Defining Adulthood

« Exit The Cultural Conte xt of Aging , Worldwide Perspectives­

CHAPTER17

'fRANSFORi\UNG THE CULTURAL SCRIPTS FOR AGING

AND ELDER CARE IN JAPAN

Brenda R. Jenike and John ·w. Traphagru1

Weekdays in Tokyo al\1<1ys begin early-too early for me (Brenda Jenike)

at least. By eight o'clock in the morning it seems that e\·eryone in my

bustling, crowded neighborhood in the n orth\1·estern TolTo working-class

ward of Itabashi has long ago started their dar. Brealfasts lm·e been sel'\"ed

and cleared. Children are off to school. Workers headed for the corporate

cent ers ofTokyo are in the midst of their daily commuting crush, standing.

pressed tightly "like sushi" against one another in unbearably steamy trains

for half an hour or longer. Housewh·es are hard at work cleaning the home or

running errands. By a lazy nine o'clock I am supposed to be at Green Hills,

the local public nursing home and senior day care center, escorting residents

and day ca re attendees to exercise class. I am, howe,·er, late as usual, madly

peddling my shiny red "h ouse\\·ife's special" bicrcle uphill and against the

win d on this brisk autumn day. On ce in the center doors, I am greeted br the

u nmistakable scent of strong detergent mingled \1·ith perspiration, a

testament to both the volum e of human acti\it)"\\ithin and the continuous

effort to cleanse it. In the genkan (entranceway), I hurriedly remo,·e my

outdoor shoes and put on my indoor sli ppers. From my locker. I grab my

light blue apron that designates me as a ,·olunteer caregi,·er. [o.ly nametag

says Burenda in the large Japanese sciipt reserved for foreign words.

Greeted by smiling nods and row1ds of "Ohayo gozaimasu!" (Good

morning !), I en ter the large recreation room just in time to escort the last few

n

participants to their seats. Exuberant music booms through the room, and I,

along \\"ith three other women \·olunteers in aprons, two roung male staff

members and one elderly but robust female sensei (teacher), lead three

consecutive sessions of physical recreation for about eighty frail sen iors.

At first, the scene is surreal. Circled round m e sit twenty-six or so dignified

eld erly Japanese women and men, some in traditional kimono (these are the

oldest, or "Meiji el de.rs"- born in the last years of the i\leiji period), whose

ages range from the mid eighties through the upper nineties. Jn truth, I feel

rid iculous playing "catch the balloonn \\ith persons who should command

more respect from a young woman such as myself. We do , luckily, manage to

share some laughs. When these day ca re attendees lea,·e the room fo r arts

and crafts, the nursing home residents, each dressed in a mix of identical

pastel sweat suits and personal articles of clothing, wheel themseh·es in for

their turn. With some acti\·e, some seemingly acti,·e but cogniti\·ely not quite

aware, and some, those in the "dandelion" (dementia) group not much aware

of an)thing. the residents are di\·ided into teams and then assembled into

rows for balloon rnlleyball. Staff members essentially play the game for the

residents. With large red balloons bopping about the room, residents

sometimes duck, sometimes try to hit the balloon, but most often get hit by

the balloon. No one can really play the game, so it is declared that each side

wins. With exercise time over, residents leave to be fed their lunch or bathed.

Dandelion members a re escorted away by staff. Volunteers go to the tea

room to chat. I spend time sitting and talking \\·ith some residents, then chat

with \"Olunteers until it is time to help \\ith the afternoon reh abiri (physical "rehabilitationn therapy) session.

The abo,·e scene from one of the author's (Jenike) field notes is one that is

repeated at n ursing homes and elder day care centers throughout Japan ­

whether in rural, urban or suburban - on a daily basis. 1 Traphagan, working

in a much more rural and remote part of Japan, has also played "catch the

«&it The Cultural Context of Aging, Worldwide Perspectives

balloon" or other similar games with elders e~q)eriencing a range of cogniti\·e

and physical problems, much like those Jenike describes. \\"hile the patterns

of acti\ity and philosophy of elder care within the context of these

institutions has remained fairly consistent o\·er the past decade and across

different parts of Japan, the approach to funding, managing and prm·iding

care has changed dramatically since the inception of the Jong-term care

insurance program- known in Japanese as kaigo hoken-in 2000.

As of 2005, Japan had the distinction of being the most aged nation in the

world, with over 20 percent (25.76 million) of the population aged si,t}·-five

or o,·er (The Nikkei Weekly 2006). EYen more startling, Japan 's l\ational

Institute of Population and Social Securit}' Research has no\\· forecast a

doubling of this figure to 40 percent aged sixty-fo·e and o,·er by 2050 (Kyodo

l\ews 2006; The Nikkei Weekly 2006). Japanese of all ages are well aware of

the demographic realit}· that tliey are lh"ing in a rapidly "graying society": the

elderly population in Japan is burgeoning, "·!tile the population of youth

needed to suppott it is shrinking.

To deal with tllis demographic conte)l.t and its associated elder care crisis,

in the 1990s the Japanese state replaced the social welfare system that had

provided elder care sen·ices \dth the pre\iously mentioned national long­

term care insuranoe program (LTCI) in April 2000. As a mandatory program

\\ithout the stigma of welfare, owr tl1e past eight years LTCJ has essentially

transformed elder care in Japan from a morally based, family-centered

welfare system to a consumer-driven entitlement system of supporti,·e and

institutional long-term community care. A range of residential ca re homes,

adult day care centers and a plethora of home care and caregiver respite

senices, as well as some hightech creativit}", are now pro,·iding ne\\· cultural

spaces for tlie growing nwubers of Japanese seniors to e)l.'})e1ience late life.

In this chapter we draw from e.'tended particjpant observation in nursing

homes , adult day care centers and caregi,·er support groups, and from in­

()

d epth inten·iews with ca regh·ers and care recipients that ham been

conducted by the authors in separate field sites, located in To1.1·0 (Jenike)

and about 500 kn1 north of Tokyo in Iwate Prefecture (TTaphagan), since the

mid-199os. Our purpose is to e:\'})lore ho\\· a rapidly aging population and the

transition to community care for frail elderly (a profound change in

approadi) are transforming core cultural concepts in Japan such as filial

piet}· and respect for the e!derlr, as well as the meaning of old age and care

itself. In considering these changes, we conclude with a discussion of what

ne\\· cultural scripts future generations of Japanese might have in store for

their O\\TI old age.

THE CHANGING DEl\IOGRAPHIC CONTEXT OF THE

JAPANESE LIFE CO U RSE AND LATE LIFE

The life course for Japanese bas lengthened considerably in only a few

decades. until quite rece ntly, e)l.treme old age-that is, not one, but two or

th ree decades of life post retirement-\\·a.s not a consideration for the

ordinary citizen and his or her family. Up until the end of World War 11,

a\·erage life e)l.'})ectancy for Japanese males and females was around age fifty.

!\ow sb.1)· years later, Japanese males can e)l.'})eCt to li,·e an a\·erage of 78.5

years, and females 85.5 years (Kyodo l\ews 2006). This longevit}", highest in

the world except for the small island nation of Andorra, actually exceeds

prior United l\ations' predictions of maximum life e:\'})ectancies in human

populations (Horiuchi 2000). Thus, today li\ing into a grand old age has

become a normath·e part of the life course for Japanese citizens.

~loreO\·er, the proportion of the population aged eight}· and over within

th e total senior population during this same time span has steadily

increased. Just 9 percent of seniors in Japan were eight}· and older iu 1950;

by 1970, this figure had on~· modestly increased to just under 13 percent.

However, by 2005 this had increased to almost 25 percent.~ Furthennore, in

c E>at The Cu ltuml Context of Aging, Worldwide Perspectives

the past decade alone, the number of cente narians in Japan has quadrupled

to over 28,000 persons, and is p rojected to top half a million by 2050

(Watanabe 2006; Yomiuri 2006b; Willcox et al. this volume). The rapidity

with which J apan transformed to a society with an aged population has been

often discussed in geron tological literature-it only took twenty-five years for

Japan to 1110\·e from a society with 7 percent of the population o,·er the age of

sixty-fo·e to one \\lth 14 percent o\·er that age, and the trend continues to the

present. TI1is demographic transition was accomplished almost twice as fast

as in any other postindustrial society (see Kinsella this volume).

The rapid gro\\th of the elder population has been accompanied by a

corresponding decline in the total fertility rate (TFR). Tiirou ghout the early

i 97os, the TFR for Japan remained relati,·ely consistent at approximately

2.13, a rate s ufficient for population replacement. By the middle of the

decade, the TFR began to d ecline, and bas continued to d o so since-in 2004,

the TFR for Japan was i.29, a number significantly below what is necessary

for pop ulation replacement. TI1e implications of this decreased fertility are

striking. Statistics produced by the Japanese government show p redictions

ofa decline in population throughout this century where the current

p opulation of approximately 127 million will drop to only 44 million by the

first decade of the 2100s unless there are interwning factors such as

increased immigration.3

Japan, ofcourse, is not unusual in experiencing a low TFR combined \\lth

a rapid growth in the population of elders; South Korea and Singapore in

Asia, and Sweden and Italy in Europe, a re prime examples of other societies

elq>eriencing a similar set of demographic changes and associated pressures

(Kinsella this rnlume). Perhaps what makes Japan, or any other society,

particularly interesting is the manner in which those demographic changes

intersect with cultural scripts about how to manage late life and ho\\· to

pro,·ide care for elders who may become increasingly frail and dependent

0

(both physically and financially). Susan 0. Long, in wri ting about how

Japanese approaclt end-oflife decision-making, draws on Seale's idea that

people use a \·ari ety of cultural scripts, some of which may contain

conflicting ,·alues, to interpret and manage the d}ing process (Long 2005:2;

Seale 1998). This approach can be equally applied when considering tl1e

manner in which people interpret and app roach the experience of aging and

the process of caring for an elderly indhi dual.

l\l uch of the literature on elde r care in Japan in recent yea rs h as painted a

rather bleak picture in which fundamental changes in ,·alues related to roles

and expectations \\ithin the family, as \\·ell as a shift from a stem to a nuclear

family system, are forcing a mo,·ement away from family-cen tered support of

the elderly to institutionally-centered support. l:nderlying these ideas is an

often explicit assumption that Japanese family structure is and has been in

the process of transforming from a patrilineal, pauilocal model in which

coresidence of adult children and elderly pa rents in three-generation

households forms the basis of social support for the elderly, to a bilateral,

neolocal model more generally affiliated with dewloped societies and those

that have gone through the demographic transition from high to low birth

and death rates (Ogawa and Retherford 1997:59).

This assumption is usually expressed in terms not simply of change, but of

a weakening of the family structure. In the postwar period, both within

popular media and social science literature on tlte family in Japan, there has

often been a tacit assumption that modernization and urbanization \\ill

ine,~tably lead to the breakd 01m of tlte traditional family form, as \·alues of

indhidualism encourage a stronger emphasis on the nuclear family structure

in part due to the pri,·acy gained by residence away from one's parents. Not

surprisingly, this perspecti,·e tends to generate rather pessinlistic opinions

about the effects of population aging and the well-being of the elderly both in

the present and in the future ofJapanese society.

• Eiot The Cullural Context of Aging, Worldwide Perspectives

Despite these trends , throughout the postwar era. the primary cultural

script that Japanese ha,·e used to cope ,,;th the process of aging and the

potential need to care for an elderly individual experiencing \arious forms of

functional decline has been one that cen ters upon in-home, family-based

pro\'ision of care for the elderly structured around Japanese kinship ideals.

This cultural script of fLlial obligations toward parents and filial piety

continues to shape Japanese approaches to elder care, e\'en \\'hile ideas

about family structure and obligations within the family are contested and

negotiated.

THE FAMILY IN JAPAN Throughout the post\\ar era, structural and ideational elements of the

family ha\·e occupied a major thread in the study of J apanese culture and

society. Ezra ,·ogel's (1963) ground-breaking study of middle-class, \\'hite­

collar workers in urban Japan set the stage for a long-term intellectual

discussion of how Japanese conceptualize and elqie1ience familr bonds, and

how this is changing in response to processes of urbanization and

modernization.

The term most similar in meaning to the English "family" is kazoku. From

a sociological perspecti,~e, kazoku places emphasis on the conjugal bond and ,

thus, implies tlle nuclear family (kaku kazoku) as it is understood in the

EuroAmeiican context (Long 1987:7). While this tennis routinely used in

Japanese discourse about the family, another term is also employed, one that

has significant implications in terms of the conceptualization of rights and

responsibilities within e:-.1ended families. This term , ie, is a complex concept

that can be understood at multiple le\'els: as a kinship term, as a tool through

\\'bich the nation-state ideology has been promulgated and as an academic

concept. In common usage, tl1e term ie refers to both a house or compound

and its residents, hence it is nonnally translated into English as "h ousehold."

0

\\"hen an indi\'id ual speaks of her ie, the reference may be either to her

house, those relati,·es wh o Ji\·e 11ith her in the same house, or inclusiw of

both. The term also has a nuanced meaning suggesting something that is

traditional, old fashioned, and often out ofdate to many Japanese. As an

academic concept, ie is understood as "a multigenerational property-o\\'ning

corporate group 1\'hich continues through time" (Long 1987:3). It is

organized not on the basis of nuclear family structure, but on a stem family

structure consisting of three generations in which there is one married

couple from each adult generation who live together \\'ith the unmarried

children of the younger genera tion. Continuity 01·er time is essential to the

structure of the ie. As has been frequently pointed out in scholarly \\'Ork on

the family, th e li\'ing and tl1e dead are linked together by the idea that family

genealogy is not sinlply relationships based on blood inheritance and

succession, but that genealogical bonds are connected to the maintenance

and continuation of the family as an institution (Artiga 1954:362; Plath 1964;

Traphagan 2oooa).

Central to the idea of the ie is tl1e idea that authority 11ithin the household

is not wsted in persons, but in social positions 11~thin the family unit. Ea ch

position \\'itl1in the household-father, mother, grandfather, grandmother,

\\'ife and eldest son-is\·ested with S)mbolic capital associated 11·ith that

position, which, in turn, is associated \\itl1 specific responsibilities to the

household as a whole and other members of tl1e household. In some

respects, the most powerful office is that of household head , nonnally

transferred from eldest son to eldest son, and it is the household head wh o

forms the li ne of succession that characterizes tl1e historical continuity of

genealogical bonds in agh·en household. The household head is the

representati,·e of tl1e household to the outside world and the final ,·oice of

authority on decisions internal to tlle household. The basic nature and

meaning of tlle ie has been a source of ongoing debate among scholars

•Exi t The Culturol Context of Aging, Worldwide Perspectives

concerned with Japanese kinship.

Although the ie sU'llctur e has a long history in Japan, it \\'as not until the

l\leiji Restoration (1868) that it became a generalized model for family

organizat ion. Prior to the Restoration, traditional norm s of maniage and

residence among peasants were flexible and did not necessarily include

changing residence upon marriage. It was decided by the bur eaucratic

leadership that such a system was unsatisfactory as the basis for building a

modern nation-state, or more precisely, a family-state (kazoku kokka). The

model that did seem appropriate was the samurai paUiarchal family

strncture that was adopted as a basis for all family o rganization in Japan.

Thus, who was to be included in the koseki (family registration) \\'as based

upon this organization (Gluck 1985:182). Indeed, the ie formed the primary

supporting beam of society, in :\leiji ideology. The emperor was the patriarch

of a " family-state," his line of descent symbolically represented the ancestral

ethnicity of the Japanese, and his ie formed the main stem family to which

all other Japanese families were connected (Gluck i985:78).4

What has become clear in postwar studies of the Japanese family is that it

must be understood as an adaptable and d)11amic social sU'llcture that

in corporates elements of indusUial and postindusUial procli\·ities towards

nuclear stl'Ucture while maintaining ideational elements associated with

stem family sU'llctures-particularly 11·hen it comes to thinking about elder

care. Jn short, whether people adhere to t11e traditional stem fam ily approach

to fami ly organization and elder care, or whether they adhere to a nuclear

approach, they continue to think about familial bonds in terms of the stem

family sU'Ucture and continue to conceptualize fa mily either in line with or in

contrast to that structure.

"\ \7AR1VI CONTACT": FILIAL CARE AND OTHER

TALES FROM AN AGING SOCIETY

(..,

As stated before. throughout the postwar era, the primary cultural script

that Japanese ha,·e used to cope 11ith the process of aging and the potential

need to care for an aged parent has been one that centers upon an in-home,

familybased pro,·isioo of care sU'llctured around Japanese stem family

kinship ideals. Coresidence with one's children in old age, traditionally (and

still most typically) with one's eldest son and his wife, has been a

fundamental social expectation, signifying the successful m aintenance of

primary relationships o,·er the life course. Whether or not a family continues

to follow the inheritance and residence patterns of the paUili:neal stem

family system, cultural norms dictate that one adult child-the designated

familr successor-is still responsible for the total care of aged parents. In the

minds of the current cohorts of elders and their own aging adult children,

then, the physical, emotional and social support of the Yet)' old (\\'ho are not

childless) are the responsibility of the child with whom they reside.

TI1is fundamental elqiectation among the older cohorts is in accordance

11ith the norms of filial piety (oyak"ok"o) upon which they were raised.

According to Confucian thought, the tie between parent an d child is one of

the fa·e primary human relationships, calling for the bene,·olent leadership

of the parent and willing obedience of the child. As anthropologist Da,id

Plath explains, "deYotion to one's parents in particular is the root of all \irtue

and the model for all human propriety" (Plath 1988:507). FUrthermore,

cultural ideals for old age in Japan call not only for IO\ing indulgence by

famil)' members, but also for an accepted dependence on the part of elderly

parents. A key characteristic of filial care, then. has been amae dependency

(Doi i973; John son 1993), which has been aptly termed "indulgent

dependency" (Lebra i976) and "legitimized dependency" (Hashimoto i996).

While the term amae is most often applied to the relationship of a dependent

young child on its mother, an aging parent will likewise in turn begin to seek

the indulgence and support of his or her adult child. Like a mother

c Exit The Cultural Context of Aging, Worldwide Perspectives

understanding the needs of her child, an attenth·e adult child (or daughter­

in-law) should understand and attend to an aged parent's needs \\ithout the

parent ha,·ing to ask for assistance. TI1is parent-child role set "encourages

passh·e helplessness" by one partner and • acth·e nurturing" by the other

(Kiefer 1987:104). Jenike's caregi,·er respondents described this relationship,

based on the feelings of oyak"'ok"o. as a natural desire to care for one's

parent, rather than a duty (Jenike 1997). An aged parent deserws support as

part of a lifelong reciprocal relationship, in which the parent has

accumulated social capital through contnbutions to the household and

sacrifices for his or her child and grandchildren (Hashimoto i996).

Symbolic of this idealized family-centered caregi,ing is the concept of

"\1-a rm con tact" (fureai) through "skinship" (physical touch by kin). \\.hile

both of these ideas refer to physical assistance. such as helping an elder to

stand up and walk, holding their hand or touching their arm or any bodily

care such as assistance 11ith bathing, they more importantly encompass the

idea of an ongoing, emotionally 11arm and empathetic family relationship.

Not Enough "Sih"er Seats" Cultural ideals are of course important in understanding \\"by people (or

institutions) behave (or function) the way they do. Ideals should not,

howe,·er, be confused with actual practices. On trains, sub\\"ays and buses in

Japan, seats near the front called usih·er seats" are reserYed for the elderly

and those \\ith physical disabilities. Ideally, this marks seniors as special,

and desening a seat. In practice, \\"hen almost e,·eryone on the bus, train or

subway is elderly, the few "silver seats" provided become meaningless.

Like\\ise, cultural ideals of filial piety-coresidence (at least in late life),

physical and emotional suppo11 within the household unit, indulgence and

encouraged dependency-should not be confused with actual practices. Just

as household m1its and family structure in Japan can greatly dh·erge from

v

the stem family ideal, the ability ofJapanese to meet tl1e ideals and

expectations for elder care that assume intergenerational coresidence and

empathetic, handson personal care has become more and more challenging.

As life e:q>ectancies ha,·e increased, and "ith them, added years of

debilitating chronic conditions, entering into and sustaining potentially

prolonged relationships of dependency are indeed fraught \1ith much

ambi\alence on the p art ofboth elderly parents and their adult children. This

ambh·alence is especially salient when one considers that many of these

adult "children" are tbemselYes o,·er age Si."-1)".

For elderly Japanese, dependency of aged parents on the yow1ger

generations is still socially encouraged. Ho\\"e,·er, becoming an undue

burden (mei11-aku) on family members by outliving and exhausting the social

capital accrued through reciprocal intergenerational relati onships over the

life course breaches the intergenerational contract, and should be ayoided

(Hashimoto 1996; Young and Ikeuchi 1997; Traphagan 1998a). The existence

of numerous poklmri ("s\\"ift" death) temples frequented by elderly Japanese

who go there to pray for a peaceful and timely death and to buy amulets for

the pre,·ention ofsenility and other disabling conditio ns of old age, attests to

the strong desire among elderly to a\·oid falling into this unilateral

relationship of dependency (\\'Coss 1993; Young and Ikeuchi 1997). In

addition, the suicide rate for Japanese aged si.xty and o,·er (35.3 per 100,000

persons for 2003) continues to be the highest for any age group (accounting

for a third of all suicides) and is high when compared to that for elderly in

other industrialized nations (Asah i Shimbun Japan Almanac 2005;

Traphagan 2005a). By comparison, the U.S. suicide rate in 2003 for men

oYer age si.'it:y-fi,·e \\"as 27.34 and -l-43 for women, \\ith both figures

s ignificantly lowertl1an in Japan.5 These two phenomena point not only to

the increased awareness among Japanese seniors of the consequences of

long-tem1 chronic illnesses in old age, but also to the long-held cultural

c EXJt The Cultural Context or Aging, Worldwide Perspectives

belief that an indi\idual has an obligation to lea\·e this world if he or she has

become burdensome (Plath 1983). In some cases, elderly J apanese ha\'e also

resorted to suicide to make a strong social statement about neglectful

children (Traphagan 2005a).

The main way, howe,·er, that caregi\ing ideals based on the stem family

structure no longer fit 11·ith reality is in tenllS of changed residence patterns.

Up until the 1990s, the majority of elderly Japanese Ji\·ed in

multigenerational households, and many had done so their whole li,·es. In

the 1990s, there began an increase in delayed coreside nce, that is, families

were postponing forming extended households until the older generation

reached ad,·anced old age or a health con cern necessitated daily care.

Delayed coresidence also often meant, if families could afford it, li\·ing in t1m

separate households on the same property-a popular choice that pro1ides

some autonomy, yet still upholds the ideal of '1i1·ing at a di stance where the

soup (if brought from one household to the ne:-.1) \\'on' t get cold" (s"upu no

samen ai l1·ori). The rise in numbers of families who postpone coresidence,

reside in separate households when they do, or, most significantly, who

ne1·er coreside in any form at all, has resulted in the doubling o\·er tl1e past

decade of the number of Japanese seniors recorded in the national census as

residing alone or with spouses only (a 10 percent increase in total

households \\ith elderly, see Figure 17.1). In 2005, 01·er half of all households

\\itl1 elderly persons (sixty-fh·e and 0\-er) we re single elderly and elderly

couple households, witl1 4.05 million elderly persons recorded as li1ing

alone, an increase of more than 1 million since the 2000 census (Japan

Statistical Yearbook 2008; Kan 2007).

0

Women pr:tying at a pokkuri temple i n Sugnmo, T okyo, an area that caters to 1hc elderl y. Photo by Jay Sokolovsky.

c Exit The Cultural Context of Aging, Worldwide Perspectives

Figure 17. l Li"ing Arrangement s fur .f t1 11ancsc 65 t1nd Over, 1985-2005

Cl Wtlh children

O Elderly couple

OAlone

ll! W1lholhom

1985 19Sl0 1995 2000 2005

Source: S1n1i<1ical Survey Dcpanmcn1. S101i<1ics Jlurcou. Minl<1ry of ln1crnal Mfoir; ond Communi· cmions. in Japm1 Statl\tko/ Yt•arhtmk. nc<:C.\!)Ctl Jnnuary 2008. n

Kowhere is this trend more apparent than in depopulated rural areas,

where the percentage of residents age sixty-fh·e and O\'er can top 60 percent.

Recent natural disasters and ei.treme weather ha\·e shed a grim light on the

\'Ulnerability ofelderly Japanese living alone in rural Japan, and the

consequences ofadult children not \\ishing to leave city jobs to mo\·e back in

\\ith and care for their aged parents. In 2006, when record amounts of snow

fell on rural northwestern Japan, elderly residents in mountain \·illages

became trapped in their homes, with snow piled to second stories. Residents,

many on fixed incomes, had to endure the cold and darkness \\ithin for

weeks on end. \Vorse, \\ith up to six feet of snow and ice weighing down their

roofs, elderly in their se,·enties and eighties li,·ing alone climbed up to

shO\·el. Many fell to their deaths or suffered se,·ere injuries. Others, tl}ing to

clear piles of snow from their yards. fell or got stuck in drifts and froze to

death. In all, eighty-five senior citizens across north\\·estern Japan died and

more than 1,000 \\·ere injured (Faiola 2006). IJ1 the summer of 200-1, when

Japan was struck by a record twenty typhoons, the majority of those killed

were elderly \\ith dementia who li,·ed alone and kept wandering out in the

midst of the st:onns (personal communication \\ith Kyoto Shin bun reporter).

Throughout Japan, the phenomenon of "kodokushi" of the elderly

- asolitary death" in which a person dies alone \\ithout care or

companionship and is often not disco,·ered for a length of time-bas been

increasing, necessitating the formation of new companies that specialize in

dealing with the deceased person's belongings at the request of family

members (Kan 2007).

Yet e\·en in the 1980s and early 1990s, when a majority of urban, rural and

suburban elderly still resided in intergenerati onal households, the increasing

pressure to continue with longer periods and more arduous care in the home

bad resulted in what became tenned as "social h ospitalization" of the

disabled elderly; that is, family caregive rs in need of a break admitted their

chronically, but 11ot acutely, ill elderly parents into clinics and hospitals for

long in-patient stays (that were subsidized by the national health insurance

system). Roundthe-clock family caregi,·ers \\·ere either una\·ailable (due to

women working outside the home) or worn out. Elderly parents were left

drugged and l}ing in beds in small hospitals not equipped to function as

nursing homes. As costs from social hospitalization soared, go,·ernment

officials realized, too, that family-centered elder care alone was no longer

viable.

FROM THE FAMILY TO THE COl\IMUNITY- SOCIAL

WELFARE AND LTCI

In 1989, the Japanese go\·emment embarked on a ten-year strategic social

welfare plan, known as the Gold Plan, in order to address the long-tem1 care

c Exit The Cultura l Co ntext of Aging, Worldwide Perspectives

needs of the gro11ing disabled senior population, as ll'ell as to try to separate

lo ng-term care costs from those of medical care. The Gold Pla n, togethe r

ll'ith the Ne\\' Gold Plan implemented in 1995 1 \\'as intended as a supplement

to, not a replacement fo r, family-centered home care and thus fa1·ored

respite and in-h ome senices Ol'er institutional care.7 The effect 01·er the

decade ll'as a tremendous nati onal e:\l'ansion of ta.'1.-payer-funded elder care

senices such as part-time adult day care. home 1isit nurses, home care

assistants, meal and bathing senices and short-term and long-term stays at

public nursing homes. As demand for such sen·ices always exceeded supply,

elder care sen·ices during the 1990s \\·ere often rationed in areas 11ith high

populations (the case in most ofTok)"o's wards and cities). This was also the

case in more rural and less densely populated areas, \\'here nursing home

beds, for example, often fell well shmt of the need, leading to multiyear

waiting lists (see Traphagan 2ooob). City and district clerks based their

decisions as to ll'hom could access social \\·el fare sen·ices not so much 011 the

needs of the elderly family member, but on the a1·ai lability of potential family

caregivers. Thus, s ingle and childless elderly, or those in elde rly only

households, had priority. Those residing with adult cbildten (daughters-in­

law and daughters) were put on long \\·aiting lists (two to four years). or were

told that they could not qualify for senices at all. Traphagan recorded

instances ll'here 1\'0men in rural areas 11·ho applied for social welfare

assistance were told to quit work so they could pro1ide the care for their

bedridden in-laws themseh·es (2ooob). Jenike heard s im ilar accounts

among· frustrated daughters-in-law in Tokyo.

In April 20001 the Japanese gowrnment promulgated a nell' social

program that was intended to reform an elder care system that was not

meeting the needs of the population. This "ca re illSurance" program (kaigo

hoken in Japanese) is a mandato1y social insurance program that prm·ides

long-term care to all people with age-related illnesses or limitations,

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regardless of familr situation or income. There were sel'eral reasons for the

creatio n of this s ystem. First, the Japanese long-term care insurance (LTCI)

program was intended to meet the needs of a 1·el)' rapidly aging population.

As well, it sought to proYide an alternati,·e system of caring fo r elders as the

country confronted a \'el)· low fertility rate, as well as a gro\1i ng number of

women ll'ho ha,·e chosen to either remain in the work force after marriage

and childbirth or to opt out of marriage and child-rearin g altogether

(Campbell and Ikegami 2000:27-28). The new program also addtessed

se,·eral administrati,·e. problems, such as inadequate co,·erage for

non medical sen·ices and high e1,penses related to lo ng-term care being

proYided in hospital settings that existed under the Gold Plans. ;\latsuda and

Yamamoto (2001) note that as of 1997, roughly 60 percent of medical

e:>q>enditures in Japan we re related to hospital sel"l'ices, and about 46

percent of hospital patie nts were sixty-fil·e and older, with -13 percent of

those patients ha1·ing a stay of more than s ix months. This \\CIS partly due to

a lack of skilled-nursing facilities and home care sen; ces that, hence, led to

few alternati1·es beyond extended stays in hospitals for elderly in need of

long-tenn care.

•Bat The Cultural Con text o f Aging, Worldwide Perspectives

Fe> ti"al at an :itlu h day cam center in cc 111 ml Tok yo. Photo by Brentla Jcnikc.

As stated before, the Japanese LTCI program is a national, mandatory

social insurance program; e1·e ryone over tlle age of forty is required by law to

contribute premiums aJtd is insured by the municipal government in which

they reside. The national a\·erage monthly premium is currently at 4,000

ren/ m ontll (USD 37), but 1-aries by municipality and income Je,·el (Koyama

and Yasuda 2006). 8 Insu rance premiums only co\·er about 50 percent of the

go\·ernment contributions associated 1\itll tlle system. The remainder is

CO\'ered by national (25 percent), prefectural (12.5 percent) and municipal

(12.5 percent) go\-ernments through taxes and copayments required at the

time of sen ice receipt. In addition, users ofser\ices are expected to pay 10

percent of costs (up to 37,200 yen o r USD 350 / month) as \\'ell as costs of

meals and housing associated wit11 Jong-term stays in ca re facilities, alt11ough

reductions in costs a re made for lo\\'income families . Senices under the

LTO progrillll are accessed through a care managemen t process that

in\"Oh·es initial assessment of the needs of t11e indi,idual and formal

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recognit ion ofan indhidual 's co ndition by a committee cons isting of health

care professionals. After a person has been determined eligible for sen·ices

under the program, a care manager assists the indi\idual and family in

fmding either public or priYate senices/ facilities that are appropriate for

that person.

Long-tenn care senices eligibility is associated with a needs assessment

that dhides potential care rec ipients into five le\·els of need. The program

differen tiates between two distinct types ofcare. Those who ha\·e "care

needs" or yokaigo, which inrnh·es continual nursing care for more than six

months normal · · de indh·iduals ''ith conditions such as dementia or

who are in need of regular help in acti,·ities of daily Ji,·ing (ADL). The second

category is for peo ple who ha,·e "assistance needs" or yoshien, which

includes people that do no t require constant nursing care, but mar need help

with ADLs such as food shopping or house cleaning. Detenninations about

the amount of the monthly allowance assigned for LTC se n ·ices is based

upon the assigned le\·el of need.

In order to obtain care through t11e LTCI program, a person must submit

an application to the municipal office whe re he or she liYes. The application

is followed up by a home \isit aJ1d an eYaluation of cognith·e aJ1d phys ical

conditions by a go,·ernment specialist, as well as a doctor's assessment. After

all assessments ha,·e been co mpleted, a comm ittee for nursing caJ·e

certification determines whethe r or not the person is e ligible fo r care . and if

the decision is positi,·e, a care manager \\'ill work in consultation ,,;tJ1 the

applicaJlt's doctor to determine appropriate seni ces.

With the creation of the LTCl program, there haYe been significant

impro1·ements 01·e r the social welfare system. Since private as well as public

sen·ice prO\·iders are allowed to compete for clients, there is a greater array

ofchoices. For example, rather than just being assigned to a facility or sent a

city home helper, elderlr clients and their family members can now decide

•Exit The Cultural Context of Aging, Worldwide Perspective s

which day care they want to attend, which home assistant to employ, or

which type of residential facility to moye into-small or large facility, a group

home for Alzh eimer's, an independentli\-ing facility or a nursing home with

maximum care and so on. There is now grea ter access to physical therapy

and rehabili tath·e senices, so elders suffering from strokes or injuries can

regain an indepe ndent lifestyle. Through the'isits of the care managers,

LTCJ also sen·es as a check on elder abuse. Abuse of an elderly parent, in the

form of neglect, emotional or physical Yiolence, or economic abuse, can no

longer be hidden away behind the closed doors of t he family home.

TOO MANY WHEELCHAIRS: CHALLENGES FACING

LTCI

While implementation of the LTO program has presented numerous

hurdles, the biggest challenge for sustaining LTCJ O\·er the long run is

undeniably the cost. Total spending of LTCI was 7.1 trillion yen in 2006

(USD 66 billion), up from 3.6 trillion in 2000 (liSD 34 billion), \\ith 4

million out of Japan's 25 million people aged sixt)·-fi,·e and older designated

as beneficia ries who need LTCI's care. This is double the figure of

beneficiaries compared t o when the system \\'ilS launched in 2000 (The

Japan Times 2006a). Initially, the go\·ernment had miscalculated the usage

and cost, assuming \\Tongly that th e \\ill to continue ''ith family care would

stem the demand for use of community care sen·ices. The significant

increase in beneficiaries, however, also means that sen·ices haYe been

provided to elderly who do not actually need intensi\-e care. Currently, the

incenti,·e ofcare managers, who are often employed by priYate senice

pro\iders, is to O\'ersell care senices to their elderly clients. Wheelchairs and

automated beds, for example, ha,·e been gi\·en to and used by people who are

still mobile, and there has been a rapid grO\\th in the number ofstores that

sell equipment for older people such as walkers or scooters. In some cases,

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senice recipients lm·e had their home helpers do all their housework, chores

and prepare their meals, like personal sen'ilnts, e\·en though they could still

do th ese actiYities themseh·es. In addition to o\·eruse problems, there

continue to be chronic staff shortages at nursing homes across Japan. The

high demand for services and shortage of care personnel finally led th e

gO\·ernment to liberalize its notor iously strict immigration policy in 2007,

easing licensing and allowing 400 Filipino nurses and 600 Filipino

caregh·ers to work in Japa n (Kyodo !\ews 2007; Th e Japan Times 2006b).

Walkers o n di,play in a •lore ded icated 10 equipment a nd s uppl ies thal cun be purcl~1>ecl or rc111cd under the L TCI program (lwa1c Prcfec111n:). Pholo by John W. T n1 phagm1.

In a mo\·e to contain ballooning costs and reduce the need for professional

medical s taff, the gorernment has recently made changes in LTCI­

• Eiot The Cultural Context of Aging, Worldwid e Perspective s

redefining need and shifting its focus to include preventati\·e care. The

gowrnment created two new "needing support" categories, for wh ich

beneficiaries will receive pre,·entative senices (strength training and

nutritional counseling), but not traditional nursing care or equipment.

Household chore help for those who fall into these new categories is now

limited to elderly who Jh·e alone, and those who receh·e it ha,·e to assist their

home helper (The Japan Times 2006a).

0Yerall, through LTCI, elder care nationally in Japan has undergone a

shift from the family-centered model of "wann contact" and "desen·ed

dependenc}?' to one of indhidual entitlement. Ofcourse, for those who still

wish to practice the "warm contact" family model of careghing for their

parents and parents-in-law, the greater a\·ailability of respite care sen·ices

that LTO pro,·ides h as increased their ability to do so. Howe,·er, \\ith LTCl's

individual-centered care model, the emphasis is now mo,·ing away fro m the

responsibility of the family toward the responsibility of theelderly,

themseh·es, to pursue independent, healthy aging.

CAREGIVING FOR THE TWENTY-FIRST CENTURY:

HIGH-TECH CREATIVITY A.l'1D "SILVER BUSINESS"

OPPORTUNITIES

One oftl1emore interesting outcomes of the LTCI program has been the

increasing commoditization of elder care sen·ices and the creation of what

amounts to an elder care industry, \\ith both new jobs, in the form of

positions such as care managers, and new products. The growth of the elder

population in Japan has brought witl1 it the potential for new markets. Care

technology has grown into a s1.08 billion market as of 2006 and is expected

to continue growing as the population of elderly increases. '.\!any of these

new and proposed new products take adva ntage of Japan's abilities and

fasci nation with high-tech solutions to problems. Recent high- tech solutions

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to the problem of an aging population range from wheelchairs ''itll ,-oice

recognition to a robotic arm fitted witl1 a spoon and fork that can be

operated with the user's chin and can manipu late even soft foods such as

tofu (Associated Press 2007).

While tile prices of these new gadgets can be quite prohibitive for the

elderly-the spoon-feeding robot ann costs S3,500-a combination of the

LTCI program, labor shortages and reduced family size have stimulated tl1e

de,·elopment of a \ariety of new technologies. Other examples of

technological solutions to the problem of an aging society include some

fascinating ideas, such as an automated bathing machine (basically a car

wash for the hwnan body), toy company TOMY's wide-eyed an ime-styled

robotic "grandchild" dolls for lonely elderly couples and partner robots to

pro\ide medical and nursing care (The Nikkei Weekly 2007). )!any of these

high-tech inno,·ations ha,·e been reported in tile Western news media with a

combined sense of c~riosity, sensationalism and suspicion. Indeed, tl1e

go,·ernment has pronioted research into robotics as a means of dealing \\;th

the rapid aging of the society and as an alternative, when it comes to health

care, to allo\\mg into the country significant numbers of immigrants who

could fill jobs left \acant as the Japanese population declines O\·er tile

remainder of this century (Hardin 2008).

The growth of the "sih·er business" has not been limited to high-tech. The

nursing care industr)" itself has become a growth area as a \ariety of ne\\"

facilities and approaches to elder care emerge. For example, in 2000, there

were 369 group homes for elders suffering from conditions such as

Alzheimer's disease that pre,·ented tliem from lh·ing on tlleir own. In Iwate

Prefecture (where Traphagan has co nducted research), tllere were a total of

se\·enty such homes. By July 2006, these numbers had increased

dramatically, ,,;tJi a total of 8,052 group homes for elders nationally and 860

\\itJiin Iwate. In manr cases, these homes are the result of entrepreneurs

c Elat The Cultural Co ntext of Aging, Worldwide Perspectives

either expanding their businesses in the health care area or entering into the

new industry. !\ot unexpectedly, the results of this rapid growth ba,·e been

\"aried, with some group homes prO\;ding excellent care and others running

afoul of the legal system for failure to pro,ide care that meets national

standards (Traphagan and Nagasawa 2008).

In a large Tokyo books1o re, piles of how-10 books for sa le on " recreation ga mes" and rehabil itation activities for the elderly, along with aisles full of manuals for L TCI and elder care. Photo by Brenda J e nike.

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c Elot The Cullurnl Context of Aging , Worldwide Perspectives

Beyond the health care industry, ,·arious companies ha,·e been tr)ing to

court the interest-and yen-ofelderly Japanese. l\TI DoCol:llo bas held

workshops in the To1.·yo area to help elders learn to use specially designed

cell phones (Yomiuri 2006a). Companies such as Lawson, which has

com·enience stores throughout Japan, ha\·e increased the size of aisles and

lowered sh eh·es, and some major department stores ha,·e attracted older

clientele by increasing areas for sitting (Associated Press 2006). This growth

has not come \\ithout problems; consumer fraud against the elderly more

than tripled O\·er tl1e first half of the decade, \\ith O\·er 46,000 cases in the

first half of 2004 alone (UPI 2004).9

NEW CULTURAL SCRIPTS

Since 2000. Japan has been undergoing a major restructuring ofelder

ca.re in which there h as been at least tl1e beginning of a mo,·e away from the

handson, family-centered expe1ieuce of elder care associated \\ilh the idea of

"wann contact" to a more distant, institutional and teclmological approach

to caring for tl1e aged. ru essence, what we see in Japan is the emergence of new cultural scripts that allow for a considerable ex-pansion in the

alternath·es an older person and his or her family ha,·e, should that person

need either minor assistance with ADLs or major, long-term nursing care.

One set of cultural sciipts, specifically set forward by the LTCf program,

im·olves the ability to make use of existing and new forms of public and

private institutional settings that, wh ile prO'l,iding an alternati\·e to the

traditional at-home care sc1ipt, also pro\ide means by which that script cau

be continued. The a\·ailability of home helpers and day care for the elderly

are good examples of this; and e\·en \\ith t11e decline in the proportion of

elders lh,ing in multigenerational contexts, this remains the most common

pattern ofli,ing for older Japanese.

Along with tl1e LTCI program has come, as noted already, a

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commoditization of elder care in which there has been a mo,·e away from

s imply ,;ewing elders as desef\'ing "respect" or "filial piety" to Yiewing them

as significant business opportunities. Elders, and their families, ha,·e become

consumers in a gro11·ing market of goods designed to help people maintain

their independen ce as they age. Robotic and otl1er computer technologies are

at the core of a gro11ing, if not yet highly accessible, market for de,·ices that

can take the place of traditional caregi,·ers.

Yet, it is important to aYoid drawing the conclusion that Japan is

undergoing a wholesale rernlution in elder ca re. Much of what we see with

the LTCI system is ronsistent \\ith existing cultural scripts-ratl1er than

replacing , new approaches to elder care augment existi ng approaches and

established sc ripts. TI1e filial child may no longer be able to coreside \\ith his

or her parents, but may set up Internet monitoring de\ices so the elderly

liYing alone can be in regular touch-even if that "touch" is not as warm as it

once was. Furthermore, although aged parents may readily use LTCJ's

community care sen·ices and spend their final years in a care residence

rather than at home, this does not mean tl1at their e~-pectations for what

constitutes an ideal, or e\·en acceptable, old age have suddenly changed.

fa'Pectations for family care remain strong, and disappointment o,·er

percei\·ed Jack of family assistance can be profound. For tl1e designated adult

child caregi\·er as well. LTO bas remedied the burden of unending arduous

care that was a common e~-pe1iencejust a decade ago. But it ha s not

alle,iated the tensions associated with care decisions that must constantly be

negotiated between in-laws, spouses and s iblings, nor the moral

responsibility to pr01ide care. On a wider scale, there is also a general

discontent among tl1e populace that it is unjust to be fo rced to pay monilily

premiums for futureserd ces that o nly an estimated 20 percent '\ill utilize.

Nonetheless, where the pre,·ious approaches to elder care under the Gold

Plans used a social welfare system in an attempt to pro,ide the same cultural

c Exit The Cultural Con1ext of Aging, Worldwide Perspectives

script in institutional care settings that was prO\ided in home care settings,

the LTCI policy and system has shifted toward a focus on the specific needs

of the elderly as indi,iduals, and as entitled consumers rather than as

dependents, providing a much broader scope of cultural scripts from which

to choose than has existed in the past.

NOTES 1. The ethnographic ,·iguette abO\·e took place ten yea rs ago when I was

conducting my doctoral fieldwork on tile renegotiation of the responsibility

for parent care in Japan (Jenike 2002). In summer 2005, I returned to

TokTO and to Green Hills for follow-up research. Gone we re tl1e llleiji elders

in k.imonos-tllere were now only Taish"o elders, who wore their own sweat

pants and shirts. Yet, to my great delight, I found some familiar faces among

the residents of Green H ills. Imeda-san, a former policeman and affirmed

Edo-ko (nath·e ofTokTo) remembered me clearly. Still walking on his 0\\11,

he told me he was now ninety-two and had been lhing in Green Hills for ten

years. One of the younger residents when he entered, he is now one of the

fi\·e or sb; oldest. H e remarked, "When l came here, I ne\·e r would ha\·e

guessed I would still be lhing here ten years later." lmeda-san's statement is

apt for many elderly Japanese today. They ne,·er expected to li\'e so long, and

ne\·er eiqiected to spend their extend ed rears in a care home for tl1e elderly.

2. These data are extracted from tl1e Japan Statistical Yea rbook online

editionhttp:// www.stat.go.jp/ English/ data/ nenkan/ index.htm.

3. These data are extracted from the Japan Statistical Yearbook online

editionhttp:// W'\\W.stat.go.jp/ English/data/nenka n / index.htm. For a

detailed discussion of population aging and demographic change in Japan,

see Traphagan and Knight (2003).

4. Vogel's work created a conte:-.1 to consider tl1e Japanese family outside

of the traditional emphasis on patrilineal linkages in genealogies (Br0\\11

(}

1966:1146) by noting the importance of the nuclear family structure among

postwar urbanites. Work that followed Vogel mo,·ed alternati\·ely between an

emphasis on the nuclearization of the family to perspecti,·es that show the

continued importance, ideationally, of the s tem family structure tl1at

emphasizes patrilineal reckoning of descent with patrilocal marriage rules

for eldest sons-m uch of the scholarly ,,·ork has centered on determining

whe ther the ie is fundamentally based upon economic ties or social ties

among its members (cf. Browu 1966; Nakane 1967).

5. U.S. Centers for Disease Control and Prevention,

http://\\·ww.cdc.go\'/ mnmT/ pre\iew/ mnmThtml/ mm5415a1.htm=i! tab.

6. Japan Statistical Yearbook. online edition,

http:/ / www.stat.go.jp/ English/ data/ nen kan/ 1431-02.htm.

7. For example, the city-run adult day care Jenike ,·olunteered at during

1996-1997 in Tok·yo's Suginami Ward used the name Fureai no ie, or "house

of warm contact," ernking (in name only) the image of family-centered elder

care (see Thang 2001 for a discussion of the use of fureai and family imagery

in elder care).

8. In Osaka, for instance, wh ere the city's nursing care operations ha,·e a

deficit of 2.7 billion yen (USD 25.2 million), premiums are 5,092 yen/ month

(USO 48) on a\·erage to cover the shortfall. In Kitak,.ushu , those sixty-fa·e

an d over with an annual income of 4 million yen or more (USD 37,400) must

pay 9,500 yen/month (USD 89; Koyama and Yasuda 2006).

9. Home reno,·ation and imprO\·ementscams have been particularly

problematic in recent years. In 2005, for example, the national police agency

repocted that 24,000 people had paid more than 22 billion yen (USO 205.6

million) to fraudulent renovation companies, which was about fa·e times the

number in 2004 ('.\JcCuny 2006).