Onsen (hot springs) in Japan—Transforming terrain into healing landscapes

Abstract

Japan is situated on the Pacific fire rim and has a large number of hot springs (onsens). There are over 27,000 sources of such springs and the country has a well regulated system of onsens. Within this geographical and cultural peculiarities certain unique traditional health practices have evolved, prominent among which is Touji or onsen therapy. The article highlights various healing practices surrounding onsens, institutionalization of these practices, current policy regulations, standards and their contemporary challenges. This research used publicly available information from literature sources and data through expert interviews. It draws attention to the fact that touji has been marginalized in the recent health policies. The study highlights that onsen as a therapeutic landscape has an important role in maintaining health and wellbeing in the country and holds immense value in building social cohesion in local communities. The study points to the need for appropriate studies on the social and symbolic healing elements related to onsen landscapes, as well as the need for developing a comprehensive strategy for strengthening their culturally specific health management roles.

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Onsen (hot springs) in Japan—Transforming terrain into healing landscapes
Mihaela Serbulea
a
, Unnikrishnan Payyappallimana
b,
n
a
25-7, Nishi Machi Shinohara, Kouhoku-ku,Yokohama-shi 222-0025, Japan
b
United Nations University—Institute of Advanced Studies, 6F, International Organizations Center, Pacifico-Yokohama, 1-1-1, Minato Mirai, Nishi-ku, Yokohama 220-8502, Japan
article info
Article history:
Received 24 January 2012
Received in revised form
21 June 2012
Accepted 25 June 2012
Available online 17 July 2012
Keywords:
Hot springs
Touji
Onsen therapy
Traditional, alternative and complementary
medicine
Japan
abstract
Japan is situated on the Pacific fire rim and has a large number of hot springs (onsens). There are over
27,000 sources of such springs and the country has a well regulated system of onsens. Within this
geographical and cultural peculiarities certain unique traditional health practices have evolved,
prominent among which is Touji or onsen therapy. The article highlights various healing practices
surrounding onsens, institutionalization of these practices, current policy regulations, standards and
their contemporary challenges. This research used publicly available information from literature
sources and data through expert interviews. It draws attention to the fact that touji has been
marginalized in the recent health policies. The study highlights that onsen as a therapeutic landscape
has an important role in maintaining health and wellbeing in the country and holds immense value in
building social cohesion in local communities. The study points to the need for appropriate studies on
the social and symbolic healing elements related to onsen landscapes, as well as the need for developing
a comprehensive strategy for strengthening their culturally specific health management roles.
&2012 Elsevier Ltd. All rights reserved.
1. Introduction
Over the last two decades a considerable body of knowledge
has been generated on the health benefits associated with specific
geographical locations or regions, better described as therapeutic
landscapes (Gesler, 1992,1993,1998,2003,2005;Geores, 1998;
Williams, 1999b;Wilson, 2003;Williams, 2007;Kearns and
Gesler, 1998;Conradson, 2005). Besides highlighting the medical
benefits of particular physical environments, these studies have
also drawn attention to their impacts on broader emotional,
mental and spiritual health and the role of such landscapes in
rehabilitation, community integration and building social cohe-
sion. Hot springs and water-related healing landscapes form a
major sub-theme within such studies (Agishi and Ohtsuka, 1998;
Gesler, 1998;Geores, 1998;Masayuki, 1998;Yasuda, 1998;Foley,
2010). However there are limited studies on non-western
approaches to healing through such landscapes as well as their
culturally specific roles in health and well-being (Wilson, 2003).
Japan is a country with many active volcanoes and has the
highest number of hot springs in the world. Estimations suggest
that there are over 27,000 sources of mineral waters in 3170
locations of the country (Ministry of Environment, 2010)(Fig. 1).
As the Japanese are a bath loving people, this geographical
advantage has given rise to certain unique cultural health practices
such as touji. Touji (literally ‘bath cures’) means the amelioration of
symptoms through hot water. Another popular term ‘onsen therapy’
(onsen ryohou), denotes a detailed approach to health management
through the use of specific onsen waters.
This article describes policies and practices related to onsens;
health and wider benefits of hot springs; and their status in
Japanese health care. The article highlights the need for better
policy support for this eroding traditional healing method called
touji or onsen ryouhou. The article starts with a section on the
history of touji, followed by sections on Health benefits and
popularity of the method; Policies, regulations and quality and
safety standards; and Initiatives related to research and training.
The article also compares the European practice of balneology
with touji. This is followed by a section on modernization, which
highlights the transformation of health related cultural traditions
in the Japanese society. The article ends by a discussion on key
challenges and the policy measures needed to strengthen such
practices.
2. History
Hot spring bathing has a history of over 2000 years in Japan
(see Table 1). During the Kamakura period, after the political
center was moved from Kyoto to Kamakura, (which started in
1192 and represented the beginning of the Middle Ages in Japan),
many hot spring areas were well known in the Kanto, Tokai, Tohoku
and Koushinetsu regions. During the war period (1493–1601)
hot springs became popular for their healing properties for
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Health & Place
1353-8292/$ - see front matter &2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.healthplace.2012.06.020
n
Corresponding author. Tel.: þ81 45 221 2374; fax: þ81 45 221 2303.
E-mail addresses: unnipm@yahoo.com,
payyappalli@ias.unu.edu (U. Payyappallimana).
Health & Place 18 (2012) 1366–1373

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wounded soldiers. In a document published in the mid-Edo period
around 100 onsen areas with their respective healing properties
and their distance from Edo have been mentioned (Japan Spa
Association, ND).
In 1868 the Meiji restoration occurred, starting a
period when Japan’s westernization movement was dominant.
Culture and technology from the Occident were imported, and
Japan experienced a rapid transition. Western medicine was
adopted officially from Germany and Dr Erwin von Baelz was
appointed as professor at the Tokyo Imperial University. He
introduced German balneology to Japan, first to Kusatsu, Ikaho
and Hakone areas and came to be known as ‘the father of Japanese
onsen medicine’. The government also commissioned country-
wide investigations. In 1886 the Ministry of Interior, Hygiene
Department published ‘the magazine of Japanese iron springs’.
The Meiji era was also a period of economic prosperity meaning
that the onsen resorts were booming as places not only for
treatment but also for relaxation and recreation.
In the Taisho era (1912–1925) Atami and Hakone (south of
Tokyo) started to fill with second residences for wealthy citizens.
At the same time many onsen resorts remained with the function
of treatment as they were in the Tokugawa period. Subsequently
in the Showa period (1926–1989) the train system developed,
thus rapidly increasing accessibility of onsen resorts from cities,
leading to an even larger number of people visiting hot spring
facilities. In the years of economic development time became
scarce and people started practicing ‘one-day retreat’ (higaeri)
bathing instead of an extended health regimen. At the same time
many facilities were renovated, newly built and onsen became a
favorite destination for short holidays.
Following the burst of the bubble economy period more
austerity measures were taken in public spending, which led to
the neglect of the healing dimensions of onsen. This has continued
till date as evidenced in the recent closing of hospitals affiliated to
national universities. Whereas there have been several rural
revitalization initiatives through decentralization and place
branding that have resulted in the revival of onsens as part of
the tourism industry, they have not substantially focused on their
healing aspects.
3. Health benefits and popularity
In addition to community bath and recreation elements, onsens
have key functions of maintaining health, and prevention and
treatment of diseases (Agishi and Ohtsuka, 1998). The main
medicinal uses are for injuries, muscle and joint complaints, skin
disorders, neurological and gynecological conditions, recovery
after overwork or disease, and rejuvenation. Onsen is used for
chronic conditions and symptoms (neuralgia, muscular pain, joint
pain and restricted movement, whip syndrome, sprains, chronic
digestive troubles, hemorrhoids, sensitivity to cold, convales-
cence, recuperation after intense work periods). It is contra-
indicated in acute diseases especially with fever, active tubercu-
losis, other infectious diseases, malignant tumors, severe heart
disease, respiratory and renal failure, hemorrhagic conditions,
advanced anemia, and the first and last trimesters of pregnancy.
Whereas there are general benefits of onsen such as disease
prevention, health promotion, rehabilitation and treatment of
chronic diseases, depending on the type of onsen and the bathing
methods there are specific indications (Table 2). There are also
specialized onsens according to specific health conditions. For
instance there are over 100 hot springs in Japan with waters
suitable for alleviating eye diseases (Okusawa, 2003). However
there is sparse data on exact efficacy or mechanism of action of
such facilities.
Drinking mineral waters is not as common in Japan as in
Europe. However consuming water in some specific onsens has a
long history, being beneficial in gastro-enterological disease and
ear-nose-throat (ENT) conditions, among others. Shima, Yunohira
and Gaga are known as the ‘three famous waters for stomach and
intestines’ in Japan. Kakeyu Miyama Onsen in Nagano prefecture,
is a hot spring resort known for a very long time for rich tannins.
Fig. 1. Onsen distribution—Prefecture-wise.
Table 1
Major historical milestones.
Early Japan (until 710)Nara period
(711–794)Heian period (794–1192)
Legendary accounts of onsens and
gradual increase in their number.
Kamakura period (1192–1333) - First onsen lodging established in
Gunma.- First description of healing
waters.
Muromachi period (1333–1573) The word ‘touji’ (healing by hot water)
appears in mid-Muromachi period.
Azuchi Momoyama period
(1573–1603)
Revival of Arima Onsen, one of the
oldest onsens in the country.
Edo (Tokugawa) period
(1603–1867)
- Several public baths started. Touji
became popular with specific health
indications, in around 60 locations.-
First edited book published on the
effects of hot springs.- Ranking system
for onsens based on quality started.
Meiji period (1868–1912) 292 onsen resorts; Dr. Erwin Von Baelz’s
studies on kusatsu onsen.
World War period (1912–1945) Onsen hospitals attached to universities
started.
Post-war (1945–1990) - 1941–1946 the Japanese Onsen Society
Scientific committee started research.-
Onsens became popular as leisure.
1990–Present - Decrease in popularity as a healing
practice.- All onsen hospitals affiliated to
national universities were abolished in
2002.
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Due to their regulating effect on the gastro-intestinal tract, they
are especially popular for alleviating constipation.
There are many methods of bathing at an onsen, depending on
water temperature (hot or warm); depth of tub (shallow or deep);
duration of bath; methods such as steam bath, shower bath and
other factors. There are also several regional peculiarities in
bathing practices. For example ‘jikan yu’, meaning bathing for a
few minutes in very hot (45 1C) water is a common practice in
Kusatsu (Gunma prefecture) and Iwai (Tottori prefecture). At
certain facilities in the Tohoku region the ground is hot due to
underground water hence this heat is utilized for treatment
through direct contact methods. This is practiced in places like
Goshougake Onsen and Kurikoma Onsen in Akita prefecture.
Another method of getting buried in hot sand is famous in Ibusuki
(Kagoshima prefecture) and Yugawara Onsen (Kanagawa prefec-
ture). Large outdoor baths (rotenburo) are well known at Fuku-
mitsu Hanayama Onsen in Toyama prefecture.
In Japanese there is a saying ‘Yu jyuunichi’ meaning that the
ideal period of stay in a hot spring resort is around ten days. The
stronger the concentration of minerals and higher the tempera-
ture, the more intense the yuatari (initial aggravation of symp-
toms after taking a bath) is. Usually this signals the beginning of
action on the body. Following this indication, improvement of
symptoms will start after a break of one to two days. If aggrava-
tion of symptoms persists for a longer period, a reason other than
‘yuatari’ has to be considered. It happens that busy people, who
want to ‘make the most’ of their stay at hot spring resorts,
intensely take baths for one or two days, several times a day, in
a state of stress and fatigue. By discontinuing bathing during the
aggravation period, they blame the ‘negative effect’ on the onsen.
This points to a general lack of awareness regarding treatment
regimens and the course of recovery.
In addition to the minerals contained in onsen water, tem-
perature, flow and water pressure are also important physical
factors contributing to the feeling of well-being. The gases and
ions contained in onsen water are absorbed through the skin and
enter blood circulation, thus being transported to every cell in the
body. It also activates directly the nervous and endocrine systems.
Depending on the temperature, onsens activate gastric secretion
(2520 1C) or inhibit it (40–45 1C). The combined effects of
physiological and psychological effects of onsen therapy are
intensified by the geographical, climatic and natural factors
surrounding the onsen locations (Agishi and Ohtsuka, 1998).
According to the Ministry of the Environment’s data, in 2006,
there were 3157 onsen resorts with accommodation, where over
137.09 million people stayed overnight. Since 1954 the Ministry
of Health and Welfare has accorded special recognition to
64 hot spring resorts capable of providing medical treatment.
Balneotherapy Institute (now called the Medical Institute of
Bioregulation) is located at Beppu Onsen. According to a report
(Otake, 2004) the number of onsen facilities, both inns with hot
spring baths and ‘tachiyori-yu’ types (no accommodation, open to
all visitors), have almost doubled in 40 years between 1963 and
2002. The number of facilities was 11,907 in 1963 and had
reached 22,127 in 2002. This exponential growth has led to
compromises in quality in terms of recycling of water, microbial
contamination and over-chlorination.
From the health point of view it is ideal to have the type of
onsen, duration of treatment, frequency of baths prescribed by a
doctor who knows one’s ailments and has detailed knowledge
about the wealth of hot springs in Japan. Whereas in Europe there
are specialist medical doctors in each onsen resort recommending
the use of mineral waters, this is rare in Japan, mostly as the
number of such specialists is limited. Due to this, patients have to
rely on their own research. Most reliable information is available
from the facilities in onsen resorts with a long tradition. These
facility owners have in-depth experiential knowledge.
4. Policies, regulations and standards
According to the Hot Spring Law (1948) (Law no. 125), a
natural spring that contains over a defined amount of at least one
of the 19 natural chemical components, or is over a temperature
of 25 1C at its point of release, is officially considered an onsen
(Table 3). The water is extracted from up to more than 1 km in
depth and should not contain gases with a major hydrocarbon
component.
In 1979, various classifications of hot springs were consoli-
dated and merged into nine new types, which are now commonly
used. The Ministry of the Environment changed the terminology
according to the International Union of Pure and Applied Chem-
istry (IUPAC) guidelines and elaborated the Mineral Spring Ana-
lysis Law Guideline, which classifies the mineral waters as follows
(Table 4):
Article 2 of the Hot Spring Law defines the exact manner in
which hot spring water is delivered to the bathtub (see Table 5).
There are several details for assuring the quality of water. For
instance there are strict guidelines for mixing the water and the
proportion of source water, which is the amount of original onsen
water present in the bathtub. Kakenagashi (mixing and flushing) is
when fresh onsen water is added regularly to the tub, let to
Table 2
Onsen therapy methods for the digestive system (Source—Japan Health and
Research Institute, ND).
Disease Type of onsen How to use
Ulcer Salt and alkaline On empty stomach,
low temperature.
Habitual
constipation
Salt, Hydrate sodium
sulfate, bitter
Before breakfast,
cold.
Stomach atonia Salt, alkaline, iron, etc. Before every meal.
Gastric hyperacidity Alkaline, sulfur, salt,
etc.
Hot, 30 min before
meals.
Gastric hypoacidity Salt, alkaline, CO2 Cold, 30 min before
meals.
Gall duct problems Hydrate sodium
sulfate, alkaline, soda
Before breakfast,
between meals on
empty stomach, at
low temperature.
Table 3
Various components in onsen water and their regulated quantities (Source—Hot
Spring Law, 1948;Government of Japan, ND).
Name of the substance Quantity/kg (over)
1 Dissolved substances (excluding gases) 1000 mg
2 Carbon dioxide (CO
2
) 250 mg
3 Lithium ions (Li
þ
)1mg
4 Strontium ions (Sr
þþ
)10mg
5 Barium ions (Ba
þþ
)5mg
6 Iron ions (Fe
þþ
,Fe
þþþ
)10mg
7 Manganese ions (Mn
þþ
)10mg
8 Hydrogen ions (H
þ
)1mg
9 Brome ions (Br

)5mg
10 Iodine ions (I

)1mg
11 Fluor ions (F

)2mg
12 Hydro-Arsenicum oxide (HAsO
4
) 1.3 mg
13 Arsenious acid (HAsO
2
)1mg
14 Sulfur ions (S) 1 mg
15 Meta-(HBO
2
) Boron 5 mg
16 Meta-(H2SiO
3
) Silicic acid 50 mg
17 Sodium bicarbonate (NaHCO
3
) 340 mg
18 Radon (Rn) 20
m
Cu
19 Radium salts (as Ra) 100 mg
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overflow, without returning it to the bathtub. ‘Circulatory kake-
nagashi’ is when fresh onsen water is ordinarily added to the tub,
let to overflow and then recovered, disinfected, filtered, heated
and returned to the tub for reuse (Hot Spring Law, 1948;
Government of Japan, ND).
Consequent to a 2005 partial revision to this Law, rigorous
standards (Table 5) have become mandatory. As a result of an
explosion due to gas accumulation, which occurred at a facility in
Tokyo’s Shibuya ward in 2007, stringent safety measures and
guidelines have been imposed. Besides, the Legionella infections
in hot springs in recent years (Yabuuchi et al., 1994;Yabuuchi and
Agata, 2004;Furuhata et al., 2004) have also prompted stricter
regulations of hygienic conditions. The last revision of the Onsen
Law took place in 2007 and stipulated that the facilities have an
obligation of showing the results of Legionella testing, frequency
of testing per year, analysis of onsen water at source or at entry to
the bathtub every five years.
During the current Heisei era (which started in 1989) the
government handed out substantial funds for ‘hometown revita-
lization’ to municipalities that faced challenges like depopulation
through ageing, smaller families and out migration of youngsters
from rural areas. Many towns set up public onsen baths to lure
tourists. This led to practices such as recycling water as the
natural flow did not satisfy capacity needed to fill bathtubs with
fresh water continuously.
In 1971 the administration of onsen was moved from the
Ministry of Health and Welfare to the Ministry of the Environ-
ment. Since then, onsen therapy has not been recognized as a
medical service by the government. This change was implemen-
ted in a wave of cost and personnel cuts in such institutions.
However, the department of Health Promotion considers onsen
therapy a medical service. Today, the Ministry of the Environment
publicly announces that onsen is a medical therapy. The Onsen
Protection and the Hygiene administration offices are under
different jurisdictions: the Ministry of the Environment (from
source to the tank) and the Ministry of Health, Labour and
Welfare (from tank to the bathtub). The Ministry of Internal
Affairs and Communications recommends onsen as special terri-
tories (territory for special structural reform). These highlight the
complexity and the need for good intersectoral coordination.
Among the numerous onsen areas in Japan, since 1954 the
Ministry of Environment designated specified onsens as National
Health Preservation Onsen Resorts according to article 14 of the
Hot Spring Law (Government of Japan, ND). As of 1 January 2011
there are 91 among the 3170 hot spring resorts (2.8%) all over the
country, based on the quality and quantity of the waters and
environment as well as expectation for the mineral waters’
effectiveness, among other criteria. In the context of advanced
urbanization and population ageing and civil society’s call for
improving connectedness with nature, these have been created to
be used by the working people for relaxing their minds and
bodies, to promote health as well as to treat and alleviate
symptoms/diseases. Since 1993, the Ministry of the Environment
has designated 13 facilities as ‘Onsen resort for connectedness and
tranquility’. Approximately 40 National hot spring health pre-
servation centers have an attached hospital, though the request
from onsen associations for a mandatory condition to have a
physician specialized in balneology at every facility has not been
fulfilled. The present health insurance system does not permit the
use of onsen as a therapeutic method even if it is prescribed by a
balneology specialist (Japan Spa Association, ND).
The Japanese Society for Complementary and Alternative
Medicine (JCAM) recognizes onsen therapy, and has encouraged
better quality standards for onsens as well as services. Still, re-
gulation has remained at the local governmental level (JCAM, ND).
In a self regulatory move, in 2005, the Japan Spa Association
Table 4
Classifications of Onsens (Source—Asahi-net, ND).
Basis Types Remarks
Chemical
content
1. Simple spring If the medicinal use
is based on a
chemical
composition at
source, and if the
composition in the
bathtub is different
this should be
stated clearly.
2. Simple carbon dioxide spring
3. Carbonated spring (former
bicarbonate earth spring and
former sodium bicarbonate spring)
4. Chloride spring
5. Sulfate spring
6. Ferruginous spring (former iron
spring and former melanterite
spring)
7. Sulfur spring
8. Acidic spring
9. Radioactive spring
Water
temperature
1. Extra hot springs (42 1C or higher) Temperature based
classification as well
as pH based
classification are
significant for
determining
indications and
contraindications of
therapy.
2. Hot springs (34 1C–411C)
3. Warm springs
(25 1C–33 1C)
4. Cold springs
(less than 25 1C)
Concentration of
hydrogen ions
1. Acidic (pH of under 3)
2. Mildly acidic (pH from 3 to 6)
3. Neutral (pH from 6 to 7.5)
4. Mildly alkaline (pH from 7.5 to 8.5)
5. Alkaline (pH above 8.5)
Table 5
Standards to be Maintained by Onsens.
General details - Additions to spring water (underground,
lake, tap, well).
- Purpose (cooling, increasing the amount,
dilution).
- Heating of water (usually or seasonally,
exact period of the year, temperature
gradient).
- Details of water circulated prior to being
provided for public bathing.
- Usage of filter and purpose.
- Bath additives.
- Sterilization of water and methods
(chlorine, ozone, UV light, etc.).
- Change in qualities, temperature from the
original water, details of mixing.
Water-related - Name of the source, sharing of source by
other facilities or exclusive use.
- Address of source, distance in meters.
- Means of transportation.
- Output capacity (litres/minute).
- Flow characteristics (natural flow,
excavation area, excavation depth –
meters).
- Characteristics of bathtubs (type, number
location of each type in each bath room)
specifying with a map.
- Details of hygiene—water change, bathtub
cleaning, frequency, method.
Designation as National Health
Preservation Onsen Resorts
- Quality, amount and temperature.
- General attributes of the place (existence
of medical facilities and trained staff,
convenience of transportation).
Self standards of The Japan Spa
Association
- Water at source:
Source name, shape of spring, temperature
and volume at source, source address, type
of water, type of drilling, distance (depth).
- Hot spring water used in bathtub:
Recycling equipment (existing or not),
water supply and drainage method,
addition, heating, injection temperature,
temperature in the bathtub, frequency of
water change, additives, sterilization.
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has created a trademark for natural hot springs. For this accred-
itation, it is necessary for onsens to comply with several standards
(Table 5) and display information publicly after a strict verifica-
tion of each bathtub at hotels and other facilities. The accredita-
tion has to be renewed at regular intervals. In 2009 there were
555 signs at 296 facilities from Hokkaido to Kagoshima (Japan Spa
Association, ND).
5. Research and training
5.1. Research
Evidence of physiological or therapeutic effects of hot springs
is a longstanding debate with a history of over a hundred years
(Anonymous, 1912). Japan has considerable documentation on
the health benefits of onsen, starting with the Chinese medicine
doctor Goto Gonzan and his disciple Kagawa Shutoku who
published the first book on Japanese curative waters in 1738
(Japan Spa Association, 2006: 32). In recent decades, several
research papers on the effects of onsen therapy on chronic
diseases such as cancer, rheumatic arthritis, skin diseases, lower
back pain and regulating blood glucose levels, and improving
immunity (Konrad et al., 1992;Okusawa, 2003) have been
published in Japanese with limited literature in English.
A review of 58 papers showed that the use of onsens has
beneficial physiological effects in increasing and retaining skin
and body temperature; lowering blood pressure; improving
peripheral circulation function, regulating gastro-intestinal hormones
secretion and gastric mucosal blood flow; increasing metabolism;
regulating the function of immune system and balance of auton-
omous nervous and internal secretion systems; maintaining skin
health; relieving stress and relaxing; and improving the quality of
life. These articles highlight that onsens are especially important
in the context of promoting physical strength and fitness well-
being of the aged and also point out that it can contribute to
reducing medical expenses of individuals and the community
significantly if appropriately promoted (Hiroharu et al., 2006;
Hongbing and Kagamimori, 2006;Kamioka et al., 2006). A critical
gap is that these studies have not been able to highlight convinc-
ingly the culturally specific health and well-being dimensions of
such therapeutic facilities in the country.
Despite literature showing benefits of onsen therapy, lack of
funding and marginalization in policy processes have resulted in
inadequate focus on research. In 2002, in a major setback, as a
cost cutting measure, all hospitals affiliated to national univer-
sities were abolished including the bases for onsen research in
Noboribetsu (Hokkaido University), Naruko (Touhoku University),
Kusatsu (Gunma University), Misasa (Okayama University),
Beppu (Kyushu University), Kirishima (Kagoshima University)
and research funds from the Ministry of Education, Culture,
Sports, Science, and Technology were cut. There were six national
universities teaching onsen medicine, but since 2009 there are no
institutions at the academic level, although minimum research is
still carried out by private organizations. Conversely, on the safety
side there is research and documentation of sudden deaths and
other adverse reaction at onsen resorts, which has led to a
negative image of onsens. However such studies have highlighted
the need for correct bathing procedures, standards and safety
precautions (Japan Health and Research Institute, ND).
There seems to be a misperception among western practi-
tioners and academics that balneology, the scientific study of
naturally occurring mineral waters, is well known and hot springs
therapy an integral part of routine medical care in Japan. How-
ever, the popular perception in Japan is that onsen is a specialty
for leisure, and thus has not attracted sufficient interest among
young researchers or doctors.
5.2. Training
The Japanese Society of Balneology, Climatology and Physical
Medicine is a professional association and has 1950 members
who are medical doctors. In 1990, as a step towards standardizing
therapy similar to those in Europe, the association started a
certified onsen therapy physician course and has been accrediting
this specialty under several professional and administrative con-
ditions. The board of the society establishes the curriculum and
examination. As of May 2011, there were 1040 certified onsen
therapy physicians in Japan and 222 licensed specialist physicians
in onsen medicine. It is not compulsory to study onsen medicine as
a medical student and there is hardly any university offering such
courses. Training in onsen therapy is performed at institutions
affiliated to university hospitals in Okayama University, Kyushu
University and Kagoshima University. There are around 25 facil-
ities all over Japan where treatment is offered, alongside with
other therapies. There are several other training programmes run
by individual onsens across the country.
In the recent disaster affected areas such as Iwaki and
Fukushima, which have rich onsen traditions, the Japanese Society
for Onsen Therapists has been offering training and certification as
‘balneo therapists’ based on the traditional practice of touji in
these regions since 2001. These specialists promote health and
welfare projects, partnering with the tourism industry, hoping to
modernize touji into the ‘spa wellness health’ paradigm.
6. Touji and the European practice of balneology
In the field of complementary and alternative medicine balneo
therapy or balneology is a term used for healing by bath as well as
consumption of both hot and cold water. The international
consensus among balneologists is that a cure should last for at
least three to four weeks at a hot spring resort. A cure may consist
of three stages: 1) spa adaptation–adjustment to the new envir-
onment, 2) a possible spa crisis, when symptoms externalize as
part of the natural healing process but can be unpleasant, such as
malaise, fever, headache, insomnia and pain, and 3) regeneration,
when an overall improvement of the indicated condition can be
observed. Balneotherapists have noted that benefits derived from
spa therapy can be extended for up to 10–12 months after
treatment (Konrad et al., 1992;Tishler et al., 2004).
‘Onsen ryohou’ is an endogenous healing approach with a very
long history in Japan, unlike acupuncture and herbalism, which
are mainly imported from China. It has been influenced by
European balneology but maintains many particularities, depend-
ing on the numerous varieties of mineral waters. It is necessary to
follow the rules of bathing in medicinal hot springs, after health
checks, following the advice and recommendation of specialist
doctors, in communication with a family physician. Unlike in
Japan, in countries like France, Germany and Italy insurance
coverage is possible if a doctor recommends and evaluates effects,
according to a care plan. There are also certain procedural
differences between the Japanese and the European traditions.
Unlike in Europe, in Japan bathing is done at 42–43 1C, bare
bodied. Indifference point, the midway point where neither heat
nor cold is felt, for bath water is 35–36 1C for Japanese, a little
higher than for Europeans. Bathing methods in Japan are open air
bath (rotenburo), waterfall shower (utase), buried in sand, mud
(colloid, or packages) and steam baths (oiran). There are also
differences in physical and biochemical compositions of hot
springs in Japan and Europe. For example the acid hot springs
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(pHo3) with strong bactericide effect and onsens with alaun
(Aluminum ions more than 100 mg/kg water) do not exist in
Europe.
7. From cultural traditions to modernization
Onsen related healing practices have an inherent link with the
cultural traditions of Japan as exemplified in the relationship
between spirituality and hot springs. Benefits of hot water with-
out fire were recognized as part of the worship of natural forces
from early days. Owing to this, like every sacred place, onsens are
full of legends depicting their discovery by animals, which are
often reflected in the toponymy (Japan Spa Association, 2010: 6),
some of which are recognized today as cultural heritage sites and
national monuments (Japan Spa Association, 2010: 46). Most hot
spring areas had shrines or dedicated monuments to the water
gods to mark hot spring sources as sacred grounds. However, in
many places these became hidden by modern buildings, placed in
hidden corners or were ruined. Donation to such shrines and
temples before entering the onsen was a familiar practice.
Festivals related to health were common at various traditional
onsens some of which are continued even today. Bathing had
significance as a means of ritual purification based on the
Buddhist teachings as reflected in onsen practices in selected
facilities, which are live even today. For instance traditional
bathing at Hirosaki onsen is to pray at the Buddhist temple,
holding a bamboo ladle, then drinking two to three sips of ‘holy
water’ and sprinkling over the ailing body part. After recovery, the
ladle is to be offered at the temple in gratitude. Today, beyond the
religious or spiritual dimension, onsens are also locations for
sharing cultural space, activities, food and drinks. This deep
cultural symbolism is reflected in the natural environment, design
of facilities, indigenous construction materials and culturally
acceptable bathing practices.
Given the modernization and urbanization in the country,
onsen healing practices have dwindled. The hectic lifestyle devel-
oped during the economic post-war boom in Japan introduced
certain attenuated practices, which were not favorable from the
point of view of balneology. Following the construction of roads
and the railway network new forms of pilgrimage became a
combination of religious worship, healing at a hot spring as well
as pleasure seeking. During the bubble economy people would
arrive in busloads to onsen resorts for entertainment, and health
promotion and maintenance. Today these traditions tend to have
evolved into shorter stays for leisure mainly owing to inadequate
social and political support. This is reflected in the fact that
according to the travel industry, for the last couple of decades the
number one tour destination today is onsen resorts. Television
programmes show benefits from various angles, but information
seems biased towards food and leisure rather than beneficial
waters. As balneotherapy is not a popular medical specialty in
Japan, cure prescriptions are uncommon and most onsen visits are
based on individual choice and preference. The length is much
shorter, so the benefits may not be fully obtained indicating the
deterioration of knowledge and practices related to touji.
During the period of economic growth, universal health
insurance coverage was achieved. Modernization of traditional
medical systems such as kampo medicine (Japanese adaptation of
Chinese traditional medicine) and their selective integration with
the insurance programmes was a key development. But several
cultural healthy lifestyles and healing practices were disregarded
in the formalization process which led to a dichotomy of public–
private space. Though in private, several such practices continued,
the lack of public legitimacy led to an erosion. Current changes in
the popular as well as state attitudes towards touji will have to be
understood in relation to the wider political, economic, socio-
cultural changes in recent decades.
8. Discussion
Visiting a public bath in the neighborhood was a cherished
activity a few decades ago. Farmers used to take yearly breaks and
visit hot springs, which recharged them with energy for the next
seasons. In addition to the medical benefits for various ailments,
the change in scenery, community interactions, indulgence in
good food, and related healthy lifestyles, had a multidimensional
health and well-being effect strongly embedded in the cultural
landscape (Fuyuto, 1995).
The slow alienation of the sector from recent policy decisions
shows that a rich community tradition and related resources are
facing attrition. Apart from this decreasing interest among the
Japanese population, high-technology centered medical care,
emergence of onsen facilities as mere recreation spots, concerns
of over-exploitation of water resources, lack of good quality
education on this therapeutic approach at the university level,
insufficient research, inadequate awareness of touji among the
public, false claims of efficacy and conflict with mainstream
medical systems for want of better evidence are some of the
major challenges in the sector today.
In spite of having documented data that onsens are beneficial
for the prevention and cure of a variety of chronic ailments as
well as ageing related health conditions, therapy is not currently
covered by the national health insurance system. This is in stark
contrast to the situation in Europe. In a positive development,
from 2009, there have been signs of some political commitment
from the ruling parties to reduce medical costs. This has
prompted a focus on ‘patient-centered medicine’ through inte-
gration of alternative and complementary practices. They have
also mooted the idea of creation of a National Project on
Integrative Medicine. But the Japanese Medical Association has
strongly objected to this move (JMA, 2010). This calls for better
linkages between conventional medicine and alternative medical
approaches. Elements of traditional, alternative and complemen-
tary medical systems such as kampo medicine, acupuncture,
moxibustion, Japanese traditional massage (an-ma), finger pres-
sure (shiatsu) and judo seifuku therapy (judo therapy) have been
substantially integrated into the health system, while several
others have been inadequately integrated. Need for better evi-
dence is often cited as the reason for their exclusion, though the
research investments for such practices have decreased consider-
ably in recent years. Lack of insurance coverage has prompted
private spending for such therapies and further decline in their
popularity. A major challenge is to create appropriate evidence,
which needs an interdisciplinary focus to research with fields
such as medicine, epidemiology, chemistry, meteorology, geogra-
phy, demography, socio-cultural studies and urban planning. At
the same time Japan being the fourth most attractive market for
the multinational drug industry, there is a challenge for health
related traditional, alternative or complementary practices to
prove their legitimacy not only medically but also socially and
politically.
Beyond the biomedical dimension, as indicated earlier, healing
takes place at these locations within a broader cultural milieu of
identity, value and belief systems, and symbolic meaning (Gesler,
1993;Wilson, 2003;Conradson, 2005). It is important to look at
local experiences and perceptions of health, wellbeing and effi-
cacy than globalized notions and medical discourses (Foley,
2010). Such cultural specificities and their contemporary rele-
vance need to be better studied and the question of evidence
needs to be contextualized within a broader health paradigm of
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socio-cultural dimensions of therapeutic landscapes and in an
inter-cultural epistemological framework.
It is evident that there has been inadequate focus on the socio-
cultural and symbolic elements of touji in the literature while
there have been several studies about the natural, physical and
built environment of onsens. It is also obvious that there has been
inadequate focus by the international community of researchers
on this Japanese heritage as evidenced in the sparse literature
available in English on touji, a gap that needs to be filled.
Similar to what Geores (1998) describes, commodification of
cultural traditions, geography and their symbolic meanings has
been an integral process of modernization, and Japan is no
exception. However this has come about at the cost of the
therapeutic dimension. This points to the need for a paradigm
shift in the promotion of onsens from a mere entertainment
approach to a comprehensive health approach. Strengthening
the healing aspects of onsens will only be possible with the
cooperation of the medical society, as well as the tourism
industry with emphasis made on their health benefits. A difficult
hurdle to overcome in this nexus is the conflict between the
medical benefits advertized by onsen facilities and medical law
that stipulates the need for medical doctors or certified healthcare
professionals for any medical intervention.
Several adverse incidents like accidents and infections have
negatively influenced the system and cast doubts on the therapeutic
effects claimed by their onsen promoters. Public health centers
nationwide have since advocated use of chlorine at all onsen
facilities, which is controversial due to the adverse effects of
chlorine. Though such incidents have resulted in better regulation
and awareness, they have not been able to strengthen the healing
aspects of onsens. Studies have suggested that through sudden
temperature changes and vasodilatation the cardio-circulatory sys-
tem can be overloaded, leading to strokes and heart attacks (Chiba
et al., 2005). Avoiding such adverse effects mainly among the elderly
population is another current challenge for the industry.
In the context of an ageing society and increasing urbaniza-
tion, onsen has a special role both in terms of health benefits as
well as building social cohesion in local communities (Ito, 2003).
In 1995, there were calls for amending the law to include facilities
recognized by the Ministry of Health, Labour and Welfare for
insurance coverage, under the recommendation of onsen therapy
specialist physicians, having such conditions fulfilled, for treat-
ment and the transportation to and from the resort. The Ministry
of Health developed an ‘active 80 health Plan’ in 1988 to increase
independence and social participation of people in their 80s
through regular physical exercise, a balanced diet and proper
rest. This included a hot spring usage program as a single day
experience at the local initiative of some hot spring resorts
(Mitama no Yu, 2009), a positive yet insufficient development.
Tsujii (1995) emphasized the importance of onsen therapy inclu-
sion in the insurance system to reduce the burgeoning medical
costs in a society ageing at an unprecedented pace. There are
different proposals and mechanisms suggested such as individual
pension insurance, survival payment insurance, endowment
insurance, and dividends usage under which such programmes
may be enhanced (Morinaga, 1995).
According to Cohen and Bodeker (2008) the spa industry has
marked a high growth within the hospitality industry with
growth exceeding other sectors such as amusement parks, box
office receipts or vacation activities. In a departure from the
traditional approach, authentic traditional knowledge practices
are being integrated into the industry. The industry is also
becoming sensitive to better social responsibility through ethical
business practices through integration of local communities and
resources. This also highlights the potential of reviving this age-
old tradition.
Revitalization of ageing rural areas would be a beneficial ‘side
effect’, especially after the devastating natural and human dis-
asters, such as the northeastern region of Japan, where most of
the onsen resorts are situated (Fig. 1), have suffered. Iwate, Miyagi
and Fukushima prefectures have suffered directly from the after-
math of the 11 March 2011 earthquake, tsunami and nuclear
accidents, in addition to the depopulation and economic stagna-
tion problems these regions already had. The region has eight
specially designated onsen areas and much systematic research
and planning is needed for their revitalization. Lastly there are
some conflicting interests with regard to hot springs. Certain
facilities that reach very high temperatures are now being utilized
as geothermal energy sources. This will also need consideration as
the country plans for to reframe its energy policies following the
nuclear disaster.
9. Conclusion
Japan has the world’s longest living population and, among the
OECD countries, its health care system ranks high for good health
at low cost (Shibuya et al., 2011). Several informal health, food
and hygienic practices integrated into the modern lifestyle may
have contributed to this good health status. One among such may
be the onsen-related healing practices, which are deeply
embedded in the geographical and socio-cultural landscape of
Japanese life. Onsen facilities continue to be popular in Japan
though the healing aspects are not adequately promoted. It is
known from old times, that it can ameliorate lifestyle-related
diseases such as diabetes, hypertension, and degenerative dis-
eases related to ageing such as rheumatism. This article highlights
the development of touji as an important healing practice, their
policy regulations and institutionalization, and the major chal-
lenges they face today.
In recent policy decisions, the sector has been neglected, as
evident in the withdrawal of government support for various
hospitals and research facilities across the country. There is
considerable potential for touji as a health management method
especially in the context of an ageing population, apart from
their value in building community bonding. A healthy lifestyle
approach can be an educative function of touji and a strategy in
reducing the demand on public health spending. This will have to
be contextualized and planned based on the culturally specific
health and well-being roles of such landscapes. On a last note, it is
vital to have a strategy to revitalize communities especially in
triple disaster affected areas of northeastern Japan, which are
abundant in the onsen practices.
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