Charting the Course: What Lies Ahead for the Minister of Health, Labor, and Welfare?

Masahiro Kami, M.D., Ph.D.

President, Medical Governance Research Institute, Tokyo, Japan

Mr. Keizo Takemi has been appointed as the Minister of Health, Labor, and Welfare.

His selection by Prime Minister Fumio Kishida, particularly as he is a candidate recommended by the Japan Medical Association (JMA), has garnered significant attention from the public.

I have had the opportunity to work with Mr. Takemi, during the initial outbreak of the COVID-19. At the time, I was asked by the former Minister of Health, Labor, and Welfare, Mr. Yasuhisa Shiozaki, who was also serving as the head of the LDP's Administrative Reform Promotion Headquarters, to assist in drafting proposals. Mr. Takemi was the chairman of the LDP's Subcommittee on Infectious Disease Governance, focusing on addressing the coronavirus-associated pneumonia, and was in a collaborative relationship with Mr. Shiozaki.

Subsequently, we appeared together on television programs related to the coronavirus several times. We often participated in shows hosted by Mr. Soichiro Tahara. When Mr. Tahara mentioned, "I will not censor your remarks. As the chairman of the Subcommittee on Infectious Disease Governance of the Coronavirus Response Headquarters, you can speak freely," Mr. Takemi responded, "I always speak the truth wherever I am, even if it leads to confrontations." Mr. Tahara held a deep trust in Mr. Takemi.

What kind of Minister will Mr. Takemi become?

I do not believe he will simply be a puppet of the Japan Medical Association (JMA). This conviction stems from his primary background as an international political scientist. While he will certainly exert effort as a politician, it seems implausible that he would hold a keen interest in the medical fee revisions, a topic highly valued by the JMA. His proactive involvement in the coronavirus measures is likely due to the importance of this issue in international politics, his area of expertise.

This is where he differs from Mr. Yoichi Masuzoe, another figure rooted in international political science who served as the Minister of Health, Labor, and Welfare. During Mr. Masuzoe's tenure, he was popularly considered as a prime ministerial candidate, evidencing his nationwide popularity. Mr. Masuzoe aimed for political advancement and tackled public concerns irrespective of his expertise. The significant social issues at that time included physician shortages, maternity care challenges, and lawsuits concerning medication-induced hepatitis. Our group collaborated in drafting proposals under the Masuzoe administration for each of these concerns. Mr. Masuzoe's approach was to juxtapose our draft with the bureaucratic proposals, eventually making a final decision himself.

Among the politicians with whom I have associated are Mr. Masuzoe, Mr. Shiozaki, Mr. Yukio Edano from the former Democratic Party, and Mr. Hiroshi Suzuki. None of them are representatives specifically of the medical sector. They all graduated from the liberal arts program of the University of Tokyo and took roles in institutions like the Bank of Japan, the University of Tokyo's College of Arts and Sciences, as attorneys, or in the Ministry of Economy, Trade and Industry before becoming members of the National Diet.

During my time at the University of Tokyo, I was a member of the university's athletic associations. Due to historical developments since the Meiji era, many of its graduates have pursued careers in national policy-driven manufacturing industries such as the Ministry of Internal Affairs and Communications and Mitsubishi Heavy Industries, Ltd. The career trajectories of the aforementioned politicians coincide with these trends. I have always felt a close affinity with them in terms of values. Except for the late Mr. Edano, I still maintain relationships with these individuals, occasionally meeting for drinks. Presumably, they feel a similar camaraderie towards me.

Personality is largely formed by young adulthood, heavily influenced by those surrounding an individual. The distinct atmospheres associated with graduates of Azabu High School, Kaisei High School, Waseda University, and Keio University are reflections of these underlying dynamics. And, throughout one's life, they are influenced by such individuals. However, this is often underappreciated.

So, who influences Mr.Takemi? He has been a "Keio boy" since his elementary school days, having graduated from the Faculty of Law at Keio University. His father, Mr. Taro Takemi, also graduated from Keio University, from the School of Medicine. Growing up surrounded by Keio affiliates, it is expected that their influence on him would be profound.

As a general observation, Keio University alumni tend to be independent of government roles. Few graduates become bureaucrats. Out of the 2,027 individuals who passed the National Civil Service Examination in fiscal year 2023, only 51 were Keio University graduates. This number is modest, especially when considering the university's 9th rank in comparison to Waseda University (4th rank with 96 successful candidates), Ritsumeikan University (5th rank with 78 candidates), and Chuo University (7th rank with 68 candidates).

An exception is found among medical technocrats, an area predominantly overseen by Keio University's Faculty of Medicine alumni. Keio values concepts such as 'independence and self-respect', 'practical learning', and, in parallel, 'collective cooperation'. Such a mindset is less common among University of Tokyo graduates, who are often ingrained with the potential perils of forming cliques. This tendency for the Keio faction to dominate medical technocracy carries with it inherent risks of unchecked actions. This represents one of the challenges within Japan's healthcare administration.

Who, one might wonder, serves as the primary advisor to Minister Takemi? It may be Mr. Hiroki Nakatani, a friend of Takemi's since their days at Keio elementary school. After serving as the Deputy Director-General at the World Health Organization (WHO), he held positions such as WHO Executive Board Member, International Collaborator at the Ministry of Health, Labor and Welfare, and Director of the National Center for Global Health and Medicine (NCGM). Additionally, he has been involved in the administration of the Takemi Memorial Foundation for Life Sciences.

In 2020, when Mr. Takemi collaborated with Mr. Shiozaki and others to consolidate proposals for COVID-19 measures, he was keen on merging the NCGM and the National Institute of Infectious Diseases (NIID) to launch a Japanese version of the CDC (Centers for Disease Control and Prevention). Although his proposal materialized, marking a significant accomplishment, it was realized in close collaboration with figures like Mr.Nakatani.

While this approach is emblematic of Mr.Takemi, I am of the belief that such endeavors won't necessarily advance Japan's healthcare. The reason being, research institutions under the purview of the Ministry, overseen by medical technocrats, are in a state of decline. The realities of the NIID were widely reported during the COVID-19 pandemic, and the NCGM was no different. In June 2023, amidst the pandemic, the Chief of General Affairs at the NCGM was arrested on bribery charges. Similar incidents occurred at the National Hospital Organization, where administrative staff rotate. An acquaintance from the Metropolitan Police Department mentioned that these incidents are just 'the tip of the iceberg' for an organization rife with corruption.

Global health is a hallmark of Minister Takemi's portfolio, and it's likely he'll invest significant effort into it. I anticipate he'll advance traditional top-down reforms, spearheaded by the Minister, medical technocrats, and related Ministry organizations. Personally, I am not optimistic about significant outcomes.

We have to face the reality

The foundation of medicine and pharmaceuticals is research capability, but how strong is Japan's commitment?

Ms. Erika Yamashita examined original papers published in the "New England Journal of Medicine (NEJM)" from January 2013 to August 2023. She specifically looked into the national affiliations of the lead authors. During this period, 2,277 original articles were published, with the United States accounting for the largest share at 1,090 papers (48%). The dominance of the U.S. in the development of COVID-19 vaccines and treatments reflects its superior capabilities.

Following the U.S., the contributions were: UK (202 papers), Canada (110), France (104), Australia (77), Netherlands (72), Germany (71), Italy (41), China (40), Denmark (31), Switzerland (31), Sweden (27), South Africa (26), Spain (25), Israel (23), and Japan (22). Japan ranks 16th, depicting its research standing. While some experts attribute this to a lack of governmental support, the fact that we trail behind nations like South Africa, Spain, and Sweden indicates that this cannot be the sole reason.

One possible reason for this is the national regulation. In Japan, the Ministry of Health, Labor, and Welfare determines medical fees and drug prices uniformly across the country. This has functioned as an "escort fleet" system. In healthcare, because the ministry sets prices even for central Tokyo, rural medical institutions make substantial profits. There's little incentive to conduct clinical research or develop new services. Pharmaceutical companies, too, have been protected by high prices set for long-listed products, allowing drug manufacturers that don't develop new drugs to thrive. The current situation mirrors the post-war structure where banks protected by the escort fleet system lost their competitiveness. We know all too well what subsequently befell those financial institutions.

Then what should we do? Rather than placing hopes in a new Health Minister or making petitions, we need to embrace the spirit of Yukichi Fukuzawa's philosophy: "Independence of the individual leads to the independence of a nation."

Originally published in Japanese in Iyakukeizai (Pharmaceuticals and Economics), Oct 1, 2023