Land of the rising geriatrics
In any other country, 100th birthdays are a cause for celebration. Not so in Japan, where extraordinary life expectancy is creating a timebomb for the nation's health and social security systems. Jeremy Laurance reports from Tokyo on a looming population crisis
With hands clasped neatly in her lap and iron grey hair combed straight back, Haru Matsumara, 100 last April, explains the secret of her long life.
"I do like milk but I could not afford it when I was young," she says. "I have never eaten a lot of meat. I like traditional foods – fermented soya beans and fried bean curd." It is not much to account for a century of existence, most of it lived in rude good health. But Mrs Matsumara, the oldest resident of the Sunflower care home in the Japanese city of Kyoto, mentions one other vital ingredient. "I have a happy-go-lucky nature," she adds. "Even if I am worried, I get a good night's sleep."
Her large, soft face with its skin like parchment breaks into a smile. Her voice may be a little hoarse now, and the folds of her neck quiver as she speaks, but her demeanour can be summed up in one word: cheerful. It is a characteristic often found in the extremely old. Jeanne Calment, the oldest person ever recorded, died at Arles in south-western France in 1997, at the age of 122. She attributed her longevity to an ability to "keep smiling".
Japan, long renowned as a society which venerates the elderly, boasts 25,000 centenarians – more than four times as many as Britain – yet its population, at 127 million, is little more than twice ours. However, it is no longer smiling at its achievement. The current record-holders both live in Japan – Yone Minagwa, the oldest woman at 114, and Tomoji Tanabe, 112, who was confirmed as the world's oldest man in June and presented with his certificate by Guinness World Records last week. Yet, instead of celebrating, he apologised for his longevity, joking: "I have been around too long. I am sorry."
Mr Tanabe's pessimism is understandable. What should have been a moment of rejoicing at a long life well lived has instead become an occasion for alarm. Japan is facing an ageing crisis as its elderly population grows. It is the fastest ageing society in the world and one in five Japanese people is over 65. By 2015, that proportion will have grown to a quarter – 33.8 million people – and it is projected to rise to 40 per cent by 2055. At the same time, the birth rate is falling because of the same social pressures facing western nations – later marriages, more women going to work and the trend for having smaller families. In 1949, Japanese women had an average of 4.32 children in their lifetime but this had halved by 1971. The birth rate has plunged further to 1.26 today, well below the replacement rate. As a result, Japan's population is projected to fall from its current 127 million to 90 million by 2055.
No country in the world has faced a challenge on this scale. As its elderly population grows, medical and pensions costs are surging but the number in the labour force who pay taxes to support the country's welfare system is falling. Thanks to Japan's long economic recession, which began with a stock market crash in 1989, the government debt is already the highest among developed nations. Today, there are three people of working age to support each person 65 but that number will have fallen to 1.2 by 2055.
Ed Wright, the First Secretary for Science and Health at the British Embassy in Tokyo, said: "It's a tough time to be 50 in Japan. People sold themselves to their companies in the 1970s in anticipation of a comfortable retirement. Now they have fears about job security, house prices which are worth a quarter of what they were. The stock market, which peaked at 40,000 points in 1989, now stands at 16,000, having been down to 7,000. They also worry about health insurance."
The ageing juggernaut about to hit Japan is heading down the tracks in all developed countries, and threatens social and economic meltdown on a global scale. That is why the world is watching closely to see how the Japanese cope. The government has responded on three fronts – with a new insurance scheme for the elderly, a strategy to stem the rise of obesity and other lifestyle diseases, and the introduction of hefty patient contributions to curb demand for healthcare. Will it be enough?
Life expectancy in Japan has been rising for 160 years at a steady pace of two years every decade. In 1840, the then record held by Sweden was just over 45 years. Today, it is held by Japan at 85.52 years for women and 78.56 years for men, almost five years longer for women and three years longer for men than in Britain. In its World Health Report this year, the World Health Organisation declared that Japanese women were once again the health champions of the planet, living longer and healthier than men and women all 193 countries. Its phenomenal success has been attributed to a combination of the right genes, helped by a diet based on rice, vegetables and fish and extremely low in animal fats.
The tropical Okinawan islands in Japan's extreme south-west are home to more than twice the national average of centenarians. Their traditional diet is deemed even healthier than that of mainland Japan, with more edible seaweeds, higher protein content and more local produce rich in antioxidants, as well as a more relaxed lifestyle. In addition, the Okinawans have a cultural habit of calorie control called hara hachi bu – or "eat until you are 80 per cent full". Since it takes the stomach's stretch receptors about 20 minutes to tell the brain how full it really is, this helps to avoid over-eating. Consequently, the Okinawans consume fewer calories and are among the leanest and fittest people in the country.
But the islanders' famed good health is now under threat, as it is in the rest of Japan, from the adoption of western lifestyles. While elderly Okinawans are still the healthiest among their generation in the world, rates of obesity, heart disease and diabetes are rising rapidly among middle-aged people raised on a diet of burgers, ice cream and sugary snacks. Japan is experiencing a fast-food epidemic. In Tokyo, McDonald's, Kentucky Fried Chicken and Krispy Creme doughnuts have pushed out the sushi bars. McDonald's recently reported record Japanese sales of 43 billion yen (£183m) and said it had sold 1.7 million Mega Macs – a towering medley of four burger patties in a bun – in four days. When a Krispy Creme opened in the city's Shinjuku district, people queued around the block to sample one of the calorie-laden doughnuts and an estimated 10,000 people visited the branch in its first three days.
The strong tradition of families eating an evening meal together is breaking down in cities where two-hour commutes are common and workers grab a calorie-laden snack as they leave their offices, rather than wait to eat at home. At Mukou City Primary School, on the outskirts of Kyoto, a smart establishment for the children of professional parents, pupils eat a healthy lunch of fish, clear soup with tofu and aubergine with minced meat. But, when asked to name their favourite dish, they chorus: "Western food." "When we go out, it is always to McDonald's," says Jackie, 11.
The government is struggling to tackle a triple threat from the growing number of elderly, the incursion of western lifestyles and the increasing demands on the health system – with mixed results. In 2000, a long-term care insurance scheme was launched to which everyone over 40 is required to contribute an average of £20 a month. The fund is used to pay for care for the elderly, whose needs are ranked on a scale, either in their own homes or in care homes such as the one occupied by Mrs Matsumara. But the scheme has already run into difficulty as demand has vastly exceeded supply. Hence, the premium has been raised 40 per cent in five years and elderly applicants have been re-classified to a lower dependency level in order to reduce their benefits. The changes have raised doubts about the viability of the scheme and heightened the sense of insecurity about the future.
Dr Testuro Ichida, the head physician at his privately-run Ichida Hospital, said: "Many of us in the field feel the long-term care system is collapsing. There is not enough to pay decent wages to care assistants. We already have four patients over 100 in our hospital, and there will be many more."
In a further effort to restrain costs, the government has announced that, from next year, health insurers will be required to offer medical checks to anyone over 40. The aim is to reduce the burden of chronic diseases such as diabetes, which affects almost 20 million Japanese. A target to reduce diabetes by 25 per cent by 2015 has been set. In Britain, such a scheme would be unlikely to change people's behaviour on the scale required but in the more conformist society of Japan, it is already paying dividends. Staff health checks introduced by the car-maker Mitsubishi are claimed to have reduced risk factors by 30 per cent after lifestyle problems were identified.
On a third front, the government has massively increased the level of patient contributions – called "co-payments" – to the costs of healthcare. Spending on Japan's health service is modest by international standards – just 8 per cent of the country's gross domestic product – but the health ministry says this will rise by 2 to 3 per cent per year from its current level of 33 trillion yen (£135bn). All Japanese have health insurance provided either by their employer or by the government and are free to visit any doctor or hospital they choose. Co-payments, Originally set at 10 per cent of the cost of treatment, were raised to 20 per cent in 1997 and to 30 per cent in 2003, with a cap of £300 a month.
The ministry has also acted to curb Japan's astonishing length of hospital stay – an average 36 days for each patient admitted, compared with just 7 in Britain – by re-classifying medical beds as long-term care beds, which are reimbursed at a lower rate. The backlash to this was immediate. Fumihito Higashi, the deputy director of the health insurance bureau at the Ministry of Health, Labour and Welfare, said: "The public reacted very strongly against us. They think we are throwing out patients by changing the definition of medical and long-term beds but, unless we do something, the cost of the health service will rise to 60 trillion yen (£25bn). That is why we have to act."
Experts say the pressures on Japan's health service will soon be felt globally. Karol Sikora, a cancer specialist at Imperial College, London, joined a study tour of the country organised by the British private health insurer, Western Provident Association. He said: "There is a global crisis affecting healthcare systems driven by the ageing of the population, technical innovation, increasing consumerism and societal change. Social solidarity is dead, the role of women is changing and being a care-giver is a low-rated job. Japan does seem to be getting value from its health service – they are paying less for items such as CT scans than we are – but politicians are stuck with an ageing population that pays very little tax putting an increasing burden on the young. You can't raise taxes beyond a certain level, which means some form of co-payment will be needed. What we are seeing here is the shape of things to come everywhere, as populations age."
Mrs Matsumara has already outlived her son, who died of cancer six years ago. She could, she says, have gone to live with her widowed daughter-in-law. But she would still have needed care, so she chose to come to the Sunflower home – with its views of rice paddies, its elegant café and its Sunset Bar – for as long as she can afford the heavily-subsidised £850 a month it costs. She leans forward to give one last homily on living a good life. "Since 1992, when I had a stroke, I have made it a rule to keep a diary so as not to forget things," she says. "Every morning I mark the calendar – it is another new day."