Panel Discussion

Chairs:	Masami ISHII (Executive Board Member, JMA) Shigeru SUGANAMI (Committee Member, President, AMDA)
Moderator:	Kunihiko SUZUKI (Executive Board Member, JMA)
Panelists:	Michael R. REICH, Masamine JIMBA, Yasuhide NAKAMURA, Taro YAMAMOTO, Takashi NAGATA, Naoki KONDO

[Dr. Suzuki] We now begin the panel discussion. Dr. Ishii and Dr. Suganami, who is a member of JMA’s Global Health Committee and president of AMDA, will chair the discussion. As you know, AMDA participated in on-site relief operations after the recent large-scale typhoon disaster in the Philippines, and JMA provided funding to help support their efforts. Well then, let us have a good discussion.

[Dr. Ishii] Speaking of AMDA and the typhoon damage relief efforts in the Philippines, the Japan Self-Defense Forces and the AMDA teams, which are now in the interior of the Philippines, finally started to collaborate with each other yesterday. They are now able to engage in humanitarian assistance while securing safety. The JMA would like to continually support AMDA, and so it recently provided a first round of funding. JMA members have asked me how the fund raising is progressing. I will let you know and ask for your support when we obtain clear information on the situation.

Let’s move on to the main topic. The speeches we heard today clarified many aspects of the main theme of this symposium—“From the community to global perspectives, from the global to community perspectives.” We would like to hear anything that the speakers would like to add.

Dr. Kondo.

[Dr. Kondo] As Dr. Jimba mentioned in his talk, Japan went from being a developing country to joining the ranks of developed countries in terms of health. There is no doubt that the achievement of universal health coverage was very much tied to that, but Japan did not reach the healthiest nation in the world just because of universal health coverage. Well then, what else did Japan do? How was it able to overcome so many infectious diseases? I talked about the fundamental assets that existed in Japan and community initiatives, and I would like to see those kinds of Japanese experiences communicated more to the world. I would like to ask Dr. Jimba how to convey this message to the world and what the current status of such initiatives is.

Dr. Jimba.

[Dr. Jimba] The establishment of the system is only part of the story; community health efforts and the practice of community medicine, which together brought the system into fulfillment, had a big part to play. By the way, something that I noticed while preparing for today’s speech was the extreme dearth of literature in English relating to community health in Japan. Most accounts are only in Japanese books and essays. Given this situation, it will be difficult for the people of the world to discover the community health initiatives in Japan. In this respect, we did not make enough effort. As for Yachiho Village, the thing that got the village going on its health promotion activities was an outbreak of dysentery in 1953. That outbreak of dysentery killed 222 people. The village created health instructors to fight the dysentery outbreak, and based on this experience, the initiatives talked about earlier were started. The health instructors who worked to combat dysentery or infectious disease later worked as health instructors fighting hypertension and other non-communicable chronic diseases (NCDs). This initiative could be introduced as a very effective example for developing countries, where the pattern of disease is shifting from infectious diseases to NCDs. However, these kinds of initiatives have not been recorded in the English literature sufficiently. If this situation is improved, the efforts made in Japanese communities could be disseminated better to the rest of the world. There is a wealth of Japanese literature, and it needs to be summarized well and disseminated.

Dr. Nakamura.

[Dr. Nakamura] I would like to add two points to this discussion from the perspective of maternal and child health. The collaboration between public health nurses, midwives, and physicians was very important in improving maternal and child health after the war. We use the term “team medicine” nowadays, but a lot of collaboration has been taking place in community medicine since much earlier. When I talked with midwives who are now in their 70s and 80s, they said that it was the community OB-GYNs who helped them out back in the old days when there were only very limited resources. That kind of collaboration existed within the community. It is just that nothing is left as hard evidence.

The other point is the bottom-up power of the people working in the community. This works in combination with the top-down suggestions given by the national government, the Ministry of Health, Labour and Welfare, and more importantly local governments. These two approaches meshed together nicely. I feel that the quintessence of community medicine in Japan lies in the ideal interaction between protection from above and empowerment from the community, as Keizo Takemi’s concept of human security implies.

[Dr. Ishii] When we look at changes occurring around 1957 and 58, when Dr. Taro Takemi became president of JMA, we find that various networks were formed in the community involving school health, community health, health checkups, and health screenings in the workplace. Something happened when these became entangled with community power. Universal health insurance became a tool to back that up. And the change had a positive effect in that the people who used to hesitate to access medical care came to feel free to access medical care whenever they needed it.

Dr. Reich.

[Dr. Reich] This is a very important question. How do we explain the fact that Japan is the healthiest nation in the world? Listening to your comments, I am inclined to conclude that there is no simple explanation. We can say that particular conditions enabled Japan to achieve a certain success. But what about the effect of universal health coverage? This was a necessary condition, but I do not think it alone was sufficient to achieve success. If you think about it, the UK had universal coverage even before Japan. But, that alone did not make the UK the healthiest nation in the world. In the end, multiple factors are involved. That is, the state of health improves when many factors, such as the political situation, the economic situation, the role of doctors in private practice, how drugs are used, food, and exercise, all fall into place. The next important question is, what will happen to Japan in the future? How will the situation change if the Japanese become fat like Mexicans and Americans? If that happens, you will eventually need something that affects human behavior. At that time, who will do what? What will be the role of physicians in private practice? What will be the role of the Japan Medical Association? This is an important theme for future discussion.

[Dr. Ishii] Japanese medical care had reached a certain height in the 1980s when the Takemi Program was created. At that time, Dr. Takemi wanted to create a platform at Harvard that would create a strong link between domestic and global health so that Japanese information would be brought out and information brought from outside would be reflected in Japan. When you actually go there, what can you see? I would like to hear some comments on that.

Dr. Nagata.

[Dr. Nagata] What I got out of the Takemi Program was the conversations I had with other Takemi Fellows from many different countries. The high value of maternal and child health handbooks was something that we did not notice on our own; It was something we were reminded of by having it pointed out from another perspective. The strength of the Takemi Program is that it provides a place where one can obtain new points of view.

[Dr. Nakamura] I want to share with you what I thought amazing about the Takemi Program. There was a health economist from South Korea on the program at the same time. He was not a physician. People who do economics come into medical schools to do public health and discuss medical economics there. I learned that such people are around here and there. I feel that Japanese physicians have fallen into the habit of interacting only with other physicians. But on the program, it was not like that; there were people with all kinds of backgrounds. There were sociologists and journalists, and they would go and talk about health. I learned that to improve health, medical care gets better by having these kinds of discussions not just among healthcare professionals but also with people in various fields. In that respect, I thought that the people from so-called developing countries were ahead of us.

[Dr. Jimba] I went to Harvard University twice and what struck me was that many different kinds of values are esteemed equally. For example, there was a researcher who, even though he didn’t have a doctorate or even a master’s degree, loved research and had written more papers than Japanese professors. He was extremely satisfied in his position. There was also a person who was living a happy life, satisfied with his position, engaging enthusiastically in fieldwork as a lecturer; he didn’t need to become a Harvard professor to feel happy. In Japanese universities, on the other hand, one gets the impression that becoming a professor is the only goal. But, I felt that depth of character not like that is wonderful. On a personal note, a previous professor of my department told me that he wanted me to fulfill a role of connecting the medical front and the university. People on the front conducting medical and health activities cannot write papers while researchers in universities who can write papers do not know the reality in the field. He told me that people who have both skills will be needed in Japan from here on. I am grateful for the Takemi Program for allowing me to strengthen myself for that kind of work.

[Dr. Ishii] Dr. Suganami is involved in community medicine and international contributions during disasters, and I would like to hear a comment from him in that regard.

[Dr. Suganami] I always think to myself, “What would Dr. Takemi do?” Dr. Takemi used the phrase “fundamental, far-reaching, and eternal” and also spoke of “professional freedom.” Having a medical license means that you should help patients, should save their lives, and should not turn your back on them. I am deeply interested in why Dr. Takemi chose the word freedom here instead of liberty. Freedom means not to allow oneself to be shackled, to be unfettered. Dr. Takemi probably meant to tell us to break any shackles in order to save patients’ lives. That is why he used the expression freedom as a professional, and in that I feel his sense of noblesse oblige (i.e. the responsibility of a person of high rank) as a physician. I associate every usage of the phrase professional freedom with noblesse oblige. This is true in community medicine and disaster medicine. To go beyond ethnicity, religion, and national borders is the essence of Dr. Takemi’s thought on noblesse oblige and professional freedom. I am working in community medicine and disaster medicine and always thinking about what professional freedom means.

[Dr. Ishii] Here is a question from Mr. Inaoka of the Ministry of Foreign Affairs. What kind of system should Japan develop in order to draw on all of its human resources and wisdom, in terms of the challenges the country faces and learning from one another with developing countries. As mentioned by Dr. Yamamoto in his talk about the future, we are facing many demands in the field. What can the national government do to help? What do you think about this?

Dr. Yamamoto.

[Dr. Yamamoto] This was mentioned in Dr. Jimba’s speech, but when the system becomes strong, the power of communities weakens. When people are provided with a good system, the decision-making power of the people who participate in that system declines. In other words, what we mean by a good system is to create a system whereby benefit is obtained reliably even if the people who benefit from it say nothing. Nevertheless, when the system gets into motion, it weakens the power of those people who participate in it. After the war, Japan built a really good system. It built a good system and managed it well, and because of that, we seem to be facing certain problems. Actually, after listening to today’s talks, I thought that the lessons and learning that Japan really needs to communicate to the world might be how to overcome and deal with those problems. Thirty years ago, Dr. Taro Takemi felt the bud of what might be a modern issue and created the Takemi Program. Sure enough, 30 years later, it has become a reality. There is a lesson there. If we are currently noticing the germination of a problem like the conflict of the people participating in a good system, we should begin to consider how we can prepare for and overcome that problem when it occurs 30 years down the road and how it will emerge as a specific challenge. I felt that Dr. Takemi taught us that by creating this program.

[Dr. Ishii] Incidentally, participants in JMA’s Global Health Committee include not only physicians in community medicine, specialist physicians, and observers (Dr. Maruyama of the Japan Primary Care Association and staff members from the Ministry of Foreign Affairs and the Ministry of Health, Labour and Welfare) but also people who are creating a network of young doctors called the Junior Doctors Network. We now have a network of specialists brought together through the Takemi Program from all over the world and from Japan. The challenge in the next phase will be how the interns working hard in community medicine will use the network as a whole. Considering about that, what can we see if we look into the future from the current situation? Michael, may I ask you for a closing comment that includes an overall forecast?

[Dr. Reich] One premise of the Takemi Program is that, ultimately, it is individuals who create the relationship between the local and the global. The growth of each participant in the Takemi Program (as Takemi Fellows) is what makes the program work. When they go back home to their organization, they make the organization better, and when the organization becomes better, the community becomes better, and when the community becomes better, the country becomes better, and when the country becomes better, the world becomes better. These connections all start with the individual. One year of studying in the Takemi Program is a luxury. For one year in your life, you have the freedom to study what you want to. How will you grow? That is a rare luxury year in a person’s life. We hope that this will make the world a better place. And after listening to the comments of these five people today, all former Takemi Fellows, I conclude that it is succeeding quite well.