By Tadao Kakizoe / Special to The Yomiuri ShimbunJapanese society has entered a new stage that can be referred to as a “high-mortality society.” According to the Health, Labor and Welfare Ministry and other organizations, about 1.36 million people died in Japan in 2018. In 2025, when those in the baby boom generation join what Japan’s health care system classifies as the latter-stage elderly cohort aged 75 or older, the annual total number of deaths is projected to rise to about 1.52 million. In 2040, the number is likely to stand at about 1.67 million.
The reason the numbers of deaths will certainly surge is due to the aging of the Japanese population. As of 2018, Japanese women had an average life expectancy of 87 years, and men 81 years. This means that Japanese people’s longevity has increased by at least 30 years since 1947 — just two years after the end of World War II — when life expectancy was 54 for women and 51 for men. In other words, our society has entered a period in which the number of elderly people prone to die natural deaths is on the increase.
In Japan, there has been a sea change in the circumstances under which Japanese people pass away. Around 1950, about eight in 10 Japanese died at home. But the balance began tilting toward hospitals in 1976, and today about seven in 10 Japanese die in hospitals.
According to a health ministry survey, about six in 10 Japanese wish to die at home, but many end up being hospitalized because they come to wish to avoid burdening family members at home and feel uneasy about the level of medical treatment that can be provided at home.
Patients wish to go home, instead of remaining hospitalized, and live together with their families until their last moments. For their part, family members wish to support and care for the patients until the end. Home health care services meet such needs with physicians and nurses visiting patients at home or other places such as nursing homes on a regular basis or making visits as requested by patients or their family members.
In my earlier medical career, I encountered various realities associated with home health care. In Nagasaki Prefecture, some of the elderly patients I met had no choice but to battle their diseases at home as they were no longer physically able to go up and down slopes to visit hospitals. In Tokyo, I met an elderly couple who lived in a fourth-floor apartment of an old public housing building that had no elevators. It was a scene in which one elderly person had to take care of another elderly person. As such, home health care services need to be diverse, depending on family structure, living environments and locations — urban or rural.
In the meantime, the government has been decreasing the number of hospital beds nationwide as a measure to reduce unnecessary hospitalization — which is part of the government’s effort to keep national health care expenditures from snowballing. This policy inevitably leads to an increase in the number of those who need to spend periods of recuperation at home or in nursing facilities. When patients and their family members think the home health care system is not fully functioning, they obviously feel less assured.
In 2007, Shinichi Oshima, the first president of the Aichi Prefecture-based National Center for Geriatrics and Gerontology, and now its president emeritus, set up the Conference on Promotion of Home Medical Care. He emphasized the importance of home health care, warning that the hospital-centric medical services model had reached its limit and proposing that it be transformed into an integrated community health care model.
Oshima’s initiative in launching that conference led to the establishment in 2016 of another national conference administered by the Health Policy Bureau of the health ministry. The national council, with participation by organizations grouping home health care physicians and nurses, research entities and municipal governments, is now compiling a national home health care strategy.
Needless to say, home health care is one of the crucial areas on which the future of Japan hinges. Therefore, a comprehensive nationwide system for home health care must be implemented as early as possible.
Akira Sato (1924-2016), known as Japan’s pioneer of home health care, defined home health care as a form of medical care that “helps the elderly continue to live where they have lived, while the dignity of each of them is respected.”
After graduating from the University of Tokyo’s Faculty of Medicine, Sato worked at a clinic in Nagano Prefecture. He called on physicians across Japan to form an association for promoting home health care, which finally came into being in 1994. The campaign culminated in the establishment of the Japanese Academy of Home Care Physicians in 1999.
Physicians, dentists, home care nurses and pharmacists who wanted to carry on the realization of Sato’s vision formed the Japanese Association for Home Care Medicine, with its inaugural national convention held in Tokyo in July this year.
Tetsuo Tsuji, a former administrative vice minister of health, labor and welfare, is one of those inspired by Sato. Almost two years after retiring from the ministry, he became a professor at the University of Tokyo’s Institute of Gerontology — where he is now a project professor — contributing to the advancement of home health care in the country.
Those who have devoted themselves to the promotion of home health care are not limited to doctors and bureaucrats. For example, Isamu Sumino, one of the founders of auto parts and accessories shop chain Autobacs Seven Co., used part of the proceeds from public offerings of the firm’s equities to launch the Yuumi Memorial Foundation for Home Health Care in 2000. The foundation has since subsidized various plans, such as for home hospice care and for building a multidisciplinary professional service network to provide home health care.
I became strongly interested in home health care for two reasons. First, as a medical doctor, I felt a sense of urgency about the need for Japan to have an effective system in place for such medical care. Second, I had an opportunity to take care of my wife at home until the end of her life.
It was 12 years ago that my wife developed small-cell lung cancer. When the tumor was identified, it was as small as 4 millimeters, yet the treatment was not successful in curing her disease. After a 1½-year struggle in hospital, she expressed a strong desire to “die at home.” I complied with her wish and we were able to spend a mere four days together at home, during which I spent virtually every second taking care of her. Even today, I vividly remember how satisfied she appeared at her last moment — prior to that, she repeatedly said to me, “This is exactly what home is meant to be.”
After my wife had gone, I published a book titled “Tsuma o Mitoru Hi” (literally: “The Day I Was at My Wife’s Deathbed”). I received many letters from readers and realized that there were many people who had desired, to no avail, to die at home or to take care of family members with that wish. Ever since, campaigning for home health care has become one of my most important tasks for the rest of my life.
Because of my experience with my wife’s end-of-life scene, I too am determined to “die at home.” In the case of a one-person household, dying at home requires scrupulous preparations. In preparation for a situation in which I become ill, I intend to enter into a contract with a clinic that makes visits to my house for in-house treatment.
However, it should be pointed out that there are many issues to be resolved with regard to home health care. When we take a look at the whole of Japan, there are areas where home health care is sufficiently available and others that are lagging behind.
In areas across the country, “support clinics of home health care” are supposed to be playing an important role in providing patients who are unable to go to hospitals with in-house treatment. They need to respond to patients’ requests for home visits on a 24-hour basis. However, a 2014 health ministry survey found that 28 percent of the country’s municipalities had no such clinics.
The government has begun implementing an “integrated community care system” to provide health care and daily life support and help the elderly stay healthy enough not to need nursing care so that they can continue to live where they are used to living. Also under this program, municipal governments are obliged to supply services tailored to the needs of the elderly, but there are geographical disparities as to the quality of services, depending on municipalities.
The Japan Medical Association has also begun actively involving itself in home health care services. For instance, while its members have traditionally made home treatment visits at patients’ requests, they now make regular home visits for treatment and everyday life support as well as to pronounce the death of patients. Close cooperation between regional medical associations and municipal governments is indispensable for improving the circumstances for home health care.
A variety of professionals, including physicians, nurses, care workers, care managers, pharmacists, dentists, dietitians and physical therapists, are involved in home health care. They should deepen their coordination and cooperation in each area where they work.
In September 2018, Japan Medical Association President Yoshitake Yokokura, who was then also president of the World Medical Association, opened the International Congress of Home Care Medicine, the first event of its kind held in Japan. Representatives from South Korea, Singapore and elsewhere gave lectures on their home health care situations and discussed how they should address the related challenges. The world is closely watching how home health care will develop in Japan, the country whose population is aging ahead of other countries in the world.
Kakizoe is president of the Japan Cancer Society and a past president of the National Cancer Center.Speech