6
The Setting and the System

The Setting

Location

Fuji-no-Sato is located on the Izu Peninsula about two hours by express train southwest of Tokyo. The peninsula has been developed as a major tourist attraction and resort for Tokyo area residents. Izu was given modern fame by Yasunari Kawabata's first novel, The Izu Dancer , which depicts the area around Fuji-no-Sato some seventy years ago. Beautiful mountains lie along the central spine of the peninsula, separating the eastern and western coasts. Because of its proximity to Tokyo, the eastern coast is the one better developed for tourism.

The peninsula has just about every requisite for a resort area. Because of the fine scenery, it is a part of the larger national park that includes Mt. Fuji. There are good natural hot springs here and there, around which tourism started about a century ago, leading to the development of the first major towns. Then, as today, a trip to a hot spring was one of the most popular enjoyments of the Japanese, especially the elderly, because it is believed to be good for relaxation and health, particularly for chronic impairments like arthritis and back pain. Today the peninsula also offers a wide range of leisure and sport facilities for the young and old and for families. Because it is in a national park, development is in general carefully controlled, and nature is well preserved. Every year the unspoiled natural environment attracts thousands of people who flee the stifling heat and smog of Tokyo to enjoy the golf courses, tennis courts, bicycle trails, and amusement parks. National highways trace the scenic coastline and attract motor tourists. Because of the peninsula's volcanic origin, beaches are few, and the coastline is mostly rocky, high cliffs. But the water is clear, and the scattered small beaches attract enormous summer crowds.

Climatically, the name Izu evokes images of a land without winter. Slightly cooler in summer than in the center of Tokyo, it is also much warmer during winter months. In early March, the blooming of wild narcissus at the southern tip of the peninsula marks the beginning of the spring sightseeing season. Although the mild climate makes tourism a yearround business, summer is the busiest season. Extra trains from Tokyo are added on routes to the eastern side. The trains are usually packed, as are the highways. Summer season starts in early July and usually ends in September, when the waves begin to run high, making swimming dangerous. The end of the summer season is generally proclaimed symbolically by a typhoon or two lashing the peninsula with violent wind and rain.

The eastern side of the peninsula, where Fuji-no-Sato is located, is within the range of a day trip from Tokyo. The immediate area is occupied by a small, relatively isolated fishing and farming village, about thirty minutes by car from the nearest city. Compared with other sightseeing spots on the peninsula, the area has an atmosphere of cultured taste, being occupied mostly by homes and small hotels—the result of private development by a railway company. Today there are a great number of these second homes, mostly Western-style cottages owned by wealthy Tokyoites. There are also many elite small hotels and rental cottages, which are leased only in the summer. In recent years, large corporations from Tokyo have built hotel-like facilities for employee recreation and training. Thus, the population of the village multiplies on weekends and in summer when people come from Tokyo to stay there. Prices at local supermarkets are higher than average, almost equivalent to those in Tokyo.

In short, the area has an established social image as an upper-middle-class resort. As such, it combines two distinct levels: the traditional village—a huddle of old houses on low land near the fishing port—and the newly developed spacious resort section on high ground near the railway and highway. The traditional economic structure of the village has disintegrated, and the old-time residents are now dependent on revenues from tourism. Citrus farming was once a booming local industry but is almost dying now. Commercial fishing has dropped sharply in recent years, probably because the local waters have been fished out by modern methods. Many former fishermen now conduct sport fishing trips.

Most of the resort section had already been developed at the time Fuji-no-Sato was planned, but sufficient land was found along the lower edge of this tract, near the village. One cannot see the Pacific Ocean from the community, but it is only about a fifteen-minute walk to the high-cliffed coastline. Fuji-no-Sato is also a fifteen-minute walk from the railway station, or five minutes by the community's shuttle bus. In the immediate neighborhood, resort cottages are scattered throughout the natural woods. There are several coffee shops and a couple of restaurants within walking distance of the community. Streets are wider than the Japanese rural average but short, curved, and without signs, so people unfamiliar with the area often get lost.

Building Structures

The stringent zoning regulations applied to development in this national park have made Fuji-no-Sato a unique retirement community in Japan. On postcards available at the community shop, an aerial view shows thirteen white buildings embedded in natural green woods. Besides the buildings, the only visible surfaces are the community's wide streets and a utility yard at the back of the community center. Under the yard is hidden a sewage treatment plant. By regulation, the buildings are two-storied and cover no more than 20 percent of the land that the community owns. The woods are so well protected that the management cannot cut a tree on its own land without prior approval from the local office of the Environmental Protection Agency. Fuji-no-Sato is, in fact, the only retirement community in Japan that has no high-rise buildings.

The community is isolated from the main village and secluded by deep woods from the shopping area near the highway and from the railway station, which is also the nearest place where the residents can catch a local bus. Although some residents enjoy walking in the woods and take shortcuts to reach these conveniences, the majority take the community's shuttle bus, which runs three times a day, or call a taxi when the shuttle service is not available. At the time of the research, only 9 of the 372 residents owned cars. Because of their geographical isolation and limited transportation, most spent their days within the grounds of the community.

The structures of Fuji-no-Sato conform to the upper-middle-class social image that the surrounding area seeks. The thirteen buildings, painted white, brighten the community with reflected sunlight. In summer particularly, the contrast between the white buildings and the dark green woods is remarkable. As one crosses the access bridge that leads into the estate, heading toward the center of the spacious community, one finds small gardens everywhere along the wide streets and among the buildings. The gardens, divided into tiny plots by volcanic rocks, are meticulously cared for by the residents. A variety of flowers grows here most of the year, and in winter, the people cultivate plants with colorful leaves.

Gardening was the most important spontaneous activity among the residents. The amount of energy they poured into this art, and the intensity of their interest in it, prompt the question whether there may be more to it than mere hobby activity. We discuss this issue in detail in Chapter 10. For instance, many residents would order seeds by mail through catalogues and plant them first in boxes in their living units, rather than buy seedlings from a nursery. This way they could carefully monitor temperature and moisture until the seedlings were strong enough to transplant outdoors. They also had to buy soil to supplement the poor, rocky earth. Early residents repeated story after story about the hardships of making the gardens, which required, among other things, removing tons of rock by hand. It was as if the gardens were symbols of their contribution to the community or territorial markers announcing their possession of it.

Many first-time visitors, prospective residents and potential developers alike, who have come to see a yuryo home for the aged, cannot conceal their astonishment at the unexpected cheerfulness and modernity. Even those who have seen photographs of the place are skeptical until confronted with the reality.

Residents vividly remember their first encounters with the community. Mr. Sonoda, a seventy-three-year-old retired bank executive, illustrates the social image problem that Japanese retirement communities have. To convince his son and daughter-in-law that his decision to move in was reasonable, he invited them to Fuji-no-Sato to see with their own eyes that this was not "one of those awful rojinhomu ." This worked well enough, but Mr. Sonoda complained that his former neighbors and friends who had not seen Fuji-no-

Sato were still skeptical. If he told them it was a rojinhomu , people immediately suspected that he had been forced by family problems to live in a gloomy institution. Eventually, he decided not to use the word "rojinhomu " and to tell those who had not seen the community that he was living at a famous resort.

The arrangement of the thirteen buildings is illustrated in Figure 6-1. Ten residential buildings surround the community center. All but three of the residential buildings are connected to the community center by second-floor bridges. The clinic and the administrative building are located near the entrance to the community.

The arrangement of the buildings is calculated to promote community building among the residents. For instance, the separation of the administrative building and the community center is based on the innovative idea that the activities in the two settings are functionally different, and this difference should be symbolized spatially. Also, compared with most other yuryo homes, Fuji-no-Sato and its sister communities have much greater, and more functionally diverse, communal activity space, the result of a deliberate attempt by the designers to promote community feeling.

One building on the grounds (not shown) is not part of Fuji-no-Sato. This is a fifty-bed toku-yo home at the southeast corner of the estate, which is run by a separate, nonprofit, social welfare organization. Although Fuji-no-Sato has a relatively large clinic of its own, the inclusion of the toku-yo home was part of planning for the long-term care of dependent residents. As in other retirement communities that have toku-yo homes on their estates, the management intended that the home would be used by their residents.

This was in practice unrealistic. As we discussed in Chapter 5, toku-yo homes are public welfare nursing homes for elderly who cannot be cared for by their families, and admission is arranged through the local social welfare agency. Despite the fact that Fuji-no-Sato provided the land for this toku-yo home without charge, the home is open to all eligible elderly in the city to which the community belongs. Fuji-no-Sato's residents share with other elderly in the area equal access, and the management has no direct control over the process. That the promotional brochure for Fuji-no-Sato emphasized the presence of the toku-yo home ("when residents become bed-ridden, there is a toku-yo home just nearby") was misleading, particularly for potential residents who were unfamiliar with the

Figure 6-1
Building Arrangements at Fuji-no-Sato

policies of toku-yo homes. In fact, some residents who were thus led to believe they would have priority for admission later expressed resentment toward the management when they learned the facts.

Free use of the land by the toku-yo home may have been a condition set by the city government for the construction of Fuji-no-Sato. The city, which had no toku-yo home until this one was built, has gained the most by this arrangement. There may have been a verbal agreement that the city would allocate some beds for Fuji-no-Sato residents in return for the land; this is a common practice in similar situations in Japan.

However, despite such a possible agreement, all beds of the toku-yo home were occupied soon after its opening, and it became very difficult for community residents to gain admission. On the average, only three out of the fifty beds were filled by residents of Fuji-no-Sato.

Although the community buildings and the toku-yo home are geographically close, they are separated by woods; so to visit the home from the community, one needs to leave the community, cross a small bridge near the entrance, and then walk about half a mile on a narrow road. Except for a group of volunteers who visited the home every weekday and a physician at Fuji-no-Sato who also served the home, the community and the home had very little interaction.

Accommodations

Fuji-no-Sato has 288 residential units in ten buildings. Four units were occupied by the staff, and two or three units were reserved for guests and other temporary needs. As of October 1, 1982, 281 units were occupied by 372 residents, of whom approximately 230 to 250 lived here full-time.

There are four types of units (Figure 6-2). Type A (36 units) is a studio, type B (66 units) a small one-bedroom, type C (112 units) a large one-bedroom, and type D (66 units) a two-bedroom. Type A is for a single resident, type D is for two, and types B and C can be used as singles or doubles. Each unit has its own balcony, where the residents set potted plants and dry their laundry.

Type A has a large room used as a combined living room and bedroom, and most residents in this type of unit use beds. At the

Figure 6-2.
Four Types of Residential Units

opposite side from the balcony, all units have a small kitchen. There is a Japanese-style bath, a toilet, a washstand with a large mirror, and space for a washing machine. Each unit has a three-hundred-liter (seventy-nine-gallon) hot water tank, operating on off-peak electrical power. The availability of hot water is far less prevalent in Japanese houses than in the United States, which in turn makes this an attractive feature of Fuji-no-Sato. Electric radiant heat is installed in the living room floor.

Emergency and safety measures are important characteristics of Fuji-no-Sato. Standards far exceed the existing regulations. As pointed out earlier, there are no regulations on retirement communities per se , and Fuji-no-Sato has adopted its own standards. For instance, the buildings are of fireproof construction. Because the whole peninsula is known for earthquakes, buildings are also designed to resist tremors stronger than the great Kanto earthquake of 1923. There are no sprinklers, but a heat detector in each unit triggers an alarm in the administration building. Cooking is done with an electromagnetic plate, a safe invention used experimentally at this facility, which heats only the contacting surfaces of pots and pans and presents no fire hazard if accidentally left on. An emergency nurse call button is installed in every room, including the toilets and the baths. These buttons, connected to a warning system in the administration building, are tested every three months. Handrails are installed in the bath and toilet. All incoming calls from outside are received and transferred by a staff operator to the appropriate resident, but the residents can make outgoing calls directly from their telephones. Although having one's own phone is not inexpensive in Japan, under this system, at least residents need not pay for installation, maintenance, and other miscellaneous fees, but only for the calls they make. All calls within the community system are free, and many residents took extensive advantage of this privilege. A third advantage of the system is that the staff takes incoming messages for absent residents.

Units are sold unfurnished. Residents have to bring all their own furniture and appliances except for the cooking plates. In gerontology, it is often argued that familiar furniture and other personal things may soften relocation stress and facilitate adaptation to a new environment, but most residents buy new goods rather than use their old familiar ones. Both practical and cultural explanations

can be given for this. Practically, old appliances may be worn out, and old furniture may not fit into the new small space. Culturally, the Japanese tend not to change residence unless their job demands it or unless they acquire a brand-new house. It is not unusual to start one's life at a new place with new furniture and appliances. The residents apparently felt little need for continuity of atmosphere in their quarters, but this itself cannot be taken as a sign of emotional independence.

Although the residents complained of the lack of space in their units, many of them made their rooms quite comfortable. Furniture was small and simple but generally of good quality and relatively expensive. More than half the residents used beds instead of Japanese futon . There was also a tendency to separate the kitchen from the living room with furniture or a curtain. Many widows had their deceased husband's photos either on the wall or on a table or dresser, usually with a small butsudan , or Buddhist altar. They would offer tea and rice to the altar every morning, and some of them also grew flowers to offer.

Although there is a dining hall and a hot spring bath at the community center, the residents could cook and bathe in their units if they wished to. Newspapers and milk were delivered at the doorstep by nearby stores upon request. However, mail was delivered to the community center, and the staff would sort it into residents' boxes, a strategy that brought residents to the community center frequently.

Community Center

The community center is located in the middle of Fuji-no-Sato. The location has the symbolic meaning that this building should be the center of the residents' life, and to a great extent, this was true. As the stage of all indoor group activities, the center has five large activity rooms: a craft room for wood-block printing and wood carving groups; a room called the "salon" for singing, record concerts, discussions, knitting, and various Christian meetings; two Japanese tatami rooms for traditional Japanese singing and music, Japanese chess, and tea ceremony; and a larger "meeting room" that can seat eighty to ninety people at one time and was used by groups with large memberships. The general meetings of the residents as-

sociation, meetings between management and residents, and funeral ceremonies were held in the meeting room. The schedule for the use of these rooms was kept by the staff and posted on a blackboard at the center.

The hot spring bath was sexually segregated, and the women's section was the larger, reflecting the community's sex ratio. Thirty men and forty-five women could use the baths at a time. They were open from 3 P.M. to 9 P.M. , with the peak use at around 6 P.M. It was rare that more than a dozen people bathed here at a given time. Most residents had their favorite bathing time, usually either before or after dinner. Hot spring water, piped in from a nearby well, is extremely salty; but it is said to be good for arthritis, rheumatism, skin diseases, and gynecological disorders. Although residents' opinions as to the healing effectiveness of bathing varied, all agreed that it relaxed and warmed them, especially in winter. Along with the dining hall, the hot spring baths were settings for the exchange of news and gossip and were the most important settings for social interaction.

The community center also had four guest rooms for families and friends of residents and for other visitors, including prospective residents, who were encouraged to experience a taste of Fuji-no-Sato before making a final decision. Next to the guest room section there was a small room where barber and beauty parlor services were offered once every two weeks; and there was also a laundry room with one washing machine and one dryer.

There was a shop in the community center, run by the management, that sold bathroom tissue, toothpaste, detergent, cooking seasonings, and other assorted nonperishables, including soil and fertilizer for gardening. In a corner of the shop was a small office where two or three staff worked. This office was open for small daily needs of the residents, whereas the main office at the administration building handled other paperwork. The residents reported to the small office for various maintenance problems in their units, made requests for room cleaning, and made reservations for guest rooms and for meals at the dining hall. A local bank provided service there three times a week.

There is a porch in front of the main entrance of the center where the shopping shuttle bus was parked. Three times a day, once in the morning and twice in the afternoon, the bus made its one-hour

trip. It was also at this porch that the staff sold fresh produce to the residents every Tuesday and Friday. Because the vegetables and fruits were both fresher and cheaper here than at the local stores, the sale was very popular. Many residents would come out early, wait ten to fifteen minutes, then pounce on the best items when the sale opened. It was a slightly frantic scene, reminiscent of a bargain sale at a department store, and some residents were disgusted by it. A local bakery also brought freshly baked breads and pastries to sell at this twice-a-week event.

A couple of bulletin boards, one for administrative notices and one for the residents association, adorned the wall between the main entrance and the shop. The staff would post announcements such as the names of new residents, funeral schedules, and other service-related messages. The minutes of the monthly executive meeting of the residents association and other important association news, such as negotiations with the management on various issues, were regularly posted on the other board. Although the two boards were equal in size, there was a clear contrast in that the administration's board was generally crowded with messages, and the other one was sparsely used. The office bulletin board was one of the two effective means of communication from the management and figured importantly in Kinoshita's research. The other communication channel was the public address system. Each residential unit had a loudspeaker, and the staff at the administration building would announce important news, such as changes in the hours of the clinic, cancellations of the shuttle bus, or temporary breakdowns of the hot spring bath, over the public address system. This may seem intrusive to Americans, but the public address system is a common method of communication in Japanese neighborhoods, and people were used to it.

As many as two hundred people can eat at one time in the cafeteria-style dining hall on the second floor. However, far fewer than this were present at any given mealtime. The hall was open one hour for breakfast (7:30 A.M. -8:30 A.M. ) and one and a half hours for lunch and dinner (noon-1:30 P.M. and 5 P.M -6:30 P.M. ), and the residents tended to leave the hall when they had finished their meals, seldom staying the full period. It is not a Japanese habit to make ordinary mealtimes into social events, as in French or American cultures. Despite this, the dining hall was an important place

for the residents to meet one another; if they did not use the dining hall and the hot spring bath, they simply lost some of the limited opportunities to meet other residents and make conversation. A lounge at one end of the dining hall would appear to have made an ideal meeting place because it had several couches, a T.V. set, and newspapers; but only a handful of residents spent time there either before or after meals. Moreover, even though Fuji-no-Sato had full occupancy, not all the residents lived there full-time. Of the permanent residents, a significant number preferred cooking in their own units to using the dining hall.

The residents were required to make reservations for meals at least one day in advance and to purchase coupons, which they dropped in a box when they received their trays. Regular users did not have to make daily reservations, although they were required to pay for the meals they missed unless they had canceled their standing reservation. Some disoriented residents, who often forgot whether or not they had eaten, were excluded from this practice and dealt with tolerantly.

Weekly menus were posted in the dining hall, and anonymous comments on the food were invited via a box provided by the residents association. Comments, more often negative than positive, were summarized in a posting on the association's bulletin board. The association also used the comments to negotiate changes with the director and the head staff of the dining section.

Special foods were prepared on traditional occasions, and these were very popular. On such occasions, dining hall patronage would swell significantly.

Administration

The administration building stands next to the community clinic. Here administrative staff do the paperwork for the community, operate the telephone exchange, manage the various warning systems, and so on. During the night, a male security guard is on duty here.

This is the information center of Fuji-no-Sato. On one wall are three important data boards indicating the daily location of each resident. The "residence" board carries name plates of all the residents, arranged by unit number. Black name plates indicate that a

resident is in the community, red ones that he or she is absent. The night guard would arrange the name plates on this board every morning before he left, using the information on the twenty-four-hour warning system.

The second data board is the "hospitalization" board. Here the names of the residents currently hospitalized, either at the community clinic or at outside hospitals, are listed. The third is the "absence board," which lists the names of the residents away from the community for several days or longer. Residents are encouraged to report where they are going and for how long and to leave telephone numbers where they can be reached in an emergency.

Fuji-no-Sato has a very advanced twenty-four-hour technological warning and safety monitoring system, divided into two parts. One part controls the fully automatic building safety warning system, such as heat detectors, machine room, gauges, and so on. The other part is the residential safety system. This device has three main functions. First, it registers residents' nurse calls. On receiving a nurse call, the staff quickly telephone the resident to verify the problem. If the call verifies an emergency or if there is no answer after five or six rings, the staff then calls the clinic to send a nurse to the distressed unit. During the night, this device and a twin device at the clinic are connected, so both the night guard and the duty nurse at the clinic can respond.

The second function of the resident safety unit is the twenty-four-hour warning. When the residents do not leave their units during a twenty-four-hour period, that is, when they do not lock the front door of the unit from outside during this period, a blinking light goes on automatically in the administration building. This alerts the staff to call the resident in that unit to make sure he or she is all right. If the resident is not feeling well or has physical problems, the staff can call the nursing station at the clinic. However, when the resident cannot be reached, things can become rather complicated because the staff must locate the resident and confirm his or her safety. Usually, one of the staff at the administration building would visit the resident's unit, but before that, staff would often call the branch office at the community center to ask if the person had been seen that day. This generally worked because most residents would visit the shop or other parts of the community center during the day. If these measures failed, the search would con-

tinue until a staff member confirmed that the resident was all right. Because the twenty-four-hour warning system was regarded as nonemergency by both the staff and the residents, and in most cases the alarms were false, particularly on rainy days, the staff's reaction was routine. They were aware of the habitual repeaters, the residents who often did not lock their doors when they left their units. However, when one of the more conscientious units was involved, the staff responded quickly.

The twenty-four-hour warning system is important because it works as a preventive measure; possible health crises are checked in their early stages by this system. In most cases—other than false alarms, of course—when the residents do not leave their units for one full day, they are very likely not feeling well and not eating properly but do not think they are sick enough to push the emergency button. Detecting this kind of situation through the alarm system, clinic staff can evaluate the seriousness of an illness, give proper advice, and follow the ill resident's condition.

There was one case in which a resident's life was actually saved by the twenty-four-hour warning system during Kinoshita's research. At 11:30 A.M. , December 8, the twenty-four-hour alarm flashed, indicating the unit of Mrs. Kaneda, a seventy-five-year-old widow. Because she was one of the false alarm repeaters, a male staff member said, "Oh, it's Mrs. Kaneda. Again!" But a woman staff member quickly called her unit. There was no answer. She then called the office at the community center to ask whether Mrs. Kaneda had been seen there or whether she had had breakfast in the dining hall (which could be easily checked by going through the meal coupons). The answer was no; no one had seen her that morning, and she had not eaten breakfast in the hall. After this, the staff woman went to Mrs. Kaneda's unit herself and found that, although she could hear a sound from the T.V. set, the door was locked from inside, and Mrs. Kaneda did not answer. Feeling that this might be an emergency, she rushed back to the office, got the master key, and returned to the unit. When she opened the door, she saw Mrs. Kaneda lying in her living room with her eyes half open, unable to speak. Using Mrs. Kaneda's phone, the staff person called the nursing station at the clinic. The head nurse and the physician came and checked Mrs. Kaneda's blood pressure. Mrs. Kaneda had apparently had a massive stroke. A later examination of

her room suggested that she may have had it sometime late the previous night.

Mrs. Kaneda was quickly hospitalized at the clinic, and her children were called in the belief that she might die. Although her life was saved and she later regained her consciousness, she was severely paralyzed and now survives on intravenous nutrition.

The third function of the twenty-four-hour warning system is to tell the staff instantly whether a given resident is in his or her unit any time of day. A green light by each unit number of the device stays on when the unit is locked from the inside, but it goes off when the door is locked from the outside. Thus, by looking at the bank of lights, the staff can tell who is home without visiting their unit. Every night at 10 P.M. , the night guard records the presence/ absence of residents in all units by this method. Because night comes early at Fuji-no-Sato, 10 P.M. is fairly late. The night guard checks this again at 7 A.M. the following morning to see whether any resident has come back after 10 P.M. , and rearranges the residence board accordingly before he leaves at 9 A.M.

The residents were quite aware of the role of the administration building as an information center and took advantage of it. When one called another and got no answer, he would call the office to find out whether the fellow resident was temporarily out of the unit or away from the community for some days.

Health Care

In 1983, Fuji-no-Sato had a clinic with eighteen beds, the largest retirement community facility in Japan at the time. In addition to acute care, the clinic also provided a service that was then rare for retirement communities: twenty-four-hour nursing care. Since 1983, there has been a dramatic improvement in the level of services provided at Fuji-no-Sato and at newer communities built by the managing company. Before we describe these, let us look at the health care system in operation at the time of the study.

Japanese law defines a clinic as a medical facility that has at least one full-time physician and fewer than twenty beds. A hospital is a medical facility with at least three full-time physicians and more than twenty beds. Thus, the medical facility at Fuji-no-Sato was clearly designed to fall within the legal definition of a clinic.

The clinic was on the ground level of a two-story building, the second floor being taken up by several apartments for single staff. Besides the eight inpatient rooms, ranging in size from a private room to a couple of four-bed wards, the clinic had a waiting room, a small laboratory in which blood and urine samples were tested, a treatment room, a physician's office, a nursing station, a special bathing room for bed-ridden patients, an X-ray room (including a CT scanner), a laundry room with heavy-duty equipment, and a small room for short-term keeping of a corpse. Most of the equipment was very sophisticated. The clinic was also unusual in having its own ambulance. Few small clinics offer this because it is a somewhat overregulated service in Japan.

A seventy-two-year-old woman was the full-time physician at the clinic. She had retired from her private practice in internal medicine, but was hired by Fuji-no-Sato in 1981 as its fourth physician. (Major problems at the clinic, such as hiring physicians, are discussed in Chapter 8.) She was on duty from Monday to Friday and lived in the community on weekdays, but she returned to her home during weekends. On the first and third Saturdays of each month, a geriatric cardiovascular specialist would come to the clinic from another city. On other Saturdays, a part-time physician, a man in his mid seventies, would come in from the neighborhood. He was also a retired physician, a former president of a large public hospital, and he was also on call in emergencies when the full-time physician was not available. No physician was on duty on Sundays.

The outpatient service was open only in the mornings; in the afternoons, the physician made her rounds of inpatients and visited the toku-yo home. Although the clinic was open for people in the neighborhood, outpatients were mostly residents of the community. On average, twenty-three residents visited the clinic each morning.

The health care program for the residents had two features: intensive checkups for all residents once a year and monthly physician consultations. Nearly all permanent residents, and even some not yet living at the community, appeared for their annual checkup; but the monthly visit schedule was poorly attended because the residents could visit the clinic whenever they liked. The majority of residents had at least one chronic illness; because Japanese law required them to wait two weeks between prescription refills, in most

cases, the residents visited the clinic regularly every two weeks, at which time their blood pressure was measured.

Due to the well-developed medical insurance system for those over seventy, residents' out-of-pocket payments for both outpatient and inpatient services are very small. In 1983, new restrictions were placed on reimbursement for hospitals with more than 60 percent aged inpatients, but these restrictions do not apply to clinics.

In deciding to build a maximum scale, combined inpatient-out-patient clinic, which could also double as a long-term care facility, the management hoped to capitalize on the government-supported medical insurance system, which reimburses clinic services well. Partly for this reason and partly out of their lack of knowledge about the care needs of the elderly, the management considered the eighteen beds, plus twenty-four-hour nursing care, adequate for all the health care needs of its residents—ambulatory, acute, and long-term. After four years of operation, however, it became obvious that the mixture of the "cure" and "care" functions of the clinic was problematic. Nearly all beds were constantly occupied by residents who were either in recovery or chronically physically dependent and/or disoriented. The problem was typified by the need to control disoriented inpatients who roamed the clinic day and night. Subsequently, the management became aware of the need to prepare for cutbacks in the medical insurance system for the elderly. They decided to build a nonpublic nursing home, called the Care Center, in the community for the residents of Fuji-no-Sato. It was completed in 1984.

One of the most important changes at Fuji-no-Sato and subsequent life-care facilities since our ethnographic research has been a far greater commitment to managing an increasingly frail resident population. The sister facilities all have larger clinics and skilled nursing capacity. All of them, including Fuji-no-Sato, now also operate an array of supportive services designed to promote independence among the chronically ill and disabled.

In 1992, the staff at Fuji-no-Sato is organized into six departments, roughly corresponding to six levels of care: general, residential, personal, nursing, medical, and terminal. The general care function has already been described. It is the system whereby staff keep track of relatively healthy residents and attend to their daily needs, both health care and otherwise. Residential care refers to

services designed to help slightly impaired residents function in their own units. In this category falls housekeeping help and the close monitoring of levels of well-being so that health problems (and coping problems for the anxious or disoriented residents) can be detected early and their consequences minimized. For example, there is now on duty at the dining room during all meals a staff person whose dual function is to help frail residents get their meals (by carrying trays, etc.) and keep track of which of the regular diners are absent, so that their whereabouts and condition can be quickly learned. If residents are absent, this person will go to their apartment and take appropriate action (deliver their food, refer them to the clinic for medical help, or call a nurse from the clinic to evaluate them at home). Staff is also available to run errands for housebound residents and help them with chores that are beyond their or their spouse's capacity.

Personal care refers to the next highest level of health support, to help with bathing, dressing, eating, managing medicines and accounts, and so on. Staff members sometimes take disabled residents to and from the dining room or the hot spring bath and help them there if they don't want to be cared for strictly in their own apartments. The decision as to what kind of help is appropriate is made in close consultation between the staff and the residents.

Much of the work at these two levels—residential and personal—is done by staff referred to as "helpers." These people, some of them housewives, are usually college educated, and many have considerable backgrounds in social work. They are paid on a level with nurses and are treated as professionals on about the same level. One of the problems faced by the administration at Fuji-no-Sato is how to allocate work between the helpers and the nurses because (as it turns out) most of the work traditionally done by nurses in an institutional setting does not actually require special medical training, but can be done by anyone with some appropriate experience.

In 1988, the Ministry of Health and Welfare passed a new law providing for the professional certification of nonnurse aides of this kind. Helpers with four years of college can take the new national examination for licensure as a social welfare worker (shakai fukushishi ). Those with two years can apply for a credential as a custodial welfare worker (kaigo fukushishi ).

Nursing care is available not only at the skilled nursing facility on the premises, but in the private units as well. Nurses make rounds of the residents who need regular services and visit other residents on an emergency basis if they cannot come to the clinic. The medical level of care is provided at the clinic, both outpatient and inpatient, and at the skilled nursing facility. Terminal care, resembling hospice treatment in the West, is provided at the nursing facility and in the residential units.

The gerontologist will recognize this as the "continuum of care" model, now gaining popularity in many Western settings. Its effective operation is based on careful tracking of each frail resident's day-to-day level of functioning and preparing a care plan that maximizes his or her autonomy. This system uses a previously untapped potential of retirement housing, a potential more difficult to develop in traditional settings: the availability of a wide range of services under one integrated management system. Residents can be moved from one level of care to another with relative ease because the personnel at each level are familiar with one another and often with the client as well.

But making the most of this potential takes experience and careful planning. At Fuji-no-Sato, a team approach to case management has gradually evolved to complement the six-level, six-department system we've described. Each case is discussed, evaluated, and planned by a team of six to seven professionals representing different skill levels and different areas of expertise. The management tries to assemble case teams that are efficient and knowledgeable without being rigid or insensitive to the individual resident's feelings. The level of success tends to vary according to the personalities of workers and residents, but on the whole, the system seems to work well. It is being studied and imitated by newer life-care facilities throughout Japan.

The Operating System

To briefly recapitulate our description of retirement communities in Chapter 1, Fuji-no-Sato is a life-care community, a type we defined as one whose contract provides not only residential accommodations specifically designed for the needs of the elderly but also skilled nursing care for physically or mentally dependent residents.

We also pointed out that, due to a lack of standards, there is great variation throughout the retirement housing industry in the terms of entrance contracts and the type and extent of services. This variability complicates the discussion even of life-care plans, let alone of retirement communities as a whole. But despite the somewhat chaotic situation in the industry, not only have the details of Fuji-no-Sato's health care system been copied widely throughout the silver business; their style of contract and overall operating system also has. This is undoubtedly due largely to the financial success and overall quality of services at Fuji-no-Sato and its sister communities.

The ownership of the property at Fuji-no-Sato resides with the management, not with the residents themselves. The residents purchase, as it were, the right to live in the community throughout their lifetime and the right to receive the promised care and services. In theoretical discussions of the rights of residents, the management uses the term "social property," which is meant to indicate that Fuji-no-Sato combines features traditionally assigned to individual and to governmental property. The notion symbolizes the philosophy that the private nonprofit sector should play a greater role in the area of services to the aged, stepping in where neither the family system nor the public bureaucracy can respond adequately.

There are restrictions on age and health status for membership in the community. One must be sixty years old or older (for a married couple, either husband or wife must meet this requirement) and must be able to care for oneself and live independently. However, no physician's examination is necessary; lay staff at the head office in Tokyo makes judgments after interviews with the applicants.

The application requirements and entrance fees are based on the expected length of an average resident's life and his or her projected care needs. However, the operating system and fiscal management scheme are also based on the premise that residents will help each other, an assumption that lowers the entrance fee. In this nonprofit facility, all fees are assigned to specific budget lines to minimize ambiguity.

After our research, the managing organization began to rely more on interviews with the prospective residents in order to as-

sure that they understood the operating system before deciding to move in and to assure that they were not being unduly influenced by the attitudes of family members. Applicants are encouraged to spend some days in the community before making a final commitment.

There are two types of fees: an entrance fee and a monthly fee. Upon signing the entrance contract, the resident pays the entrance fee, which varies according to the size of the unit and the number of occupants. As of 1983, the entrance fees ranged from a low of $100,964 for a type A unit (single occupancy) up to $201,186 for a type D unit with two people. The corresponding March 1991 fees were $184,667 for the type A and $363,037 for the type D for two. For simplicity's sake, all these figures are at the March 1991 exchange rate of 135 yen per dollar. The entrance fee covers, among other things, the cost of land acquisition, construction, depreciation, various taxes, overall maintenance of the facility, and the long-term care fee, which was $22,222 per person in 1983. The long-term care fee is calculated to cover all future care costs of the average resident as his or her dependency increases, thereby avoiding the need for additional payments for any services. The management estimated that the average length of stay at Fuji-no-Sato would be fifteen years. The entrance fee is partially refunded, pro-rated by the length of stay, if the contract is terminated within ten years by the resident or by his or her death.

The monthly fee in 1983 (again using 135 yen per dollar) was $215 for single occupants and $348 for double occupants, regardless of the size of the unit. By March 1991, these figures had risen to $280 for singles and $447 for doubles. The annual operating cost, more than half of which goes to staff salaries (excluding personal and health care personnel), is covered by the monthly fee. Even though the contract states that the monthly fee may be raised or at least reexamined once every two years in accordance with general price increases, the success of Fuji-no-Sato made it possible for the management to hold to the original fees set by negotiations between the management and representatives of the residents association in 1983 until new negotiations in 1989. (The 1983 negotiations are described in Chapter 9.)

The monthly fee, however, does not include utilities (electricity, water, telephone) or meals. According to the information brochure

published by Fuji-no-Sato, the average total expense per month in 1983, including the monthly fee, was $638 for a single occupant and $1,212 for a couple (135 yen per dollar). As of March 1991, these figures were $743 for a single occupant and $1,312 for a couple. These amounts do not include such expenses as clothes, leisure activities, or transportation.

Is it expensive to live at Fuji-no-Sato? This is an extremely sensitive question for the management, whose aim has been to provide services for average elderly people. We have mentioned that the community has been widely covered in the mass media, which have consistently reinforced the image of Fuji-no-Sato as a deluxe place for the wealthy elderly, much to the disappointment of its builders. As far as monthly living expenses are concerned, it does not seem to be particularly expensive. The main debate is whether or not the entrance fee is beyond the reach of most people. In black and white, the figures do look high. But the issue should be judged from the viewpoint of the average person's alternatives in preparing for safety and security in old age and the costs of those alternatives. Then there is the matter of the competition. In spite of the relatively high staffing and quality of care at Fuji-no-Sato, the fees are significantly lower than those of many life-care communities of comparable size as of March 1991.

The value of home ownership in Japan, particularly in the greater Tokyo area, is relevant in this regard. The vast majority of the residents came from the Tokyo area, and many sold their homes to move to Fuji-no-Sato.

The case of Mr. and Mrs. Shirase is a good example of the strategic value of selling a house. Mr. Shirase, seventy, is a retired journalist. After graduating from an elite university, he worked for a large newspaper as a journalist for thirteen years. Then he became a free-lance journalist, writing on politics and social issues. He also made money translating books into Japanese. He perceived his income as somewhat precarious, particularly because in Japan one's financial security and social status are largely determined by the company one works for. After he reached sixty, Mr. Shirase recalls, it was getting harder to earn a living, and he began to worry about his old age. Mrs. Shirase, sixty-six, is a housewife who never worked after marriage. They have no children and never thought of adoption.

Shortly after World War II, the Shirases managed to buy land in a suburb of Tokyo, on which they eventually built a modest house. Soon the postwar reconstruction began, and the price of land in the metropolitan area literally skyrocketed. The former farmland around their house is now an upper-middle-class suburb, and their investment in property obviously turned out to be a lucky one.

The Shirases had modest savings for their old age. However, because Mr. Shirase was self-employed, he got no retirement bonus or pension. He and his wife have a small national pension. When his wife saw an advertisement for Fuji-no-Sato, they discussed it and agreed without much argument to sell the house and move there. It was apparent that if they continued living in their house, their financial woes would get worse as they grew older.

Although Mr. Shirase did not disclose the sale price of their house and land, they were able not only to pay the entrance fee for a type D unit but also to purchase a small one-bedroom condominium in Tokyo, which they rent out, and still keep a comfortable amount in savings. Both Mr. and Mrs. Shirase said that financially they felt more secure than ever and agreed that without selling the house, this could not have been possible.

Of course, it could have been a completely different story if the Shirases had a child, as most Japanese elderly do, and wished to leave the house to the child.