Shigeaki HINOHARA^*1

　

　In this paper I mention the 19-year history of International Health Evaluation Association (IHEA) which was started in Washington D.C. by the great effort of Dr. G. Gilbert in Hawaii. In 1973 three regions were organized in this Association: 1) U.S.A., 2) Europe and 3) Pan-Pacific including Asia.

　I also mention the history of periodical health check-ups in U.K., U.S.A. and Japan. In Japan it started in 1954, however, after adopting the system of Automated Multiphase Health Testing designed by the Kaiser Foundation of Auckland, Calif., in 1973, Japanese people paid much attention to this health screening system and the number of hospitals and clinics for health screening has increased tremendously and the number of examinees amounted to 2,875,449 in 2001.

　Finally, I conclude that IHEA should create a multidisciplinary system to sustain a lifestyle with a high level of Quality of Life (QOL) for the people who really want to live fruitful lives by the successive health education.

　

　Periodic health check-ups, multiphase health testing, health promotion

　

　

　It is a great honor for me today to be designated the Chairman of the Program Committee of the Year 2000 International Health Evaluation Association Conference. I am also deeply delighted that thanks to the devoted effort on the part of Dr.Sung, the President, and the Organizing Committee, the Conference has opened in Taipei on such a magnificent scale, and is attended by numerous distinguished participants.

　It was 1970, 30 years ago, when the first Conference of the Association was held in Washington D.C. The Association was a pioneer group at the time, concerned with problems of health evaluation. This first Conference of the IHEA would not have materialized if it hadn't have been for Dr.Fred Gilbert and his colleagues, who had been systematically conducting health screening in Hawaii, USA, and selflessly proposed and worked for the Conference.

　The next year, in 1971, the Association convened for the second Conference in Hawaii. In the subsequent year, the third Conference was hosted in Chicago. London was the site of the fourth Conference in 1973. At that time, the Association became divided into three Regions: Region I consisted of the USA, Region II of European countries, and Region III consisted of the Pan-Pacific countries including Hawaii. Since then, Japan, along with Hawaii, has become a member of Region III. At that time it was decided that the Conferences should be held biannually, that is, every other year, and each time should be organized and hosted by one of the above three Regions.

　I attended the fifth IHEA Conference, which was held in San Francisco. It was the first time that I participated at the Conference. It was at that fifth conference that it was decided that the next sixth Conference would be held in Tokyo in 1976, in cooperation with the Japan Society of Automated Multiphasic Health Testing and Services (JAMHTS).

　Since then, the biennial Conferences of IHEA have been held on schedule. In 1998, we convened for the 17th biennial Conference in London, and the city of Taipei in the Republic of China In Region III was chosen as the host of the next 18th biennial Conference. It was scheduled for October 2000, with Dr. P. K. Sung as the President. Therefore, it gives me particular joy to attend this Conference today, which shows such promise of great success.

　Today, I would like to briefly introduce the 19-year history of this Association. At the same time, I wish to reflect upon the methods and objectives of early health screening, to illustrate how it has developed over the years to attain the goals of the present. Finally, I wish to discuss the future course of IHEA activities by presenting my views on the perspective and mission of the Association.

　

　After World War II, tuberculosis was the primary cause of death in Japan. To cope with this problem, mass chest X-ray surveys were introduced by the government and conducted by the Prefectural and municipal authorities. As the result of this extensive campaign which took place during the early post-war period, the incidence of death due to tuberculosis decreased after a few years. In fact, after 1951, cardio-vascular accidents (CVA) replaced tuberculosis as the primary cause of death of the Japanese people. It can be said that this changing trend alerted people to have regular health check-ups done. At that time, periodic blood pressure check-ups were recommended to cope with the ever-prevalent cardio-vascular accidents. The check-ups were conducted within companies or in local communities.

　Since 1957, a health check-up system started under the name "the check-up for adult diseases". This was designed for the early detection of chronic diseases in adults, such as hypertension, circulatory diseases, stomach cancer, diabetes, or renal and liver diseases. The check-ups were conducted nationwide, screening the Japanese people to detect the above mentioned diseases earlier and apply prompt treatment. The objective and methods were much simpler then, being carried out within individual local communities.

　Incidentally, it was Dr. Horace Dobell (1) of London who first advocated the importance of periodic health check-ups for adults. As early as 1861, Dr.Dobell insisted that a system of periodic health evaluation be devised and established in the future, and that all citizens including children should benefit from it.

　Then in 1913, William Howard Taft, the President of the United States, founded the Life Extension Institute. This was based on a plan originally conceived by American life insurance companies, banks, physicians, and many others. Since then, its phenomenal accomplishments have continued for half a century, with over 300 million people in the United States and Canada receiving health check-ups.

　Actually, in 1922, 9 years after the establishment of the Life Extension Institute, the American Medical Association (2) predicted the next major challenge in the field of preventive medicine. It was: "enhanced periodic health check-ups for all ages". S.S.Goldwater (3) also discussed a similar view in 1914. Reflecting this tendency, in 1927, F.L.Fisk (4) published a monograph titled "How to Make the Periodic Health Examination".

　Who received periodic health check-ups during this period in the United States? They were the people who felt that it was meaningful to take preservation of their good health into their own hands. Eventually, entrepreneurs came into the picture. It seems that entrepreneurs first participated in the periodic health check-up program in the year 1948. A railroad company in Ohio carried out periodic health check-ups for its employees.

　In Japan, it was the year 1954 (29th year of Showa, which is 46 years ago) when the first multiphasic health-testing program was introduced by St. Luke's International Hospital and the First National Tokyo Hospital.

　It was a one-week program and required hospitalization. Thus it was called: "Hospitalization Human Dry Dock Program" (1 week). The objective of this program was the early detection of chronic diseases, which at the time were prevalent among Japanese adults. During the one-week hospitalization, all major organs of the body were thoroughly examined. The program gradually gained acceptance and people participated in the program in hospitals and clinics in various parts of Japan.

　However, the fact that this whole-body health check-up required one week of hospitalization was inconvenient. It was too long and too expensive. Therefore, in the 1960's, a three-day long ambulatory service program started in general hospitals and health screening centers in Japan.

　The next step was a one-day check-up program. Moreover, the results should be available on the same day. And it would be ideal if health guidance regarding the individual's lifestyle could be provided together with the test results. However, in order to accomplish these objectives, many precision testing instruments had to be set up in a laboratory, and the obtained data had to swiftly be processed by a computer. That was the only way to produce the check-up report within a day.

　This became possible in 1964, when the Kaiser Foundation of Auckland, California, succeeded, for the first time, in automated specimen testing and data computerization. (It should be mentioned that Dr. Collen had been associated with this project since its early days.) The Kaiser Foundation system allowed a large number of specimens to be analyzed automatically and immediately. It then processed the results, correlating them to the clinical observations. The results were then printed out in a clear table. This progressive program was called Automated Multiphasic Health Testing. As the service of giving health guidance for everyday life was added to the system, the term "service" was added. The formal name thus became the Automated Multiphasic Health Testing and Services, which was abbreviated as AMHTS. In Japan, this was called the Automated Health Testing Services.

　The automated system made it possible to screen a large number of people in a very short time. In Japan, the automated health testing services, originally developed by the Kaiser Foundation, were swiftly adopted 6 years later by the Toshiba Health Examination Center.

　In 1973 (48th year of Showa), a group of Japanese started a study group for automated health testing systems. In 1979, this group founded the Japan Society of Automated Multiphasic Health Testing and Services (with Dr. Ryosei Kashida as President). Later, in 1987, the Society changed its name and became the Japan Society of Multiphasic Health Testing and Services, and I served as its President from its founding up to 2 years ago. Incidentally, in 1998, this Japan Society of Multiphasic Health Testing and Services established a structure in cooperation with the Japan Hospital Association. It assesses and supervises the testing institution regarding the content, quality and accuracy of testing, computerization and so on, in both technological and administrative aspects. It also accredits the physician as a "Registered Qualified Physician of the Human Dry Dock ". In the past two years of its activity, about 1000 physicians who work in the field of health evaluation have been accredited.

　I have discussed how health evaluation medicine has developed and spread throughout Japan. The favorable reasons, which contributed to this dissemination of the practice among a fair proportion of the Japanese people can be summarized as follows:

　

　Thus, more and more people in Japan sign up for health check-ups, and proportionally, the number of medical institutions that offer the evaluation services has risen every year. In addition, health-screening programs similar to the above have spread quickly in various countries in East Asia in the past 10 years, its forerunners being the Republic of China and South Korea. Currently, the number of recipients in those countries surpasses the number in Japan.

　In this worldwide trend, numerous superior clinics and medical centers were established to conduct health check-ups. Also, an increasing number of the departments that conduct health check-ups have come into existence in major representative general hospitals of Japan. The Japan Society of Multiphasic Health Testing and Services conducts an investigation of an institution by sending it an anonymous sample to be analyzed. The society also invigorates the appointment of trained professionals. Upon meeting the standards, the Society accredits the institution as superior in quality control, health evaluation, and health promotion. Let me present the figures to illustrate the rate of increase of these testing institutions (Fig.1).

　The Society also designates the testing items and evaluation categories in order to make the health evaluation effective. When an innovative method of testing arises, it is again the Society's duty to introduce it into the existing testing schemes. The number of Japanese people who receive periodic health check-ups in a highly qualified institution is on the rise every year.

　

　

　I have already said that in 1974, the 5th IHEA Conference was held in San Francisco. It was at that membership meeting that I became aware of the various activities of this Association. On my way back to Japan, I stopped over in Hawaii to visit Dr. Gilbert at Straub Clinic and learned first hand from him how to run a health evaluation program. Since then, Japan has been a member of IHEA.

　Six years later, in 1980, Japan was a member of Region III of IHEA along with Hawaii. That year, the Japan Society of Multiphasic Health Testing and Services hosted the 8th biennial meeting of IHEA in cooperation with MEDINFO. At that time, Japan was the only country in East Asia which was a member of Region III of IHEA.

　Four years later, in 1984, the biennial meeting was hosted by Region II in London. At that time, the theme of the meeting was: "Promoting the Well-being of the Elderly". Up until then, in particular around the year 1964 when the Kaiser Foundation started automated multiphasic health testing and services, a massive number of younger adults received health check-ups, but there were few eldery recipients. This seems similar to the current situation in the Republic of China.

　However, in the subsequent 20 years, the general elderly population increased in Japan, as well as in the United States and Europe. This explains why more elderly people received health check-ups in these later years.

　In Great Britain and the United States, health check-ups always came along with health guidance. This was the case in its early stage. The guidance was given in order to prevent the chronic diseases of adulthood. Of course, the primary purpose was early detection of diseases, but the belief was that by giving suggestions to improve an individual's lifestyle, the onset of chronic diseases could be delayed or avoided altogether. However, in Japan, there was a period when the emphasis was laid on early detection of diseases and prompt treatment.

　It was at that time that I founded an organization called the Life Planning Center. That was in 1973, 27 years ago. In this Center, we not only started automated multiphasic health testing and services, but also a program, which emphasized adult health education. We did this to change unfavorable lifestyles and habits. As time went on, it became clear that to change lifestyles and habits, we must identify the risk factors prevalent in the everyday life of the recipients of the testing and services, and hand the list of risk factors to them. Research was started on teaching methods, because we wanted a program which led to behavioral change, which the traditional didactic teaching method could not accomplish.

　Regarding this point, the Americans had already started prospective medicine in the year 1965, 35 years ago. This prospective medicine was advocated by Dr. Levis D. Roblins (1909-1990). Just like Dr. Roblins, I was interested in science that would bring about behavioral change. Therefore, from early on, I have devoted a lot of time towards introducing prospective medicine into the philosophy of health check-up programs in Japan. We received research grants from WHO in 1984, 1987 and 1990 which enabled us to study the current situation and eating habits of the Japanese people. Our goal was to devise a primary preventive strategy to alleviate the incidence of diseases, which were caused by unfavorable lifestyles and habits. In Japan, the term "Seijin byo", meaning "diseases of the adult", had been in use since 1957 (32nd year of Showa). My intention was that this term was incorrect. As of 1980, I continuously suggested to the government that the term "Seijin byo", meaning "diseases of the adult", should be changed to "Shukan byo" which means "habit diseases" or "life-style-related diseases". Finally in 1998, a law was passed and the term "Seikatsu shu-kan byo (life habit diseases)" was formally adopted by the Japanese government.

　The discipline called "prospective medicine" ascertains from the individual's lifestyle the risk factors that cause chronic diseases. Here. "lifestyle risk factors" refer to smoking, drinking, a high-fat and high-sugar diet, obesity, lack of exercise, stressful life, and so on. Prospective medicine assesses the time of onset of the diseases and the span of life, which will be shortened, if such habits were to persist in the future. Prospective medicine also provides positive predictions. For example, the client can be told that if he or she gets rid of the risk factors, then he or she can expect a certain outcome. The client can be pursuaded by presenting data effectively.

　It is very important that we try to motivate, and not didactically teach, the clients towards adopting a better lifestyle. We should also try to put the suggestions into actual practice. For this, we must use the tools derived from studies of behavioral medicine. Furthermore, assistance should be given to the clients so that behavioral changes persist throughout their lives. Methods learned from both behavioral science and prospective medicine should be applied. When we succeed, health education of the individual as well as the community is successful. This will propagate into a national scale, as we promote and maintain the health of the citizens of the whole nation.

　I became Chairman of the Board of Directors of the Life Planning Center in 1973, and subsequently of St. Luke's International Hospital. With the collaboration of these two institutions, and with immeasurable assistance from Professor K. Yoshida and others, we started health-risk appraisal using the data obtained from the ordinary automated multiphasic health testing and services. The details of this research were published in "Methods Inf Med" 1993; 32:260.

　The health screening system in Japan began in 1954. Since then, for 46 years, the health screening system has functioned for secondary prevention, for the early detection of diseases, and providing health guidance. The outcome was not necessarily favorable, as the health guidance consisted mainly of didactic teaching. Didactic teaching often created a new disease, hypochondriac neurosis.

　However, since 10 years ago, secondary prevention and behavioral science have been adopted in Japan. Along with that, the direction of health guidance also changed. Health guidance used to be physiciandirected, but now it has become more of "team guidance" involving all health care staff, including nurses and dieticians.

　These changes in the Japanese health screening system make me look back on the early days of IHEA. At biennial meetings, topics covered were, for instance, health history taking, testing items, health guidance, and utilization of information science. The presentations dealt with problems of secondary prevention, assessment of the test results, or testing efficiency. But gradually the topics turned to, for example, the quality of health education, or introduction of methods of prospective medicine.

　In 1986, the first International Conference on Health Promotion was held in Ottawa, Canada. It was hosted by the WHO, the Canadian Government and the Canadian Public Health Service. It was on this occasion that the Ottawa Charter on Health Promotion was formulated, which evolved from the activities led by the WHO on health promotion. The Charter reads as follows: "Health promotion is the process of enabling people to increase control over, and to improve, their health." Furthermore, it states: "To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. Health is, therefore, seen as a resource for everyday life, not the objective of living."

　In view of this development, IHEA also took up health promotion as an issue of importance in addition to health screening and health evaluation. In Japanese, the word "health promotion" was translated as "kenko zoshin (enhancement of health)". The term connotes the state where a person gains more stamina and acquires robust muscle tones. At least that is the image the Japanese people visualize. However, the essence of the WHO definition of "health promotion" is that people take control of their own health and the environment, thus increasing the opportunity to choose the lifestyle leading to good health. Ideally, people learn about it through their own daily living, and train themselves further so that they can cope with chronic diseases and handicaps in all stages of their lives.

　As we are "earthen vessels", our body ultimately ages and succumbs to diseases. However, we can live our lives with gratitude if the body contains a healthy spirit, which contributes to a high level of QOL. In other words, a healthy spirit gives us energy and joy of living. The obligation of the government and society is to provide support so that we can individually choose to live this way. My interpretation of the term "health promotion" is a way of life where all of us live with a sense of gratitude for our good health.

　At the moment, a proposal has been made to the IHEA Board of Directors. It suggests that the name of the Association be changed, by adding "health promotion" before the "A" of "IHEA". I wholeheartedly support this proposal. The new name, the International Health Evaluation & Health Promotion Association, will express our expectation that all of us pursue a high level of QOL in all aspects of our daily living. Moreover, the perspective will make all of us give thought and make an endeavor towards the creation of a good environment suitable for health promotion. Under the new name, there is no doubt that the Association will expand vigorously as it faces the forthcoming 21st century. It is my heartfelt wish that this would come true.

　

　

　In closing, I reviewed the history of IHEA, and discussed its present problems. By presenting the following, I also wish to identify the direction, which IHEA might be heading towards in the future.

　

　It is human destiny for health to decline with age and to die of an illness. But although bound by forthcoming physical disintegration, a human being can still appreciate and enjoy the value and meaning of life during their last years of life. Ideally, even when the body is ill, the mind should stay sound. This is the life that all of us should strive for. My hope is that this International Conference contributes towards creating an environment in which such a movement bears many fruits.

　I would like to show you the list of the past IHEA Conferences since the year 1970 (Table 1). I also listed the names of the Presidents who organized them. My deepest gratitude goes to the late Dr. Gilbert, Mr. Oldfield, Mr. Timken, Dr. Kashida and many others who dedicated their efforts toward the development and growth of IHEA.

　Finally, I wish to say "thank you very much" from the bottom of my heart to Dr. Sung, who took on the responsibility of holding this 17th Conference here in Taipei, and to Mr. Sou, who generously sponsored it.