II. Future of Human Society
Focusing on Public Health, Social System, and Bioethics.
From the Viewpoint of Health
Ibaraki Occupational Health Promotion Centre
I currently work for Ibaraki Occupational Health Promotion Centre, an organisation mentioned just now. This centre belongs to the Labour Welfare Corporation which is an organisation affiliated with the Ministry of Health, Labour and Welfare and supports the activities of companies in preventing occupational injuries and creating comfortable working environments.
As you know, Industrial injury hospital is a place for treating the workers and those suffering from job-related diseases and injuries. Starting about 10 years ago, Occupational health promotion centres have been built at many prefectures based on the idea that it is not sufficient to treat people with job-related diseases and injuries and that more emphasis should be placed on prevention. Today, the coverage has reached all but a few prefectures. Although Ibaraki Occupational Health Promotion Centre is a very small organisation of 6 persons, it cherishes a very high philosophy and purpose. Government has been backing the efforts by companies to protect the health of their workers. An example of such efforts is company visits made by labour standards inspection office for offering guidance.
However, such practice has fallen out of step with the times. Instead, companies are making voluntary efforts to eliminate illnesses and injuries. Occupational health promotion centres were created to support these efforts by the companies. In reality, however, customers rarely utilise these centres. The centre staff including myself, companies and government will therefore have to work together more closely so that this wonderful system would be able to produce more results. I think about this as I perform my work from day to day.
Let us move on to today's theme of population. I agree with the presenters at the morning session about the gloomy picture. However, we naturally have to take some measures for our survival and for the happy life of future generations.
I am not an expert on population problems or international health care. I graduated from medical school and then studied public health. I worked for National Institute for Environmental Studies and also worked in the field of industrial health which I am currently involved. In this sense, I am an expert in the field of environmental issues such as air pollution. Today, I would like to talk about my views on the population problem from the viewpoint of a person that studied public health. I would also like to offer some answers in my own terms.
We ask the question "What is population problem?" My answer to this question is as follows. This earth where we live is home to various countries and regions. As people lead their lives by clinging to these countries and regions, one question we need to ask ourselves is the amount of life resources that the earth and these regions can offer for the survival of people living on them. I believe that this morning's lectures touched on this question. However, I think that there is another way to look at this issue. In other words, we need to pay attention to each and every individual comprising the population because each individual is living and existing in its community, giving birth to its future generation and raising them. I would therefore like to rephrase the question to "How much resources are available to individuals for this purpose?"
The right of individuals to live and exist is clearly stated in the Constitution of Japan as "All people shall have the right to maintain the minimum standards of wholesome and cultured living". The Constitution goes on to say that "In all spheres of life, the State shall use its endeavors for the promotion and extension of social welfare and security, and of public health" as it proposes the goal that the country should aim for. Furthermore, it is stated in the Preamble that "We desire to occupy an honored place in an international society striving for the preservation of peace, and the banishment of tyranny and slavery, oppression and intolerance for all time from the earth" and that "We recognize that all peoples of the world have the right to live in the peace, free from fear and want". In other words, one can say that Japan has proudly declared to contribute to the international community as a country and is making efforts in that direction.
Turning our eyes to the international community. UNDP's Human Development Report (1997 edition) asserts that poverty can mean more than a lack of what is necessary for material well-being. It can also mean denial of opportunities and choices most basic to human development". It emphasises the technical assistance for promoting development in all socioeconomic areas of the developing countries by pointing out that disparity in wealth is creating inequalities beyond regions and generations to hinder sustainable development not only of the region but of the entire world. While a big question remains as to whether such task is attainable, making efforts in this direction has become the norm of the international community.
When you face reality, however, you will see that the Sub-Saharan countries are cited as extremely poor countries and that their income has not changed since 1950. To make things worse, their foreign debt continues to increase. Furthermore, it is indicated that living conditions of the region has deteriorated considerably in the recent years due to war and excessive development and that people are being driven into poverty as they are deprived of essential life resources such as clean water, nutritious food and hygienic housing. This news has been covered by TV and newspaper, and you will find an article about this in every issue of Time. Nevertheless, we, including myself, seem to be reacting to the situation with a sense of distance.
On the other hand, many people living in Japan and other countries and regions that have accumulated wealth from all over the world are not facing extreme poverty, but are suffering from numerous kinds of stress in the industrial society in which extreme efficiency is pursued.
Thus people on earth are living in their respective regions with marked gap in distribution of economic and living resources. The level of health for individuals and population groups formed by these individuals represent a multitude of conditions by corresponding to the level of living resources of that region such as environmental hygiene, food hygiene and health and nutrition. For instance, a study of physical constitution of population group shows that increase in height and weight of Japanese has changed dramatically since 1950. This may be common sense, but the same can be said about physical strength. Disease structure and mortality structure, which represent patterns of health impairment, are also determined according to the level of living resources.
Comparison of Indonesia, a developing country, and Japan, a developed country
Since we may not go anywhere if we simply talked in general terms, I would like to make a comparison between Indonesia, which is a developing country, and Japan. I had the fortune of hearing a precious story about Indonesia from Professor Shousuke Suzuki of Gunma University who has been involved in offering support to public health activities in Indonesia for many years.
Indonesia has GNI(gross national income), an index for economic production capacity per capita of a country, of 2,700 dollars − about one-tenth of the same index for Japan which is 25,000 dollars − ranking the country as a developing country of intermediate level.
There is a problem with drawing any conclusions based on statistical data across the board because the poorer the country, the greater the economic disparity between urban and rural areas. But let us take a look at Indonesia as a whole based on statistical data in any case. The county currently has a population of 210 million which is 75 percent larger compared to 30 years ago. In the case of Japan, the population 30 years ago was about 100 million, which means that it has increased by 20 percent and will reach a stable level in not too far future.
While Indonesia is said to have a large population, current population size of an average household is 4.5 persons. I am now 67 years old. And in Japan, back when I was young, I had a friend who was the eighth son of the family. I myself had 4 siblings. There is an expression "The poor have large families", but in those days, I remember there being very many children in the community. In Indonesia's age structure, children aged 15 years and under account for one-third of the entire population while those aged 65 years and above account for 4 percent. Average life expectancy is 66 years. Since Japan's average life expectancy was 66 years in 1960, it appears that Indonesia is currently at this level.
Taking a look at vital statistics of population of Indonesia for every thousand population, fertility rate is 23, mortality rate is 8 and infant mortality rate is 41. Maternal mortality rate for every 100,000 births is 470, which is very high compared to maternal mortality rate of 176 around 1950 in Japan. With the exception of maternal mortality rate, Indonesia has the same level of age structure and population dynamics as Japan around 1950, immediately after World War II. Incidentally, present day Japan surpasses all other countries in the world in these areas with fertility rate of 10, mortality rate of 7, infant mortality rate of 4 and maternal mortality rate of 12.
Let me reiterate the fact that age structure and population dynamics of today's Indonesia is at almost the same level as those of Japan around 1950. Professor Suzuki has said that it took the enormous efforts that were made toward the improvement of health and sanitation over the past 20 years to reach this level.
Let us analyse the disease and mortality structure in some more detail. The most common cause of death in Indonesia today is perinatal death. In other words, there are many deaths of newborn babies. This is followed by heart disorder, stroke, respiratory diseases such as influenza and pneumonia, tuberculosis and traffic accident. The largest cause of death in Japan back in 1950 was tuberculosis, which was common among young people, followed by stroke, cancer, heart disorder, accident, pneumonia and suicide. Today, deaths from tuberculosis became rare and the order has changed to cancer, heart disorder, stroke, pneumonia, accident and suicide.
In the case of Indonesia, a concern exists over significantly high incidence of perinatal death, rather high infant mortality rate and high prevalence of infectious diseases. However, this does not necessarily mean that larger number of people die from infectious diseases such as typhoid, amebic dysentery, diphtheria, tetanus, rabies and tuberculosis compared to other diseases. We must understand that Indonesia has also overcome infectious diseases and malnutrition as causes of death and that her disease death structure has shifted in the direction of increasing incidence of adult diseases that are largely affected by lifestyle. I think that it is necessary to have exchange with and offer support to the people of the country by understanding the conditions of their health.
Indonesia currently spends 0.7% of her national budget on health and medical expenses. I assume that there is a limit to the amount of money that can be spent in this area with GNI of 2,700 dollars. However, the reality is that disease/death structure has shifted in the direction of adult diseases becoming more predominant and average life expectancy has gone up to 66 years in spite of this income level.
People becoming ill and dying mainly of adult diseases is a phenomenon observed in developed countries that requires large amount of money for prevention and treatment. This can be understood instantly if you look at the case of Japan. Eight percent of our gross national income is spent on national health and much debate is currently taking place on the subject of medical reform. I assume that it will cost a lot of money for Indonesia in the future.
Japan's course towards becoming a developed nation
Let me put aside the topic of Indonesia for now and look back on the course that Japan took towards becoming a developed nation after 1950. Please remember, if you will, the severe food shortage immediately after the war and the increase in food production. Petroleum took over as the main energy source, but there was a period when coal mining was encouraged to increase energy production. Then Japan produced large quantities of high add-value products by making the shift from materials production industry to light industry mainly comprised of manufacturers, and earned foreign currency by exporting these products to overseas. Japan's rapid economic growth was made possible by this export.
In addition, high-quality labour force was supplied through migration of young population from rural to urban areas. Infrastructure such as water supply and sewage systems and transportation network was rapidly built at the same time. Another important element was the improvement of social security system including National Health Insurance. Advancement in establishment of health care system played a role as income standard, living standard and health standard of the Japanese people reached their favourable condition today.
Needless to say, the efforts of the entire population from the leaders of all sectors of society to the labourers as well as the rapid economic growth triggered by war boom from the Korean War and Vietnam War played an important role in the process. However, what I would like to stress here is the fact that untiring efforts of the people at the front line of the administrative authorities and private companies, as well as of the experts and the people of each community, towards the improvement of living standard were largely responsible for this feat. It makes me reaffirm my determination to exercise ingenuity like our predecessors in the Occupational Health Promotion Centre work I am currently involved, in an effort to obtain greater results. I think that there is a need for such effort in all sectors of my country.