How Japan stood up to old age
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Akira Kawahito and Shigenobu Kambayashi don’t exactly look like doctors. Out on house calls in their compact car, with their string ties, short-sleeve shirts and slightly dishevelled demeanour, they look for all the world like an ageing country-and-western duo. Even under the icy-blue skies of December, Kambayashi wears sandals and dangles his stethoscope nonchalantly over his sweater as if it were a fashion accessory. Kawahito, 66, has jet-black hair. Kambayashi, 71, has let his turn a silvery grey. Both wear the expression of people who know something of the world and have mostly enjoyed what they have seen. Though much of their time is taken up with sickness and death, they seem to revel in the funny side of things, taking it in turns to crack jokes or gently rib each other. Officially retired, neither man has given the idea of stopping work a second’s thought.
Kawahito, the author of a book called I Want to Die at Home, is a proselytiser for the cause of home-based care, which has a long tradition in Japan. The attraction of community care partly arises from a stigma associated with sending family members to nursing homes – institutions that, at least until recently, were regarded as only for those unfortunates who had been abandoned by uncaring relatives. Those sent away were sometimes referred to as “grannies dumped on the mountain”, a reference to an alleged practice in ancient times.
Children, not the state, have long been regarded as primarily responsible for looking after ageing parents, with the burden often falling on daughters-in-law. But as Japan’s extended family structure has unravelled and as more women work, the state has had to find alternatives. Hospitals have sometimes filled the gap, with tens of thousands of beds given over to long-term patients. The fact that elderly people pay only 10-20 per cent of their medical fees from their own pocket has made this relatively affordable for individuals, if not for a deeply indebted government trying to rein in costs. In response, the state has increased the payments doctors receive for home visits in an effort to incentivise more home-based care.
Kawahito has long been convinced that it is better for patients to spend their final years and months in familiar surroundings than in some faceless hospital. “Our philosophy of caring for the elderly is to support their quality of life,” he says. “We want to make sure they have moments of joy, that they can eat great food and spend more time with the friends and family they love. We are less concerned with extending life than in maintaining its quality.” About a third of the patients he treats are neta-kiri, or bedridden. Many have a terminal illness. In the last month of life, he says, hospitals often spend huge amounts of money trying to prolong life. Some patients and their families want to eke out every last day, and that’s fine. But some don’t. “Many patients say, ‘Please let me go.’”
The community he works in is called Yanagihara, a nondescript sliver of land in the flatlands of eastern Tokyo. Here, the backstreets have no pavements and are so narrow only the smallest vehicles can squeeze past the squat buildings. Yanagihara was once part of the so-called “low town” when Tokyo was known as Edo. Close by were the Yoshiwara pleasure quarters, the biggest concentration of brothels, theatres, playhouses and restaurants in the capital’s “floating world”. Nearby, too, were the Kozukappara execution grounds, where students of western anatomy once conducted investigations of recently beheaded criminals. Yanagihara has remained mostly poor and mostly forgotten, a throwback to a less prosperous era before Japan’s postwar economic boom.
Altogether six doctors take it in turns to sleep in Kawahito’s tiny clinic, from which they provide a 24-hour emergency service. “We are part of this community,” he says, drawing his finger across a map on the wall with a tiny coloured dot for each house visited. “To be able to cure a community’s ills is not just to deal with illness, but to look at things in the round.”
The ageing of Japan, indeed of any country, is invariably presented in wholly negative terms. To state the blindingly obvious, an ageing society is one with increasing numbers of old people, a stage of life in which our youth-oriented culture finds few redeeming features. Unlike in Japan – as well as China and South Korea – where older people command a respect born of Confucian tradition, in much of the west old age is mostly associated with sickness, senility and death. Older people tend to be marginalised and treated as unproductive members of society.
If ageing is a disease, then Japan is in the advanced stages. In 1950, only 5 per cent of Japanese were over 65. Today that figure is 25 per cent. With the exception of Monaco, Japan is the world’s oldest society, with a median age of 44. The equivalent figure in the UK is 40, with the US a relatively sprightly 37. At this rate, by 2035, one in three Japanese will be 65 or older.
As the population ages, more than 400 schools are closed down each year, with many converted to care homes or leisure facilities. According to Mayumi Hayashi, a fellow at King’s College London, Japan has the highest provision of day centres for the elderly in the world. Some municipal parks have replaced swings and roundabouts with equipment aimed at elderly fitness. In the countryside, whole communities have been virtually abandoned by youth, leaving older generations to fend for themselves. The oft-repeated tale that the Japanese buy more adult nappies than infant ones is probably not true, though it could soon be on current trends. But it captures our repulsion at the idea of a country with more geriatrics than gurgling babies. Almost subliminally, we think, such a place must offend against nature itself.
Japan is not quite the outlier it is often assumed to be. True, its fertility rate – at 1.41 births per woman – is well below the 2.1 needed to replenish a population. However, according to George Magnus, author of The Age of Aging, fully 62 countries, home to nearly half the world’s population, including Britain, have fertility rates below replacement level. Japan is by no means the world’s least fecund country. Below it come the likes of the Czech Republic, Poland, Slovenia, Belarus, Bosnia, South Korea, Taiwan and Hong Kong. Germany, Italy, Greece and Hungary all have almost exactly the same fertility rate as Japan. China, at about 1.5, is in danger of growing old before it becomes rich. Singapore produces the lowest number of babies in the world – at just 0.79 per woman. “The key feature of today’s low fertility rates,” says Magnus, “is that they are pretty much universal.”
Ageing presents a society with a multitude of challenges, from maintaining economic growth to providing adequate care and paying for pensions. The Japanese have the highest life expectancy of any large country in the world, with men living, on average, to 80, and women to 86. Japan thus stands at the forefront of an experiment that, sooner or later, is likely to be conducted by nations from Germany to China and from South Korea to Italy. True, Japan may be an extreme case because of its resistance to mass immigration. The Japanese still tend to talk more about how robots can help take care of their elderly than how Filipinos or Indonesians might. But in other countries, too, the ability of immigrants to replenish populations will diminish as poorer nations close the gap on western living standards and as their birth rate drops towards global norms. Unless we imagine that the world’s population, already above 7bn, will continue to rise indefinitely, rich societies will find it increasingly difficult to import youth from elsewhere.
In Japan, the low birth rate is already reversing what had been a tripling of the population in the 20th century. Last year, the number of Japanese fell by 244,000, or 0.2 per cent, to 126.4m. In 30 years’ time, the population is likely to have dropped to around 100m. The most pessimistic forecasts – which may underestimate the ability of the birth rate to recover – have it collapsing further to 45m by 2100, right back where it was in 1910. (Some Japanese actually relish the idea of a less crowded archipelago, recalling the “rabbit hutch” jibes levelled at the country when the population was exploding.)
In fact, the birth rate has ticked up in recent years from 1.27 to 1.41, though this is still nowhere near enough to reverse the long-term trend. Certainly, it has not dissuaded politicians from making alarmist predictions. The government once put out a report stating that, on current trends, there would be only 500 Japanese left by the year 3000. “If we go on this way,” Chikara Sakaguchi, a former health minister, has said, “the Japanese race will become extinct.”
John Creighton Campbell, professor emeritus at the University of Michigan, has devoted much of his career to studying responses to ageing in Japan. He takes issue with some fellow academics who associate what has become known as Japan’s “hyper-ageing” with inevitable economic catastrophe, even civilisational collapse. One virtue of the ageing “crisis”, he says, is that it happens slowly and predictably, giving governments, labour markets and society in general time to adjust. By around 2017, the number – though not the proportion – of over-65s will actually stabilise, he says, meaning the costs associated with ageing will tend to level off.
As far back as the early 1960s, the government became aware of the imminent ageing problem and began to establish nursing homes and home helpers. In the 1970s, benefits for retirees were more than doubled and a system of virtually free healthcare for older people was established. In 1990, Japan introduced the “Gold Plan”, expanding long-term care services. Ten years later, it started to worry about how to pay for it, and imposed mandatory insurance for long-term care. All those over 40 are obliged to contribute. The scheme’s finances are augmented with a 50 per cent contribution from taxes and recipients are charged a co-payment on a means-tested basis. Even then, there have been financing problems and the government has had to scale back the level of services provided. Still, Campbell calls it “one of the broadest and most generous schemes in the world”.
As a result of these and other adaptations, he argues, Japan has struck a reasonable balance between providing care and controlling costs. Other countries, including Britain, have studied Japan closely for possible lessons. Of course, 15 years of deflation have left Japan’s overall finances in lousy shape, with a public debt-to-output ratio of 240 per cent, the highest in the world. Spending on healthcare per capita, however, is among the lowest of advanced nations, though outcomes are among the best. That is partly down to lifestyle. Most Japanese eat a healthy, fish-based diet and consume less processed food and sugary drinks than westerners. Obesity is far less common. So are violence and drug abuse. But even taking into account such factors, Japan gets a big bang for its healthcare buck. Every two years, the government renegotiates reimbursement fees with doctors, hospitals and pharmaceutical companies, routinely imposing restraints or reductions. Primary care is given priority over specialist treatment: the Japanese visit the doctor far more often than Americans but receive far fewer surgical interventions.
The amount of money a country spends on healthcare is determined more by its system of provision than by its age profile, Campbell argues. Having more older people doesn’t necessarily mean escalating costs. Thus, total expenditure on healthcare in the US runs to 18 per cent of gross domestic product against just 9.3 per cent in Japan. “The economic burden of ever-growing medical spending is a serious problem for the young United States, not for old Japan,” Campbell says.
One thing in Japan’s favour, he adds, is that people don’t just live longer, they stay healthier longer. A World Health Organisation study in 2000 found that Japanese people enjoyed an average of 74.5 years of healthy life, compared with 71.7 in the UK and just 70 in the US. Another factor is that older people tend to be treated as important members of society. On social occasions, they are offered the seats reserved for those due most respect. In many companies, hierarchies are still governed largely by age. Until recently, it was fairly common to have cabinet ministers in their eighties. Yasuhiro Nakasone, a former prime minister, was livid when he was forced to quit politics aged 85, regarding it as an affront to Japan’s traditional respect for the wisdom of elders. He even wrote a haiku to register his displeasure: “Everything is human theatre/The autumnal sun is now setting.”
Back in Yanagihara, Kawahito says most of his seriously ill patients are in their late seventies and eighties. In some families, he says, 70-year-old children are looking after their 90-year-old parents. One afternoon, I accompanied the doctors on their rounds.
The first patient we saw had Parkinson’s. He lived with his wife in a home the size of a crofter’s cottage. His wife said they moved into the house in 1957 after an omiai, a marriage in which a go-between introduced the prospective partners. Soon after, developers bought adjacent land and built so close to the house that the original entrance became unusable. They had to install a second door so they could squeeze in and out of what was already an uncomfortably cramped abode – just 10ft wide and perhaps 30ft long. This was not a wealthy part of town.
The patient, 76, used to work for a precision engineering company. Outwardly, he looked fit, with a bright attentive face. He had put on a suit for the doctors’ call. The bed on which he sat took up most of the room. “I’m sorry, the house is so small,” his wife said whenever there was a lull in conversation. “Small and hot. Like a shoebox.” Kawahito took the patient’s blood pressure and gave him a quick physical check-up. As we made to leave, both the patient and his wife came to the door to bow deeply.
The doctors made their way from house to house in their little car. In one lived a frail white-haired lady, bedridden and hard of hearing. In another, a patient had suffered an apoplexy, making it difficult for him to swallow. In yet another house, most of which had been given over to a Mister Donut, an elderly lady had retreated to the two small dark rooms that had not been rented out to the fast-food outlet. The name of her father, who had recently died aged 100, still hung by the door. The daughter, 80, had since had a cerebral haemorrhage and was in a bad way. When Kawahito let himself in – many of the patients trust the doctors with keys – she was sitting in a wheelchair, her head lolled over a little table.
These visits continued through the afternoon. The doctors knew all about their patients, from their matrimonial squabbles to their daily care arrangements. Their rounds over, Kambayashi became philosophical. “The values of the boom years were misplaced and Japan became a difficult place to bring up children,” he said, seeking to explain the fall in birth rate. “The men were the ‘warriors’ of the economic miracle. The women had to bear the burden of looking after the elderly.”
Now that system was under strain, he said. He judged the state’s resources inadequate for really humane care. Those without means suffered, he said. Basic care was provided but the little extras were not. One of his patients, for example, had applied for someone to help him bathe. His application had been denied. “The only place you have the right to bathe two times a week is prison,” Kambayashi snorted. “That is shameful for such a rich country.”
Ageing is not just a question of what happens to the old. It also affects the size of the working population. The trend of Japan’s so-called dependency ratio looks stark. In 1960, there were 11 people of working age for every person over 65. In 30 years’ time, there are only likely to be 1.3. One government official, brow furrowed, compared the Japan of old with a portable shrine carried by dozens of young people. Now the ratio, he said, was more like kibasen, a contest in which just three people lift one fighter into mock battle.
The bald figures, though, are misleading. What’s important is the ratio of workers not to elderly people but to non-workers, including children and women. By this measure, Japan’s dependency ratio doesn’t look so bad. There may be more old people but there are fewer (unproductive) children to worry about and more women in the workforce, if still not enough. Crucially, people are working longer. The retirement age, 55 in the mid-1980s, is being shunted towards 65 and will doubtless be edged up again. In practice, the average age for Japanese to quit work is in their late sixties, three to four years above the OECD average. Women, as well as men, work until they are surprisingly old. Many of Japan’s elderly, in other words, are producers as well as consumers.
Japan’s seniority system, in which wages rise with age rather than ability, means employers often don’t want to keep staff on past retirement. But many Japanese have skirted such rigidities, going on to second careers. Some are professionals who continue to command good salaries. Others work in more menial, less well-paid jobs, sweeping up leaves in the park, stacking supermarket shelves or waving red nightsticks at construction sites. It is fairly common to see people in their seventies working as station attendants on Tokyo’s crowded subway or frying up pork cutlets in busy restaurants.
Seventy-two-year-old Makoto Hashimoto does a part-time job at a bike-rental lot in Sakura Shinmachi, or Cherry Blossom New Town, in the southwest of Tokyo. When I went to see him one day, I caught him earnestly polishing a ticket machine. From what I could tell, the surface was already gleaming but it was evidently not up to his standards.
Hashimoto wore a cap emblazoned with the words, “Silver Human Resources Centre”, from which little tufts of greying hair poked out. He looked trim and sturdy, certainly more than capable of working the 25 hours a week he spends at the lot. “I was in the printing industry,” he said.
“When I turned 60 I retired but spent two years moping around the house. I put on weight and realised that it was not a healthy lifestyle. Normally it’s difficult for people over 60 to get a job. So I thought, let’s go Silver,” he said, referring to Silver Human Resources, a nationwide government-subsidised work programme. “The legal retirement age is 65 but at that age we are still fit and able to work.”
There were hundreds of such lots in Tokyo, each with space for several thousand bikes. Many were staffed by people between 60 and 80 years old. “We do whatever is required. Even if we need to build something, we do it. Some of us put up shrubbery or trim it,” he said, pointing to a hedge that wouldn’t look out of place at Hampton Court. “They are little jobs. But they need to be done.” For Hashimoto, who had a pension from his printing firm, money didn’t seem to be the main motivation. He described the $600 or so a month he earns as “play money” – for eating out or for taking a trip to a nearby hot spring resort.
How was Japan coping with ageing, I asked? “We are a little worried about the low birth rate,” he said. “Any society needs to replenish itself, needs to have enough children coming up. We really don’t know how it will turn out.”
Hashimoto was more concerned about the younger generation than his own. Over-65s control the bulk of Japan’s enormous household savings. Rather than being a burden, Japan’s elderly are transferring wealth to younger generations by spending money on their children and grandchildren or by leaving it to them when they die. “We enjoyed the surge in the economy,” Hashimoto said. “My son didn’t have the same advantages. He’s now in his forties and things may turn out to be harder for him than they were for me.”
Much of the ageing is happening away from the big cities, in the provinces. The average age of Japanese farmers is 70. Even in non-farming communities, there are increasing numbers of elderly. Inukai is a village of 4,000 people in Oita prefecture, 500 miles southwest of Tokyo. Well over one-third of its residents are 65 or older. Masaya Shin, a retired headmaster, lives there with his wife Yoshie in a house with traditional tiled roof and a garden decorated with pine trees, rock displays and a stone lantern. Around are terraced allotments and a scattering of other houses.
Shin, small and wiry with short-cropped hair, is 72, though you would never know it if you had to face one of his forward topspin drives. In addition to table tennis, which he plays to a high standard in his garage, he practises and teaches kendo, a martial art in which participants spar with bamboo swords. He is the fifth oldest in his dojo. “Our motto is: ‘Let’s do kendo until we’re 100,’” he said.
Shin also regularly attends iaido sessions, a martial art whose practitioners make controlled movements with a real sword, blunted or otherwise. Iaido is not for the faint-hearted: once, one of his companions was drawing his sword from its scabbard when he accidentally sliced off part of his own ear.
In addition to his hobbies, much of Shin’s time is taken up with paid employment teaching Japanese to casual farm labourers from China, Thailand and the Philippines. He also teaches on a voluntary basis. He’d like to learn calligraphy, and is interested in local Meiji history. “But there’s so little time,” he said ruefully.
Both he and Yoshie are active in the community, where people of his age keep an eye on those a generation older. One neighbour organises a “salon”, cooking for older villagers or organising tea-ceremony afternoons. Another staffs a daycare centre so that mothers can work. These activities don’t show up in data measuring economic activity.
Inukai has recently introduced a scheme to keep records of people’s vital details – their blood type, history of illness, insurance number and so on – in a little plastic cylinder in the fridge. That way, emergency services can quickly attend to people who may be confused or unable to explain their situation. Even in such a tight-knit community, people slip through the net. “A man recently died in his home without anyone knowing,” Shin said. “It was many days before they found him.”
Shin himself pursues a lifestyle that would exhaust many a younger man. “It’s all to do with ikigai,” he said, using a Japanese word that translates as “a reason to live”, something to keep mind and body active. It’s become fashionable, he said, to talk about something called pinpin korori, a brutal but almost comic way of describing an active life followed by sudden death. “Drop down dead,” he laughed. “That’s a good way of saving on medical bills.” Then he paused to reflect. “After all, we don’t want to be a burden on the youngsters.”
David Pilling is the FT’s Asia editor. His book ‘Bending Adversity: Japan and the Art of Survival’ is published by Allen Lane. This is not an excerpt.
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