Community and Government Policy

During the Tokugawa period, the strength of the market and the balkanization of entitlements under the dual administrative system of bakuhan rule kept the nominal bakufu government of Japan out of entitlement programs aimed at the mass of its populace. For this reason the new Meiji government was reluctant to pursue an activist entitlement policy. But as Japan opened herself up to trade and to contact with the West, it became apparent to the former samurai who, as the educated elite, assumed responsibility for guiding the country along the path to industrialization that foreign models could be profitably and efficiently studied and adapted in many areas outside of that involving industrial machinery. As a rational borrower Japan could pick and choose the countries it wanted to imitate depending on the type of institution involved: thus the Meiji government designed its new police system along French lines, its military along German lines, its higher academic system along German lines, and so forth. But two factors constrained the government in its eagerness to follow Western guidelines: financial and resource limitations and potential resistance to social engineering, namely, the extent to which Tokugawa institutions were so deeply rooted that new institutions were unlikely to be accepted, or accepted only at the expense of social unrest. Financial constraints and the Tokugawa legacy of balkanized entitlements and reliance on the market must be given pride of place in attempting to explain why the Japanese government exhibited a strong "supply side" technological bias in its health/population quality maintenance and enhancement programs, eschewing social engineering in the entitlement field in favor of importing Western medical and public health methods and knowledge.

Not surprisingly, the technological bias was already evident during the later Tokugawa period and especially at the close of the Tokugawa era—known as the bakumatsu period—when Western ideas and goods starting streaming into Japan as isolationism collapsed under American pressure in the early 1950s. Dutch treatises concerning anatomy and surgical and other medical treatments had made their way into Japan through the small Dutch population residing on Dejima in Nagasaki harbor, Tokugawa Japan's sole window onto the West.^[4] For instance, in

1774 Gempaku Sugita published Kaitai Shinsho , which describes Western concepts of anatomy. While the bakufu sponsored a special academy for the study of Chinese medicine (kanpo ), over fifty individual fiefs set up schools to teach medicine, in some of which Dutch methods—so-called rangaku —were espoused (Sugaya 1976: 51 ff.). This espousal of Western methods, however, was opposed by the kanpo doctors, who managed to get the bakufu to require that all books be reviewed by the Igakuin (Academy of Medicine) before publication. Thus, while it is not untrue that the mainstream Tokugawa tradition of medicine inherited by the Meiji government was that distilled from Chinese medical theory, Western ideas had some currency during the bakumatsu period, when the bakuhan system was steadily collapsing. Indeed H. Hirota (1957) estimates that at the inception of the Meiji period around 19 percent of the doctors practiced Western medicine. In short, it was far easier for the central authorities to swing the country toward Western technical concepts of public health and medicine than toward a restructuring of the system of entitlements, which, even more than medical theory, was tied up with deeply held cultural traditions. But even in the area of medicine a strong opposition campaign was mounted by the defenders of Tokugawa traditional practice.

The new Meiji government took up the challenge laid down by the kanpo school and carried through the struggle by decisively tilting in favor of the Western school. But the issue was not quickly settled. The Meiji oligarchs proceeded on a variety of fronts, at first placing the Inuka (Medical Affairs Section) under the control of the Ministry of Education, but later renaming it the Eisikyoku (Sanitary Bureau) and placing it under the Ministry of Interior. To this agency was delegated the authority and responsibility for issuing guidelines on the standards expected of medical and public health personnel, the formulation of regulations for dealing with epidemics (with the opening up of the country to international trade after the mid-1850s epidemics became a problem), and the control over and testing of drugs. After systematic comparison between the efficacy of Western and Chinese medical practices, the Inuka bureaucrats decreed that Western concepts were to be given preference in the examination tests required of those seeking certification as doctors and in the licensing of schools offering programs in medicine (see Sugaya 1976:45 ff.). However, since most doctors already practicing during the early Meiji period used Chinese methods, kanpo practices continued to dominate throughout the late nineteenth century, a fact that increasingly ran counter to the posture of the government.

Within the government a growing belief in the efficacy of Western medical practices—especially German practices, on which Dutch rangaku medical theory was based—led the government to not only tilt in favor of Western medical concepts in examining and training doctors but also to enthusiastically embrace the new field of bacteriology. For example, the bacteriologist Shibasaburo Kitasato, who was the first to isolate the tetanus bacillus, was sent at government expense to work with Robert Koch in Germany.

In short, the Meiji government actively exploited Western imports in the area of technological improvements—what I call supply side improvements as opposed to demand side factors such as the organization of national entitlement programs like those developed in Germany under Bismarck—to enhance population quality. In particular, through its power to impose regulations the central authorities actively pursued a policy of raising standards for medical and public health personnel. Doctors were required to register with the government, and it was decreed that examinations for certification of doctors were to follow nationally imposed guidelines (although a fully standardized national test was not introduced until after World War II). In 1899 midwives were brought under regulation and in 1915 regulations for nursing were promulgated. One of the consequences of this policy of standardizing around Western medical principles was a temporary reduction in doctors per person. The kanpo doctors aged and eventually either died in active service or retired. Due to inevitable delays in the establishment and staffing of educational and medical institutions designed to train young personnel in Western methods, replacements to the ranks of the medical profession were outpaced by the older generations of kanpo doctors. This explains why, as we see in the lefthand column of table 9, the number of doctors per capita decline between the decade 1911-1920 and the decade 1921-1930, before increasing thereafter. Even in the area of medical personnel the legacy of the Tokugawa period lingered far into the Meiji period. And because of the tradition of balkanization of entitlements central to Tokugawa government policy, gradually gathering momentum toward centralization was slowed.

But the long-run trend definitely favored centralization, and one of the most important agents of that change was the military. A case in point is the military's innovations in preventing the spread of disease in military camps due to waterborne microorganisms. During the Sino-Japanese War in the 1890s, the number of Japanese soldiers dying from infections far exceeded the number dying from war-related wounds.

Because of this the Japanese military authorities began a systematic study of why epidemics broke out in military encampments: they dispatched a research team abroad to study methods of preventing infection in foreign military organizations, finally settling on American practices, which they then methodically implemented. Henceforth they equipped all base and field hospitals with bacteriological laboratories; they made certain that every division included a sanitary detachment that carried water-testing kits; they made compulsory the boiling of water; and so forth. Thus during the Russo-Japanese War at the beginning of the twentieth century, the ratio of those dying from infection to those dying from wounds dropped to one to four. And of course, since military service was compulsory—although exemptions to military service were granted—the military innovations diffused down to the village level both through government regulation and through word of mouth.

In contrast to its assertive role in promoting the importation and dissemination of German medical and public health knowledge, the Japanese government showed remarkably little interest in adopting German innovations in the field of entitlements, for example, health and disability insurance, legislation regulating contamination in factories, and so forth.^[5] The reason has already been stated: the legacy of the Tokugawa period carried with it an assumption that voluntary agreements between employer and employee lay at the center of health enhancement and that insofar as governments felt compelled to intervene, responsibility was to be exercised at the local community level. A telling illustration of this point is the protracted length of time required for passage and implementation of national mining and factory acts setting minimum safety standards, restricting the amount of overtime work, and outlawing child labor: over a half century of debate and study went into this effort. The lethargic speed at which legislation was adopted could hardly be said to be due to lack of knowledge of Western practice: during the early Meiji period the government had passed legislation assuming responsibility for the factories it directly managed. For instance, it hired French doctors in the Ikuno branch of the Government Mining Bureau to look after the health of the French technicians and miners who worked in the pits. By the 1910s mining injuries were in excess of 150,000 a year, many stemming from accidental explosions of inflammable gases, and yet stiff regulations were limited to government-managed operations. Moreover, the central bureaucracy had actually tried to draft and get Diet passage for a mining law as early as

the 1880s. Finally in 1905 a mining law passed the Diet. And even more time was required to pass a factory act: even when the Kogyoho (Factory Act) finally reached the floor of the Diet in 1910, resistance to the legislation remained widespread among the ranks of organized business who argued the "beautiful Japanese traditions" governing the relationship between employer and employee should not be subject to government intervention and regulation. And the law that was finally passed in 1911—whose twenty-five articles included banning employment of minors; stipulating that a certain number of minutes should be set aside each workday for rest; requiring that factory owners compensate employees disabled by dint of their duties in the factory; and appointing a small number of factory inspectors to investigate conditions in factories above a minimum size—was not actually implemented until 1916, almost fifty years after the Meiji Restoration.

Given the central government's bias toward supply side—technological—solutions to health enhancement and away from demand side—entitlement—approaches, the responsibility for organizing and financing public health and medical activities and for policing factories largely fell to local authorities. For this reason we should not be surprised that there is a fairly close relationship between per capita income and size and density of communities—the larger a community, the greater the economies of scale in the provision of clean water, removal of sewage, and the dispensing of medical knowledge—and per capita levels of investment in public health and medicine. In regard to this point see table 17, which gives figures for the forty-seven prefectures of Japan classified by levels of urbanization and per capita levels of medical personnel, hospitals, and hospital capacity during the late nineteenth and early twentieth century.^[6] There are certainly exceptions—see the figures on maximum levels for group D—but in general the greater the level of urbanization, the greater the per capita resources devoted to enhancing health. Balkanization of health-enhancing entitlements was continuing. Now, however, the force of per capita income and the tax base and scale economies were dictating the geographic pattern, not the dual administrative bakuhan system. And that local areas, not the central authority, were carrying the main fiscal burden for these programs helps us to make sense of the very low levels of national government expenditure on social security (including public health and medicine) evident in table 16.^[7] In short, many aspects of the Tokugawa heritage in entitlements were, under a new guise, being perpetuated in the Meiji period, even four decades after the bakuhan system lay in ruins.