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Health problems of the year 2000 and beyond
Health Policy, 4 (1985) 307-3 19
307
Elsevier
HPE 00028
Health problems
of the year 2000 and beyond* Akira Koizumi
Chairman. Department of Public Health. Faculty of Medicine, University Bunkyo-ku, Tokyo 113, Japan (Accepted
for publication
I
January
ofTokyo, 7-3-1 HOQO,
1985)
Summary Health problems of developed nations in the 21st century are mainly discussed. As the forthcoming century is a continuation of the present century, health in Japan in the latter half of the 20th century is reviewed as an example of the transition of the nation’s health, which has been remarkable. Health problems in the 21st century are then presumed and a possible solution is suggested. health
indicators;
life expectancy;
Japan
Introduction It is well known that the World Health Organization (WHO) has been promoting Primary Health Care (PHC) in every country of the world, aiming for the target of “Health for All by the Year 2000”. Quite recently Japan attained the world’s longest life expectancy at birth, although there are still many health problems mostly common to other developed countries. In this paper, health in developed nations in the forthcoming century is discussed.
* Based on presentations made at the “International Symposium on an Aging Society: Strategies for 21st Century Japan”, held on November 24-27, 1982 in Tokyo, Japan, and the “Third International Conference
on System Science in Health Care”, held on July 16-21,
earlier draft of this paper was also presented at the “Carnegie in Western
Europe and the United States”,
1984 in Munich,
Corporation
held on June 18-22,
An
1984 in Bellagio, Italy, as a reference
paper.
0168-8510/85/SO3.30
West Germany.
Conference on Societal Aging
t 1985 Elsevicr Science Publishers B.V. (Biomedical
Division)
308
However, since the 21st century is a continuation of the 20th century, health in Japan in the present century is also reviewed as an example. Proposals are then made to help prepare for health in the forthcoming century.
Rapid extension of life expectancy at birth in Japan in the 20th century (a) Annual trends of life expectancy Life expectancy at birth of Japanese males was reported in 1983 to be 74.20 years of age, and that of females to be 79.78. These figures rank first among the countries of the world. It is, however, only a recent phenomenon that Japanese life expectancy at birth has increased to such a high level. In 1971, life expectancy at birth was 70.17 years for males and 75.58 years for females, which marked the achievement of a long-cherished wish by the Japanese people for an average life expectancy for males of above 70 and for females of above 75 years. In 195 1, the life expectancy at birth of Japanese males reached into the 60’s and, in 1952, that of females exceeded 65 years of age. In 1948, it was 55.6 years and 59.4years for males and females, respectively. A year before, in 1947, it was 50.06years and 53.96 years which was based on the 8th Life Table. The 6th Life Table (1935-36) showed 46.92 and 49.63 years, and the 4th Life Table (1921-25) showed 42.06and 43.20years. Due to the unreliability of statistical material, the average life expectancy at birth before the 4th Life Table has not been included in this study (Table 1). Life expectancy of the Japanese at birth has followed the path of other developed countries until quite recently. For a considerable time, the longevity of Scandinavian people, particularly the Swedish, continued to be far beyond our reach, and it took many years to catch up with countries such as England, Wales, the U.S.A. and France (Table 2). The infant mortality rate (the number of deaths in 1000 children less than one year old) is also taken into consideration. This rate, which was more than 150 in Japan in 1920, decreased steadily to 90.0 in 1940,60.1 in 1950, 30.7 in 1960, 13.1 in 1970, 10.0 in 1975 and finally to 6.6 in 1982 (Table 3). Infant mortality is further categorised into “neonatal mortality” (less than four weeks after birth), and “early neonatal mortality” (less than one week after birth). In Japan, infant mortality on the whole has been on the decline due to the decrease in deaths by infectious diseases, but neonatal deaths, particularly early neonatal deaths, have been fairly high until recently due to hereditary causes. (6) Relationship between &tieexpectancy and medical expenditure In spite of the reported rapid growth of life expectancy in Japan, a mathematical model (Fig. 1) indicates that this rate has been lowering and will reach a plateau in the future. This is based on an analysis of recent trends. On the other hand, national medical expenditure has been growing continuously in Japan, therefore, we examined
309 TABLE
1
Life expectancy
at birth (years)
Year
Male
Female
Year
Male
Female
1921-1925* 19261930* 1935-1936 19478 1948 1949 1950-1952* 1951 1952 1953 1954 19558 1956 1957 1958 1959 1960* 1961 I962 1963
42.06 44.82 46.92 50.06 55.6 56.2 59.57 60.8 61.9 61.9 63.41 63.6 63.59 64.24 65.98 65.21 66.32 66.03 67.23 67.21
43.20 46.54 49.63 53.96 59.4 59.8 62.97 64.9 65.5 65.7 67.69 67.75 67.54 67.6 69.61 69.88 70.19 70.79 71.16 72.34
1964 1965; 1966 1967 1968 1969 1970* 1971 1972 1973 1974 1975* 1976 1977 1978 1979 1980 1981 1982 1983
67.67 68.74 68.35 69.91 69.05 69.18 70.31 70.17 70.50 71.70 71.16 72.73 72.15 72.69 72.97 73.46 73.32 73.79 74.22 74.20
72.87 72.92 73.61 74.15 74.30 74.67 74.66 75.58 75.94 76.02 76.31 76.89 77.35 77.95 78.33 78.89 78.83 79.13 79.66 79.78
?? Complete Life Table. Figures after 1947 include Okinawa Prefecture. Source: Abridged and Complete Life Tables, Ministry of Health and Welfare,
TABLE
Tokyo.
2
International
comparison
of life expectancy
at birth
Country
Year
Male
Female
Japan Iceland Sweden Norway Denmark Netherlands Switzerland France England & Wales Canada U.S.A. Puerto Rico
1980 1979-1980 1980 1979-1980 1979-1980 1979 1968-1973 1978-1980 1977-1979 1975-1977 1979 1979
73.32 73.70 72.76 72.75 71.20 72.40 70.29 70.05 70.20 70.19 69.90 69.60
78.83 79.70 78.81 79.00 77.30 78.90 76.22 78.20 76.40 77.48 77.80 76.07
Years show the period on which the statistics
are based.
Source:
Demographic
Yearbook,
UN, 1981.
310
TABLE Infant
3 mortality
rate: international
comparisons 1960
(per 1000)
Country
1940
1980
Japan
90.0
30.1
Australia
38.4
20.2
Denmark
50.2
21.5
8.4
France
95.3
27.4
10.0
Netherlands
39.1
16.6
Lx2**
Sweden
39.2
16.6
6.9
7.5* 10.7
Switzerland
46.2
21.1
9.1
U.S.A.
47.0
26.0
11.7
U.K.
57.4
21.8
12.0
* 6.6 in 1982. ** Value in 1981. Source:
UN Demographic
Yearbook,
1940-1978,
WHO World
Health
Statistics
Annual,
1970-1982.
the relationship between changes in life expectancy at birth and per capita national medical expenditure. To remove the influence of long-term price fluctuations on these figures, a correction was made using the consumer’s price index published by the Bureau of Statistics at the Prime Minister’s Office. If we express the life expectancy at birth (average of males and females) as “x” in a year, and per capita national medical expenditure for the same year as “Y” in yen, there is a correlation between “x” and “Y” which is shown by the following equation: Y = 4 * 10-S * l.344X The greater the life expectancy at birth, the more additional per capita national medical expenditure is required to generate a unit increase in life expectancy at birth. Therefore, “marginal cost” which is relative to the marginal increase in life expectancy at birth, is increasing continuously as shown in Fig. 2. The above-mentioned equation also indicates that the benefit or efficiency of national medical expenditure in terms of life expectancy at birth does not increase linearly with expenditure [1,2]. (c) Regional differences in the mortality rate and its changes as shown by the standardized birth and death rate by prefecture Fig. 3 shows the distribution of standardized birth and death rates for every five years per 1000 population between 1950-80. The standardized death rate is shown by the horizontal axis and the birth rate by the vertical axis. The population of Japan in 1930 is used as the .basis for standardization. The results for each turn of every five years are shown by the rectangular frame of full lines covering the minimum and maximum values of each axis. The 1950 basic results show a remarkable decrease in the level of standardized birth
311
Fig. 1. Gomportz
curve fitted to annual
change
of life expectancy
at birth in Japan.
and death rates of 1955; prefectural differences narrowed at the same time. The standardized death rate after 1955 shows a constant decline, and the prefectural difference is narrowed. The level of the standardized birth rate continues to decrease until 1960, and then evens out to a nominal decrease thereafter. The prefectural differences of the standardized birth rate narrowed, particularly in 1970. The major factors leading to the lowering of the average standard, and to the narrowing of the prefectural gap in birth and death rates, were successful family Xl 0'yen
.344x
64
66
66
70
I
I
I
72
74
76
eo
Life Expectancy at birth
Fig. 2. Relationship between life expectancy at birth and per capita medical expenditure expectancy is a weighted average of male and female.
in Japan.
Note: life
312
.I950
01970
.1955 ,+1975 o 1960 ‘J 1960 t 1965
;I1
b
I ’
1
5
”
”
1
10
’
”
1
’
15
STANDARDIZED DEATH RATE
Fig. 3. Standardized death and birth rates by Prefecture and year (per 1000). Source: Vital Statistics 1980 Japan, Ministry of Health and Welfare, Tokyo, 1980.
planning and the improvement of health and medical care services. These services were carried out not locally but on a national level. This leveling tendency was also observed in the average income and standard of living in the different prefectures, with some prefectures heading the trend. Factors contributing to the narrowing of prefectural gaps were the dissemination of information, even to remote areas, through the mass media, a nationally unified health and medical services system, and subsidies to regional governments from the central government. (d) Factors causing the rapid extension of life expectancy
Statistics have proven that life expectancy has increased rapidly in Japan and a high standard of health has been reached. Who could have foretold thatrsuch a development would take place some decades ago when the standard of health of the Japanese was still at a low level? This progress, together with rapid economic growth, could be regarded as the miracle of Japan. It was not easy, however, to discover the causes behind this miracle. It is indeed remarkable that the death rate due to infectious diseases decreased sharply in a few years, mainly in the period from 1950-55. Even this great decrease could not compare with those of other developed countries at the time as the death rate from epidemics in Japan had previously been so high. It is only recently that Japan has come to equal the low death rate of other developed countries, whose improvement came at a much earlier time and made steady progress. Japan, however, had to progress from a much lower standard of
313
health at an accelerated speed which is still continuing today. There are many factors involved in the extension of life expectancy and all of them are inter-related; it would be a mistake to single out any one factor. No one can dispute the effect that antibiotics, in their fight against infectious diseases such as tuberculosis, gastroenteritis, pneumonia and bronchitis, have had on the decrease of the mortality rate. At the same time, easy access to medical care cannot be ignored as a supporting factor of the decrease. Tuberculosis already had an established preventive system before antibiotics became available. Improvement in nutrition may have been beneficial in enhancing the effects of antibiotics. Rapid economic growth began in Japan around 1955. In 1961, a new era was entered with the introduction of a nationwide health care system, “health insurance for the whole nation”. Economic growth enabled a major portion of the people’s medical expenses to be publicly financed, which led to Japan becoming a nation with a high accessibility to medical care services. Medical technology, which increasingly advanced along with other services, was also supported economically. The nutritional levels of the Japanese diet have been enhanced with the average intake of calories, protein and fat still below the level of Western countries. This works favorably in sustaining a comparatively low death rate by aiding in the prevention of degenerative diseases. It is now widely accepted that the eating habits of the Japanese are better for health than those of Western countries, particularly in preventing heart disease. Another noteworthy factor in elevating the health standard of the Japanese is a unique program based on the concept of Kenko Kanri, a group health program which is characteristic of Japanese society [3]. The collective medical check-up, which is one of the main approaches in Kenko Kanri, was first introduced in the mid-1950’s for workers in large enterprises and government offices. It then spread to workers in the factories of small-scale industries, schools and urban community health programs. This could be classified as “primary health care in an industrialized society”. Mr. Kazuo Uemura, Director of the Division of Epidemiological Surveillance and Health Situation and Trend Assessment at WHO, pointed out that although the populationphysician ratio of Japan is comparatively low, the death rate of males between the ages of 40-69 was among the lowest in the world [4]. I would like to mention that Kenko Kanri seems to be’one of the reasons making a great contribution [3,5]. As mentioned so far, Japan’s miraculous extension of the average life expectancy was not made possible by any single factor. Rather, it should be pointed out that many favorable factors worked together at the appropriate time, but whether this was inevitable or due to chance, it is hard to say. There is no guarantee that these positive elements would be realized again in the future and produce the same effect.
Health in the 21st century (a) Goals and tasks
The decrease in the death rate in the latter half of the 20th century is particularly
314
remarkable in Japan, but the general picture of health is not necessarily positive because of the increase in the number of people receiving medical treatment [2]. Whereas people used to be more inclined to think of medicine as curative, there has recently been an increased consciousness concerning health aimed at the prevention of poor health. With the advancement of medical technology, there is a fear that patients will be treated not as human beings but as objects -like broken-down machines. There is presently an increased emphasis by medical experts on the necessity of health education. They clearly consider that a truly healthy body can be achieved only when people are well informed of their health. It is also true that the efficacy of medical treatment would be greatly influenced by the patient’s general knowledge, attitude and behavior towards illness. There has also been an increasing demand on the part of patients to get as much detailed information as possible from their physicians as to the causes, expected progress of the disease and the lifestyle required during treatment. This demand is, in fact, not satisfied due to the limited time allocated to each patient for treatment. Many physicians are reluctant to explain to patients their problems because they feel that the patient can be cured by simply administering drugs or other methods of treatment. Others feel reluctant because they regard the patient as having enough knowledge and judgement not to need any explanation. In either case, this thinking seems to be associated with the idea that patients are only broken-down machines requiring treatment. In the 21st century, the above conditions must be satisfied reinforcing the concept of health education and the proper use of health information. Many people do not pay attention to their health and body when they are enjoying a healthy life and not receiving any medical treatment, but once they require medical care, they become hungry for information related to their disease and its treatment. This is, of course, natural human behavior but information that is obtained only when the necessity arises is only an immediate solution or countermeasure. It is not necessarily based on systematic principles or rules. If people had a basic understanding of the body and disease, more immediate countermeasures could be properly and effectively utilized. Knowledge that is applied without a fundamental theory may be misused, but this could be avoided by reinforcing health education and by the correct use of health information. Besides the limited treatment time, the gap in medical knowledge between the physician and the patient should be pointed out. The term “take less salt” may have for physicians a comprehensive meaning based on the accumulation of research results, but this may not be conveyed in full to patients. Is it possible to expect a greater rapport between physicians and patients for mutual understanding and awareness? This thinking may unfortunately be too optimistic. It is impossible to introduce the same amount of knowledge into physical education in high school. college or compulsory level education as is studied by students of medicine. It is almost absurd even to think that physicians and patients share the same expert knowledge aad awareness. It may also happen that when medical professionals, such as physicians or nurses, require treatment that problems in communication may exist between patient and physician. Knowledge on the part of the patient may act as an obstacle to effective treatment.
315
Even patients who have a high level of medical knowledge may similarly be concerned about their lives. The ideal situation would be for patients to have complete trust in their physicians, and for the physician to do his utmost. However, unless the patient accepts the physician’s treatment unconditionally and is fully satisfied, there is a need for greater communication between the two. If the patient is a physician or a nurse, he or she will have a basic understanding of the contents of the medical care and the medical philosophy and logic. It is impossible to expect patients who are not medical professionals to have the same understanding. Is there no way for persons who are not medical professionals to share expert knowledge systematically and not in segments? The goal of a healthy life in the 21st century should aim for every person to assume responsibility for his or her own health from adequate information based on well-structured, systematic knowledge. (b) Development of a new health indicator As previously discussed, the mortality rate has decreased remarkably because of medical advancement and improved accessibility to medical services, resulting in increased levels of health, including the life expectancy at birth. In spite of these objective improvements, the ratio of people who are ill and receiving medical treatment is increasing [2]. Fig. 4 is the combined result of a survival curve given by the Abridged Life Table (1979) and three different surveys conducted by Japan’s Ministry of Health and Welfare the same year. It includes the rate of medical care recipients according to the Patient Survey; the morbidity prevalence rate according to the National Health
Females
Males Number of Survivors
ieceiving
medical treatment
Number of Survivors
receiving
medical treatment
100,000
100,ooo
w,ooo
90,000
60,000 -
60,000
70,000
-
70,000
60,000
-
60,000
50,000 -
50,006
-
40,000
so.ooa-
30,000
40.000
0
IO
20
Fig. 4. Proportion
SO
40
50
60
70
60
Age
of survivors by subjective feeling of health.
r of ors
316
TABLE
4
Proportion
of sick people and people who visited physicians
Sex
Age group
Year
O-14 Sick People Male
3.3 6.4 9.2 6.8
7.4 9.0 9.4 8.8
19.1 27.0 31.4 35.6
1965 1970 1975 1979
3.3 5.4 8.4 6.6
7.4 10.4 10.7 10.3
16.8 24.2 32.3 38.0
1965 1970 1975 1979
5.1 6.4 5.5 6.5
6.5 7.0 6.2 6.0
8.6 12.0 16.8 17.2
1965 1970 1975 1979
4.5 5.9 5.7 5.8
6.3 7.5 7.1 6.9
7.0 IO.8 18.3 19.1
Care Users
Female
TABLE Proportion Subjective
65-85
1965 1970 1975 1979
Female
Medical Male
15-64
5 of different feeling
subjective
feelings on health
Age group Male
In very good health Almost healthy Not in good health
Female
20-64
65-85
20-64
65-85
17.4 62.6 20.0
10.7 43.8 45.5
II.8 62.3 26.0
5.9 38.2 55.9
Survey; and health consciousness according to the Basic Survey on Health Status. This would present the quality of life as seen from the health aspect. This figure has some limitations due to inconsistencies in the timing of observations, surveys and differences in the sample groups of the surveys of the original material. These inconsistencies are: the death rate comprising the summarized life table based on a year-round basis; the medical care recipient rate being confined to the third Wednesday in July, 1979; and the rate ofdisease being limited to three days in the
317
Number of Survivors
Number of Survivors
Male
Female
90.u00
60.000 70.000' 6o.OGQ' 50.000' 40.000' IY7Y 30,wJ
3OsnJO
XIOOO.
197Y 1975
20.000'
IO.OWJ~
1970 965
10300
0 0
. 10 .
Fig. 5. Number
. . 30 . 20
. 40
.
50 .
.
fi0 .
.
70
. .Age 80
I!)75 IW7U 1965
1
OoL@ 30
40
50
60
70
80
of survivors.
beginning of October. Material relating to health consciousness was obtained at the same time as the rate of disease material. With regard to the sample groups, the number of living is based on annual death rates according to sex and age calculated from national demographic statistics. The medical care recipient rate, morbidity prevalence rate and health consciousness are based on sample plans for each survey Number of Survivors 100.000,
Number of Survivors
Male
Female
Ywmo 6u.ooo 7u.uw M).wl 5O.WU~ 4u.uw~ 3u#00 2U.uoo'
1979 1975 1970 19-35
10.1JwJ .
uA
0
IU
Fig. 6. Number
2u
30
40
so
M
70
50
Age
o-Age
0
of survivors who received no medical treatment.
10
20
30
40
50
60
70
na
318 Number of Stir-vivors
Male
Number of Survivors
Female
100.000,
1979 1975 1970 1965
ol................
0
Fig. 7. Number
10
20
30
40
50
60
70
60
* Age
of survivors with no disease.
and are equal in the fact that the total national population is the target, but the sampling error is not always the same. Despite such shortcomings, Fig. 4 would serve as a sample for devising a new health indicator. The vertical axis represents the number of living, and the horizontal axis represents the age of males and females separately. The solid curve at the top represents the number of living by age, the second solid curve represents the untreated population by age and the dotted curve represents the non-diseased population by age. The “subjective” judgement of the condition of health is also shown in Fig. 4and divided into: (1) “not in good health” between the third solid curve from the solid curve; (2) a majority of “almost healthy” between the third and fourth solid curves; and (3) “in very good health” between the fourth solid curve and the bottom. This subjective consciousness is shown only among people over 20. Details of the number of living can be found at any age level (Tables 4 and 5). Fig. 5 shows the transition of the number of living in 1965, 1970, 1975 and 1979 for males and females separately. Fig. 6 shows those who received no medical treatment, and Fig. 7 shows those with no disease. In Fig. 5, a constant and steady improvement is observed per year, but the same trend is not necessarily seen in Figs. 6 and 7. In Fig. 7, in particular, each year overlaps except for the infancy period. This seems to have some significance. The above are the results of part of the attempt to develop a new indicator of health levels based on data obtained in Japan. The development of this new indicator is still in its beginning stages and needs further improvement. It is presented here, however, as an example of the efforts being made for a healthy life in the 21st century.
319
Acknowledgements The author wishes to express his thanks to Dr. Alvar Svanborg, Professor of Geriatrics and Long-Term Care Medicine, Vasa Hospital, Giiteborg, Sweden; Dr. Toshio Kuroda, Emeritus Director of Nihon University Population Research Institute, Tokyo, Japan; and Mr. Kazuo Uemura, Director of the Division of Epidemiological Surveillance and Health Situation and Trend Assessment, World Health Organization, Geneva, Switzerland, for their comments on an earlier draft of this paper. The author also appreciates the assistance of Mr. Shunji Nishii, Mr. Kunihiko Miura and Dr. Motofumi Masaki, Department of Public Health, Faculty of Medicine, University of Tokyo, in the computation and preparation of the figures.
References 1 2 3 4 5
Koizumi, A., Nishii, S. and Sakai, N., Estimation of life expectancy by mathematical models, Minzoku-Eisei (Japan Journal of Health and Human Ecology), 45 (5) (1979) 184-188. Koizumi, A., Longevity and health care: A cost-benefit type analysis of life expectancy and medical expenditure, Journal of Population Studies, 7 (1984) 9-14. Koizumi, A., Development of public health in Japan, Asian Medical Journal, 25 (1982) 14-20. Uemura, K., personal communication. United Nations Economic and Social Commission for Asia and the Pacific, Population and Health Development. In “Population of Japan”, Country Monograph Series No. 11, pp. 187-199, United Nations, New York, 1984.
307
Elsevier
HPE 00028
Health problems
of the year 2000 and beyond* Akira Koizumi
Chairman. Department of Public Health. Faculty of Medicine, University Bunkyo-ku, Tokyo 113, Japan (Accepted
for publication
I
January
ofTokyo, 7-3-1 HOQO,
1985)
Summary Health problems of developed nations in the 21st century are mainly discussed. As the forthcoming century is a continuation of the present century, health in Japan in the latter half of the 20th century is reviewed as an example of the transition of the nation’s health, which has been remarkable. Health problems in the 21st century are then presumed and a possible solution is suggested. health
indicators;
life expectancy;
Japan
Introduction It is well known that the World Health Organization (WHO) has been promoting Primary Health Care (PHC) in every country of the world, aiming for the target of “Health for All by the Year 2000”. Quite recently Japan attained the world’s longest life expectancy at birth, although there are still many health problems mostly common to other developed countries. In this paper, health in developed nations in the forthcoming century is discussed.
* Based on presentations made at the “International Symposium on an Aging Society: Strategies for 21st Century Japan”, held on November 24-27, 1982 in Tokyo, Japan, and the “Third International Conference
on System Science in Health Care”, held on July 16-21,
earlier draft of this paper was also presented at the “Carnegie in Western
Europe and the United States”,
1984 in Munich,
Corporation
held on June 18-22,
An
1984 in Bellagio, Italy, as a reference
paper.
0168-8510/85/SO3.30
West Germany.
Conference on Societal Aging
t 1985 Elsevicr Science Publishers B.V. (Biomedical
Division)
308
However, since the 21st century is a continuation of the 20th century, health in Japan in the present century is also reviewed as an example. Proposals are then made to help prepare for health in the forthcoming century.
Rapid extension of life expectancy at birth in Japan in the 20th century (a) Annual trends of life expectancy Life expectancy at birth of Japanese males was reported in 1983 to be 74.20 years of age, and that of females to be 79.78. These figures rank first among the countries of the world. It is, however, only a recent phenomenon that Japanese life expectancy at birth has increased to such a high level. In 1971, life expectancy at birth was 70.17 years for males and 75.58 years for females, which marked the achievement of a long-cherished wish by the Japanese people for an average life expectancy for males of above 70 and for females of above 75 years. In 195 1, the life expectancy at birth of Japanese males reached into the 60’s and, in 1952, that of females exceeded 65 years of age. In 1948, it was 55.6 years and 59.4years for males and females, respectively. A year before, in 1947, it was 50.06years and 53.96 years which was based on the 8th Life Table. The 6th Life Table (1935-36) showed 46.92 and 49.63 years, and the 4th Life Table (1921-25) showed 42.06and 43.20years. Due to the unreliability of statistical material, the average life expectancy at birth before the 4th Life Table has not been included in this study (Table 1). Life expectancy of the Japanese at birth has followed the path of other developed countries until quite recently. For a considerable time, the longevity of Scandinavian people, particularly the Swedish, continued to be far beyond our reach, and it took many years to catch up with countries such as England, Wales, the U.S.A. and France (Table 2). The infant mortality rate (the number of deaths in 1000 children less than one year old) is also taken into consideration. This rate, which was more than 150 in Japan in 1920, decreased steadily to 90.0 in 1940,60.1 in 1950, 30.7 in 1960, 13.1 in 1970, 10.0 in 1975 and finally to 6.6 in 1982 (Table 3). Infant mortality is further categorised into “neonatal mortality” (less than four weeks after birth), and “early neonatal mortality” (less than one week after birth). In Japan, infant mortality on the whole has been on the decline due to the decrease in deaths by infectious diseases, but neonatal deaths, particularly early neonatal deaths, have been fairly high until recently due to hereditary causes. (6) Relationship between &tieexpectancy and medical expenditure In spite of the reported rapid growth of life expectancy in Japan, a mathematical model (Fig. 1) indicates that this rate has been lowering and will reach a plateau in the future. This is based on an analysis of recent trends. On the other hand, national medical expenditure has been growing continuously in Japan, therefore, we examined
309 TABLE
1
Life expectancy
at birth (years)
Year
Male
Female
Year
Male
Female
1921-1925* 19261930* 1935-1936 19478 1948 1949 1950-1952* 1951 1952 1953 1954 19558 1956 1957 1958 1959 1960* 1961 I962 1963
42.06 44.82 46.92 50.06 55.6 56.2 59.57 60.8 61.9 61.9 63.41 63.6 63.59 64.24 65.98 65.21 66.32 66.03 67.23 67.21
43.20 46.54 49.63 53.96 59.4 59.8 62.97 64.9 65.5 65.7 67.69 67.75 67.54 67.6 69.61 69.88 70.19 70.79 71.16 72.34
1964 1965; 1966 1967 1968 1969 1970* 1971 1972 1973 1974 1975* 1976 1977 1978 1979 1980 1981 1982 1983
67.67 68.74 68.35 69.91 69.05 69.18 70.31 70.17 70.50 71.70 71.16 72.73 72.15 72.69 72.97 73.46 73.32 73.79 74.22 74.20
72.87 72.92 73.61 74.15 74.30 74.67 74.66 75.58 75.94 76.02 76.31 76.89 77.35 77.95 78.33 78.89 78.83 79.13 79.66 79.78
?? Complete Life Table. Figures after 1947 include Okinawa Prefecture. Source: Abridged and Complete Life Tables, Ministry of Health and Welfare,
TABLE
Tokyo.
2
International
comparison
of life expectancy
at birth
Country
Year
Male
Female
Japan Iceland Sweden Norway Denmark Netherlands Switzerland France England & Wales Canada U.S.A. Puerto Rico
1980 1979-1980 1980 1979-1980 1979-1980 1979 1968-1973 1978-1980 1977-1979 1975-1977 1979 1979
73.32 73.70 72.76 72.75 71.20 72.40 70.29 70.05 70.20 70.19 69.90 69.60
78.83 79.70 78.81 79.00 77.30 78.90 76.22 78.20 76.40 77.48 77.80 76.07
Years show the period on which the statistics
are based.
Source:
Demographic
Yearbook,
UN, 1981.
310
TABLE Infant
3 mortality
rate: international
comparisons 1960
(per 1000)
Country
1940
1980
Japan
90.0
30.1
Australia
38.4
20.2
Denmark
50.2
21.5
8.4
France
95.3
27.4
10.0
Netherlands
39.1
16.6
Lx2**
Sweden
39.2
16.6
6.9
7.5* 10.7
Switzerland
46.2
21.1
9.1
U.S.A.
47.0
26.0
11.7
U.K.
57.4
21.8
12.0
* 6.6 in 1982. ** Value in 1981. Source:
UN Demographic
Yearbook,
1940-1978,
WHO World
Health
Statistics
Annual,
1970-1982.
the relationship between changes in life expectancy at birth and per capita national medical expenditure. To remove the influence of long-term price fluctuations on these figures, a correction was made using the consumer’s price index published by the Bureau of Statistics at the Prime Minister’s Office. If we express the life expectancy at birth (average of males and females) as “x” in a year, and per capita national medical expenditure for the same year as “Y” in yen, there is a correlation between “x” and “Y” which is shown by the following equation: Y = 4 * 10-S * l.344X The greater the life expectancy at birth, the more additional per capita national medical expenditure is required to generate a unit increase in life expectancy at birth. Therefore, “marginal cost” which is relative to the marginal increase in life expectancy at birth, is increasing continuously as shown in Fig. 2. The above-mentioned equation also indicates that the benefit or efficiency of national medical expenditure in terms of life expectancy at birth does not increase linearly with expenditure [1,2]. (c) Regional differences in the mortality rate and its changes as shown by the standardized birth and death rate by prefecture Fig. 3 shows the distribution of standardized birth and death rates for every five years per 1000 population between 1950-80. The standardized death rate is shown by the horizontal axis and the birth rate by the vertical axis. The population of Japan in 1930 is used as the .basis for standardization. The results for each turn of every five years are shown by the rectangular frame of full lines covering the minimum and maximum values of each axis. The 1950 basic results show a remarkable decrease in the level of standardized birth
311
Fig. 1. Gomportz
curve fitted to annual
change
of life expectancy
at birth in Japan.
and death rates of 1955; prefectural differences narrowed at the same time. The standardized death rate after 1955 shows a constant decline, and the prefectural difference is narrowed. The level of the standardized birth rate continues to decrease until 1960, and then evens out to a nominal decrease thereafter. The prefectural differences of the standardized birth rate narrowed, particularly in 1970. The major factors leading to the lowering of the average standard, and to the narrowing of the prefectural gap in birth and death rates, were successful family Xl 0'yen
.344x
64
66
66
70
I
I
I
72
74
76
eo
Life Expectancy at birth
Fig. 2. Relationship between life expectancy at birth and per capita medical expenditure expectancy is a weighted average of male and female.
in Japan.
Note: life
312
.I950
01970
.1955 ,+1975 o 1960 ‘J 1960 t 1965
;I1
b
I ’
1
5
”
”
1
10
’
”
1
’
15
STANDARDIZED DEATH RATE
Fig. 3. Standardized death and birth rates by Prefecture and year (per 1000). Source: Vital Statistics 1980 Japan, Ministry of Health and Welfare, Tokyo, 1980.
planning and the improvement of health and medical care services. These services were carried out not locally but on a national level. This leveling tendency was also observed in the average income and standard of living in the different prefectures, with some prefectures heading the trend. Factors contributing to the narrowing of prefectural gaps were the dissemination of information, even to remote areas, through the mass media, a nationally unified health and medical services system, and subsidies to regional governments from the central government. (d) Factors causing the rapid extension of life expectancy
Statistics have proven that life expectancy has increased rapidly in Japan and a high standard of health has been reached. Who could have foretold thatrsuch a development would take place some decades ago when the standard of health of the Japanese was still at a low level? This progress, together with rapid economic growth, could be regarded as the miracle of Japan. It was not easy, however, to discover the causes behind this miracle. It is indeed remarkable that the death rate due to infectious diseases decreased sharply in a few years, mainly in the period from 1950-55. Even this great decrease could not compare with those of other developed countries at the time as the death rate from epidemics in Japan had previously been so high. It is only recently that Japan has come to equal the low death rate of other developed countries, whose improvement came at a much earlier time and made steady progress. Japan, however, had to progress from a much lower standard of
313
health at an accelerated speed which is still continuing today. There are many factors involved in the extension of life expectancy and all of them are inter-related; it would be a mistake to single out any one factor. No one can dispute the effect that antibiotics, in their fight against infectious diseases such as tuberculosis, gastroenteritis, pneumonia and bronchitis, have had on the decrease of the mortality rate. At the same time, easy access to medical care cannot be ignored as a supporting factor of the decrease. Tuberculosis already had an established preventive system before antibiotics became available. Improvement in nutrition may have been beneficial in enhancing the effects of antibiotics. Rapid economic growth began in Japan around 1955. In 1961, a new era was entered with the introduction of a nationwide health care system, “health insurance for the whole nation”. Economic growth enabled a major portion of the people’s medical expenses to be publicly financed, which led to Japan becoming a nation with a high accessibility to medical care services. Medical technology, which increasingly advanced along with other services, was also supported economically. The nutritional levels of the Japanese diet have been enhanced with the average intake of calories, protein and fat still below the level of Western countries. This works favorably in sustaining a comparatively low death rate by aiding in the prevention of degenerative diseases. It is now widely accepted that the eating habits of the Japanese are better for health than those of Western countries, particularly in preventing heart disease. Another noteworthy factor in elevating the health standard of the Japanese is a unique program based on the concept of Kenko Kanri, a group health program which is characteristic of Japanese society [3]. The collective medical check-up, which is one of the main approaches in Kenko Kanri, was first introduced in the mid-1950’s for workers in large enterprises and government offices. It then spread to workers in the factories of small-scale industries, schools and urban community health programs. This could be classified as “primary health care in an industrialized society”. Mr. Kazuo Uemura, Director of the Division of Epidemiological Surveillance and Health Situation and Trend Assessment at WHO, pointed out that although the populationphysician ratio of Japan is comparatively low, the death rate of males between the ages of 40-69 was among the lowest in the world [4]. I would like to mention that Kenko Kanri seems to be’one of the reasons making a great contribution [3,5]. As mentioned so far, Japan’s miraculous extension of the average life expectancy was not made possible by any single factor. Rather, it should be pointed out that many favorable factors worked together at the appropriate time, but whether this was inevitable or due to chance, it is hard to say. There is no guarantee that these positive elements would be realized again in the future and produce the same effect.
Health in the 21st century (a) Goals and tasks
The decrease in the death rate in the latter half of the 20th century is particularly
314
remarkable in Japan, but the general picture of health is not necessarily positive because of the increase in the number of people receiving medical treatment [2]. Whereas people used to be more inclined to think of medicine as curative, there has recently been an increased consciousness concerning health aimed at the prevention of poor health. With the advancement of medical technology, there is a fear that patients will be treated not as human beings but as objects -like broken-down machines. There is presently an increased emphasis by medical experts on the necessity of health education. They clearly consider that a truly healthy body can be achieved only when people are well informed of their health. It is also true that the efficacy of medical treatment would be greatly influenced by the patient’s general knowledge, attitude and behavior towards illness. There has also been an increasing demand on the part of patients to get as much detailed information as possible from their physicians as to the causes, expected progress of the disease and the lifestyle required during treatment. This demand is, in fact, not satisfied due to the limited time allocated to each patient for treatment. Many physicians are reluctant to explain to patients their problems because they feel that the patient can be cured by simply administering drugs or other methods of treatment. Others feel reluctant because they regard the patient as having enough knowledge and judgement not to need any explanation. In either case, this thinking seems to be associated with the idea that patients are only broken-down machines requiring treatment. In the 21st century, the above conditions must be satisfied reinforcing the concept of health education and the proper use of health information. Many people do not pay attention to their health and body when they are enjoying a healthy life and not receiving any medical treatment, but once they require medical care, they become hungry for information related to their disease and its treatment. This is, of course, natural human behavior but information that is obtained only when the necessity arises is only an immediate solution or countermeasure. It is not necessarily based on systematic principles or rules. If people had a basic understanding of the body and disease, more immediate countermeasures could be properly and effectively utilized. Knowledge that is applied without a fundamental theory may be misused, but this could be avoided by reinforcing health education and by the correct use of health information. Besides the limited treatment time, the gap in medical knowledge between the physician and the patient should be pointed out. The term “take less salt” may have for physicians a comprehensive meaning based on the accumulation of research results, but this may not be conveyed in full to patients. Is it possible to expect a greater rapport between physicians and patients for mutual understanding and awareness? This thinking may unfortunately be too optimistic. It is impossible to introduce the same amount of knowledge into physical education in high school. college or compulsory level education as is studied by students of medicine. It is almost absurd even to think that physicians and patients share the same expert knowledge aad awareness. It may also happen that when medical professionals, such as physicians or nurses, require treatment that problems in communication may exist between patient and physician. Knowledge on the part of the patient may act as an obstacle to effective treatment.
315
Even patients who have a high level of medical knowledge may similarly be concerned about their lives. The ideal situation would be for patients to have complete trust in their physicians, and for the physician to do his utmost. However, unless the patient accepts the physician’s treatment unconditionally and is fully satisfied, there is a need for greater communication between the two. If the patient is a physician or a nurse, he or she will have a basic understanding of the contents of the medical care and the medical philosophy and logic. It is impossible to expect patients who are not medical professionals to have the same understanding. Is there no way for persons who are not medical professionals to share expert knowledge systematically and not in segments? The goal of a healthy life in the 21st century should aim for every person to assume responsibility for his or her own health from adequate information based on well-structured, systematic knowledge. (b) Development of a new health indicator As previously discussed, the mortality rate has decreased remarkably because of medical advancement and improved accessibility to medical services, resulting in increased levels of health, including the life expectancy at birth. In spite of these objective improvements, the ratio of people who are ill and receiving medical treatment is increasing [2]. Fig. 4 is the combined result of a survival curve given by the Abridged Life Table (1979) and three different surveys conducted by Japan’s Ministry of Health and Welfare the same year. It includes the rate of medical care recipients according to the Patient Survey; the morbidity prevalence rate according to the National Health
Females
Males Number of Survivors
ieceiving
medical treatment
Number of Survivors
receiving
medical treatment
100,000
100,ooo
w,ooo
90,000
60,000 -
60,000
70,000
-
70,000
60,000
-
60,000
50,000 -
50,006
-
40,000
so.ooa-
30,000
40.000
0
IO
20
Fig. 4. Proportion
SO
40
50
60
70
60
Age
of survivors by subjective feeling of health.
r of ors
316
TABLE
4
Proportion
of sick people and people who visited physicians
Sex
Age group
Year
O-14 Sick People Male
3.3 6.4 9.2 6.8
7.4 9.0 9.4 8.8
19.1 27.0 31.4 35.6
1965 1970 1975 1979
3.3 5.4 8.4 6.6
7.4 10.4 10.7 10.3
16.8 24.2 32.3 38.0
1965 1970 1975 1979
5.1 6.4 5.5 6.5
6.5 7.0 6.2 6.0
8.6 12.0 16.8 17.2
1965 1970 1975 1979
4.5 5.9 5.7 5.8
6.3 7.5 7.1 6.9
7.0 IO.8 18.3 19.1
Care Users
Female
TABLE Proportion Subjective
65-85
1965 1970 1975 1979
Female
Medical Male
15-64
5 of different feeling
subjective
feelings on health
Age group Male
In very good health Almost healthy Not in good health
Female
20-64
65-85
20-64
65-85
17.4 62.6 20.0
10.7 43.8 45.5
II.8 62.3 26.0
5.9 38.2 55.9
Survey; and health consciousness according to the Basic Survey on Health Status. This would present the quality of life as seen from the health aspect. This figure has some limitations due to inconsistencies in the timing of observations, surveys and differences in the sample groups of the surveys of the original material. These inconsistencies are: the death rate comprising the summarized life table based on a year-round basis; the medical care recipient rate being confined to the third Wednesday in July, 1979; and the rate ofdisease being limited to three days in the
317
Number of Survivors
Number of Survivors
Male
Female
90.u00
60.000 70.000' 6o.OGQ' 50.000' 40.000' IY7Y 30,wJ
3OsnJO
XIOOO.
197Y 1975
20.000'
IO.OWJ~
1970 965
10300
0 0
. 10 .
Fig. 5. Number
. . 30 . 20
. 40
.
50 .
.
fi0 .
.
70
. .Age 80
I!)75 IW7U 1965
1
OoL@ 30
40
50
60
70
80
of survivors.
beginning of October. Material relating to health consciousness was obtained at the same time as the rate of disease material. With regard to the sample groups, the number of living is based on annual death rates according to sex and age calculated from national demographic statistics. The medical care recipient rate, morbidity prevalence rate and health consciousness are based on sample plans for each survey Number of Survivors 100.000,
Number of Survivors
Male
Female
Ywmo 6u.ooo 7u.uw M).wl 5O.WU~ 4u.uw~ 3u#00 2U.uoo'
1979 1975 1970 19-35
10.1JwJ .
uA
0
IU
Fig. 6. Number
2u
30
40
so
M
70
50
Age
o-Age
0
of survivors who received no medical treatment.
10
20
30
40
50
60
70
na
318 Number of Stir-vivors
Male
Number of Survivors
Female
100.000,
1979 1975 1970 1965
ol................
0
Fig. 7. Number
10
20
30
40
50
60
70
60
* Age
of survivors with no disease.
and are equal in the fact that the total national population is the target, but the sampling error is not always the same. Despite such shortcomings, Fig. 4 would serve as a sample for devising a new health indicator. The vertical axis represents the number of living, and the horizontal axis represents the age of males and females separately. The solid curve at the top represents the number of living by age, the second solid curve represents the untreated population by age and the dotted curve represents the non-diseased population by age. The “subjective” judgement of the condition of health is also shown in Fig. 4and divided into: (1) “not in good health” between the third solid curve from the solid curve; (2) a majority of “almost healthy” between the third and fourth solid curves; and (3) “in very good health” between the fourth solid curve and the bottom. This subjective consciousness is shown only among people over 20. Details of the number of living can be found at any age level (Tables 4 and 5). Fig. 5 shows the transition of the number of living in 1965, 1970, 1975 and 1979 for males and females separately. Fig. 6 shows those who received no medical treatment, and Fig. 7 shows those with no disease. In Fig. 5, a constant and steady improvement is observed per year, but the same trend is not necessarily seen in Figs. 6 and 7. In Fig. 7, in particular, each year overlaps except for the infancy period. This seems to have some significance. The above are the results of part of the attempt to develop a new indicator of health levels based on data obtained in Japan. The development of this new indicator is still in its beginning stages and needs further improvement. It is presented here, however, as an example of the efforts being made for a healthy life in the 21st century.
319
Acknowledgements The author wishes to express his thanks to Dr. Alvar Svanborg, Professor of Geriatrics and Long-Term Care Medicine, Vasa Hospital, Giiteborg, Sweden; Dr. Toshio Kuroda, Emeritus Director of Nihon University Population Research Institute, Tokyo, Japan; and Mr. Kazuo Uemura, Director of the Division of Epidemiological Surveillance and Health Situation and Trend Assessment, World Health Organization, Geneva, Switzerland, for their comments on an earlier draft of this paper. The author also appreciates the assistance of Mr. Shunji Nishii, Mr. Kunihiko Miura and Dr. Motofumi Masaki, Department of Public Health, Faculty of Medicine, University of Tokyo, in the computation and preparation of the figures.
References 1 2 3 4 5
Koizumi, A., Nishii, S. and Sakai, N., Estimation of life expectancy by mathematical models, Minzoku-Eisei (Japan Journal of Health and Human Ecology), 45 (5) (1979) 184-188. Koizumi, A., Longevity and health care: A cost-benefit type analysis of life expectancy and medical expenditure, Journal of Population Studies, 7 (1984) 9-14. Koizumi, A., Development of public health in Japan, Asian Medical Journal, 25 (1982) 14-20. Uemura, K., personal communication. United Nations Economic and Social Commission for Asia and the Pacific, Population and Health Development. In “Population of Japan”, Country Monograph Series No. 11, pp. 187-199, United Nations, New York, 1984.