From the Ministry of the Interior to COVID-19: Japan's Healthcare Paradox (Part 3 of 3)

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

President, Medical Governance Research Institute, Tokyo, Japan

The Meiji government began its efforts to organize medical administration in the 7th year of the Meiji era by promulgating the "Medical Law" (Isei) — Japan's inaugural comprehensive health system. At the core of this initiative was Nagayo Sensai, who, alongside individuals like Ōkubo, was a member of the Iwakura Mission that traveled extensively overseas.

Nagayo hailed from a lineage of physicians who served the Ōmura domain. He pursued Western medicine at institutions such as Ōgata Kōan's Tekijuku and the Nagasaki medical training center. A towering figure in the Meiji era's medical community, Nagayo held simultaneous roles such as the Director of the Ministry of Education's Medical Affairs Bureau and the Dean of the Tokyo Medical School, the predecessor of today's University of Tokyo Faculty of Medicine. Evidently an accomplished medical scholar, it is said that he coined the term "衛生" (Eisei, or "hygiene") as the Japanese translation for the English term "Hygiene."

The situation took a tumultuous turn the following year, in the 8th year of the Meiji era, when jurisdiction over the "Medical Law" was transferred from the Ministry of Education to the Ministry of the Interior. Nagayo and Yamagata Aritomo, who assumed the role of Minister of the Interior in the 16th year of the Meiji era, were not in harmony. Yamagata appointed Ishiguro Tadaatsu, the Deputy Chief of the Military Medical Department, as the Deputy Director of the Health Bureau.

Ishiguro was born in Yanagawa, present-day Fukushima Prefecture, and tragically lost both his parents at a young age. Overcoming numerous adversities, he graduated from the Shogunate Medical Institute and later became a lecturer there. However, with the Meiji Restoration, he lost his position. Subsequently, through an introduction by Matsumoto Ryōjun, he joined the Ministry of War and became a pioneering military physician during its nascent phase.

Perhaps a testament to his hardships, Ishiguro appeared to have a keen sense for navigating the intricacies of the world around him. Not only was he favored by Yamagata Aritomo, but also by prominent Satsuma military leaders such as Ōyama Iwao and Kodama Gentarō. On the other hand, he was known to be quite strict with his subordinates. His feud with Mori Ōgai is particularly well-known.

The inner workings of the Ministry of the Interior, which held the reins of police power, were intricate. With the transition of public health administration to the Ministry of the Interior, various entanglements emerged. It's noteworthy that while the Health Bureau was established in the 19th year of the Meiji era, its operations were heavily influenced by the sanitary police administration, which had been overseen by the existing Public Safety Bureau.

The Public Safety Bureau, following the High Treason Incident in the 44th year of the Meiji era, established the Tokko (Special Higher Police) — essentially the thought police. This bureau was also responsible for the Public Order Maintenance Law enacted in the 14th year of the Taisho era. At the time, bureaucrats from the Public Safety realm would often rotate between the sanitary police and the Tokko. This rotation played a significant role in shaping the foundation of public health in Japan.

Even today, its influences linger in various aspects of society. From Hansen's disease (leprosy) to COVID-19, the rights of patients have often been disregarded in favor of policies that emphasize isolation, which serves as a prime example of this legacy.

Such policies birthed a myriad of discriminations. "The Castle of Sand," a film directed by Yoshitaro Nomura and released in 1974, delves into the prejudice against Hansen's disease (leprosy) sufferers. Director Nomura hailed from Kyoto, and his father, Hōtei Nomura, was a pioneering figure in Japanese cinema. The director's educational journey spanned the Gyosei Elementary and Middle Schools, established by the Maria Foundation, followed by Keio University.

During World War II, he was involved in the Imphal Campaign in 1944, in which British and Indian forces successfully defended the city of Imphal, India, against the invading Japanese Army, marking a turning point in the Burma Campaign. It's plausible that Nomura had some friction with the Ministry of the Interior and the Imperial Japanese Army. Indeed, "The Castle of Sand" contains several critiques of these institutions throughout its narrative.

The issues do not solely reside in the Infectious Disease Control Law. The Hotel Business Law is another such example. This law mandates that guests provide their full names and addresses when staying at a hotel. One of its aims is to prevent the spread of infectious diseases. While it is argued that such a requirement aids in tracing the origin of outbreaks, such as mass food poisoning or contagious diseases, there isn't a rational reason to treat hotels differently from workplaces, schools, public transport, and restaurants. The persistence of such a law likely stems from its convenience for authorities: individuals on the run from the police are unlikely to register at hotels under their real names. This loophole has been exploited for incidental arrests, a practice that spans from the pre-war era to modern times. A case in point is the Aum Shinrikyo incident in 1995, wherein sect members were arrested for lodging under false names. The allowance of such "incidental arrests" can be traced back to the legacy of the sanitary police during the era of the Ministry of the Interior.

Incidental arrests are not just confined to the example given. An acquaintance of mine, a former official of the Ministry of Health, Labour, and Welfare, mentioned, "Even today, if the police request it, we provide information based on breaches of the notification obligations under the Infectious Disease Control Law. Such information is often used as a premise for incidental arrests." This individual had been deputed to a certain prefecture and had, on occasion, provided information to local police when inquiries were made.

Looking back at our nation's history, there are innumerable instances where the state's interests took precedence over the health of its citizens in the realm of medical and health administration. As previously mentioned, the Ministry of Health and Welfare was separated from the Ministry of the Interior in 1938. This move was initiated due to requests from the Army Ministry, with the foremost bureau being the Physical Fitness Bureau. They enacted the National Physical Fitness Act and fervently promoted conscription.

After World War II, the Ministry of Health and Welfare absorbed both the Army and Navy Ministries. The National Hospital Organization, which was investigated by the Tokyo Metropolitan Police Department's Second Investigative Division for bribery during the COVID-19 pandemic, is the successor to the Army and Navy hospitals. In the fiscal year 2021, they received a subsidy of 131.7 billion yen, 28 times more than what they received pre-pandemic. However, as of August 3, 2022, amidst the seventh wave of the pandemic, their acceptance rate for dedicated COVID-19 beds was a mere 65% of what they had declared, betraying the trust and expectations of the public.

Amidst the COVID-19 pandemic, the Ministry of Health, Labour, and Welfare, along with affiliated experts, restricted citizens' rights to testing and medical care under the guise of "protecting Japan's hospitals." Should friction arise between patients and the state, it is the physician's duty to side with the patients. This is a responsibility that physicians, as professionals, have upheld since the Greco-Roman era. The fact that they could make such statements without remorse indicates that the intrinsic value system of Japan's public health administration, inherited from the days of the old Ministry of the Interior, prioritizes national stability over individual rights.

Of course, within the Ministry and among the experts, there are undoubtedly those who question such an approach. However, voicing "just and proper" arguments grounded in personal conscience can hinder one's career advancement. To remain in the Ministry, one must accept this "intrinsic value system", or else they must leave. Recently, the reason cited by young bureaucrats for leaving the Ministry is that they "grow disillusioned with their work" (as stated by a former official). While the media frequently attributes early resignations among bureaucrats to excessive workload, the real crux of the issue lies elsewhere.

The problems with our nation's health and labor administration run deep. It's futile to expect significant reforms from even the most aspirational politicians or bureaucrats. The fact that even the Abe and Suga administrations couldn't exercise control over this matter is telling.

The government is a reflection of the level of its citizenry. If there are issues with health and labor administration, it's because there's a problem with our nation's people. It's almost accurate to say the Japanese remain perpetually "twelve years old." So, what should we do? The first step is to trace the essence of the problem back through history, initiate societal discussions, and then build a healthcare system that fits our true capabilities. As long as we entrust our healthcare to an institution like the "Ministry of the Interior," which prioritizes national control above all else, Japan's medical sector will not progress.

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