Hserv 534 Session 10

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Hserv 534 Session 10

• Japan
• Dr. Tsukasa Namekata

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Email responses from Session 9

• April 25 Vancouver Sun front page report on study
  of 52 communities in Saskatchewan where small
  hospitals either closed or converted to clinics
  in 1993-4,
• found death rates dropped fasted in communities
  where hospitals were closed!
• Similar study for Manitoba
• why did Canada go down in the health Olympics,did
  the inequalities increase ?

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Assessing the Impact of the 1993 Acute Care
Funding Cuts to Rural Saskatchewan
Hospitals.(1999) Saskatoon, Health Services
Utilization and Research Commission.
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Age, sex standardized death rates per 100,000
population by community group, before and after
the 1993 acute care funding cuts
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Email responses from Session 9

• One of the maps shown in the class indicated
  Canadians who live in areas closer to the borders
  with the U.S. are healthier.
• What is their perception of the gap between the
  rich and the poor, do they naturally look at the
  U.S. and feel that they are less wealthy?

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Email responses from Session 9

• Big difference in population density between
  Canada and the U.S.
• How does it affects the social cohesion
• Rural areas tend to be agricultural or
  subsistence society, thus more social cohesive,
  despite being economically poorer than urban
  areas.
• But rural areas in Canada are less healthy than
  urban areas. Doesn't this indicate that public
  health system is more relevant factor for health
  than socio-economic structure such as social
  cohesion?

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Email responses from Session 9

• Both Norway and Canada have a history of a social
  contract lacking in the US, wonder what the
  "resistance factor" might be here
• Comparisons, between BC and Washington state,
  and the US, Canada Norway, pretty compelling
• (either we can spend our money on damage
  control, or we can change the structures that
  produce it in the ?rst place).
• Sure BC spends more in taxes up front, but the
  American taxpayer is probably paying more in
  "after-the-fact" funds in the social welfare
  arena (i.e. in the form of prisons, etc).

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Email responses from Session 9

• Sweden and Canada share one major feature
• Investing in Social Goods
• Education,
• health care all heavily subsidized
• Progressive tax

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Email responses from Session 9

• Enough evidence that the only way to improve
  population health in U.S.is to reduce the gap
  between the rich and the poor by redistributing
  wealth,
• why is the government going to other direction?
• Do they really care if U.S is in 25th or lower in
  health Olympics?
• Do they care of the poor?
• Do the rich people in this country think that it
  is bad for them to be in 25th in health Olympics?

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Email responses from Session 9

• Universal insurance provides the opportunity for
  health care which may do more harm than good. on
  a population health level make little if any
  difference.
• Reason to support universal insurance is it does
  provide a redistribution of wealth.
• The stigmatism of free and reduced care is
  diminished. If used to promote efficacious care
  rather than more care, then indeed universal
  health insurance may contribute to reducing heath
  disparities.

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Too much information hazardous to our health?

• Japanese CEO salaries are not published, so
  Japanese CEOs are not aware of how much their
  counterparts are making.
• When CEOs' salaries are revealed, adds pressure
  to boards to raise more funds to attract and keep
  CEO's happy.
• This means companies shift more money towards CEO
  salaries,
• means less money is going towards getting better
  health care coverage for all other employees.

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Email responses from Session 9

• When we, Japanese, are asked why are we so
  health, we attribute it to our food.
• My friends say Japanese prefer non-fat food and
  eat less, while Americans are just the opposite.

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Email responses from Session 9

• Okinawa is the healthiest state in Japan, and
  poorest.
• Divorce rate of Okinawa is the highest in the
  nation, before Osaka and Tokyo.
• you can have social cohesion if you don't have
  family cohesion
• Okinawa's political participation is amazingly
  low. It ranked 44th among 47 states in voter
  turnout the latest Upper House national election
  in 2000, despite a number of hot political
  agendas such as US military presence, economic
  development, and so on.
• Okinawa infant mortality rate? No children's
  hospital in Okinawa.

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Learning Objectives

• state the past achievements of Japans health
• present the health situation in Japan today
• list the features of Japans health care system
• discuss why a great disparity in health exists
  between the Japanese and the American populations
  in terms of health achievement
• present a forecast of future problems that most
  of the developed nations including the US and
  Japan commonly share.

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Shibuya, K., et al. (2002). Individual income,
income distribution, and self rated health in
Japan cross sectional analysis of nationally
representative sample. BMJ 324

• Data collected on household income, self rated
  health, and other sociodemographic
  characteristics at the individual level from
  comprehensive survey of the living conditions of
  people on health and welfare in a nationally
  representative sample from each prefecture.
• Setting Prefectures in Japan. Participants 80
  899 people aged 15 years with full records in
  survey.
• Main outcome measures Dichotomous variable for
  self rated health of each respondent (0 if
  excellent, very good or good 1 if fair or poor).
  Results Inequality in income at the prefecture
  level measured by the Gini coefficient was
  comparable with that in other industrialized
  countries.
• Unadjusted odds ratios show a 14 increased risk
  (odds ratio 1.14, 95 confidence interval 1.02 to
  1.27) in reporting poor or fair health for
  individuals living in prefectures with higher
  inequality in income.
• After adjustment, individual income was more
  strongly associated with self rated health than
  income inequality.
• Additional inclusion of regional effects showed
  that median income at the prefecture level was
  inversely related to self rated health.
  Conclusions Individual income, probably relative
  to the median prefecture income, has a stronger
  association with self rated health than income
  inequality at the prefecture level.

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Possible Reasons

• Very low reporting fair to poor health (0.8
  poor, 9 fair) and only one validation study in
  Japan
• Dichomization of variable (fair-poor vs other 3)
• Japan has low levels of inequality compared to
  the US and maybe there is a threshold to see
  effects
• Time lag between recent increase in inequality in
  Japan and health effects (15 years in some
  studies)
• Prefecture the optimum level of aggregation?
• Income inequality effects may depend on specific
  social and political characteristics (Income
  inequality captures part of hierarchy)

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Health Olympics Age 80
Whites
Willcox 2001
Manton NEJM 1995
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Mean Score on Total Battery
Second International Mathematics Study
7
0
6
0
5
0
J
a
p
a
n
C
a
n
a
d
a
4
0
r
a
c
e
Mean Percent Correct
d
3
0
2
0
1
0
0
92
1
1
1
2
2
2
6
3
8
4
2
5
3
6
9
7
1
8
1
9
1
Percentile Rank of Fathers Occupation
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International Comparisons
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Health Olympics Age 80
Whites
Willcox 2001
Manton NEJM 1995
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Life Expectancy as a health measure

• Kobe earthquake in Jan 17, 1995 killed 5500
  Japanese, yet the life expectancy drop was only
  .04 years for females and .02 years for males in
  Japan that year (calculated with and without
  earthquake deaths)
• Kosei no shihyo (Journal of Health and Welfare
  Statistics) Special issue Kokumin eisei no doko
  (Trends of Nation's Health) 2003 50 (9)p 420
• Armenian earthquake 1988 25000 died (pop 3 mil.)
• Effect of September 11, 2001 on NY state of US
  life expectancy?

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Health Care Public Health in Japan

• Medical School training
• No patient contact throughout entire period
• Can go out and practice, never having touched a
  patient
• Average doctor sees 75 patients a day
• No appointments (3 hour wait, 3 minute
  consultation)
• Hospital stays
• Very long ( one month)
• Must supply own cup for a drink, chopsticks for
  meals
• Men shower on M, W, F, women the other days
• Toilets down the hall, must supply soap, towel
  and shampoo
• Appendectomies (more common than in US)
• 60 of appendices removed were normal
• Public health 1000 measles deaths in 2002

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MacArthur Medicine

• Academic freedom,
• Free universal education,
• Right of workers to organize and bargain
  collectively
• Maximum Wage (65,000 yen in 1947 4333)
• Decentralization including breaking up zaibatsu
• and land reform (father had advocated in
  Philippines)
• "Controlled revolution"