Once More the Doctors have Disappeared from the Okinawan Islands
by Moriguchi Katsu
In the battle of Okinawa between one third and one fourth of the Okinawan population was killed in the cross fire between Japanese and American forces. In the early years of the twenty-first century Okinawa is once again facing an acute shortage of medical personnel, particularly on the outer islands which are simultaneously facing aging and depopulation.
About 100 kilometers off the coast of the main island of Okinawa lies Kumejima, in the East China Sea. A 77 year old medical practitioner, known as an ikaiho (medical assistant or paramedic), is still practicing his craft on the island. For over half a century the lives of those living on the island have rested in his hands. With few medical facilities the people of Kumejima, and of the other outlying islands, face new difficulties as they look to their future.
In May this year, on one of the small islands in Yaeyama, I followed an old medical officer. Shirota Nobuhiro (82 years old) had been a respected, historical icon on the island on which he'd lived for about fifty years. Kuroshima, an island in the district of Taketomi Town, has a population of about 200 people, and is thirty minutes by fast ferry from Ishigaki. On an island on which one person out of three is over sixty years old, Shirota-san has devoted his life to medicine. He gave up work recently because he's had a chronic illness himself, and has become too old to work, he says. After his departure there remains simply an empty clinic/examination room. Although there are forty inhabited islands in Okinawa, with his retirement, now twenty have no medical care.
After the war there was a severe lack of medical staff in Okinawa. This was because most doctors were killed during the war. Survivors from the former Japanese army medical corps were given simple training by the American occupiers and were then sent to the outer islands to work as medical officers. Shirota-san was one of those called ikaiho (a paramedic) who had no formal medical qualifications, yet was deemed trainable by the occupying army. There were 126 of them in 1951. Shirota san had been a medical orderly with the Japanese army in Burma (Myanmar). He was transferred to Kuroshima by the Americans from his home on Ishigaki in 1951. He became largely self-sufficient, growing vegetables and making just enough from work to survive.
"Although it was called a clinic, in fact it was just a single room," he said, describing his working environment." So in the beginning, sometimes patients were forced to sleep on the engawa (verandah) and I had to examine and treat them out there. It was terrible. There was no running water, no electricity, and not even a bicycle on the island. We had to use rain water stored in vats, and because hygiene was so poor, there was a lot of skin disease, and things like conjunctivitis. So I was forced to treat a variety of complaints. A lot of people were bitten by habu (vipers), for example. While there was antiveneme, because we didn't have electricity, I didn't have a refrigerator, so I had to keep the medicine buried underground. When a person was bitten by a snake I would go outside and dig up the medicine. It was a hard life, no question about it.
"Of course, until reversion to Japan, there was no medical insurance. This was bad, too. There were some patients who could not afford to pay for my services, so I let them work in the garden to pay off their debts. These conditions continued for years."
Medical Conditions on the Outer Islands
Uehara Soken, an ikaiho on Kumejima, had a similar set of experiences. When patients came to see him they sometimes brought him a bag of rice.
"I was on the main island of Okinawa for 10 years after the war. There were 30,000 people on the island when I opened up my clinic here. At the time there was only one ‘real' doctor and 2 ikaiho. Every morning at 6 a.m. there were lots of patients queued up waiting for me to open for business."
He had to treat up to seventy or eighty patients a day, including emergencies, difficult deliveries, and snake bites. Sometimes, in the middle of the night, he'd have to go on horseback to pick up emergency cases, such as when children had intense fevers. It was a hard life. Now, Uehara-san is 77 years old. Last year he had a stroke and has difficulty hearing and walking. His wife died four years ago, and his eldest son's wife, Nobuko, now helps out in his practice.
The ikaiho system was established under the US occupation and was not a Japanese invention. After Reversion, the Japanese government recognized the ikaiho as legitimate doctors in a bid to equalize medical relations between Okinawa and Japan; that is, to ensure that there were enough doctors in the prefecture. In areas where there was a high population density doctors were quite common, but the more sparsely populated areas still had negligible medical support.
On Kumejima, the prefecture and Kumejima-town built the new forty-bed hospital. But Uehara's patients continued to come to see him. Although such a nice hospital was built, patients still prefer to see paramedics, or clinicians, on a face-to-face basis, it appears. The patients say that Uehara's clinic is convenient, it is nearby, there's little waiting time to get in to see him, Uehara spends considerable time with each patient, and having known them for a long time, he can treat their illness with ease. One terminally ill old woman said that she wanted Uehara-san to take care of her until she dies. Although Uehara's health is failing, people still come to see him daily.
Only two of the original ikaiho are still working, largely due to attrition caused by aging. On Taketomi, with the passing of the last ikaiho, there is no one left to look after the people. As the elderly ikaiho retire, for those on the islands, it's a return to the nightmare conditions that once existed. On Hatomajima in Taketomi Town, after the retirement of the ikaiho, a number of people died of tuberculosis, stomach cancer, and heart disease. These people were in their 50s and 60s. If they'd been diagnosed earlier, they might have survived.
On the outer islands, where there are no doctors. A patient who wants to see a doctor has to fly or take a ship to the main Okinawa island. To do this is an expensive undertaking. Very few people do this regularly, even if they notice serious changes in their medical condition. This is a lost opportunity for elderly people on remote islands to live to the extent of their expected life course. One medical exam per year from a visiting doctor is certainly not enough for these people.
It is clear that without appropriate medical care the population of the remote islands will continue to decrease, partly due to attrition, and partly due to emigration to places where better medical facilities exist.
In an attempt to provide appropriate medical services to Okinawa prefecture in general, the Medical Faculty at Ryukyu University was completed in 1979. There were high expectations for the university, with more than 100 students graduating from the faculty each year. By summer of 2003, approximately 1500 students had graduated in medicine from the school. However, of all those graduates, only ten have gone on to work in the outer islands.
Uehara-san from Kumejima laments:
"Although they built the medical school specifically to address the problem of the small number of doctors in Okinawa, still no young graduates choose to come and work in the outer islands. Young people want to working in the city hospitals and look after their own interests, regardless of what's happening in our world."
At Kumejima Hospital, the big concern is how to retain medical staff. They need five doctors at a minimum to run the hospital, work shifts, and so on, but have always had vacancies. Indeed, for that reason, the hospital has introduced six month contracts for all their doctors. The prefecture pays their basic salary, but the town itself is forced to pay an extra bonus of 190,000 yen a month to each doctor.
The hospital has had to extend its search for doctors to the mainland of Japan – to Fukuoka and Kagoshima – in order to staff the hospital, and the mayor has had to represent the hospital personally in order to convince doctors approached to come to the island.
In Japan there is currently an oversupply of doctors, and consequently intense competition among doctors to keep patients. When will the doctors on the main island of Okinawa, and the mainland of Japan recognize that there are people with real needs in the outer islands of Okinawa who need their help?
This article appeared in Shukan Kinyobi, November 21, 2003, pp. 38-42. Translated and edited for Japan Focus by Matt Allen, Seitaro Kawawa and Kuniko Maehara.