Foreign Blood and Domestic Politics:
The Issue of AIDS in Japan

James W. Dearing

Japan is, by any measure, a country with a low incidence of acquired immune deficiency syndrome. As of September 1, 1990, the Japanese Ministry of Health and Welfare reported a total of 285 cases out of a population of over 120 million. Estimates by the World Health Organization in Geneva place the number of actual cases in Japan at about 500. Despite the low number of AIDS cases in Japan relative to some other countries, the issue of AIDS took Japan by storm for fourteen months beginning in January 1987. The short-lived yet remarkable salience of the issue of AIDS, juxtaposed with few actual AIDS cases in Japan, offers several insights concerning the Japanese society's reaction to an epidemic and to minority demands.

The issue of AIDS has gone through three distinct phases in Japan. The first phase was dominated by the international problem of AIDS and the policies of the Japanese Ministry of Health and Welfare; the second, by aggressive mass media coverage and public-interest groups that reacted to the threat of AIDS in Japan. In the third and current phase, the issue of AIDS has become routinized in Japan. After telling this three-phase story of AIDS in Japan, I then compare the history of the issue of AIDS in Japan and the United States.

AIDS In Japan

AIDS was first detected in Japan in 1982.^[1] Through August 1988 1,048 AIDS carriers were identified by the Ministry of Health and Welfare.

Current unofficial estimates by the World Health Organization are higher, but questionable epidemiological extrapolations by the Ministry of Health and Welfare make the number of people in Japan carrying the HIV virus very difficult to determine. Of the 1988 official total, 1,029, or 98 percent, were male. There were 90 identified persons who had developed AIDS, 46 of whom had died. Virus infection in Japan began later than in Africa, the United States, and Europe; although the rate of infection was similar through mid-1987, there is reason to believe that it has grown more slowly in Japan than in other countries since then.^[2]

In Japan the disease has overwhelmingly been contracted through the use of imported blood-clotting coagulant by hemophiliacs. Hemophilia is a genetic disorder, inherited from the mother, of immoderate bleeding even from slight injuries. The disorder is inherited almost exclusively by males. In 1988 over 92 percent of all AIDS carriers in Japan were thought to be hemophiliacs.^[3] Therefore, the vast majority of AIDS carriers in Japan are male. It is the regulation, prescription, importation, and use of blood coagulant which came to define the issue of AIDS in Japan.

Throughout the 1980s Japan imported one-third of the world's blood products, 90 percent of which came from the United States. Japan itself has a high rate of blood donation, but until recently donations to the Japanese Red Cross have been used only for whole-blood transfusions, not for making blood products for commercial sale.^[4] Commercial blood products for sale in Japan are manufactured by several large companies in Japan as well as a few firms in the United States and West Germany. Patient prescriptions for blood products are controlled by physicians and hospitals, many of whom maintain their own blood dispensaries; so in Japan the profit in blood products is shared by manufacturers, hospitals, and doctors. The cost of blood coagulant to Japanese hemophiliacs is about four times higher than for hemophiliacs in the United States. Because of the dependence on U.S. manufacturers of blood coagulant, whose blood supply was contaminated with the AIDS virus, the Ministry of Health and Welfare estimates that up to 40 percent of Japan's 5,000 hemophiliacs are carriers of AIDS. Nongovernmental estimates suggest that as many as 60 percent of hemophiliacs are infected.^[5] In 1988 about 44 percent of hemophiliacs identified by the Ministry as carrying the AIDS virus were twenty years of age or younger;^[6] 30 percent of them were under fifteen years of age.^[7]

The Mass Media Agenda

In modern societies the mass media often determine what issues policymakers and citizens think about, as well as the relative importance they ascribe to those issues.^[8] The influential newspapers and television networks serve as the forum in which the issues of the day are shaped and debated, much as town squares, country markets, and coffee shops served this public function in preindustrial societies. Thus, an understanding of the "life" of a public issue requires an analysis of mass media coverage. How important has the issue of AIDS been in the mass media's news agenda in Japan? And how have the mass media covered this issue?

Our analysis suggests that for several years AIDS was considered strictly a foreign problem. When it was made public in 1983 that the disease had been identified in Japan one year earlier, responsibility for bringing the disease to Japan was attributed to non-Japanese, even though tens of thousands of Japanese businessmen travel abroad every year on organized group "sex tours."^[9] The first newspaper articles on AIDS tended to frame the disease as an international curiosity. Most articles were from international wire services.

With the first case of AIDS in Japan, domestic coverage began. NHK, the dominant national (and public) television network, broadcast a fifty-minute informational program in 1983. By 1985 about 30 percent of AIDS stories in the general-interest Asahi Shimbun and about 55 percent of AIDS stories in the four financial Nikkei newspapers (including the Nihon Keizai Shimbun , often referred to as "Japan's Wall Street Journal ") were about AIDS in Japan. As the number of Japanese AIDS patients increased, the percentage of domestic-based articles increased, to over 50 percent for the Asahi Shimbun and over 60 percent for the Nikkei newspapers in the second quarter of 1988. Meanwhile, the percentage of articles about AIDS cases outside of Japan clearly declined. Many of the articles in the Nikkei group of newspapers centered on new product developments and the public stock values of domestic and foreign pharmaceutical companies.

The over-time distribution of the number of articles in these same newspapers is shown in figure 4. As this figure makes clear, early coverage of AIDS tended toward the foreign problem of AIDS, but the issue was of little importance in the print media. The first AIDS story to capture the public's attention occurred in November 1986: A Filipino nightclub prostitute working in the Nagano Prefecture city of Matsumoto

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4. Japanese Newspaper Coverage of AIDS
SOURCE : Adapted from data from NIkkei NEEDS data base (an electronic
source owned by the Nikkei Corporation for accessing mass media stories).

was found to have AIDS, and it was suspected that she may have transmitted the disease to men in the area. The prefectural government quickly deported the woman back to the Philippines, declaring her visa expired.^[10]

With the death of a single woman in January 1987, AIDS became a dominant issue in Japan. The January 1987 story had all the right news angles to propel the issue of AIDS to the top of the news agenda: it was domestic, it was about sex and death, and it implied that approximately one hundred anonymous Japanese men might be transmitting a deadly disease to their wives and other partners (extramarital sex is quite common in Japan).

The January story also involved a Kobe prostitute, but she was Japanese. She, her illness, and the public issue they would give rise to could not just be deported. Nevertheless, the AIDS Surveillance Committee of the Ministry of Health and Welfare did not release news of her illness until two days prior to her death on January 20, 1987, though she had been too sick to work for six months. She was the eighteenth Japanese to die from AIDS, and the first woman. In describing the woman as a

"habitual" prostitute, the Ministry said that she might have had sex with about one hundred men.^[11] This announcement and its aftermath were widely covered by all the mass media in Japan. The most sensational news treatment was in the weekly tabloids, which have a circulation of more than one million. One of these tabloids had been tipped off about the family's funeral arrangements, and it subsequently published a photograph on its front page showing the woman in her coffin. Thus, she did for AIDS in Japan what Rock Hudson and the ostracized schoolboy Ryan White did for AIDS in America. Whereas the five newspapers of study printed a total of 2 stories about AIDS in January of 1985, in March of 1987 the same newspapers ran 189 articles about AIDS (the Asahi Shimbun alone printed 76 of these). The peak in mass media coverage in the first quarter of 1987 (fig. 4) represents this story and its aftershock, which included a sensational story about a pregnant Japanese woman with AIDS who refused to abort her child. These three heavily covered stories domesticized the issue of AIDS in early 1987 and represented the beginning of the second phase of the issue in Japan.

How did the Japanese mass media cover the issue of AIDS? The major mass media, with the exception of the Nihon Keizai Shimbun and perhaps NHK, have a reputation for liberalism and sensationalism. According to the present research, early AIDS coverage was dominated by international wire service stories, which stressed homosexual and intravenous drug transmission. When cases first were diagnosed in Japan, staff-written stories and special reports appeared. Yet very few received print space or broadcast time prior to the Ministry of Health and Welfare's announcement that the Kobe prostitute was dying of AIDS. Overnight a maelstrom of AIDS stories dominated the news. For example, on January 19, 1987—one day after the Ministry announcement—NHK began a week of nightly seven-minute informational segments on AIDS on its Today show. Television ratings indicated that 20 percent of the Japanese population saw all or a part of the segments.^[12] Certainly a part of the mass media fascination with the Kobe prostitute story centered on the means of transmission, which was heterosexual and thus strikingly different from what reporters and editors had been previously conditioned to think about AIDS transmission. They were forced to interpret AIDS in a new way, framing the issue with a new meaning. The Ministry of Health and Welfare, which served as the primary news source for AIDS information, had steadfastly framed the epidemiology of AIDS transmission in Japan as paralleling the spread of AIDS in the United States.

An analysis of the Asahi Shimbun articles on AIDS, in which the articles were coded into twenty-two "subissue" categories, indicates that stories were most often about (1) government spending and policy responses, (2) the epidemic spread of the disease, (3) explanation of the disease and new information reported by medical scientists, (4) tests for AIDS antibodies and the effects of such tests on civil rights and privacy, and (5) means of transmission of the virus, including blood coagulant infection. Table 1 shows that the Asahi Shimbun 's coverage is quite similar to that of four major mass media in the United States.^[13] The Pearson's rank-order correlation between the Japanese and American coverage is .86, which is significantly different from zero at the .001 level.

Figure 5 compares the distribution of stories by Japanese mass media (the Asahi Shimbun and the four Nikkei newspapers) with the distribution of stories by U.S. mass media (the New York Times , the Washing Post , ABC, and NBC) from January 1985 through June 1987. The distributions are somewhat similar (r = .69, significantly different from zero at the .001 level), although they clearly peak at different times.

Through 1987 Japanese news reporters generally did not question what their sources told them about AIDS. As in the United States, there was little if any investigative reporting about AIDS. But as the disease spread, mass media coverage became more aggressive. Reporters began writing stories about AIDS patients. And Japanese AIDS patients were angry.

On February 5, 1988, the general-circulation Mainichi Shimbun published the first article in a comprehensive series of front-page investigative reports. And these reports changed the direction of influence in the relationship between the Ministry of Health and Welfare and, on the other side, the mass media and public-interest groups. The Mainichi ran a banner-headline interview with a university vice-president, Takeshi Abe, who was also a medical doctor and who had chaired the Ministry's AIDS Surveillance Committee. In the interview Abe stated that clinical testing in Japan of heat-treated blood coagulant (which had been on the market in the United States and in West Germany since late 1983) for use by hemophiliacs had been delayed twenty-eight months (clinical trials had been completed in one month in the United States). Abe, who had been completely in charge of the testing, defended the delay:

When one company is ahead of the others in the research and development of a new drug, the duty of a research council is to coordinate things among

the companies to make them even, for the drug inspection by the Ministry of Health and Welfare. At least two or three companies should be bound together. … We needed to give patients the impression that all pharmaceutical companies are reliable to the same degree. … All companies must compete fairly. … It was for the sake of the patients. Those who complain don't understand things.^[14]

Apart from what these comments imply about the Japanese coordination of industrial policy, epidemiologists estimate that Abe's delay may have infected over one thousand Japanese hemophiliacs with the AIDs virus. Ministry of Health and Welfare sources anonymously suggested that, although the policy may have led to an increased number

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5. Mass Media Coverage of AIDS in Japan and the United States, January 1985–June 1989

of hemophiliacs' contracting the AIDS virus, their experts worried that heat-treated blood coagulant might cause a degeneration of protein. Moreover, they said, AIDS had never been a priority within the Ministry.^[15]

The Mainichi did not stop with Abe's explanation—damning as it was. The newspaper also revealed that the leading Japanese blood company, which had not yet developed the heat-treatment process, had paid Abe $850,000 to set up a nonprofit corporation (the headquarters of which was a two-bedroom apartment that was usually empty) and that Abe had induced two of the foreign firms to pay money to the corporation. The implication was clear: Abe had delayed the clinical testing process to allow a Japanese firm, which had paid him a large amount of money, to develop heat-treatment technology so that the firm would not lose market share to foreign rivals. Meanwhile, the foreign firms were pressured into paying Abe money in order to stay in the race for access to the lucrative Japanese market.^[16]

The trail of deceit, scandal, and profiteering was lengthened in March 1988, when the Mainichi broke the closely related story that imports of

untreated blood coagulant actually increased during the two years of Abe's delay, while other nations were phasing out untreated blood coagulant for fear of AIDS infection.^[17] American blood suppliers, seeing that their markets for untreated blood had evaporated in the United States, discounted their prices to rid themselves of untreated coagulant inventories. Japanese hospitals bought the discounted coagulant and resold it to hemophiliac patients for large profits.^[18]

The Mainichi Shimbun stories fundamentally changed the public issue of AIDS in Japan. Prior to the newspaper's breakthrough, the importance of the issue and the way that it was interpreted were controlled by the Ministry of Health and Welfare. After the Mainichi series the previously vocal but ineffective hemophiliac association became more successful in having its own goals adopted by both the Ministry and the national Diet. Other, more traditionally efficacious, interest groups joined hemophiliacs in denouncing Ministry policy. Legal suits were filed by hemophiliacs. And news coverage of AIDS policy became more critical. A news editor at another Japanese daily newspaper said, "The Mainichi did the best job of any of the media. It was a big scoop and they really pursued it."^[19] The three reporters who worked on the stories received the Mainichi Shimbun Editor-in-Chief's Award for outstanding reporting. By and large, however, while acknowledging the Mainichi scoop, other mass media did not accord the scandal a high position on their news agendas. The Asahi Shimbun , for example, reported on the scandal on page 26, three days after the Mainichi Shimbun broke the story.^[20] A news director at NHK was unaware of any particularly outstanding mass media coverage of AIDS, except for NHK's own reports.^[21] Though hemophiliacs and their supporters have sued corporations and the government, the traditionally slow pace of litigation in Japan has helped to drop the issue of AIDS to what most media observers describe as a "nonissue." Nevertheless, control over the definition and shared interpretation of the issue had been wrested away from the government by the newspaper.^[22]

The distribution over time of the number of articles about AIDS (fig. 4) in the Japanese mass media shows a positive correlation with the distribution over time of the number of articles about AIDS in the U.S. mass media.^[23] This similarity is perhaps accounted for by the juxtaposition of two variables. First, the United States has approximately 500 times more AIDS carriers and AIDS patients than Japan. Whereas the U.S. mass media underreacted to the issue of AIDS in relation to the large number of patients,^[24] it appears that the Japanese mass media

overreacted. In January 1987, when media coverage in Japan began to peak, there were fewer than twenty deaths nationwide attributed to AIDS. Theoretically, we would have expected less of a media response (or at least a more moderate one) to the threat of AIDS. But the scarce real-world evidence of AIDS was perhaps little heeded because the Japanese mass media were "primed" for the disease; that is, reporters and editors were aware of what was happening in the United States and in Africa, where the number of AIDS cases was multiplying rapidly. If either of these two conditions (few actual cases but awareness of the U.S. experience with the disease) had occurred separately, such a similarity between the distribution over time of the number of mass media stories about AIDS in each nation would not be expected.

Public Opinion And Public-Interest Groups

Whereas in the United States mass media organizations and public opinion pollsters had asked representative samples of the American adult population over 400 questions about AIDS midway through 1987,^[25] relatively few surveys of Japanese public opinion about AIDS have been collected. In the present research, therefore, survey results have been supplemented with other indicators of public opinion, such as the public activities of affected interest groups.

In August 1983 the National Hemophiliac Society petitioned the Ministry of Health and Welfare to stop the importation of untreated blood coagulant. One month later the society requested the drafting of special legislation to facilitate the quick changeover to heat-treated blood coagulant. Both initiatives ended in vain. Instead, the Ministry required all untreated blood products to be certified not to contain blood from groups of people at high risk of contracting the AIDS virus. In October 1983 about fifty mothers of hemophiliac children banded together and entered a Tokyo factory of Nihon Pharmaceutical, where only domestic blood was used for making coagulant. The mothers pleaded and then screamed for the firm to increase its production of domestic coagulant. Again they were rebuffed.^[26]

In October 1984, when the U.S. National Hemophilia Foundation recommended that only heat-treated coagulant be used, the new product had already been on the U.S. market for one year. Almost all Japanese doctors assured their hemophiliac patients and their families that imported untreated blood from the United States was safe. Most Japanese doctors would continue to give such assurances until 1986.^[27] Even

so, one Tokyo hospital alone tested 1,400 walk-up volunteers for the presence of AIDS antibodies between October 1985 and September 1986.^[28]

The death of the Kobe prostitute and its ensuing media storm brought AIDS to the forefront of public concern. Within six days of the Kobe woman's death, more than 10,000 local citizens there approached public health officials to inquire whether they too might have the AIDS virus.^[29] This panic was repeated throughout Japan.^[30] AIDS discussions drew overflow crowds.^[31] One week after the death of the Kobe woman, a Tokyo metropolitan AIDS hotline had received 170,000 calls.^[32] After their business had declined by more than half, seventy owners of massage parlors in Gifu Prefecture held a lecture on the prevention of AIDS and the testing of employees.^[33] Ministry of Health and Welfare officials soon realized that calming the public would be one of their main tasks.

Public apprehension led to suspicion of foreigners as AIDS carriers. Public baths and massage parlors posted signs saying "No Westerners admitted." Hostess clubs advertised "Japanese girls only" and "No foreign items work here." In Tokyo's Kabuki-cho red-light district, two previously popular sex nightclubs which featured foreign women closed for lack of business. Newspaper articles mentioned that non-Japanese had lost their jobs because they were suspected of having AIDS. A survey of 390 Japanese high school students in early 1987 found that when asked which ideas they associated with AIDS, the students most often mentioned (1) homosexuality, (2) death, and (3) foreigners.^[34] Government attempts to educate the public about AIDS prevention stressed the danger of sexual intercourse with foreigners, and may have perpetuated the ready association of foreigner with AIDS carrier. According to Feldman, the Kobe city government distributed a comic book to 70,000 high school students which showed "a map of the world with a large finger pointed at Africa, and a boatload of devilish-looking creatures sailing toward Mount Fuji."^[35]

Public opinion surveys show that awareness of, and personal concern about, contracting AIDS stabilized by at least May 1987.^[36] As in the United States, the distribution over time of data about the means of transmitting the AIDS virus indicates a certain degree of confusion on the part of the public. For example, in a sample of 1,400 blood donors in February 1988 at twenty-one Red Cross donation centers across Japan, 13 percent of the respondents who said they would not donate blood in the future cited the possibility of getting AIDS as their reason.^[37] The number of blood donors fell by nearly 5 percent in 1987, the

second consecutive yearly decline.^[38] One media analyst suggests that public response to sensational mass media coverage of AIDS has counterbalanced other effects from the mass media; specifically, the fear of contracting AIDS may have reversed a trend toward increased extramarital sex by Japanese women, a trend influenced by exposure to popular television soap operas featuring married women involved in extramarital sex.^[39]

Respondents to a May 1987 survey about AIDS said that they had learned about AIDS from (1) television, (2) daily newspapers, (3) weekly newsmagazines and tabloids, and (4) other people. The weeklies, which carried the most sensationalistic and perhaps inaccurate coverage of AIDS, were cited as an information source about AIDS by 53 percent of respondents aged twenty to twenty-nine, who are most sexually active.^[40]

National Aids Policy

After January 1987 Japanese government officials were aware that the government had to play a role in AIDS education and prevention. Official collection of AIDS data was entrusted to the Ministry of Health and Welfare's AIDS Surveillance Committee. This committee served as a coordinating body for linking the efforts of other groups, such as the Ministry's Blood Products Division, its AIDS Patients and Virus Carriers Future Estimate Research Group, the private AIDS Prevention Foundation, the Japan Public Health Association, the Japan Society for AIDS Education, the Tokyo Metropolitan Research Group on AIDS, and prefectural public health departments.

Despite this intra-Ministry coordination, traditional animosity between the Ministry of Health and Welfare and the Ministry of Education has prevented any cooperation regarding AIDS prevention and education. The Ministry of Health and Welfare has jurisdiction over epidemiological research and patient treatment for the disease, and has received supplementary funding from the Ministry of Finance for both tasks. Although the Ministry of Education has supported some educational programs on AIDS awareness and prevention, it has not received supplementary funding for AIDS education from the Ministry of Finance. There is, then, a lack of funding for AIDS education in Japan; there is also virtually no money for educational campaigns about discrimination against individuals perceived by Japanese to be at high risk. Because of the low incidence of sexually transmitted AIDS in Japan,

this task of defusing discrimination among Japanese has been identified as by far the most important aspect of AIDS in Japan by the Japan AIDS Prevention Association.^[41] Between 1987 and 1988 the amount of money allocated by the national government for AIDS doubled, from $7.2 million to $15.7 million, but subsequent annual funding has not increased at such a high rate.

By late January 1987 the Ministry of Health and Welfare had published 1.5 million copies of two AIDS pamphlets. One was distributed to the general public through local governments, medical institutions, and public health centers; the other pamphlet was for public health center counselors. In early February another pamphlet was produced for the general public.^[42] By late February the Ministry proposed AIDS legislation that included (1) fines and prison sentences for AIDS carriers who continued to have sex or to donate blood, (2) fines for doctors who failed to report AIDS cases, and (3) the right to refuse entry into Japan to foreigners previously identified as AIDS carriers.^[43] A watered-down version was soon passed by the Social Affairs Subcommittee of the ruling Liberal Democratic Party. The bill eventually stalled in the Diet.

The Ministry of Health and Welfare soon directed local governments to assist in the dissemination of AIDS educational materials, set up AIDS consultation centers for concerned people, and provide special counseling services for AIDS carriers.^[44] Acupuncturists were ordered to use only disposable needles.^[45]

A nationwide public health campaign included the distribution of 340,000 AIDS prevention posters, a toll-free telephone counseling service, and AIDS reference books for physicians.^[46] The Japan AIDS Prevention Association distributed videos and sponsored seminars on AIDS.^[47] The national government also distributed public service announcements, which were aired on television stations.^[48] Schools were instructed to distribute teaching manuals and videos about AIDS prevention to teachers in March 1988. Apparently, little use was made of these materials. Many teachers refused to talk about a topic that they were unfamiliar with and regarded as offensive. The Ministry reported that the anti-AIDS video was shown at only 3 percent of big-city schools and at less than 1 percent of rural schools. The opposition of school teachers was understandable, since sex education had not previously been a topic discussed in junior or senior high school.

After the Mainichi Shimbun exposé in February 1988, hemophiliacs found it easier to influence national health policy. Hemophiliacs successfully defeated national legislation that they considered discriminatory.

They also demanded monetary compensation from the national government and from pharmaceutical companies, as well as a formal apology from the Ministry of Health and Welfare.^[49] Though the national government has steadfastly refused to accept blame or to apologize, Japanese pharmaceutical companies finally decided to "donate" 200,000 yen per month (about 1,500 U.S. dollars at an exchange rate of 130 yen to the dollar) to each hemophiliac eighteen years of age or over, and 80,000 yen per month to those under eighteen, who have been infected with the AIDS virus through blood coagulant.^[50] Persons in the general public not personally affected by the disease may have sensed that the issue of AIDS in Japan had reached a stage of resolution.

Noboru Takeshita, then prime minister, promised that the government would financially assist hemophiliacs by covering the costs of treating asymptomatic patients as well as some inpatient hospital costs.^[51] By September 1988 this promise was specified as paying up to 180,000 yen (about 1,500 U.S. dollars) per month to hemophiliacs with AIDS, payments of about $45,000 to families of hemophiliacs who have died of AIDS, about $1,000 for funeral expenses, and about $80 per month to hemophiliacs who test positive for antibodies to the HIV virus.^[52]

So the national government, mostly through the Ministry of Health and Welfare, did take action on AIDS. Yet its public response was not only slow but also, for several years, directed toward the wrong risk groups. Many Ministry statements about AIDS referred to the threat of disease spread by homosexuals and drug users; in effect, the Ministry was echoing the epidemiology of AIDS in the United States and seemingly refusing to acknowledge that the disease was following a completely different epidemiology in Japan. This mistargeting of risk groups led some critics, particularly hemophiliacs and their representatives, to charge that Ministry AIDS policy was deliberately deceitful. Perhaps a more likely explanation is that the Ministry had not conducted epidemiological research about AIDS in Japan prior to 1987, and there were few reported cases of AIDS.

The Ministry of Health and Welfare refused to criticize the activities of its former AIDS Surveillance Committee chairman, Dr. Abe. Somewhat remarkably, Abe has not been the target of official sanction by either the Ministry, the Japanese medical association, or his university.

The Nonissue Of Aids In Japan

The previous three sections suggest that the issue of AIDS has reached a certain "maturity" on the mass media news agenda, in the public

consciousness, and in the minds of policymakers in Japan. If the salience of public issues can appropriately be thought of as cyclically rising and falling,^[53] then the issue of AIDS is clearly ebbing at present in Japan. Because of a unique epidemiology (in that most AIDS cases were transmitted nonsexually), the disease is not as much of a public health threat in Japan as it is in some other countries.

The real threat as a result of AIDS in Japan is the generalized perception, demonstrated through public opinion surveys, that anyone other than a "normal" Japanese—meaning foreigners, Japanese hemophiliacs, Japanese homosexuals, and Japanese IV drug users—is likely to have AIDS and should be avoided. In interviews during 1988 Japanese respondents said that they avoided grasping subway handles or using toilets, public telephones, and water fountains after non-Japanese had done so.

Even though it has fallen from importance on the agendas of the mass media, the general public, and policymakers, the issue of AIDS, like the disease itself, has not gone away. The issue has been routinized and institutionalized. Consider the following points:

1. In mass media organizations AIDS is now one of the health problems about which health and science reporters must consider writing. For journalists the issue stands as another example of why reporters must critically appraise the information they receive from authoritative news sources.

2. For the Japanese hemophiliacs who will live through the epidemic, the issue may bring legitimacy to their public identity. The unified response to the disease and to the government has led to far greater efficacy for the National Hemophiliac Society. Though the persons infected by coagulant have yet to receive the full apologies and money that they have demanded, the government and the blood companies have acknowledged some degree of fault. These acknowledgments, which have been reported by the mass media, may suffice as indications to the general viewer and reader that the problem has been handled (and thus that the issue is cognitively routinized).

3. The national government now has a network of offices, counseling centers, and hospitals which deal explicitly with AIDS. Routes for diffusing information about the disease are now established. The Ministry of Health and Welfare has a coordinating AIDS Office. The government has financially contributed (although modestly) to the efforts of the World Health Organization in attempting to curb the worldwide spread of AIDS.

This evidence that the issue of AIDS has been routinized in Japan represents a somewhat typical response to social problems. By this process of institutionalization, issues are legitimized. Legitimization is a goal of issue proponents. In the present case hemophiliacs sought to legitimize the idea that they had been victimized by the government, blood companies, and their doctors. The legitimization process, made visible through institutionalization, transforms an issue into a nonissue. The perception results that "something is being done" and finally that "the problem has been resolved." As early as February 1988, the Japan Times editorialized that "the AIDS problem is being marginalized" and that there is a "growing complacency" about the disease.^[54]

A Comparative Conclusion About Society And An Epidemic

The present essay has told the story of AIDS in Japan by focusing on how the mass media, public-interest groups, and government policymakers influence one another in defining and controlling a public issue. When this history is compared with the history of the issue of AIDS in the United States,^[55] several comparative conclusions can be drawn about how societies deal with an epidemic.

1. Both national governments responded very slowly to the threat of AIDS. In both countries groups assumed to be at high risk for AIDS had been ostracized from society prior to the threat of AIDS; when they were identified as at high risk for AIDS, they were stigmatized even further. A main reason for slow government action was that the disease primarily affected groups outside of mainstream society. In Japan, a relatively homogeneous society, little accommodation by the national government was offered to minority or ostracized societal groups whose members are most affected by AIDS. In the United States, a relatively heterogeneous society, the national government has been far more accommodating of the demands of affected societal groups. The egregious government AIDS scandal in Japan faded from the public consciousness after media coverage subsided, the villain never punished. Competition from other public issues (such as the Recruit Cosmos scandal in which public officials were given large amounts of corporate stock), combined with a lack of new sensational information about AIDS, drove this issue down the agendas of producers, news editors, and reporters. Such a scandal most certainly would have been rectified more in line with the demands of the affected societal groups if it had occurred in the United States.

2. Certain of the mass media in each country provide examples of outstanding investigative journalism centered on government inaction. In each country such media coverage led to changes in national government policy regarding AIDS. In Japan heroic journalism was largely ignored by the other, competing mass media. In the early 1990s AIDS is a nonissue in Japan. In the United States heroic journalism by a few sources eventually put AIDS on the news agenda of virtually all the mass media. The disease has remained on the U.S. news agenda, no doubt influenced by editors' perceptions of issue salience. In comparison with Japan, the United States has a far greater number of people with AIDS, persons carrying the virus, and especially people who know someone with AIDS.

3. In each country the amount of mass media coverage skyrocketed when perceptions spread that AIDS was a threat to the general heterosexual population. In Japan people perceived that the disease was relevant to them when it became known that Japanese prostitutes had AIDS. Extramarital sex is common in Japan. In the United States the illness of Rock Hudson, a movie star who was a stereotype of masculinity, and especially the illness of a teenage schoolboy, Ryan White, gave people the impression that anyone could get AIDS.

4. Policy solutions to AIDS have not satisfied claimants in either country, particularly in Japan. Policy actions in response to mass media coverage of an issue provoke an image of issue resolution to the general public, regardless of whether the issue has really been resolved. In Japan hemophiliacs are still very angry at the government, but the lack of current attention in the mass media means that the government need not respond. In the United States the sheer number of AIDS patients, as well as extrapolations of future patient loads, demands a more proactive government set of policies toward AIDS. Yet, aside from the much greater real-world problem of AIDS in the United States, the present results suggest that in the United States well-organized public-interest groups, such as gay political activists, have been able to affect policy (in contrast, IV drug users are paid little heed by the U.S. government because their interests and needs are not represented by a well-organized political action group), whereas in Japan such groups (even the well-organized National Hemophiliac Society) apparently play a much lesser role in the formation of national policy.