believe, or engage in science … [and] the organization of scientific work” (Ben-David 1971, 169).
In Japan the government has played a direct role in creating both of these conditions, but it has done so by including elements of the past as well as imported technology. My examination shows continuities in the role of the physician as a “professional,” the dependence on private practice, the cultural interpretations of sex roles and educational background that influence social ranking, and the importance of government-physician relations. Policy, then, may be viewed as a factor intervening between technology and social structure, helping to adapt technology to a specific sociocultural environment. I would therefore question the assumptions of those who argue for an eventual convergence of Japanese and Western social systems. Careful investigation of the medical system 85of Japan does not show that the adoption of foreign technology leads automatically to changes in social structure. Rather, the technology and social structure of Japan’s medical system have both faced the scrutiny of people in positions of power.
In addition to published sources on the history of medicine in Japan and on the current medical system, many of the ideas presented in this study result from my year’s observation in 1977–1978 of the Japanese medical system and from interviews and discussions with numerous biomedical health care providers. I am grateful to my fellow panelists at the 1983 meeting of the American Anthropological Association, at which this paper was initially presented, and to James Bartholomew and David Plath for their comments and suggestions.
1. For example, midwifery, a folk healer role, now requires a special degree and is legally classified with nursing. For a discussion of how kampō physicians (specialists in the prescription of herbal medicine) must have biomedical licenses and the recent inclusion of certain herbal medication in the insurance system, see Lock 1980 and 1984.
2. Lock (1980) follows Otsuka (1976) in characterizing the return to the classical Chinese text (a.d. 200) the Shang han lun (A treatise on fevers) as a uniquely Japanese development. On the other hand Okazaki (1976, 147) claims that a call for a return to the classics arose in Ch’ing China. Although this interesting question needs to be resolved, it is only a side issue to the thrust of my argument here.
3. Some han, or feudal domains, sponsored medical schools and certification for that han.
4. I base this assumption on stories about a healer being called in after an earlier attempt by another healer has failed to bring results (see, for example, Okazaki 1976, 148) and my observations of contemporary health-seeking behavior in Japan.
5. This may be due in part to the lack of knowledge of European internal medicine in the early Tokugawa period.
6. Rampō literally means “Dutch medicine.” The term contrasts the Dutch-German style of Western medicine of Tokugawa with both the Sino-Japanese and the Southern European style introduced earlier.
7. I here follow the argument that it was primarily the government’s recognition of its own weakness that led to these policies. In medicine, however, an additional factor was present. Siebold, a German physician employed by the Dutch at Dejima, had been caught smuggling a map of Japan and other contraband out of the country in 1828. Siebold had been particularly active both in teaching Western medicine and in learning about Japan and had become highly 86respected. This incident may have increased the government’s xenophobia in the 1830s (Bowers 1970, 92–126; Okazaki 1976, 198–210).
8. The Japanese government considered other models of biomedicines, in particular the more public-health-oriented British system, but decided in favor of the German system. The prestige of German medicine in Europe, especially the spectacular advances in the bacteriology of thstande late nineteenth century (see Bartholomew 1974, 1982) and the familiarity with German texts, teachers, and so on, from Tokugawa “Dutch medicine” seem to have been important factors in this decision (see Bowers 1980).
9. Fuse (1979, 146) provides the following breakdown for 1899:
Medical school graduates
Foreign graduates or licensure by examination
Public officials or teachers
10. Fukuzawa Yukichi, a student of Ōgata Kōan, is perhaps the best-known example. For discussions of the role of physicians as modernizers in other Asian nations, see Silcock 1977 and Madan 1980.
11. Salaried physicians can and do join the Japan Medical Association, but the association is broken down into separate sections. According to Nakano (1976, 108–109), 72 percent of Japan’s physicians are members, broken down as follows:
Section A—private practitioners
Section B—employed clinical physicians
Section C—university or research institute staff
In my experience, physicians join Sections B and C because their hospital automatically pays their dues and/or, in the case of administrator-physicians, for political reasons.
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