Medicine and health

Social medicine

By William Wetherall

Growing up in the 1940s and 1950s exposed me to practices of medicine that today are either rare or outlawed. We were living in San Francisco and my mother usually took me or my brother or sister to a nearby clinic. But I recall a couple of times when a doctor came to our home, but my siblings cannot recall with certainty, and our parents are no longer alive and testify.

There were fewer formalities when it came to clinical trials. My grandfather had come from a small town in Idaho to live with us in the city to receive state-of-the-art treatment for his skin cancer. It had started around his left eye and worked its way into his brain. His eye had to be removed and he was horrified by the prospect of anyone seeing his disfiguration. He was essentially a guinea pig in a cancer research program that was exploring new treatments for a disease the very word of which implied imminent death. His treatment included the production of a prosthetic eye and tissue that matched his skin, but I recall him wearing only an eye patch. I imagine he felt more comfortable looking like a war veteran (which he wasn't) or pirate (which he wasn't) than a zombie (which he would have resembled if he'd worn the prostetic).

"Free medicine" extended also to me. I have had "hay fever" for as long as I can remember, and in both San Francisco and Grass Valley I recall my mother liking the fact that most doctors gave us medicine so she didn't have to buy any. Every year the medicines were different. I later thought they might have been clinical samples, but my mother said the doctors were participating in clinical tests. She didn't recall a lot of formalities. Today patients would receive reams of legal documents and have to sign consent forms if they wished to participate.

Our family doctor was a surgeon who had served in Southeast Asia during the Pacific War. I remember him as friendly but brusque. He wore a light tan rather than white smock. The only surgical scar on my body is his, for he corrected my right inguinal hernia when I was in high school. He got some attention in the local press when, on the small lawn at the entrance to his cinder-block clinic, he erected a tombstone inscribed "Here lies socialized medicine" or something to that effect. This was in late 1950s. McCarthyism was alive and well. And Grass Valley was a haven of anti-socialist conservatism.

I say this because, when coming to Japan, and working here, I wasn't sure that I wanted to participate in the national health insurance program. I didn't then have a choice, however, as it was a mandatory part of a mandatory health, pension, disability scheme that came with my employment at an incorporated educational foundation. I have generally enjoyed good health and rarely had an occasion to visit a doctor. My only complaints for 40 years were occasional bouts with bronchitis, a couple of asthma attacks, and a bladder infection.

As a father, however, I experienced having to stay over night in the small clinic where my children were born to attend to them and their mother in what was called a "tsukisou" (付き添う) system. Patients had an option of hiring someone to assist with cleaning and feeding and other non-medical "nursing" needs if a member of the family or friend was not available. Today hospitals, and most clinics, provide full care and generally don't allow family members to stay with a patient.

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Eugenics

Eugenics (yūseigaku 優生学) -- as a field of study that sought to develop theories of the quality of human races and societies, and ways of improving humans biologically and socially -- has been generally discredited as a "science". The word is practically unspoken today other than in historical accounts such as this.

However, most eugenic concerns in the late 19th and early 20th centuries were of the kind that fit very comfortably into the fields of public health and physical and medical anthropology today. This also true of eugenics in Japan, where it arrived during the late Meiji period, developed during the Taisho and early Showa periods, and influenced imperial policy during the 1930s early 1940s.

Certain eugenic projects that had begun before and during the war, mostly studies of physical and physiological differences of racial and racioethnic groups in Japan and East Asia, were completed during the early postwar years, and few new studies were initiated during the Occupation of Japan and early post-Occupation years. But the field of "Race Hygiene" (Minzoku Eisei 民族衛生) as the journal of The Japanese Association of Race Hygiene" (Nihon Minzoku Eisei Gakkai 日本民族衛生學會) was titled in English -- referring to "racioethnic" or "national" or "Volk" hygiene or health -- dissolved into studies of what today would be conducted under the rubric of medical ethnology or anthropology.

Eugenics, originally a social philosophy, evolved into a science that combined aspects of biology, genetics, medicine, anthropology, psychology, sociology, and other fields for the purpose of improving the quality of the human species and human life. It began in the late 19th century, blossomed in the early 20th century, and quickly inspired policies and guidelines that, for example, sought to improve public health through better nutrition and prophylaxis, and minimize birth defects. But it also encouraged some people to advocate the breeding a superior race, and to sterilize individuals and even eradicate groups that were considered genetically or racially inferior.

The belief that the human condition could be perfected through science, by manipulation of the circumstances of reproduction, growth, and maturation, fed all manner of dreams that ranged from utopian to paranoid. Such were the themes of a number of imaginary novels, from the rather romantic Men Like Gods (1923) by H. G. Wells, to the more cautionary Brave New World (1932) by Aldous Huxley.

Eugenics also motivated research into possible differences between putative races of people. Such research raised hopes in political quarters in some countries for evidence that would justify present or future racialization of social policy, to maximize the vitality of a racially-defined nation in terms of its collective intelligence, strength, and health.

Proponents of "national eugenics" and "racial eugenics" ran the gamut, from those interested in public health in the form of sound bodies and minds, to those who sought to protect a putatively superior race against another by protecting its racial integrity -- through anti-miscegenation and other forms of anti-fraternization, if not total segregation. Extremists favored sterilization, and even genocide, of individuals or groups they regarded as pollutants.

While eugenics has largely been discredited as a field of science, especially by scientists who regard "race" as a non-scientific concept, most of the research that was done under its banner was in fact science. Even research into racial differences of intelligence, however controversial today, was intended as science, and conducted scientifically.

Much of the research that was done in the interest of reducing rates of, say, delinquency, divorce, venereal and other infectious diseases, and congenital disorders, continues to be done today. And in countries like the United States, where race boxes are more evident in public life today than in the past, such research makes full use of racioethnic demographic data.

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Illness and disease

Being "sick" is to have real or imaginary signs or symptoms that indicate one is not "well". I learned when training to be a corpsman in the US Army that "signs" are what a doctor or another 3rd party observes, while "symptoms" are what a patient experiences are reports.

A "sickness" though could be an "illness" or "disease" or "disorder" or "syndrome" et cetera. While "illness" and "disease" are synonyms, I learned to think of an "illness" as something "acute" and transitory, while a "disease" is apt to be "chronic" or reoccur. An "illness" is more likely to have an external cause, while a "disease" probably originates from something that is either congenital or was acquired later in life continues to reside in the body.

I have thought of pneumonia and strep throats as illnesses caused by bacteria, but chronic chest infections may be secondary effects of a disease that weakens the immune system. Ultimately both conditions involve collaborations of external and internal factors.

The field of nosology -- the classification of diseases -- is extremely controversial. Some of yesterday's illnesses have been reclassified to the "within the range of normal human behavior" side of the ledger. And some of yesteryear's normal behaviors have become objects of clinical concern if not criminalized.

Each year my local doctor in Japan prescribes medicine for my hay fever, which I now understand is a set of allergies to various pollens, mold spores, and mites or rather their carcasses in house dust. The medication is over-the-counter in the United States, but is regulated in Japan. Unlike some my heart medication, which can be dispensed for 70 days, the anti-allergy medication is limited to 30 days. But what I want to say here is that, when finished with the annual oral interview to update the doctor's record, he sends he home with the comment that I don't need a consultation for refills since "pollinosis isn't a disease (kafun-shō wa byōki de wa nai 花粉症は病気ではない), This always amuses me before "-shō" (症) is the same suffix in "kyōshin-shō" (狭心症) -- "narrow-heart disease" or "angina pectoris" -- which is definitely a disease, and getting refills requires a consultation.

Pregnancy is a condition that today is generally overseen and managed by medical doctors. Conventionally a woman living with her family in a community would deliver her baby with the assistance of would assistance of women who had experienced delivery, possibly including a trained midwife. There would be no doctor, much less support in the form of a delivery room and nurses and technicians specializing in childbirth. In biological principle, the woman could drop her baby alone by the side of a road or behind a tree somewhere, and she knew what to do, and if she were healthy and knew what to do, she could walk away from the site with baby in her arms.

In my maternal mother's generation, kids grew up in families experience both childbirth and death at home. And even a dumb man, who knew everything about animal husbandry, could probably assist his wife in the push and shove and pull operation, tie off the umbilical cord, and clean up the mess.

If pregnancy is a disease, then so is sex. Here the distinction between "normal" and "abnormal" also comes in handy. Sex is biological condition, sexual intercourse is a prerequisite for the continuation of the species whether within or outside the social contrivance of a marriage or family. But sex can be a disease when it becomes an addiction or an object of uncontrollable impulses.

Speaking of sex -- what about masturbation? Is it an anomaly because, generally though not invariably, it is done alone? It seems natural enough, but in some societies it has been regarded as a sin or at least as something one ought not do. I remember my mother once, when collecting the sheets from the bunk bed I and my slightly younger brother shared from infancy through high school, saying "You boys stop playing with yourself."

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AIDS

My reporting on AIDS in Japan was my first foray into medical issues. The social aspects, more than the medical issues, drew me to the subject, as AIDS was regarded an "exotic" disease that had been brought to Japan by foreigners, or by Japanese who had contact with foreigners overseas.

My investigations of AIDS as a contagious condition led me to read about earlier experiences in Japan with diseases which had spread to Japan from elsewhere. The most fascinating twist came in the form the infectious cancer called ATL (adult T-cell leukemia), which some researchers thought had slowly been making inroads in remote parts of Japan since the start of its peopling millennia ago.

I came away from my reportage on AIDS with a deep respect for what the history of disease tells us about human contact and migration.

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Cancer

My interest in cancer began with witnessing the fairly rapid decline of my maternal grandfather when living with us in San Francisco the last few months of his life in 1949, when I was 8 years old. He is my middle-name namesake, possibly the major source of my more conspicuous genes, and definitely the inspiration, along with my maternal grandmother, who outlived him by 30 years, for most my youthful imagination about life in late 19th century and early 20th century America.

My more mature encounter with cancer was through the experiences of one of my more important mentors, Wagatsuma Hiroshi, who was instrumental in my ability to mount lawsuits against the Japanese government concerning my children's nationality, as well as in my continuing studies of racial, ethnic, and even simply cultural mixture.

Wagatsuma, aware that he was dying, and knowing why, wrote one of the most important examinations of the taboo of telling patients or even their families that they had "cancer", the idea being that it was better not to mouth a word that most people connoted certain death. This theme of "not telling" entered orbit around my studies of "shiseikan" (死生観) or "death-life-views" in Japan, which is more than a study of "thanatology" as this term is sometimes mistranslated.

"Shiseikan" (死生観) is regarded as a study of "life" (sei 生) through the study of "death" (shi 死). Some people prefer to speak of "seishikan" (生死観), which puts "life" before "death" and otherwise seems a more "natural" way to view the two, since presumably death follows life -- though, in some religious, life -- as a reincarnation -- begins in death.

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Leprosy

My interest in leprosy led me to write several leprosaria in Japan for reports of their facilities and activities. I was especially interested in the extent to which Chosenese who were confined to leper sanatorium in the prefectural Interior of the Empire of Japan became isolated from their Chosenese if not their Interior families during the colonial period and after 1945, when the Allied Powers severed Chōsen from Japan's control and jurisdiction and ultimately from its sovereignty.

The percentage of Korean and Chosenese residents of Japan's national leprosy facilities was a few times times higher than percentage of Koreans and Chosenese in Japan's total population. I was unable to determine if this represented a higher rate of incidence among Koreans and Chosenese, or whether it only reflected an accumulation of Chosenese who were placed in facilities and remained there after most Chosenese left the prefectures for the peninsula both before and after 1945.

I arranged to visit a sanatorium on the outskirts of Tokyo. I spoke directly with one of its officers, an elderly man who himself exhibited mild signs of Hansen's Disease. By then the facility was practically abandoned as its resident population was only a fraction of what it had been when it included people of all ages.

Since then, meaning the late 1980s, more elderly leprosy patients have died, and more have braved release to the care of families willing to accept them. In the meanwhile, new cases among Japanese have been extremely rare. Over the years, a few new cases have surfaced among Brazilians and Filipinos who have migrated to Japan to work.

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Treatment and care

For 20 years I studied suicide as a visiting researcher at the the National Institute of Mental Health, when it was located at Kōnodai in Ichikawa city in Chiba prefecture. It was right beside Kōnodai Hospital, a national general hospital which is now also a National Center for Global Health and Medicine. Some NIMH staff researchers saw patients at the hospital. The two facilities were joined by a covered walkway that was later enclosed.

The hospital was old and gloomy and crowded, and whenever there I felt like I was in an early postwar black-and-white movie. The first time I was there was to see the psychiatric clinical facilities my NIMH colleagues had at their disposal, which included apparatus for recording clinical sessions related to their research. I was never an in-patient, but once I had cold symptoms that caused the researcher then sponsoring my affiliation with NIMH to march me over to the hospital and walk me through the congested general out-patient clinic in order to get a prescription, which of course was filled at the hospital pharmacy. He ran me through the procedures and left me there, and by the time I got the medicine, some three hours later, my symptoms were gone. The medicine consisted of powders and grains packaged in small paper envelopes. I worried mainly that, while waiting shoulder to cheek with other sneezing and sniffling patients, I had picked up someone else's more serious bug.

I have seen the new Konodai Hospital only from a bus, but it looks bright, roomy, and well-equipped like a few hospitals closer to my present home, which I have frequented as an out-patient and in-patient patient with arrhythmia and coronary artery problems. I also regularly visit a local one-doctor clinic for regular tests of various kinds provided for older people through the national health insurance program, which is managed by the municipality in which an enrollee resides.

The present system continues to limit the amount of time that patients can spend with a doctor. Waiting rooms, though larger, better lit and air-conditioned, and more comfortable, are as crowded as ever, and face-to-face consultations are typically five minutes or less. The revolving-door system encourages dependency on objective clinical tests and by-the-numbers diagnoses, and patients are pretty much left to their own resources to acquire an understanding of their medical conditions. This doesn't bother me, for I like nothing better than to look up technical words and read widely about my condition. It would be nice at times to engage in more personal conversations with doctors, but I've learned to discipline my impulse to say anything that would constitute a digression from the matter at hand.

At first a bit dismayed and critical, I have come to be a strong proponent of Japan's one-payee universal national health insurance program, in which anyone can enroll for a fee based on their income and assets. It covers practically everyone in Japan, and everyone it covers is free to visit any clinic or hospital which accepts national insurance, which means practically every medical facility in the country. Most clinics and all hospitals continue to dispense their own drugs, but an increasing number clinics give patients prescriptions to fill at the increasing number of pharmacies that specialize in filling prescriptions. Most hospitals also now offer patients the option of being issued a prescription they can have filled at a third-party pharmacy.

Growing up in the United States, I learned that doctors weren't allowed to own or have any interest in a pharmacy, the idea being that this would constitute a conflict of interest in which the doctor would make more money by prescribing more drugs. This continues to be one of the criticisms of the system in Japan, where doctors in small clinics and large hospitals alike may order or prescribe unnecessary tests or drugs in order to increase receipts from insurance payouts.

One of the doctors at NIMH who sponsored my affiliation was an anxiety specialist. I assisted him and others in their research on sociophobia. He also also studied and wrote about hypochondria, which he thought was more common in Japan than other countries. He felt that many patients see doctors with expectations of receiving medicine on the basis of brief consultations that do not involve time-consuming verbal examinations of life-style, attitudinal, and other contributing factors that might reduce the kinds or amounts of medicine if not obviate the need for medicine.

My American friends are astonished by my tales of Japan's "social medicine". Those who are unable to get coverage they like at prices they can afford are extremely envious. Those who have enjoyed the coverage of corporate-sponsored plans that give them access to well-appointed hospitals managed by HMOs have difficulty imagining themselves having only a few minutes with a doctor who gets straight to the point, doesn't want to talk about pets or gardening, and will not volunteer a lot of explanation and will minimize answers to questions.

I hear reports from a sister who was once a nurse, and a sister-in-law who is retired from a career in nursing and HMO administration, that lead me to believe that health care in the United States has changed considerably from the time I was living in California 40 years ago. I witnessed at the clinic where my sister used to work the lavish ways in which pharmaceutical companies peddle their wares. And I am told about how HMOs, in the interest of maximizing profits, limit the choices of affiliated hospitals and doctors to those permitted by HMO guidelines or by managers who look over a doctor's with the bottom-line in mind, which limits the quality of health care for people who can't afford insurance, and can't afford the more comprehensive supplementary plans.

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Mental health

Depression can be an illness or a disease or both. If purely reactive, in response to the death of a loved one or loss of a job, I would call it an "illness" from which one can expect to completely recover -- if one is "normal" in the sense that practically everyone has such experiences, and usually overcomes the acute sense of loss or shock in fairly short period of time. The loss of someone on whom one has deeply depended both physically and emotionally, however, may set in motion a depressive condition that never quite resolves itself. The underlying "disease" would be the excess dependency that leaves one unable to cope when alone.

Ditto for the loss of a job with no hope of finding another. Someone with marketable occupational skills, and the attitudinal and social skills that enable them to beat the pavement and market themselves, will eventually find a new job. Those who lack such skills may end up permanently unemployed and hopeless. The "disease" in this such cases might be a "social malady" that results from a lack of opportunity to study in a supportive home and/or the acquisition of attitudes that prevent one from being ambitious, confident, and hopeful.

The root cause of a "mental" or "spiritual" sickness may be so deeply "psychogenic" -- "mental or emotional rather than physiological in origin" -- that its etiology remains unknown, cloaked by the mysteries of neural pathways that refuse to reveal their workings. Such pathways appear to account for gloomy dispositions, manic-depressive polarities, multiple personalities, and all manner of obsessions and compulsions. They also seem to play a role in inabilities to control emotions and impulses, hence habitual tantrum throwing or loss of temper constituting a "rage control" problem, and addictions ranging from alcoholism and other forms of substance abuse to shoplifting, gambling, and 7/24 social networking.

Some conditions, like "psychogenic fugue", are simply inexplicable. Or rather they are used to explain inexplicable behavior. "Fugue" is a metaphor for chasing and fleeing, but ultimately returning, and this is the sense of its use in musicology. In psychiatry it is called a "dissociative disorder" that involves spells of wandering during which one becomes a different person and acts accordingly. Fugue spells may last only a few moments, but they typically continue for a few hours or days, and may go on for weeks or months, even years. When recovering from a spell, memories of one's life prior to the onset of the spell return, but there is partial or total amnesia regarding what happened during the episode.

I have known people who have had these problems. They are not easy for the affected individual or those around them to live with.

As a suicide specialist I've had to consider various kinds of "self-destructive behaviors" including forms of so-called "chronic suicide" -- meaning what? Alcoholism? Heavy (or any) smoking? Getting up every morning, working all day, and sleeping all night?

Kierkegaard regarded suicide as a "sickness under death". But if life itself inevitably leads to death, then isn't continuing to live tantamount to killing oneself?"

When you're trying too hard -- training too strenuously, studying too late, working too much overtime to finish a project or boost your reputation -- someone will tell you "Stop killing yourself" -- and they may add "It's not worth it" or "You need to get a life".

There is no conclusion to this story. It wanders on. And when, if ever, I return to where I was when it began, I will likely have forgotten it, or why I wrote it.

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Topics

This is a mixed bag of articles written about a variety of subjects, including social issues, that are medical in nature. Any topic related to medical anthropology or the sociology of medicine would qualify for inclusion here.

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Abortion

Abortion was of course a very controversial topic in the United States even in the late 50s when I understood what it meant. Naturally I wondered why it seemed to be more "accepted" in Japan. It turned out of course that it wasn't really more accepted but simply more tolerated, for reasons that required understanding of religious views, laws, and medical practice.

The issue became more personal when the child which had been conceived a couple of years after my daughter's birth had to be aborted in its 4th month for therapeutic reasons. Its mother had been chronically hemorrhaging, which endangered her life, but also suggested abnormalities in the way the fetus was growing in her womb.

The aborted fetus, a still-born child by law, was duly cremated, still in the plastic bag in which I carried it to the crematorium. The small scraping of charred plastic that remained on the slab that came out the furnace was placed in the vault of its mother's family tomb. The stone calls the child Mizuko (水子) or "water child" -- the name given to all aborted children whose souls are reposed this way.

I advocate prevention of unwanted pregnancies but am not opposed to after-the-fact abortions if performed early and if the child is unambivalently not wanted. Freedom of choice also includes keeping the child and raising it, whether within or outside wedlock.

Some OB-GYN physicians in Japan turn own requests for all but therapeutic abortions. Most, though, will consider the mother's emotional and other states and perform an abortion if that seems to be in her best interest. I don't share the cynical remarks made by some researchers that doctors perform abortions simply to make money. Some may be motivated primarily by money, but I am willing to wager that the money is secondary to their concerns.

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The brain

My interest in the "brain" was inspired by a book I reviewed which explored sexual sexual differences in brain development, structure, and functioning. This had nothing to do with Japan.

The "Japan connection" in my interest in the brain involved debunking claims by a Japanese audiologist that Japanese brains were more likely to hear insect and other such natural sounds as "music" owing to the "nature" of the Japanese language. It was not the good doctor's methodology or quantitative findings that I disputed. Though some aspects of his research design puzzled me, I had no way to evaluate the design or his physical observations.

What I disputed was the way he imputed to his data cultural meanings which appeared to stem from exceptionalist notions about the putative uniqueness of Japan, its people, and their language and culture.

In the end he did not actually argue that the "Japanese brain" as an anatomical brain was in anyway different from the anatomical brains of any other human nationality. What he meant, he insisted when pressed to clarify the meaning of the "Nihonjin no nō" (日本人の脳) title of the bestselling book of the several he wrote, was that it not really "The brain of Japanese people" that was different, but the language that a child was exposed to in his or her formative years. Moreover, he contended, it was not just the Japanese language, but also Polynesian, that programmed a child's forming brain to behave as he observed in adult subjects.

Even if the title had been "Nihongo nado no nō" (日本語等の脳), however, I would insist on more objective data to prove that "The brain of Japanese and other languages" somehow predisposed their speakers to appreciate the sounds of nature. I must say, though, the good doctor had fun espousing his theories, and it was always entertaining to read them.

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Facets of Medicine

I began writing this series of vignettes for a magazine aimed at medical students preparing for board exams. I wrote the installments in English, roughed them into Japanese, and left the polishing to a friend. I acknowledged her as the translator, since she did a lot of retranslation.

We quarreled a lot her retranslations, as I am a stickler for close metaphoric and phrasal translation. We usually compromised by my rewriting the English, and she rewriting the Japanese, so that they more closely corresponded with each other.

Eventually we both tired of this process, and I ended up asking the psychiatrist who invited me to replace him as the original writer of the column to kindly let me off the hook, which he did. I now regret that I didn't continue -- and she, too, has said she wishes she had tried to learn more about the process of translation, no matter how contentious it might have been under my rigid standards. I had a long list of issues that I wanted to address in the column, including some that she had suggested.

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