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    Bureaucracy in action

    Japanese language and culture, as you’ve probably heard many times, are full of nuances as impossible to grasp as the wisps of smoke that curl toward heaven from a bowl of incense in a darkened room. Therefore, it may interest you to know that some concepts translate into and from English with no loss of meaning at all.

    Consider, as an example, the reform of government programs undertaken by the Koizumi adminstration and the ruling coalition that supports it. The idea is to deregulate and even privatize certain operations in certain spheres–Japan Post reform has gotten the most attention, but the health-care behemoth is on the list, too:

    Ministers attending a Cabinet meeting Tuesday agreed to give the report, presented Friday by the Council for Promotion of Regulatory Reform, an advisory body to Prime Minister Junichiro Koizumi, serious consideration.

    In another gesture supporting easing government regulations, one of the prime minister’s key structural reform initiatives, the Cabinet approved a plan to revise in March the three-year deregulation promotion program that has been in force since April.

    In line with Koizumi’s public pledge to push forward with deregulation as an integral part of his reform agenda, in May the government established the Headquarters for Promotion of Regulatory Reform, made up of all Cabinet members.

    One of the top discussions in the regulatory reform council was on the idea of lifting the ban on providing mixed medical services, enabling patients to receive a combination of medical treatment covered by government-backed health insurance plans and medical treatment not so covered.

    The mixed medical service system currently is limited to hospitals designated by the government as medical institutions with specially advanced medical technology.

    The ban, of course, prevents some patients from having access to the best combination of treatments for whatever ails them. Westerners who have swallowed the entire media diet of stories about the self-abnegating Japanese, and thus think of the place as populated by 125 million potential kamikaze pilots, seem to imagine that everything federal employees do is attuned to the greater good. If you’re one such trusting soul, it may interest you to know that Japanese bureaucrats act like…well, bureaucrats:

    Objecting strongly to the council’s argument was the Health, Labor and Welfare Ministry, bureaucrats of which were anxious about a decline in the role of government-backed health insurance plans that come under the ministry’s jurisdiction.

    In defending its position, the ministry claimed that a mixed medical service system would deprive patients of the right to equal treatment.

    Major university hospitals, including those attached to Tokyo University and Kyoto University, meanwhile, pushed for a complete lifting of the ban, arguing that progress in advanced medical technology was being hindered by too many regulations around the government-backed health insurance plans.

    This resulted in a compromise being hammered out that ensured the ban remained, in return for a ministry promise to expand the current system to extend government-backed insurance coverage to exceptional cases currently not covered, such as heart transplants from brain-dead donors.

    It’s the sort of thing that belongs in a textbook, huh? Unelected officials find their authority (and thus their source of influence) threatened, and they justify their opposition by claiming that what they’re worried about is, of course, that reforms will infringe on the rights of citizens. Being career civil servants, they’re much better at strategy than their opponents, who, as the people who have to deal with the day-to-day problem being addressed, don’t make their livelihoods by maneuvering. Then, somehow, their territory is actually expanded by the plan ultimately extruded by the chain of committees, compromise proposals, and negotiations.

    I think it’s fair to say that most of the people who go into civil service here are as patriotic and idealistic as their counterparts. The problem isn’t really that Japanese bureaucrats are worse than bureaucrats elsewhere; it’s that the system disproportionately favors them. They get used to having their way as a matter of course, but they still get to see themselves as sacrificing personal gain because of the revolving-door system (that is, you take lower-than-private-sector pay through your normal working life, then get a cushy job in a private or semi-public company on retirement so you can spend the next 20 years making good on the connections you’ve built up). The recent economic troubles have made that system shakier, and the various bureaucracies have, understandably, therefore been clinging all the more to the power they’ve got. Reform is, needless to say, difficult in such an environment. Even a slight loosening of restrictions on treatments people can get is a good thing, though.

    5 Responses to “Bureaucracy in action”

    1. John says:

      “Right of equal access”? Really? And what the heck does that mean, anyway? So, someone going to old Doc Tanaka (who hasn’t changed the way he practices medicine since he retired from the University in 1984) at the corner clinic is getting equal access to someone who is going to TMU in Shinjuku? In most systems, Doc Tanaka would have to refer you to TMU, but in Japan you can bypass Tanaka and go to the world-renowned virologist about your cold and sniffles. Equal access in theory, but in reality the TMU doc makes you wait for 3 hours and sees you for less than 3 minutes. Poverty of care for all, but at least the bureaucrats control everything, so everyone’s equally poor, right? I’m only exaggerating very slightly, here. Of course Koseirodosho and the NHS are also concerned about skyrocketing fees just when they managed to make some relatively meaningful reforms in the reimbursement system, but they’ll never admit that.
      This as it relates to your previous post is all but a guarantee that Japan will never lead the world in medical science (in the aggregate, there is always the possibility for lone genius).
      In defense of Koseirodosho, however, allowing non-covered medicine to flourish is also going to boost the “chuu-i” docs who will now attach themselves to legitimate Western clinics. Some of them are good, but there is a lot of charlatanism in Chinese medicine, even as practiced in Japan.
      But as far as the Koseirodosho maneuvering goes, it’s no different from that described in Straightjacket Society. The Boomer generation of Japan will have to pass away before reform comes in reality. There’s just too many of them in the government, and their private sector contemporaries have, in many ways, the government they deserve.

    2. Sean Kinsell says:

      Well, there are lone Japanese geniuses in medicine even now, but they tend to move to research centers in Western countries where they aren’t constricted by the patronage system. (BTW, for anyone wondering what the heck John is talking about: TMU is Tokyo Medical University, one of Japan’s most prestigious medical schools, with its affiliated hospitals; and the Koseirodosho is the Ministry of Health, Labour, and Welfare.)
      Just out of interest, how much easier would it become for purveyors of shady medicine to bilk people if non-covered treatments were less restricted? My understanding of the current bill is that it allows doctors who are in the National Health system to prescribe a mixture of covered and non-covered treatments. Would that just make it more likely that people would get their untested diet aids and herbal medicine directly from their GPs?

    3. John says:

      I was thinking more of useless acupuncture therapies. If you look at Chinese folk practices, most use herbal medicine and shy away from acupuncture, unless as a last resort. Westerners who use Chinese medicine are the opposite, because the acupuncurists made common cause with the chiropractors and got a lot of publicity with Western neo-luddites. People who want to take OTC Chinese medicine such as the diet aids that killed people’s livers are still going to get it from the pharmacy with the deer penis in the window that I used to stroll past on my evening constitutional. The widespread stories of adulteration and mis-labeled herbs and dosages in Chinese OTC preparations should be enough to kill that market, but P.T. Barnum was, unfortunately, on to something.
      I object to traditional healthcare insurance covering Chinese or other alternative therapies. There is just too much charlatanism and too much of the placebo effect for insurers to make rational decisions. If you want that coverage, pay more for it, but don’t expect me to subsidize it. In NYC, Oxford is now covering that crap. In Japan, Meiji-era reforms drove the indigenous medicine underground, and it didn’t resurface until post-WWII. It resurfaced as a sort of hybrid, with all approved Chinese prepaprations being factory-made. Unlike in the rest of Asia, Western (in the sense of medicine, not ethnicity) docs can prescribe Kampo, and about 150 preparations are on the reimbursement list, but they are extracts, not fresh herbs. Most Western docs in Japan have very little clue about Kampo, and there are Kampo departments in most major universities. My in-laws who practice Chinese medicine in the ROC think that extracts are nearly worthless, and both the extract and fresh herb camps have some evidence to their claims. However, Koseisho has no way of regulating fresh herbs, so Kampo as practiced in Japan is about 80% factory-made extracts.
      I most object to the wording of equal access. ALL healthcare payment schemes seek to ration unequally. Counterintuitively, that is the fairest system. Anyone who says otherwise is lying. In Japan, its convenience that drives you to the corner doc rather than the University Hospital . In America, it’s the referral system. Not everyone graduates at the head of the class, so not all care is or should be valued the same, even in systems that artificially level prices. The waiting times for the good docs in Japan are the way that the patient demonstrates need, so everything’s equal, except that retirees with time on their hands take more of the good docs’ time. while working stiffs just see the corner doc. Since most if not all docs do not make appointments in the University systems, the waiting rooms become senior citizens’ social clubs.

    4. Sean Kinsell says:

      I have to admit to seeing both a chiropractor and an acupuncturist–but that’s because I have chronic back pain, not because I think anyone’s unleashing the power of my life-force conjunctions or fixing kooky-mysterioso subluxations.
      I hope the deer penis helped you feel reconstituted.
      Um, what else? Oh: yes, you’re right about the accessibility problem. Japan being a culture in which the proper introduction is highly prized, it is the case that referrals will open doors for you. They’re not the same as the official, take-a-number kind of referral you get in the States, of course, but they have their effect.
      Otherwise, you’re right. In America, the endurance test is money; in Japan, it’s time. If you have the leisure to fill out forms and wait at five successive counters for a full weekday afternoon, you’re golden. Otherwise, you go to your local clinic and take what you get.
      Incidentally, my experience is only anecdotal, but I will say that the kampo extracts I’ve gotten from my (non-National Health) GP have been really helpful. I don’t know what they’d do if given alone for illnesses that mean Big Trouble, but when I’ve taken the things gives me to keep my appetite and energy up over a course of antibiotics, I really have started feeling better more quickly than with the antibiotics alone from other (National Health) doctors. Of course, it could be separate placebo-effect-ish factors: that he actually tells me what he’s giving me with a demeanor that conveys confidence about their effects; that he listens to me as if I know my own body; and that, in general, once you’re receiving treatment, you tend to start taking care of yourself like someone who expects to get well. FWIW. Whether I’m Barnum’s sucker of the minute, I can’t really judge. In any case, it’s definitely better than being given packets of mysterious white powder, then going home and looking up the trade name on the web to find out they’re full of powdered acetominophen.

    5. John says:

      Well, I didn’t mean to totally trash acupuncture, I know of one recent DBPC study where it was much more effective than non-surgical Western interventions to prevent breach delivery and get the baby to turn around. In my limited experience though, there are more charlatans in the US practicing acupuncture than herbal medicine. Chinese people themselves look at needles as a last resort, and given the levels of hygene in much of China, I don’t blame them. St. Luke was on to something with the laying on of hands, though: that and the prick of a needle anywhere (not just on a “meridian”) is enough to invoke a powerful placebo effect for pain. In fact, even in trials of Western pain meds, there is often a pbo effect of over 30% from the better care and more careful attention from the doc that comes along with enrolling in a trial.
      I myself use Chinese medicine (not acupuncture, but herbs, massage, and moxibustion) for a few things: my distant in-laws practice folk medicine in a remote area of Taiwan. I balk at drinking the alcohol with the wasps in it, though. And I don’t even want to think about getting an STD from powdered deer penis.
      As far as Kampo goes, I know how much variation in batches there are in herbs (think about how much microclimate influences the taste of wine), so the Japanese Kampo may be more reliable than some Chinese fresh preps, but extraction does destroy some potentcy, so as I said, both the extract and fresh herb camps have some evidence on their side. Koseirodosho relaxed their requirements for purity for Kampo drugs because of the batch-to-batch variability problem, which the FDA will not do, so you’ll never see Kampo preps approved as drugs in the US. You can get them in the US (especially the Tsumura stuff) from suppliers who sell them as nutritional supplements, though. None of the 150 or so Kampo preps are approved as stand-alone drugs for Big Trouble, so far as I know. Much Kampo is used as chemotherapy adjunctive therapy to counter side effects such as lowered immunity and anemia, similar to the reasons you took them.
      In the PRC and ROC, you must be a certified Chinese Medicine doc to prescribe Chinese meds; Western-trained docs don’t have that right, and vice versa. Very few docs in China are cross-trained. In Japan, one 7 week rotation in Western medical school is spent on Kampo. There are docs who only study and dispense Kampo, but they are Western-trained docs who decided to do that. No Chinese-trained Chinese Medicine doc has the right to give medical advice in Japan unless they went to a Western medical school.
      As for Chronic Low Back Pain, no western med is really good for it – it is probably what we call a “mixed pain” state, meaning that several different types of nerve conduction are involved, so NSAIDs like ibuprofen or opiates like codeine do not take care of all the problem – each one of those only hits one kind of nerve conduction, and even combining the two won’t hit neuropathic pain that is caused by non-pain signal nerves getting in on the act.