Impressions of Japan in the 1990s

My grandson John Last junior's partner is moving soon from Istanbul to Tokyo, so I dusted off my 'Impressions of Japan' written about 20 years ago, and post these here. I wish we'd had longer there and more opportunities to revisit. I'm well aware that my impressions are sure to be misleading and wrong in many respects, so readers, please feel free to jump on me. If anyone cares to comment, whether to correct or contradict me, I promise to post whatever you say.

In 1991, Humio Tsunoda, MD, Professor and Head of the department of public health sciences at Morioka University and President of the Japanese Public Health Association (JPHA), invited me to visit Japan and give the keynote address at the annual congress of the JPHA, held that year in his home city of Morioka.

Our sojourn in Japan in October 1991 was brief and crowded so it would be easy for the memories to blend into a vague blur. The following account is based on letters written immediately after returning to Ottawa, with some additional thoughts after a visit to Nagoya in August 1993 and a short piece that I wrote for the American Journal of Preventive Medicine. This wasn’t our first visit to Japan. I had passed through twice on the way back to Canada from China, once in 1981 on my own when I flew in from Shanghai and had an overnight stay in Tokyo. In 1982, Wendy and I stayed in Tokyo for two days on our way back from Beijing. What I remember best from those short visits is rain, the choked highway from the airport into the city, the crowds, the neon signs, the outrageous cost of meals, the bewildering difficulty of finding our way around in the absence of street signs in a recognizable language (a problem I’ve had also in Shanghai, Beirut, Bangkok and a few other places). We didn’t know anyone in Japan at that time, and we felt alone and alien, and rather vulnerable, among huge, bustling crowds. 

It rains a lot in the beautiful islands that make up the nation of Japan, rather reminiscent of the British Isles. The resemblance is sustained if we compare Great Britain at the beginning of the first industrial revolution with Japan at the beginning of the next. Energetic competitive striving has led Japan, as it led Victorian Britain, to a position of economic supremacy among the nations. And since wealth advances health, the Japanese have an enviable record: the lowest infant mortality rate and the highest life expectancy in the world, achieved with modest expenditure of gross national product on health care. (Since I wrote this Japan has experienced a prolonged period of economic stagnation but I am told that this has had little or no impact on living standards or health status).

In less than half a century, Japan moved from the upper ranks of developing nations to the topmost position in the league table of health indicators among industrially developed nations. How has this been accomplished? There is virtually universal coverage of the population for health insurance and social security through employment-related or other insurance modalities; maternal and child care are well-organized and comprehensive; but the way the health care system is organized and financed may not influence health levels as much as some other factors.   Japan is a highly urbanized industrial nation, with universal literacy, tremendous zeal for learning, and good, if often cramped, housing conditions. Education is highly valued in this nation of achievers. Probably, as in Kerala state in India, and Sri Lanka, the educational system is more directly responsible than the health care system for the impressive statistical picture shown by many health indicators.

All is not perfect of course. Low birth rates in the past two generations and in the present generation have changed the shape of the population profile dramatically. Early in the 21st century, more than 20 percent of the population are over 65 years of age. Therefore the need for facilities to care for the aged is increasing sharply, aggravated by declining family size and vanishing extended families. Other time bombs are ticking: Japanese men have among the world's highest rates of cigarette smoking, and the women are beginning to take up the habit, as well as inhaling their menfolk's sidestream smoke. So tobacco-related cancer and cardiovascular death rates are high and rising, and very little has been done to control the smoking epidemic.

Competitive striving and ancient traditions contribute to social attitudes towards suicide that are different from those in the west, although my hosts during the 1991 visit said that suicide is not a serious problem among children and young people who fail university entrance examinations.  Quite the contrary they said: like traditional dress, suicide as an honorable way to absolve social disgrace is dying out. [But suicide is a problem; it is common among young men, and is among the leading causes of death among men in their 40s and 50s, according to the 1990 Report of Health and Welfare Statistics for Japan]. My hosts also assured me that social and working relationships between men and women are moving towards those in western industrial democracies, although my own observations don’t bear this out. In 1991, women comprised a much smaller proportion, by my eyeball estimate probably fewer than 10%, of the audience at the annual conference of the Japanese Public Health Association, in contrast to 50% or more at annual conferences of the American Public Health Association; and the status of women has not changed much in recent years: an articulate young professional woman who had lived several years in California told me that her professional expertise goes unrecognized and unrewarded. Sawako Takikawa (Humio Tsunoda’s daughter) was one of less than 10 percent of women in her graduating medical class; she came at or near the top of her class throughout medical school whereas her husband, another gastroenterologist, just passed. Yet he has the prestigious post in the professorial unit in the medical school, while she works in a peripheral clinic 40 Km away. She believes that women have little or no potential for leadership roles in the medical profession in her country.

There are increasing difficulties in these crowded islands in finding places to dispose of garbage, to say nothing of toxic wastes. There is some dissonance between the loving concern that people have for their immediate environment and their disregard for environmental or ecological conditions in places more remote from where they live. This may help to account for the existence of unsightly industrial wastelands, and for the contributions that Japanese commercial and industrial interests have made to environmental depredation in such places as tropical rain forests and ocean fisheries.

My hosts asked me about the social and economic consequences of ‘colour-blind’ immigration policies that have produced multiracial and multicultural societies in nations such as the United States, the United Kingdom, France and Canada. After my keynote lecture to the Japanese Public Health Association, in which I had mentioned HIV/AIDS in the USA Black population, I had a rather chilling 2-hour conversation with a professor of medical history (who had translated Hippocrates from Greek and Galen from Latin into Japanese) and a professor of psychiatry who had worked in the USA for 20 years and spoke perfect English. They seemed, judging by their questions, to regard the prospect of diluting their own racial and cultural stock as a potential disaster of unimaginable dimensions. They have known only a culturally and racially homogenous society in Japan, and aspire to keep it that way. They have no interest in the benefits of miscegenation and cultural diversity, are worried only about the potential for social chaos and attendant costs. It remains to be seen whether Japan can remain aloof from the turbulent population mobility that characterizes most of the rest of the world in the late 20th and early 21st centuries. Only a tiny proportion of the people who inhabit the Japanese islands are not ethnically “pure” Japanese stock, and those who are have a status rather comparable to India’s Untouchables.  They work in menial jobs like garbage collection. We saw some cleaning carriages on bullet trains. Their appearance, clothing and unkempt hair marked them out as “different” and the body language of other Japanese who came close to them revealed the distain with which they are regarded. 

A chronological/geographical record of our travels in 1991 can be quite brief. We arrived in Tokyo on October 13, just after a typhoon had left much of the place under water. We were met by Sanae Oda, who had translated my keynote address on the “Future of Health and Public Health Services” into Japanese, and by two of Humio Tsunoda's children, both physicians (Ikuo, a male neurologist and Sawako, a female gastroenterologist). We stayed overnight in Tokyo and took the Shinkansen ("bullet") train next afternoon to Morioka, after a brief and damp expedition to a couple of Tokyo highlights, including lunch on the 53rd floor of one of the new high-rise towers with a spectacular view over the city. Ikuo left for his home base, and was replaced by Tsunoda's younger son Masashi, another physician, this one training in epidemiology, my specialty. We were accompanied by Sawako and Masashi on the Shinkansen which is nearly as fast as the TGVs in France, and quieter if anything, and they were our guides together or separately for the remainder of our stay in Japan. 

About to board Bullet train Tokyo to Morioka

With Dr Sawako Takikawa, Morioka, Oct 1991

We had a day's sightseeing in and around Morioka, including a dip in a hot pool (in the nude, but segregated by sexes). This gave my Japanese confreres the opportunity to flaunt their impressive genitals, demonstrating that they were very well endowed compared to me. I got the impression that this demonstration was a primary purpose of this visit. Next day I gave my talk on the Future of Health and Public Health Services to an audience of about 5000 without mishap; my slides appeared behind me as I spoke, in English on one screen, in Japanese translation on the other, and as I spoke, the Japanese translation of the text scrolled down on a third screen in the middle. I had a couple of other professional discussions of fairly mind-expanding dimensions (both included as the price of admission, so to say, at lavish banquets). This amounted to a total of about five or six hours of professional activity. My (our) reward for this was my air fare and about half of Wendy's, and total coverage of all our travel and living expenses for the entire stay. The travel included many taxi rides (one about 250 Km, costing about $300!) and all the conducted tours, which in Kyoto according to a brochure we saw, cost about $200 each, for a total of $800. I have never been treated with such reverence and respect (although years later our VIP treatment in Turkey in 2004 came very close). We felt like royalty as people bowed to us, and made what I consider to have been extravagantly effusive remarks about my achievements - all very good for my ego, and I trust that Wendy will join in praising me to the skies as everybody else was doing there. 

The 250-km taxi ride was to a Samurai village across the mountain range from Morioka, over a superbly engineered road with many tunnels (one over 2 km long). The Samurai village was very interesting and rather picturesque. One memory stands out. There was a museum devoted to the Japanese military campaigns in Manchuria, China and South-east Asia in the 1930s and 1940s, in which we could not read the captions but the photos unambiguously glorified the military triumphs. Then we came back to Tokyo by Shinkansen and on south to Kyoto, past Fujiyama, which we actually saw, its conical summit white with snow (a rare sighting, we were told, and we saw it again on the return journey; more often than not it is obscured by clouds and smog). 

Kyoto is a beautiful city with many lovely temples. We would have enjoyed a much longer stay there, but diligent and exhausting sightseeing under the demanding schedule set by Masashi Tsunoda covered a great deal in the limited time we had (he is a marathon runner, and a slight little man with the most voracious appetite we have ever seen; no doubt he burns enormous amounts of energy getting about at a cracking pace we had difficulty matching).

We had been advised of the custom of presenting a small gift to the host and to others who are hospitable, and we took a few little things, mainly rather grotty souvenirs of Ottawa. In return we were given most beautiful and costly gifts: indigo dyed table mats, a handsomely painted fan, and a lovely address book with a lacquer cover inlaid with gold leaf figures, among other items. We bought a lot of gifts too, and came home loaded down with loot, perhaps more than the amount legally allowed returning travellers, but not enough to make us feel like serious smugglers, especially when most of what we had were gifts we didn't actually pay for. 

Obviously one can't begin to generalize about a nation as complex as Japan on the basis of ten or so superficial days, even when these days are spent in the company of highly intelligent professional men and women. Their command of written English is excellent but many had neither heard it nor spoken it very often; their pronunciation was sometimes unintelligible and they had trouble also comprehending what we said, even when we spoke very slowly and clearly. So much of what I perceived is based mainly upon my observations. 

There is considerable dissonance in Japanese life, society and customs: spectacular technological wizardry provides glimpses of what the 21st century might be like, and the architecture of new buildings is often exciting and aesthetically pleasing - but Tokyo is a mish-mash of non-planning, one of the ugliest cities I have ever seen, and the beautiful countryside to which the Japanese are obviously devoted, is blighted by hideous industrial waste-lands reminiscent of the worst that New Jersey, the Ruhr Valley or the north Midlands of England can offer. The ancient shrines are cared for, though many are not all that ancient because of a tradition and widespread custom of destroying and replacing them - and their destruction by fire or earthquake when they are not deliberately demolished. A curtain of inscrutability seems to prevent communication about some basic values that we hold dear, and in some other respects, for example the status of women, their values clearly differ from ours. There seems to be a ruthlessness in their business and professional transactions which exceeds the bounds of courtesy as we understand it, and they tend to take credit where it is not due. For instance, my gracious host, a charming and civilized man, did not translate my talk, Sanae Oda did; but he and every other professional man at the banquet firmly seemed to believe that he did, and he was accepting compliments from all his colleagues for its excellence; Sanae Oda commented wryly to me that women have no status even in modern Japan, where very few hold prominent professional positions. Japanese women have achieved high positions in several UN agencies. But some observations at the Japanese Public Health Association’s banquet were revealing.  The “entertainment” included an eating competition, in which six eminent public health specialists seated at a table on the stage scoffed down bowls of noodles; the winner was the man to ate the largest number of bowls in the shortest time. They were waited on by a bevy of attractive young women in revealing, very tight dresses; and more young women moved among the gathering that was overwhelmingly male. It was rather reminiscent of a frat house party, a rather sickening demonstration of male chauvinism and supremacy. It was also hardly a good example of healthy behaviour by a gathering of public health professionals! 

A few times I saw evidence of a resurgence of militarism. In several of the museums we visited, for instance on the upper floors of the museum houses in the Samurai village, there are lovingly tended memorabilia and photographs of the Japanese war against Russia (which maybe is justifiable) and of the more recent and far less excusable war against China. The old Rising Sun flag, supposedly as extinct as the Nazi swastika, is flown or displayed here and there, and the statues of military heroes in the parks in Tokyo include several of the generals and admirals of the second world war; the first time we saw one of these it had a display of rising sun flags around its base, though this had gone when we had a closer look at the same statue on our last day in Tokyo. Was it removed by official edict or because the flags, made of paper, had become soggy and bedraggled after heavy rains?

They have the best health performance in the world, judged by infant mortality rates and life expectancy; they have a comprehensive social security system, a superb network of transport and communications by rail and road (though it doesn't stop Tokyo strangling and choking in its own automobiles and of course the peak hour subway crowds are legendary). I got the impression that medicine is not a very high status profession, though it is hard to be sure about this, and when I asked, my questions seemed not to be understood. Medical research of course is outstanding, judged by citations and representation in the leading peer-reviewed journals. Yet when I gave them a keynote lecture made up largely of derivative material, they were overly impressed by its scholarly content - and I am confident that here I know whereof I speak, because I discussed it in depth with two Japanese colleagues of long standing, the man who translated the Dictionary of Epidemiology and Kunio Aoki, my fellow IEA Council member, as well as with Humio Tsunoda and several of his colleagues. I can summarize this part of my impressions with the observation that the approach to biomedical science at least, if not to science in general, is rather uncritically enthusiastic, which is certainly dissonant with their scientific record and achievements since the late 19th century.  There is dissonance too in their occupational health standards, but this is too technical a subject to go into in this account. This situation resembles the dissonance between their devotion to their own immediate environment and their disregard for other people's environments - again, a familiar theme. 

Much that I’ve read about Japan since those visits in the 1990s reinforces my impression that the alien aspects of its culture and its variant of modern western civilization are too complex for any casual visitor like me to comprehend. Like India, like China, it would take a lifetime of living among Japanese people to understand what makes the country tick. Unfortunately my lifetime was mostly behind me by the time I began visiting Japan, first just in transit for a few days on the way back from China in the early 1980s, then two short visits in the 1990s.  This was not nearly enough to make meaningful generalizations.  

(The above account was written in the early 1990s, revised and expanded after my visit to the IEA meeting in Nagoya in 1993 and lightly touched up again more recently. I'm sure it is inaccurate and my generalizations are unjustifiable so I will welcome suggested amendments and corrections).