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April 2008, Vol 98, No. 4 |American Journal of Public Health Bezruchka et al. |Peer Reviewed |Government, Politics, and Law |589
GOVERNMENT, POLITICS, AND LAW
Interplay of Politics and Law
to Promote Health
Source.Data were derived from the United Nations Development Programme.49
FIGURE 1—Top 30 countries in the United Nations rankings of life expectancy for 2004.
Improving Economic Equality and Health: The Case
of Postwar Japan
|Stephen Bezruchka, MD, MPH, Tsukasa Namekata, PhD, DrHSc, and Maria Gilson Sistrom, RN, MSN
year (Figure 1).1By contrast, at
the end of World War II, the
health status of Japan’s popula-
tion was very poor. We used life
expectancy as a measure of na-
tional health to examine explana-
tions for Japan’s rapid improve-
ment in health status from the
postwar years to the present day.
Preston pointed out that coun-
tries’ income levels are related to
mortality but that, over time,
only a minimal portion of life
expectancy gains can be attributed
to increases in income.2What ex-
plains the upward shift described
by Preston for Japan, a country
that started far behind in the
“health Olympics” at the end of
World War II? Murray and Chen3
suggested 3 interdependent fac-
tors that modulate the income–
longevity relationship: level and
distribution of national income,
effectiveness of public policies,
and efficiency and effectiveness
of expenditures directed toward
control of mortality.
Extensive research now points
to measures of equality and eco-
nomically democratic forms of
governance as major factors af-
fecting societal health.4The cross-
sectional association between in-
come distribution and health is
compelling evidence of this rela-
tionship5but does not illuminate
policies and structures that pro-
duce the desired effects. Siddiqi
and Hertzman6showed that below
acertain threshold gross domes-
tic product economic growth,
The health situation in Japan
after World War II was ex-
tremely poor. However, in less
than 35 years the country’s life
expectancy was the highest in
the world. Japan’s continuing
health gains are linked to poli-
cies established at the end of
World War II by the Allied oc-
cupation force that established
a democratic government. The
Confucian principles that ex-
isted in Japan long before the
occupation but were pre-
empted during the war years
were reestablished after the
war, facilitating subsequent
health improvements. Japan’s
good health status today is not
primarily the result of individ-
ual health behaviors or the
country’s health care system;
rather, it is the result of the con-
tinuing economic equality that
is the legacy of dismantling the
prewar hierarchy. (Am J Pub-
lic Health. 2008;98:589–594. doi:
10.2105/AJPH.2007.116012)
JAPAN ENJOYS THE HIGHEST
life expectancy of any nation and
thus currently stands as the
leader in what can be termed the
“health Olympics”: the rankings
of country life expectancies pub-
lished in the United Nations
human development reports each
American Journal of Public Health |April 2008, Vol 98, No. 4590 |Government, Politics, and Law |Peer Reviewed |Bezr uchka et al.
GOVERNMENT, POLITICS, AND LAW
GOVERNMENT, POLITICS, AND LAW
Source. Reprinted with permission from Yanagishita and Guralnik.8Copyright 1988, Population Association of America.
FIGURE 2—Life expectancy trends of selected countries: 1960–1982.
together with conditions of income
equality, affects health outcomes.
In 1989, Marmot and Davey
Smith speculated on reasons for
Japanese longevity improvements.7
They noted an impressive reduction
in mortality during the 1980s that
could not be attributed to medical
care (Figure 2). They found that
population mortality was substan-
tially reduced for conditions not
amenable to medical intervention.
Potential explanations for the con-
tinuing remarkable gains in Japa-
nese longevity included low levels
of income disparity, greater secu-
rity and control in the workplace,
and the psychosocial benefits of
loyalty and group commitment.
A common way of looking at
national health changes is to
consider disease-specific mortal-
ity rates over time.8Johansson
and Mosk9conceptualized pro-
tection from exposures to disease
and resistance to or recovery
from such exposures as key ele-
ments in a biological analysis of
mortality change. However, the
health of nations is increasingly
seen to be related to upstream
factors such as a nation’s political
system and its influences on the
economy and on the nature of
social relations.10 Policies that pro-
duce more-egalitarian societies
may explain profound health im-
provements.11 These improve-
ments are probably associated
with biological mechanisms re-
lated to reductions in chronic
stress,12 and they may be more
dependent on political changes
than on specific public health
programs.
Wilkinson highlighted the fact
that Japan has low levels of in-
equality and equitably shared
economic growth.4,13 Japan’s
situation is unique in that the
country had an opportunity (al-
beit forced) to reestablish its
governing and social systems
after World War II. We examine
how population health improve-
ments followed the establishment
of more-egalitarian social struc-
tures, political systems, and re-
source redistribution after World
War II, mandated by the Allied
occupation as part of the recon-
struction of Japanese society and
government.
HEALTH TRENDS IN
JAPAN BEFORE AND
AFTER WORLD WAR II
In the late 1860s, the Meiji
Restoration in Japan dismantled
the feudal Tokugawa Empire. A
reasonable standard of living ex-
isted in the country from the
17 th through the 19th centuries,
with relatively small disparities
between the ruling Samurai class
and commoners.14 , 15 There was
a focus on education during the
Tokugawa period, when Japan’s
literacy rates were comparable
to those of many European coun-
tries.15 Fertility declined,16 with
Confucian traditions (based on
original virtue rather than origi-
nal sin and valuing duty rather
than individualism) playing a
role. Toward the end of the
Tokugawa period, more land
began to be held by residents
than by absentee landlords,17
and an entitlement system ex-
isted between workers and
their supervisors.16
As Japan industrialized begin-
ning in the late 1890s, powerful
families called zaibatsu (including
the Mitsubishi, Mitsui, and Sumit-
omo families) established them-
selves as corporate-like entities.
They amassed great wealth and
political control and dominated
Japanese society. Income inequal-
ity increased dramatically leading
up to World War II.18 The zaibatsu
influenced political and military
leaders, creating fear of United
States hegemony in the region
and pushing for militarism in the
Pacific. Entitlements declined
and the central government did
not attempt to redistribute re-
sources.16
April 2008, Vol 98, No. 4 |American Journal of Public Health Bezruchka et al. |Peer Reviewed |Government, Politics, and Law |591
GOVERNMENT, POLITICS, AND LAW
Japanese health and longevity
suffered greatly during the zai-
batsu reign and the war years
subsequent to the Meiji renais-
sance19 according to vital statis-
tics records from the period,
which are widely believed to be
accurate. The humiliating defeat
of Japan had devastating conse-
quences for the country’s health.
Johansson and Mosk9reported
that life expectancy at birth
among men had dropped to 24
years in 1945 as a result of the
large numbers of war deaths.
General Douglas MacArthur,
the supreme commander of the
Allied Powers, had unprece-
dented control of the occupying
forces in Japan from August
19 45 to April 1951. His top
priority was to dismember the
Japanese empire, promote
democracy, and “blast apart the
concentrations of wealth and
power claimed by Japan’s
wartime elites, dismantle the
structures through which they
worked their supposedly evil
ways, and encourage the growth
of new constituencies.”15 (p543)
MacArthur recognized the im-
portance of the country’s citizens
regaining self-respect. Removing
the traces of Japan’s feudal struc-
ture, developing an economic
foundation based on social jus-
tice, instituting land reform poli-
cies, and giving voice to women
and labor unions were largely
accomplished through the estab-
lishment of a new constitution
and attendant legislation.20 His-
torians characterize the accom-
plishments of the MacArthur
period as the “3 Ds”15 : demilita-
rization of Japanese society, de-
mocratization of the political
process, and decentralization of
wealth and power.
Demilitarization was achieved
through abolishing the Japanese
army. The Japanese were forced
to screen and remove from pub-
lic life all “active exponents of
militarism and militant national-
ism.”15(p53 4) According to the
“peace clause” (article 9) in the
Japanese Constitution, “the Jap-
anese people forever renounce
war as a sovereign right of the
nation and the threat or use of
force as a means of settling
international disputes.” It further
pledged that “land, sea, and air
forces as well as other war
potential . . . will never be main-
tained.”15(p54 0)
Democratization was car-
ried out through the drafting
of the new constitution, which
MacArthur assembled from a
review of the constitutions of
other democracies, including
the United States. The resulting
document21 was arguably more
liberal than the US Constitution,
providing for academic freedom,
free universal education, and the
right of workers to organize and
bargain collectively. The emperor
was left as the symbolic head of
the country, but the Shinto reli-
gion was disestablished, thus
separating church and state.
An important difference be-
tween the Japanese and US con-
stitutions is that Japan’s details
the “rights and duties of the peo-
ple” in 31 clauses. Three of these
clauses have the important impact
of forcing the Japanese govern-
ment to reduce economic dispar-
ity and improve the health status
of citizens. For example, accord-
ing to article 11, “the people shall
not be prevented from enjoying
any of the fundamental human
rights”; article 14 declares that
“all of the people are equal
under the law and there shall be
no discrimination in political,
economic or social relations be-
cause of race, creed, sex, social
status or family origin”; and, fi-
nally, article 25 gives all people
a “right to maintain the minimum
standards of wholesome and cul-
tured living. In all spheres of life,
the State shall use its endeavors
for the promotion and extension
of social welfare and security,
and of public health.”15 The Japa-
nese government has, with the
exception of several interpreta-
tions of the peace clause, followed
these constitution-defined articles.22
MacArthur saw centralization
of wealth and power in Japan as
antithetical to the growth of
democracy. Corwin Edwards,
the head of the State Department
mission, reported that the
concentration of economic con-
trol enabled the zaibatsu to con-
tinue a semi-feudal relationship
with employees, to suppress
wages, and to hinder the devel-
opment of independent political
ideologies. Thus the formation
of the middle class, which was
useful in opposing the militarist
group in other democratic
countries, was retarded.15(p543)
To bring about conditions con-
ducive to the establishment of a
middle class, MacArthur en-
forced the breakup of zaibatsu
business conglomerates, fostered
the growth of labor unions, re-
moved control over education
from the hands of the central
bureaucracy, and rewrote the
civil code. In addition, a maxi-
mum wage was legislated.21
At the end of the war, al-
though more than half of Japan’s
residents lived in agricultural
villages, these individuals owned
less than 10% of the land they
cultivated. The land reforms
that were instituted after the
war allowed tenants, called
kosakunin, to purchase their land
from the country’s roughly
36000 landowners at a fixed
price based on a complicated
formula involving rice prices and
production costs. The land was
sold to the kosakunin, and they
were granted 30-year low-interest
loans to pay for it. More than
90% of the country’s land was re-
distributed among the kosakunin
during this period. Most tenants
paid for the land in cash or had
repaid the loans by 1948. There
were minimal incidents of vio-
lence between landlords and
tenants, and no loss of life was
reported. Historians term this the
most successful land reform pro-
gram in world history. Its success
can be attributed to the cultural
values of reciprocity inherent in
Japan that were a carryover from
the late Tokugawa period and the
Meiji Restoration.23
Japan’s labor unions were
organized at an individual busi-
ness level rather than at the oc-
cupational level, producing co-
operative agreements between
management and labor. Large
firms incorporated labor into
management and cultivated loy-
alty among workers by offering
long-term employment as well as
wage increases tied to seniority.24
Such an organizational model
for labor contrasts with a market
model in which workers are
viewed as commodities.25
American Journal of Public Health |April 2008, Vol 98, No. 4592 |Government, Politics, and Law |Peer Reviewed |Bezruchka et al.
GOVERNMENT, POLITICS, AND LAW
The Fundamental Law of Edu-
cation, passed in 1947, declared
that the primary goal of the edu-
cation system was to “esteem in-
dividual dignity and endeavor to
bring up people who love truth
and peace.”15(p54 9) Textbooks
were rewritten to emphasize the
virtues of democracy and paci-
fism. The most radical change
was that students were required
to complete 9 years of public ed-
ucation as opposed to 6 years.
In addition, because MacArthur
recognized the important role of
women in society, women were
ensured educational opportuni-
ties equivalent to those of men.21
HEALTH GAINS IN JAPAN
IMMEDIATELY
FOLLOWING THE WAR
Crawford F. Sams, director of
the Public Health and Welfare
Section under MacArthur, noted
Japan’s astounding health gains
during and after the period of
the Allied occupation:
Between the years 1895 and
1946, the life expectancy of
Japanese men remained station-
ary at 42.8 years. The life ex-
pectancy for women during the
same period was increased only
from 44.3 to 51.1 years. But
between the years 1946 and
1951 the life expectancy at
birth for males took an as-
tounding jump from 42.8 to
60.8 years, and that for women
increased from 51.1 to 64.8.
This constituted a gift of life of
18 additional years for men
and 13.7 for women.19(p345)
He went on to describe this
phenomenon as “unequaled in any
country in the world in medical
history in a comparable period of
time.”19(p3 45) Early improvements
in the longevity of Japan’s popu-
lation certainly came from the
provision of basic needs, includ-
ing food, water, sanitation, and
shelter, immediately after the
war. Strict price controls were in-
stituted to ensure equal distribu-
tion of rice, the main source of
food in the country’s households.
Child growth did not falter.16
Collective cooperation efforts en-
sured the collection of waste and
the distribution of disinfectants.26
Johansson and Mosk9reported
that after the war life expectancy
rose at a pace unprecedented in
both Japanese and world history.
This increase occurred “despite
the fact that income per head had
not yet returned to pre-war levels
[italics in original].”9(p232) Johans-
son and Mosk attributed these
gains to drugs such as antibiotics,
public health expenditures, and
urbanization and did not con-
sider the Allied occupation.
Mosk wrote of Japan’s remark-
ably rapid transition from a
balkanized system of entitlements
rooted in feudalism to a successful
adoption of Western technology
subsequent to the country’s de-
velopment of “population quality”
(i.e., improvements in nutritional
intake leading to increased work
capacity) coupled with advances
made through political protest
movements during the late
Tokugawa period. This situation
led to a period of balanced eco-
nomic growth during 1880 and
19 2 0 .16 Siddiqi and Hertzman6
stressed the importance of equity
policies directed toward educa-
tion, especially of women; main-
tenance of the agricultural sec-
tor; and an orientation toward
an export economy focusing on
domestic labor that allowed lower-
income segments of the popula-
tion to benefit economically.
It can be proposed that the
“3 Ds”—dismantling the prewar
and war period economic and
social hierarchy and restoring
supportive elements of Japanese
society—in combination were
directly responsible for the im-
provements in health and longev-
ity in Japan, the most rapid such
improvements ever seen in the
country; however, a national de-
sire to carry out reforms was
present in the liberal wing of the
government before the war.16
The occupation was a historical
tipping point, but public opinion
leaders had advocated for many
social justice concepts decades
earlier.26 The prewar tension
“between capitalism and a
Confucian-tinged socialism”
helped make postwar changes
possible.27(p189) Land reform was
effective partly because of the in-
digenous social forces the occu-
pation had unlocked.
Translation from English of
Article 25 of the constitution,
with its public health clause, re-
sulted in confusion among the
Japanese population. In Japan
there is no indigenous concept of
“natural rights” and their asser-
tion26; Japanese culture, with its
Confucian ideals, stresses the im-
portance of duties rather than re-
ciprocal rights. Caring is a duty
rather than a policy. The coun-
try’s business model, based on
historical values, evolved to in-
clude productivity elements that
Western nations strived to dupli-
cate. A system of flexible rigidities
governed Japan’s economy and
business climate, producing rapid
economic growth that benefited
all. Americans were demonized
in the prelude to the war; after
the war, however, Japan became
the United States’ greatest friend,
with Japanese citizens turning
their rage against militarists, ul-
tranationalists, and feudal ele-
ments as they embraced defeat
and worked toward job security
and elimination of gross eco-
nomic disparities.22
Hierarchies in Japan reside in
social relationships encompass-
ing all spheres of life, and the
strict norms that govern behav-
iors between superiors and sub-
ordinates in an organization are
more rigidly observed than in
Western societies. In addition,
Japanese companies differ from
those in the West in that there
is more flow of information
from below, more consensus
decisionmaking, and more con-
cern for the personal welfare of
all members of a group. Out-
siders view Japan’s lack of indi-
vidualism as a lack of rights,
but the country’s hierarchy can
be better thought of as the
enemy of individualism because
deference to those of higher
status is such a well-respected
principle in Japan that superiors
do not have to behave in an au-
thoritarian way.17
HEALTH GAINS IN THE
POSTWAR DECADES
In 1979, Japan’s life expect-
ancy became the highest of any
country, and it continues to be
the highest today.8,28 Crime and
violence are very low as opposed
to the increases seen in other
nations. By the end of the 1980s,
April 2008, Vol 98, No. 4 |American Journal of Public Health Bezruchka et al. |Peer Reviewed |Government, Politics, and Law |593
GOVERNMENT, POLITICS, AND LAW
Japan had the lowest income-
distribution gap of any country
reporting to the World Bank.13
Income inequality is again in-
creasing in Japan,18 as in much
of the world, but the health gains
made half a century ago coupled
with the Japanese cultural con-
cept of social harmony29 may
insulate the country’s population
from the adverse outcomes ob-
served elsewhere.30 Countries
respond in different ways to the
call for market capitalism. Japan
advocates its model, which val-
ues social solidarity.31
Today the world is seeing pro-
found changes in disparities both
among nations and within na-
tions, a situation partly attributa-
ble to the forces of corporate-
centered trade and globalization.32
An economic egalitarian ethos
continues in Japan, with a pro-
ductive focus on outcomes rather
than market opportunities as well
as a focus on societal rather than
individual gain.
The effectiveness of political
and policy changes depends on a
nation’s history, culture, and
values. Japan has a higher tax
threshold and much higher levies
for high incomes than the United
States. CEOs and managers are
known to take pay cuts rather
than lay off workers, and the
wage ratio between CEOs and
entry-level workers remains very
low, especially in comparison
with that of the United States.33
Whereas participatory work
structures and managerial pater-
nalism characterize Japanese
manufacturing plants,24,25,34 the
tendency in the United States is
to lay off workers, with attendant
adverse health effects.35
OTHER EXPLANATIONS
FOR JAPAN’S POSTWAR
HEALTH GAINS
Three influences often sug-
gested to explain Japan’s remark-
able health gains are the coun-
try’s health care system, the
genetic makeup of its people,
and factors related to health be-
haviors. However, it is generally
agreed that care provision has
at best only a limited effect on
health at the population level,36,37
and Japan’s health care system
was not and is not exemplary.38,39
Marmot and Davey Smith argued
that the mortality declines ob-
served in Japan were not caused
by improvements in medical care.7
The public health infrastructure
leaves much to be desired.
Measles is common, and immu-
nization rates are low.40 Half of
Japan’s residents did not have
piped water and sanitation in the
mid-1990s.14 In addition, studies
of migrants from Japan to the
United States have shown that
their health tends to decline after
they leave home, implying that
their genetic makeup is not the
reason for their superior health.41,42
The male smoking prevalence
rate in Japan is among the high-
est in any wealthy country, yet
the country’s male population
still has the highest life expect-
ancy in the world, suggesting that
this personal health behavior is
not a key factor. Male smoking
rates in the United States are
among the lowest of all devel-
oped countries, but life expect-
ancy among male US residents is
very low for a wealthy country.43
A diet high in fish and low in
meat also has been proposed as
a reason for Japan’s impressive
longevity. The Japanese diet,
however, has changed radically
since World War II, with gains
in longevity continuing apace de-
spite the population’s much more
common consumption of West-
ernized diets of meat and dairy
products.44 Finally, Japan’s ho-
mogeneous population is not the
reason for its good health.45
Japan’s example of rapid im-
provement in mortality exempli-
fies two interdependent factors
defined by Murray and Chen3:
equitable distribution of national
income and effective public poli-
cies directed toward reductions in
mortality. Wilkinson’s gearing fac-
tor between income and health—
according to which, over time, the
same amount of income “buys”
progressively better health—is
relevant as well. Wilkinson con-
sidered related but unmeasured
salutary psychosocial changes
that piggy-backed on economic
growth as the most important
benefit. In this process societies
become less harsh materially, but
also less repressive and cruel to-
ward one another, as the quality
of social relations softens.46
CONCLUSION
Today’s huge health gap be-
tween Japan and the United
States could not be bridged even
by eradicating heart disease, the
leading cause of death in the
United States.47 Moreover, the
United States continues to fall
further behind, ranking 21st in
life expectancy in the 1992
United Nations report48 and
30th in 2004.49 The discrep-
ancy between the two countries
may result from Japan not expe-
riencing the levels of income in-
equality and wealth polarization
found in the United States in re-
cent decades.18
Changes in a society’s eco-
nomic hierarchy can have pro-
found health effects, and Japan’s
example is remarkable. The Al-
lied occupation provided Japan
with the opportunity to estab-
lish a democratic, peaceful, and
relatively economically egalitar-
ian society. The country’s eco-
nomic recovery was aided by a
new constitution facilitated by
Japanese values. These struc-
tural changes produced social
conditions conducive to health
and longevity, and the benefits
of an increasing life span con-
tinue. Although few nations
experience forcible reconstitu-
tion of their societies and gov-
erning structures, much can be
learned from the effects of such
restructuring in Japan on the
country’s health.
About the Authors
Stephen Bezruchka is with the School of
Public Health and Community Medicine,
University of Washington, Seattle. Tsukasa
Namekata is with the School of Public
Health and Community Medicine, Univer-
sity of Washington, and the Pacific Rim
Disease Prevention Center, Seattle. Maria
Gilson Sistrom is with the School of Nurs-
ing, Oregon Health & Science University,
Portland.
Requests for reprints should be sent to
Stephen Bezruchka, MD, MPH, Department
of Health Services, School of Public Health
and Community Medicine, Box 357660,
University of Washington, Seattle, WA
98195-7660 (e-mail: sabez@u.washing-
ton.edu).
This article was accepted August 24,
2007.
Contributors
S. Bezruchka originated the article idea
and led the writing. T. Namekata provided
American Journal of Public Health |April 2008, Vol 98, No. 4594 |Government, Politics, and Law |Peer Reviewed |Bezruchka et al.
GOVERNMENT, POLITICS, AND LAW
important details. S.G. Sistrom wrote an
initial draft. All of the authors reviewed
drafts of the article.
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