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Social problems and tuberculosis in Japan

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Social problems and tuberculosis in Japan

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Content r ~ i
SOCIAL PROBLEMS AND TUBERCULOSIS IN JAPAN
r t
A T h e s is
P r e s e n t e d t o
th e F a c u l t y of th e D epartm ent of A s i a t i c S tu d ie s
U n i v e r s i t y of S o u th e rn C a l i f o r n i a
In P a r t i a l F u l f i l l m e n t
of th e R equ irem ents f o r th e D egree
M a ste r of A rts
by
P'leda A. Jones
Januàry 1^ 9 6 1
L _ J
UMI Number: EP54753
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UNIVERSITY OF SO U T H E R N CALIFORNIA
GR ADUATE S C H O O L
UN IV ER SITY PARK
LOS A N G ELE S 7, C A LIF O R N IA
A A, J 7 6
This thesisj written by
...Fleda à# Jones..........................................................
under the direction of h^T....Thesis Committee,
and approved by all its members, has been pre
sented to and accepted by the Graduate School,
in partial fulfillment of requirements for the
degree of
Dean
Date J L g 6l .......................................
THESIS COMMITTEE
^ ^ Chairman
r -I
TABLE OP CONTENTS
PAGE
LIST DP T A B L E S.,........................................................................................... 111
CHAPTER
I , INTRODUCTION.................................................................................. 1
I I . NATIONAL PROBLEM....................................................................... 7
H i s t o r y . ...................................... 7
M i l i t a r i s m and I n d u s t r i a l i s m .............................. 19
I I I . COMMUNITY PROBLEM..................................................................... 29
Urban and R ural ................................................... 29
O c c u p a tio n , Age, and Sex ............ 33
IV. FAMILY PROBLEM..................... 47
N u t r i t i o n . ........................................................ 47
H a b i t a t i o n ................................................................................ 54
R e h a b i l i t a t i o n . •• • ......................................................... 61
V. EVALUATING THE PROBLEM.................................................. 66
SUMMARY........................................................................................................................ 76
CHRONOLOGICAL REPORT OF MEASURES FOR PREVENTION AND
CONTROL OF TUBERCULOSIS IN JAPAN................................................... 79
BIBLIOGRAPHY. .......................................................... 80
11
J
r 1
LIST OP TABLES
TABLE PAGE
1 . T u b e r c u lo s is D eath Rate p e r 1 0 ,0 0 0
i n J a p a n . . . . . . . . . . . . . . . . . ............ 10
2 . T u b e r c u lo s is M o r t a l i t y R a t e s . . . . . . . ............................ 14
3* Y e a rly T u b e r c u l o s i s D eath Rate b y
G roup. ............................ 38
4 . M o r t a l i t y from T u b e r c u lo s is a t D i f f e r e n t
Age P e r io d s I n Jap an and I n t h e U n ite d
S t a t e s ............ 41
r 1
CHAPTER I
INTRODUCTION
"The t h r e a d s of h e a l t h and I l l n e s s a r e woven I n
t o th e s o c i o - c u l t u r a l f a b r i c and assume f u l l s i g n i f i c a n c e
o n ly when p e r c e i v e d a s p a r t of th e t o t a l d e s i g n . An im
p o r t a n t a i d t o u n d e r s t a n d i n g th e community and i t s r e
a c t i o n t o a m e d ic a l o r h e a l t h problem i s th e c o n c e p t of
c u l t u r e w ith i t s a c c e n t on p a t t e r n and f u n c t i o n as w e l l
a s on th e s p e c i f i c ite m s of b e l i e f and p r a c t i s e . " ^ The
enh an ced m eaning of th e p r e s e n t - d a y c o n c e p t of " h e a l t h , "
t h e r e f o r e , e x te n d s i n t o c r o s s - d i s p l i n a r y c h a n n e ls i n
v o lv in g th e s o c i a l and b i o l o g i c a l s c i e n c e s . The term
" h e a l t h c a r e " a c t u a l l y means h e a l t h p ro m o tio n , d i s e a s e
p r e v e n t i o n , and r e h a b i l i t a t i o n , a s w e ll a s d i a g n o s i s ,
and t r e a t m e n t . C l i n i c a l m e d ic in e i s b e g in n in g to t h i n k
of i t s e l f a s a s o c i a l i n s t r u m e n t and p u b l ic h e a l t h h a s
become more c o n c e rn e d w ith t h e p ro blem s of th e i n d i
v i d u a l .
Surgeon G e n e ra l S c h e e le a p t l y e x p re s s e d th e
i d e a i n t h e s e words :
S o c i a l f a c t o r s a r e th e v e ry c o re of p r e v e n t i v e
^B enjam in D. P a u l ( e d . ), H e a lth , C u ltu r e and
Community (New York: R u s s e ll Sage F o u n d a tio n , 1 95 5 ),
p . 477.
i_ 1 J
^ 2
m e d ic in e and p u b l i c h e a l t h . One c a n n o t d is c o u n t th e
r e l a t i o n s h i p of p o v e r t y and d i s e a s e , n o r y e t th e
r e s p o n s i b i l i t y of th e p u b l i c a g e n c ie s and th e m e d ic a l
p r o f e s s i o n f o r a t t a c k i n g b o th s o c i a l and p h y s i c a l
p a th o lo g y . I w ish t o em phasize t h a t when we a re
t a l k i n g a b o u t th e s o c i a l a s p e c t s of m e d ic in e we a r e
c o n c e rn e d w ith th e t o t a l h e a l t h c a r e o f an i n d i v i d u a l
i n s o c i e t y . We a r e t a l k i n g a b o u t w h e th e r o r n o t a
community h a s th e f a c i l i t i e s to p ro v id e p r o p e r and
a d e q u a te s e r v i c e t o a l l c l a s s e s of p a t i e n t s . We a r e
t a l k i n g a b o u t w h e th e r o r n o t a m an’s o c c u p a tio n i n f l u
e n c e s h i s d i s e a s e , i f s o , can he b e r e h a b i l i t a t e d or
can a more s a l u b r i o u s o c c u p a tio n be found? We a r e
t a l k i n g a b o u t w h e th er o r n o t c h r o n i c a l l y i l l p a t i e n t s
can be ta k e n c a r e of a d e q u a te ly i n t h e i r homes -
b o t h f o r th e m e d ic a l b e n e f i t s t h a t may r e s u l t and f o r
th e more e f f i c i e n t u se of h o s p i t a l b e d s . W e a re
a s k i n g : how can p ro lo n g e d i l l n e s s be l i n k e d w ith
r e s t o r a t i v e s e r v i c e s , i n c l u d i n g g e n e r a l e d u c a tio n
f o r c h i l d r e n and v o c a t i o n a l r e h a b i l i t a t i o n f o r th e
a d u l t s ? ^
The t h i n k i n g of b o t h of t h e above s o u r c e s p r o j e c t s
t h e c o n c e p t of m e d ic in e beyond th e c o n f i n e s of d r u g s >
a n t i b i o t i c s o r s u r g e r y . These p r o j e c t i o n s a re made n o t
w ith o u t r e g a r d t o t h e e x t e n s i v e im provem ents w h ich ;h av e
b e en made i n u n d e r s t a n d i n g b o d y f u n c t i o n s and s t r u c t u r e .
Nor have th e g a i n s w hich have been se c u re d i n t h e r e
c o g n i t i o n of d i s e a s e and i t s t r e a t m e n t b e e n c a st a s i d e .
T here i s r e c o g n i t i o n t h a t t h e s e im provem ents and g a in s
have t h e i r f o u n d a t i o n f o r t h e most p a r t i n p h y s i c s ,
c h e m is tr y , and m a th e m a tic s . A lso , t h e r e i s r e c o g n i t i o n
t h a t t h e m e d ic a l p r o f e s s i o n sh o u ld n o t become c o m p le te ly
a b so rb e d i n t h e s c i e n t i f i c a p p ro a c h and h a l f f o r g e t th e
^L eonard A. S c h e e le , " O p p o r t u n i t i e s i n T eachin g
of P r e v e n t a t i v e M e d ic in e ," J o u r n a l of th e A s s o c i a t i o n of
American M edical C o l l e g e s , XXV ( J u l y , 1 9 5 0 7 2 4 2 .
L _ ' J
3 "
f a c t t h a t th e p r i n c i p a l s u b j e c t of s tu d y i s man, a s o c i a l
b e in g ; a u n i t of a f a m i l y , and a member of a community.
Man can n o t be ta k e n out of h i s e n v iro n m en t and
c o n s id e r e d a s a t h i n g a p a r t . Man i s s u b j e c t t o c e r t a i n
s o c i a l la w s, and i s p a r t o f a s o c i a l s t r u c t u r e . I f he i s
removed from t h i s s o c i a l e n v iro n m e n t, th e n o n ly a p a r t i a l
and in c o m p le te u n d e r s t a n d i n g i s p o s s i b l e . V a rio u s e le m e n ts
of t h i s s o c i a l e n v iro n m e n t have im p o rta n t b e a r i n g s on th e
b e h a v i o r and a t t i t u d e s of man. These b e h a v i o r s and a t t i
tu d e s a r e i n t i m a t e l y r e l a t e d t o m an’s t o t a l l i v i n g , h i s
w e l l - b e i n g , h i s s i c k n e s s , h i s h e a l t h .
The p a t h o l o g i c a l p r o c e s s of t u b e r c u l o s i s i s c a u se d
by th e p re s e n c e i n th e body o f th e t u b e r c l e b a c i l l u s o rl
M ycobacterium t u b e r c u l o s i s . While t h e r e a r e many t y p e s of
t u b e r c l e b a c i l l u s , o n ly two of t h e s e , t h e human and b o v in e
v a r i e t i e s , a r e o f p r a c t i c a l im p o rta n c e a s t h e c au se of
d i s e a s e i n man. The human b a c i l l u s i s r e s p o n s i b l e f o r th e
v a s t m a j o r i t y of c a s e s of t u b e r c u l o s i s . A p p a r e n tly , t h e r e
i s no d i f f e r e n c e i n th e form s of d i s e a s e c a u se d by th e
human and M. b o v i s t y p e s , n e i t h e r i s t h e r e any c o n c lu s iv e
e v id e n c e of d i s s i m i l a r i t y i n th e d e g re e of v i r u l e n c e . I f
t h e r e i s a d i f f e r e n c e i n th e v i r u l e n c e , i t h a s n o t demon
s t r a t e d any p a r t i n d e te r m in in g th e c l i n i c a l c o u rs e of
d i s e a s e i n man.
D ia g n o s is of th e d i s e a s e i s made by c l i n i c a l e v i
d e n c e s , b y r a d i o l o g i c a l e v id e n c e o f l e s i o n s o r c a v i t i e s ^
4 "
c a u s e d by th e d e s t r u c t i v e n a t u r e o f t h e b a c i l l i , and by
b a c t e r i o l o g i c a l p r o o f of th e p r e s e n c e o f t h e b a c i l l i i n
an y m a t e r i a l w hich h a s b e e n c o l l e c t e d f o r e x a m in a tio n .
Mo o rg an o r t i s s u e of t h e body i s immune from th e a t t a c k
o f t h e b a c i l l u s .
The mere e n tr a n c e of t h e t u b e r c l e b a c i l l u s i n t o
t h e b o dy i s n o t th e s o le c o n d i t i o n w hich d e te r m in e s t h a t
p r o g r e s s i v e i n f e c t i o n w i l l o c c u r . Only a sm a ll p r o p o r t i o n
of i n f e c t e d i n d i v i d u a l s e v e r d e v e lo p d e m o n s tra b le t u b e r
c u l o s i s . The n a t u r e of r e s i s t a n c e t o th e i n f e c t i o n i s
n a t i v e o r a c q u i r e d . I n e i t h e r c a s e , th e developm ent of
r e s i s t a n c e i s i n f l u e n c e d b y h e r e d i t a r y a b i l i t y to d e v e lo p
r e s i s t a n c e , b y d i f f e r e n c e s i n t h e same i n d i v i d u a l a t d i f
f e r e n t age p e r i o d s of t h e l i f e sp a n , and by th e im p o r ta n t
r o l e p la y e d b y each sex a t c e r t a i n p e r i o d s of th e l i f e
s p a n . I n o t h e r w ords, i f p r o g r e s s i v e i n f e c t i o n i s t o
o c c u r a f t e r b a c t e r i a e n t e r th e bod y , th e h o s t m ust be i n
a s u f f i c i e n t l y s u s c e p t i b l e c o n d i t i o n ; and th e d e g re e of
s u s c e p t i b i l i t y v a r i e s from tim e t o tim e and i s i n f l u e n c e d
b y d i v e r s e e le m e n ts .
C irc u m sta n c e s w hich have a b e a r i n g upon t h e r e
s i s t a n c e t o th e d i s e a s e a r e im p o r ta n t n o t o n ly a s a
t h r e a t t o t h o s e who have an a c t i v e o r a r r e s t e d c a se o f
t u b e r c u l o s i s b u t th e y a r e of g r e a t im p o rta n c e a l s o to t h o s e
who a r e exposed t o i n f e c t i o n . The f a c t o r s t h a t a c t t o
J L n t e r f e r e w ith th e develo p m en t o r o p e r a t i o n of r e s i s t a n c e ^
5 "
a re of d e c id e d im p o rta n c e to th e i n f e c t e d and t o th e popu
l a t i o n a t l a r g e .
T here i s s t i l l much know ledge to he g a in e d a b o u t
th e c o n d i t i o n s w hich a r e f a v o r a b l e o r u n f a v o r a b l e t o th e
m a in te n a n c e of an e f f e c t i v e r e s i s t a n c e t o i n f e c t i o n by th e
t u b e r c l e b a c i l l u s . I t i s t h e r e f o r e h i g h l y d e s i r a b l e to
s t r i v e t o g a i n more i n f o r m a t i o n a s t o th e e le m e n ts which
a r e b e l i e v e d t o g r e a t l y i n f l u e n c e t u b e r c u l a r i n f e c t i o n
w h e re v e r t h e d i s e a s e i s fo u n d . F o r t h i s p a p e r , th e w r i t e r
h#s s e l e c t e d Ja p a n as an a r e e where t u b e r c u l o s i s i s known
t o have a h ig h i n c i d e n c e . Em phasis i s p la c e d upon th e
i n f l u e n c e t h a t th e s o c i a l en v iro n m en t can have upon th e
p r e v e n t i o n of t u b e r c u l o s i s and t h e p ro m o tio n of i n d i v i d u a l
and community h e a l t h i n t h i s p a r t i c u l a r s e c t i o n of A s ia .
D e s p ite t h e e x tr e m e ly h ig h in c i d e n c e of t u b e r c u l o s i s
f o r many y e a r s i n Ja p a n , v e ry l i t t l e p u b l is h e d m a t e r i a l
c o u ld be found c o n c e rn in g any of th e s o c i a l problem s r e
l a t i n g t o th e d i s e a s e i n t h a t c o u n tr y . The i n f o r m a ti o n
f o r t h i s p a p e r h a s b e e n ta k e n from p u b l i c a t i o n s in th e
Ja p a n e se la n g u a g e , from E n g lis h t r a n s l a t i o n s of a r t i c l e s
w r i t t e n in t h e Ja p a n e se la n g u a g e , and from a r t i c l e s i n
E n g lis h w hich were p u b l is h e d i n Japan and i n th e U n ite d
S t a t e s .
The Ja p a n e se a p p ro a c h i n m e d ic a l p u b l i c a t i o n s h a s
le a n e d a lm o st c o m p le te ly tow ard t h e h i g h l y t e c h n i c a l ,
^ h e m i c a l , p h y s i o l o g i c a l , b i o l o g i c a l , and b a c t e r i o l o g i c a l ^
6
a s p e c t s . I n th e s o c i a l s c i e n c e s t u d i e s th e l e a n i n g h a s
b e e n tow ard th e q u a n t i t a t i v e s t a t i s t i c a l and h i s t o r i c a l
a s p e c t s w ith o u t g i v i n g much i n t h e way o f a n a l y s i s con
c e r n in g t h e i n t e r a c t i o n and i n f l u e n c e of th e s o c i o l o g i c a l
e le m e n ts upon th e p e o p le i n r e l a t i o n t o h e a l t h and t o
t u b e r c u l o s i s . By c o rre s p o n d e n c e w ith p u b l ic h e a l t h o f f i
c i a l s i n J a p a n , th e w r i t e r r e c e i v e d e x te n s i v e s t u d i e s on
t u b e r c u l o s i s b u t few o f th e s e s t u d i e s have any r e f e r e n c e
to t h e e le m e n ts of th e s o c i a l e n v iro n m en t and th e p a r t
t h e y p l a y i n th e h e a l t h of t h e p e o p le of J a p a n . E very
a r t i c l e from Japan w hich had r e f e r e n c e t o t h e s e s o c i a l
e le m e n ts h à s b e e n u s e d in t h i s p a p e r and h a s b e e n men
t i o n e d i n t h e b i b l i o g r a p h y .
B ecause th e a v a i l a b l e m a t e r i a l d i d n o t g iv e s u f
f i c i e n t a n a l y t i c a l d a t a , th e w r i t e r a tte m p te d t o make
a n a l y s i s of some of t h e a p p a r e n t s o c i a l e le m e n ts and t o
i n t e r p r e t t h e i r r e l a t i o n t o t u b e r c u l o s i s i n Japan i n a s
much as th e y r e f e r t o th e m a jo r t e n e t s of t h i s p a p e r ,
i . e . , i n f e c t i o n by t u b e r c u l o s i s , c o n t r o l o f t u b e r c u l o s i s ,
and r e h a b i l i t a t i o n of th e t u b e r c u l o u s p a t i e n t .
n
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CHAPTER I I
NATIONAL PROBLEM
H i s t o r y
V i t a l s t a t i s t i c s w hich i n c l u d e d d e a t h from t u b e r
c u l o s i s h a s b e e n a v a i l a b l e i n Jap an s i n c e 1 89 9 . A few
y e a r s e a r l i e r , 1 8 9 3 , New York C i t y was t h e f i r s t g e o
g r a p h i c a l a r e a i n t h e U n ite d S t a t e s t o r e q u i r e t h a t a l l
c a s e s of t u b e r c u l o s i s i n p u b l i c i n s t i t u t i o n s and a l l c a s e s
u n d e r t h e c a r e of p r i v a t e p h y s i c i a n s (1897) sh o u ld be r e -
p o r t e d t o t h e H e a l t h D e p a rtm e n t.
A f t e r t h e R e s t o r a t i o n i n J a p a n , th e I m p e r i a l g o v
ernm ent u r g e d p r o p h y l a c t i c t r e a t m e n t a g a i n s t t u b e r c u l o s i s .
In 1890 when K och’ s t u b e r c u l i n was f i r s t p r e p a r e d , t h e
J a p a n e s e M i n i s t r y o f Home A f f a i r s i s s u e d a d e c r e e con
c e r n i n g t h e u s e of K och’s t u b e r c u l i n and b y 1904 th e same
d e p a rtm e n t i s s u e d an o r d in a n c e r e l a t i n g to p r e v e n t i o n o f
p u lm o n a ry t u b e r c u l o s i s . ^ The d e c r e e s t a t e d t h a t i n a l l
s c h o o l s , h o s p i t a l s , f a c t o r i e s , t h e a t e r s , and o t h e r p l a c e s
'Z .
J . A r t h u r M yers, " H i s t o r y o f T u b e r c u l o s i s , " The
F u n d a m e n ta ls o f P ulm onary T u b e r c u l o s i s , e d . Edward Hayes
t S p r i n g f i e l d , i l l . : C h a r le s C. Thomas, 1 9 4 9 ), p . 6 .
^ T a d a s h i S atow , "The P r e v e n t i o n of T u b e r c u l o s i s i n
J a p a n ," l ’U nion I n t e r n a t i o n a l e c o n t r e l a T u b e r c u l o s i s
B u l l e t i n / I I I ( J u l y , 1926) / p . 5 5 .
7
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r -1
8
d e s i g n a t e d b y l o c a l o f f i c e r s , s p i t t o o n s s h o u ld be p l a c e d
and s p i t t i n g i n any o t h e r p l a c e s p r o h i b i t e d . I t a l s o
s t a t e d t h a t i n n s a t m i n e r a l s p r i n g s , w a t e r i n g - p l a c e s , and
h e a l t h r e s o r t s s h o u ld p r o v i d e " a d e q u a te p r e v e n t a t i v e accom-
5
m o d a t i o n s ." S i m i l a r m e a s u re s were e n f o r c e d i n p r i s o n s ,
go vern m ent s c h o o l s , m u n ic i p a l a lm s h o u s e s , r a i l w a y s t a t i o n s ,
t r a i n s and o t h e r p l a c e s w here p e o p le c o n g r e g a t e . At t h a t
tim e t h e p o l i c e o f f i c e r h a d c o m p lete c h a rg e of t h e s e h e a l t h
m a t t e r s .
The f i r s t t u b e r c u l o s i s s a n a to r iu m was b u i l t i n
Germany i n 1853 and D r. T ru d eau b u i l t t h e f i r s t s a n a
to r iu m f o r t u b e r c u l o u s p a t i e n t s i n th e U n ite d S t a t e s i n
t h e s t a t e of Hew York i n 1 88 4 . I n Ja p a n t h e go vern m en t
e n a c t e d a law i n March 1914 f o r th e e s t a b l i s h m e n t of
s a n a t o r i a i n c i t i e s w i t h 500 ,000 p e o p le o r m ore. F iv e
y e a r s l a t e r i n 1919, t h e "Law f o r t h e P r e v e n t i o n of
T u b e r c u l o s i s " p r o v i d e d f o r s a n a t o r i a i n c i t i e s of n o t
l e s s t h a n 5 0 ,0 0 0 p e o p l e .
A cco rd in g t o t h e above d a t a , J a p a n had some
i n f o r m a t i o n a b o u t t u b e r c u l o s i s v e ry e a r l y i n th e h i s t o r y
of t h e c o u n t r y . Cam paigning a g a i n s t t h e s p r e a d o f th e
d i s e a s e b e g a n i n J a p a n , Germany, and t h e U n i t e d S t a t e s
a t a p p r o x i m a t e ly t h e same t i m e . As f o r t h e m o r t a l i t y
r a t e o f t h e s e t h r e e a r e a s i n 1900, Ja p a n r a n k e d t h i r d
^ I b l d . . p . 3 4 .
L _ j '
9 ^
w ith a r a t e of 127 p e r 1 0 0 ,0 0 0 p o p u l a t i o n . The U n ite d
S t a t e s h ad a m o r t a l i t y r a t e of 197 p e r 1 00,0 00 i n t h e same
y e a r and Germany, 225 p e r 1 0 0 ,0 0 0 p o p u l a t i o n . ^ I t was i n
Germany t h a t th e d i s c o v e r y of th e c a u s a t i v e organism of
t u b e r c u l o s i s was made.
P u b lic h e a l t h , f r e e s a n a t o r i a , m e d ic a l t r e a t m e n t ,
and o t h e r s o c i a l m ea su re s r e l a t i n g t o t u b e r c u l o s i s p r o
b lem s d e v e lo p e d more r a p i d l y i n Germany and in th e U n ite d
S t a t e s th a n i n Ja p a n . Ja p an expanded m i l i t a r i l y and i n
d u s t r i a l l y , e s p e c i a l l y e m p h a siz in g th e m i l i t a r y s i d e .
B oth of t h e s e p ro g ram s, m i l i t a r i s m •and i n d u s t r i a l i s m , a r e
7
b e l i e v e d t o have a d v e rs e i n f l u e n c e s on t u b e r c u l o s i s and
Ja p an d e m o n s tr a te s t h i s p o i n t e x c e l l e n t l y a s t h i s c h a p t e r
w i l l a tte m p t t o show.
T a b le 1, page 10, shows th e i n c r e a s e d d e a t h r a t e
from t u b e r c u l o s i s i n th e y e a r s 1905 t o 1919. Ja p an made
some e f f o r t s t o p r e v e n t t h e s p re a d of th e m enace. The
J a p a n e s e Red C ro ss b e g an i n 1913 w ith i t s work on th e
e a r l y d i a g n o s i s and t r e a t m e n t of t u b e r c u l o s i s and opened
h o s p i t a l s i n Osaka, Hyogo, A ic h i , G if u , P ukushim a, and
Kagoshima p r e f e c t u r e s . About th e same tim e S a i s e i k a i ,
^G od ias J . D rp ie t , "E p id em io lo g y of T u b e r c u l o s i s , "
C l i n i c a l T u b e r c u l o s i s , e d . B enjam in G oldberg ( P h i l a d e l p h i a :
A. D a v is Company,'1 9 4 6 ) , I , p . A -45.
*^Yasuo Takayama, S t a t i s t i c a l S tu d ie s on T u b e r
c u l o s i s M o r t a l i t y i n J a p a n , From t h e D epartm ent of P u b lic
H e a lth (O saka, Ja p a n : Osaka U n i v e r s i t y M edical S c h o o l,
1 9 5 3 ), p p . 1 11 -1 33.
L _ J
r
10
L
A)
"S
V -
TABLE I
TUBERCULOSIS DEATH RATE
PER 1 0 ,0 0 0 IN JAPAN
in
31
31
30
S ,^
9 ^ 7
U
13
Zi
A/
% o
i* r
H
n
ic
iS
i< ^
/3
U
/f
•'?
g
7
5
3
6
;
\ —
A
Zify ^ i é k poy>K loif/an
o v e r S a , o o o
-
fn'txre na.tion.
•VN.'S, N . -N ^ ^ ^ ^ ^ "
QO O O O O O o *v. ^ / s4 > o M > s» X ) X , A) X ) ^
i l l 1 [ i u i 111I I 1I I I I n M 1 u 1 1 1
L ^ k . ^
&«@'O«QXkSS'%~0 'û
^ u j W ^ U» (Ai ojt»sA»j Cm u >-^
1 1 1 M 1 I I I I f
/ T-' t UCe-
( T T l I t n 1111111M 11 H I I I 1 / I I 1
oy r>-Mx*Q-^ 4 cÀ-». V » -4 ^ o »» Cw^ K si-îs-i. Oi
1 1 I I 1 M M I I
J C 'f 'O • • ' O - . i û . X
39
35
37
36
BS
3 < é
33
32-
3 /
30
t î
ay
a r
af
13
aa
1/
A ?
/f
/y
/3
//
//
?
7
V
3
2
Prom: A. Imamura, The E p id em io lo g y and P r e v e n tio n
o f T u b e r c u l o s i s i n J a p a n , R e p o rted i n th e G e n e ra l M eeting
of t h e 1 1 th Ja p a n e se M ed ical A s s o c i a t i o n , Tokyo, 1942,
p • ’ 2 .
( _
J
^ 11
a p h i l a n t h r o p i c o r g a n i z a t i o n endowed by th e i m p e r ia l
h o u s e h o ld , e s t a b l i s h e d s e v e r a l s a n a t o r i a . A side from th e
t u b e r c u l o s i s s a n a t o r i a c o n t r o l l e d e n t i r e l y b y them , t h e s e
two o r g a n i z a t i o n s p ro v id e d a i d th ro u g h many l o c a l h o s p i t a l s
and p ro v id e d m e d ic a l s e r v i c e f o r t u b e r c u l o u s p a t i e n t s who
c o u ld n o t a f f o r d such t r e a t m e n t . The o r g a n i z a t i o n of th e
Ja p a n e se Red C ro ss was n o t d i s s i m i l a r t o t h a t o f t h e
Am erican Red G ross b u t i n f u n c t i o n i t f o llo w e d t h e E uropean
p a t t e r n w ith s p e c i a l em p h asis p la c e d on a n a ti o n - w i d e
sy stem of h o s p i t a l s , c l i n i c s , s a n a t o r i a , and s c h o o ls of
n u r s i n g .
The J a p a n e se W hite C ross S o c i e t y was o r g a n iz e d i n
1911 and i n 1916 t h i s s o c i e t y p a id s p e c i a l a t t e n t i o n t o
c h i l d r e n and t o p o o r t u b e r c u l o u s p a t i e n t s . The a t t e n t i o n
g iv e n to c h i l d r e n was a s p e c i a l a tte m p t t o d ia g n o s e t u
b e r c u l o s i s a t th e tim e when t h e d i s e a s e t a k e s such a h ig h
t o l l . The J a p a n e s e W hite C ross S o c i e t y was th e f i r s t in
Jap an t o s t a r t a p erm an en t open a i r s c h o o l f o r c h i l d r e n .
In 1913 th e Ja p a n e s e A s s o c ia t io n f o r th e P r e
v e n t i o n of T u b e r c u lo s is was o r g a n iz e d . T h is o r g a n i z a t i o n
fo u n d ed c e n t e r s i n t h e p r o v i n c e s f o r t h e p u rp o se of p r o
p a g a t in g e d u c a t i o n a l i n f o r m a ti o n t o t h e p u b l i c c o n c e rn in g
p r e v e n t i o n of t u b e r c u l o s i s . I t i s s t i l l i n e x i s t e n c e and
h a s s e n t t o t h e w r i t e r much of th e m a t e r i a l w hich a p p e a rs
i n t h i s p a p e r .
By t h e s e c o n tin u o u s e f f o r t s t u b e r c u l o s i s b eg an t o
12 ^
g iv e e v id e n c e of a s l i g h t d e c l i n e . At l e a s t , th e d e a t h
r a t e d i d n o t i n c r e a s e and t h e r e a p p e a re d t o be a g e n e r a l
t r e n d to w ard a d e c r e a s e a f t e r 1918. A v e ry low p o i n t was
r e a c h e d i n 1932 even when Jap an h ad one of i t s g r e a t e s t
8
a n n u a l p o p u l a t i o n e x p a n s io n s . But t h i s h e a l t h s t a t u s d i d
n o t rem ain v e r y lo n g . In 1936 t u b e r c u l o s i s a g a i n became
t h e l e a d i n g c a u se of d e a t h and i t h e l d t h a t r e c o r d f o r
a b o u t f o u r t e e n c o n s e c u t iv e y e a r s . ^ I n v e s t i g a t o r s w orking
w i t h Supreme Commander f o r th e A l l i e d Powers have p l a c e d
t h e d e a t h r a t e a t 2 2 5 .9 p e r 1 0 0 ,0 0 0 p o p u l a t i o n f o r Ja p a n
d u r i n g 1943 and r e p o r t e d t h a t a s th e h i g h e s t o f any i n
d u s t r i a l i z e d c o u n t r y i n th e w o rld . In t h i s same y e a r th e
U n ite d S t a t e s t u b e r c u l o s i s d e a t h r a t e was 4 1 .9 p e r 1 0 0 ,0 0 0
p o p u l a t i o n ; E ngland and W ales, 6 1 .9 ; Germany, a p p ro x
i m a t e l y 6 2 .^ ^
C o n fu sio n a f t e r t h e s u r r e n d e r of World War I I
g i v e s good r e a s o n f o r u n r e l i a b l e s t a t i s t i c s d u r in g th e
y e a r s 1944 th r o u g h 1946. The O ccupied F o rc e s b e g an
im m ediate work on t h e m a jo r h e a l t h p roblem s i n Jap an i n
c l u d i n g t u b e r c u l o s i s . The h e a l t h program s t a t e d by th e
^ Jo hn F . Embree, The J a p a n e se N atio n - A S o c i a l
S urvey (Blew York: F a r r a r & R i n e h a r t , I n c .^ 19451, p . 47
9
Supreme Commander of th e A l l i e d Powers G e n e ra l
H e a d q u a r te r s , P u b lic H e a lth and W elfare in J a p a n . Annual
Summary (Tokyo, 1 9 4 9 ), p . 3 8 .
^ ^ F r a n c is M. P o t t e n g e r , T u b e r c u lo s is ( S t . L o u is :
The C. V. Mosby Company, 1 9 4 8 ), p . 5^76.
i_ J
^ 13 ^
O ccupied F o r c e s was a s f o l l o w s :
(b) D u rin g th e f i r s t y e a r of t h e O c c u p a tio n , th e
u rg e n c y of e s t a b l i s h i n g h e a l t h c o n t r o l m e a su re s f o r
th e more a c u te comm unicable d i s e a s e s , such a s ty p h u s ,
r e s u l t e d i n th e t u b e r c u l o s i s c o n t r o l r e c e i v i n g s e c
o n d a ry a t t e n t i o n . I t was n o t u n t i l O c to b er 1946
t h a t an a c t i v e c o n t r o l program was i n a u g u r a te d i n
w hich t h e im m ediate o b j e c t i v e may be summarized u n d e r
f i v e h e a d in g s :
^ To e n c o u ra g e th e r e t u r n of a c t i v e c a s e s of
pulm onary t u b e r c u l o s i s t o h o s p i t a l s by p r o v id in g
n e c e s s a r y fo o d s u p p l i e s and e n a b l in g h o s p i t a l s t o c a r e
f o r t h e s e p a t i e n t s .
2 Em phasis upon e d u c a t i o n of t h e m e d ic a l and
n u r s i n g p r o f e s s i o n s i n d i a g n o s i s , t r e a t m e n t and c a r e .
3 The i n a u g u r a t i o n of a s c h o o l lu n c h program f o r
s u p p le m e n ta l f e e d i n g o f s c h o o l c h i l d r e n t o p r o v id e
a more b a la n c e d d i e t and i n c r e a s e d r e s i s t a n c e t o
i n f e c t i o n .
4 The mass e x a m in a tio n of s c h o o l c h i l d r e n , t o
g e t h e r w i t h I n d i v i d u a l c ase f i n d i n g , t u b e r c u l i n
t e s t i n g and BCG im m u n iz a tio n s .
5^ Mass e x a m in a tio n of w o rk e rs i n f a c t o r i e s and
o th e ’ r i n d u s t r i a l o r g a n i z a t i o n s .
( c ) F u l l p u b l i c i t y was g i v e n t h i s program th r o u g h
a l l m edia of i n f o r m a t i o n , r a d i o , p r e s s , p o s t e r s and
l a y and p r o f e s s i o n a l J o u r n a l s and m a g a z in e s . Many
p r e f e c t u r e s o r g a n iz e d T u b e r c u lo s is Care Committees
whose p r im a r y f u n c t i o n I s t o a s s i s t p a t i e n t s i n
e n t e r i n g s a n a t o r i a , m a in te n a n c e of t h e i r f a m i l i e s
d u r in g h o s p i t a l i z a t i o n and o b t a i n i n g s u i t a b l e occu
p a t i o n s upon t h e i r r e t u r n from th e s a n a t o r i a ,
s i g n i f i c a n t r e s u l t s were im m e d ia te ly n o t i c e a b l e .
Through i n c r e a s e d r a t i o n s t o h o s p i t a l s and i n s t i
t u t i o n s , augum ented by v o l u n t a r y c o n t r i b u t i o n s th r o u g h
L ic e n s e d Agency f o r R e l i e f i n A sia (LARA) th e fo o d
s i t u a t i o n h a s im proved and a l l p r e f e c t u r e s a re r e
c e i v i n g i n c r e a s e d d i e t s f o r t u b e r c u l o s i s p a t i e n t s .
A s c h o o l lu n c h program was s u c c e s s f u l l y i n a u g u r a te d
and h a s b e e n expanded t o now s e rv e a p p ro x im a te ly
6 ,6 5 0 ,0 0 0 c h i l d r e n . X -ra y equ ipm ent was f u r n i s h e d b y
r e b u i l d i n g o ld u n i t s , a l s o b y m a n u f a c tu r in g new e q u ip
m en t. Case r e p o r t i n g was r e q u i r e d i n J a n u a ry 1947 and
r e p r e s e n t s th e f i r s t tim e t h a t c l i n i c a l t u b e r c u l o s i s
i_ J
14*^
h a s e v e r b e e n r e p o r t e d In Ja p a n . The n a ti o n - w i d e
e x a m in a tio n program f o r t h e d e t e c t i o n and c o n t r o l
of t u b e r c u l o s i s h a s b e en v i g o r o u s l y f o llo w e d .
The O ccupied F o rc e s en co u rag e d BCG v a c c i n a t i o n and
l a t e r r e p o r t e d a r e d u c t i o n i n d e a th r a t e from 280 p e r
1 0 0 ,0 0 0 p e r annum i n 1945 t o 181 p e r 1 0 0 ,0 0 0 p e r annum in
1 9 4 8 .^ ^ A cco rd in g t o t h i s r e p o r t t h e d e a t h r a t e i n non
immunized g ro u p s d i d n o t reduce d u r in g th e same p e r i o d .
T a b le 2 shows th e re m a rk a b le d e c l i n e i n t h e t u b e r c u l o s i s
d e a t h r a t e a f t e r 1950 and a l s o shows a c o m p ariso n of th e
r a t e i n o t h e r c o u n t r i e s .
TABLE 2
TUBERCULOSIS MORTALITY RATES
PER 100 ,0 0 0 POPULATION^
C o u n try 1960 1951 1952 1953 1954 1955 1956
Jap an 1 4 6 .4 1 1 0 .7 8 2 .5 6 6 .7 6 2 .4 5 2 .3 4 8 .5
U n ite d S t a t e s 2 2 .5 2 0 .1 1 5 .8 1 2 .3 1 0 .2 9 .1 8 .4
E ngland & W ales 3 6 .4 3 1 .6 2 4 .1 2 0 .2 1 7 .8 1 4 .7 1 2 .0
Denmark 1 3 .8 1 3 .3 1 0 .9 8 .8 7 .7 6 .3 5 .1
S in g a p o re 1 4 5 .5 1 2 4 .7 1 1 1 .9 8 9 .8 8 2 .7 8 1 .7 5 6 .0
Taiwan 1 6 0 .3 1 4 0 .9 9 0 .1 7 6 .6 6 8 .6 6 6 .8
Hong Kong 1 4 4 .4 2 0 8 .1 1 5 8 .8 1 3 0 .6 1 2 6 .3 12 0 .1 1 0 7 .7
^Anthony M. L o w e ll, T u b e r c u lo s is i n New York C ity
(New York: New York T u b e r c u l o s i s and H e a l t h , 1 9 5 6 ), p . - J
Supreme Commander o f th e A l l i e d Pow ers, op. c i t .
p p . 7 - 8 .
i_ ^ ^ I b l d . J
r 15 ^
When s tu d y in g t h e c y c le of an e p id em ic i t i s i n t e r
e s t i n g t o o b se rv e and t o compare th e tim e t h a t th e e p id em ic
r e a c h e s t h e c r e s t of t h e c y c l e . T here i s no dou bt a b o u t
th e e p id e m ic c h a r a c t e r of t u b e r c u l o s i s , th o u g h i n c o n t r a s t
w i t h th e more a c u te i n f e c t i o n s i t m a n i f e s t s i t s e l f i n a
c o m p a r a tiv e ly slow c y c l e . Most of t h e p r e v io u s s t u d i e s of
t u b e r c u l o s i s have r e l i e d on m o r t a l i t y s t a t i s t i c s f o r com
p a r a t i v e r e s u l t s such a s a r e r e c o r d e d i n T ab le 2, b u t t h i s
d o e s n o t r u l e out o t h e r means of com paring th e h a z a r d of
t h e d i s e a s e .
D e s p ite t h e f a c t t h a t t h e m o r t a l i t y r a t e r e a c h e d a
v e r y h i g h mark i n 1943 i n J a p a n , th e c r e s t had b e e n r e a c h e d
i n 1918 when th e r a t e was 253 p e r 1 0 0 ,0 0 0 p o p u l a t i o n .
Ja p a n was c o m p a r a tiv e ly l a t e i n r e a c h i n g th e c r e s t of th e
c y c l e . I n s t a n c e s where th e t u b e r c u l o s i s wave re a c h e d th e
to p much e a r l i e r a r e : Sweden i n 1 8 3 0 ’s ; E ngland and
W ales, 1854; S c o t la n d , 1870; U n ite d S t a t e s , 1880;
A u s t r a l i a , 1885; B a v a r i a , 1 8 8 8 -9 0 ; I r e l a n d , 1898;
H ungary, 1903; U ruguay, 1 9 1 6 .^ ^
«
R e s is ta n c e t o t u b e r c u l o s i s may be d i v i d e d i n t o two
p a r t s , n a t u r a l o r n a t i v e r e s i s t a n c e and a c q u i r e d r e s i s -
t e n c e . T h ere i s a g r e a t w e ig h t of e v id e n c e t o d e m o n s tra te
t h a t r e s i s t a n c e by h e r e d i t y a s shown i n e x p e r im e n ta l
John B. M cDougall, T u b e r c u l o s i s ; A G lo b a l S tu d y
i n S o c i a l P a th o lo g y (E d in b u rg h : E. & 8. L iv i n g s t o n e L t d . ,
1 9 4 9 ), p . 183.
i_ J
^ 16
a n im a ls h a s o c c u r r e d hy n a t u r a l s e l e c t i o n i n th e human
s p e c i e s . ^ ^ I t a p p e a rs t h a t r a c e s and s u b -g ro u p s of man
w hich h a v e b e e n e x t e n s i v e l y exposed t o t u b e r c u l o s i s i n
f e c t i o n f o r many h u n d re d s o r even th o u s a n d s of y e a r s , show
a m a rk e d ly g r e a t e r r e s i s t a n c e t o t h e d i s e a s e th a n r a c e s
w hich have b e e n ex p o sed o n ly i n r e l a t i v e l y r e c e n t t im e s .
S in c e i t i s im p o s s ib le t o t e s t th e d e g re e of r e
s i s t a n c e t o t u b e r c l e b a c i l l i i n man by p r o p e r l y c o n t r o l l e d
e x p e r im e n t, t h e c o m p a ra tiv e d e g re e of n a t i v e r e s i s t a n c e
p o s s e s s e d by d i f f e r e n t r a c e s can be e s t i m a t e d o n ly by c a r e
f u l l y com paring th e c l i n i c a l c o u rs e and th e p a t h o l o g i c a l
a l t e r a t i o n s t h a t a r e o b se rv e d i n a l a r g e number of i n
d i v i d u a l members o f d i f f e r e n t r a c e s who have o r 'h a v e had
th e d i s e a s e , t a k i n g i n t o a c c o u n t a s f a r a s p o s s i b l e a l l
e x t e r n a l c o n d i t i o n s w hich a r e known t o i n f l u e n c e th e
f r e q u e n c y , th e t y p e , and th e s e v e r i t y of t h e i n f e c t i o n .
C o n c lu s io n s c a n n o t be drawn h a s t i l y from m a t e r i a l o f t h i s
n a t u r e , f o r i n t h e v a s t m a j o r i t y of t h e i n d i v i d u a l c ase
s t u d i e s , t h e o n ly a c c u r a t e l y known q u a n t i t y i n t h e e q u a
t i o n i s t h e e f f e c t . Most o f th e c a u s a t i v e i n f l u e n c e s ,
among w hich n a t i v e r e s i s t a n c e i s o n ly a s i n g l e ite m ,
\
c a n n o t be d e te r m in e d .
y In s p i t e of t h e c h a r a c t e r of t h e m a t e r i a l w ith
R obert J . D a v ie s , " T u b e r c u l o s i s , " Pulm onary
D i s e a s e s , e d . Roscoe L. P u l l e n ( P h i l a d e l p h i a : Lea &
P e b i g e r , 1 9 5 5 ), p . 362.
J
17
w hich one h a s t o d e a l , th e same d i f f e r e n c e s i n t h e r e a c t i o n
of c e r t a i n d i f f e r e n t r a c e s of men r e c u r w ith a p e r s i s t e n t
f r e q u e n c y , and p r e s e n t such s t r i k i n g c o n t r a s t s , t h a t th e
t r e n d seems t o i n d i c a t e t h a t d i f f e r e n c e s i n r a c i a l c o n s t i
t u t i o n c o n f e r m arked d i v e r g e n c e s i n th e a b i l i t y t o r e s i s t
t h e a t t a c k of th e t u b e r c l e b a c i l l u s .
T here i s no agreem en t on th e s u b j e c t of r a c i a l
s u s c e p t i b i l i t y t o t u b e r c u l o s i s . R ich s t a t e s :
The c o m p a riso n of t h e r e a c t i o n of t h e n e g ro and
th e w h ite t o I n f e c t i o n w i t h th e t u b e r c l e b a c i l l u s
i n d i c a t e s t h a t th e w h ite h a s th e r a c i a l q u a l i t y o f
b e in g a b le t o b u i l d up a more e f f e c t i v e and more
d u r a b le a c q u i r e d r e s i s t a n c e f o llo w in g i n f e c t i o n
th a n h a s th e n e g ro . The o b se rv e d d i f f e r e n c e s i n
th e d e g re e of f a c i a l r e s i s t a n c e t o t h i s i n f e c t i o n
i n man t h u s a p p e a r 't o be d u e , i n p a r t a t l e a s t , t o
d i f f e r e n c e s i n th e n a t i v e a b i l i t y t o d e v e lo p and t o
m a i n t a i n a c q u i r e d r e s i s t a n c e . . . .
I n s t r e s s i n g t h i s p o i n t th e p r e s e n t w r i t e r h a s
no i n t e n t i o n o f m in im iz in g th e im p o rta n c e of a d v e rs e
econom ic and e n v ir o n m e n ta l c o n d i t i o n s a s f a c t o r s
t h a t i n f l u e n c e t h e t u b e r c u l o s i s m o r t a l i t y r a t e of
t h e n e g r o . . . . T h e p u rp o se of th e p r e s e n t d i s c u s s i o n
h a s b e en o n ly t o examine th e e v id e n c e f o r t h e lo w e r
d e g re e of r a c i a l r e s i s t a n c e of t h e n e g r o .
The n a t i v e r e s i s t a n c e of th e Am erican I n d i a n , and
of o t h e r p r i m i t i v e r a c e s , h a s r e c e i v e d much l e s s
s tu d y th a n t h a t o f th e n e g ro , and i t i s i m p o s s ib le t o
d e r i v e any. s a t i s f a c t o r y c o n c l u s i o n s from t h e a v a i l a b l e
l i t e r a t u r e .
In c o n t r a s t t o t h i s Dormer s t a t e s :
i From a rev ie w of e p id e m io lo g ic and r e l a t e d d a t a
c o n c e rn in g t u b e r c u l o s i s i n th e Union of S outh A f r i c a ,
i t i s b e l i e v e d t h a t i t i s n o t r a c i a l s u s c e p t i b i l i t y
^ A r n o l d R. R ich, The P a th o g e n e s is of T u b e r c u l o s i s
( S p r i n g f i e l d , 1 1 1 . : C h a rle s G, Thomas, 1 9 5 Î 1 , p p . 146-
147.
i_ J
r 18 ^
b u t , r a t h e r , s o c i a l and e v ir o n m e n t a l s t r e s s e s t h a t
c a u s e d a m a jo r e p id e m ic o f t u b e r c u l o s i s among t h e
c o l o r e d and B an tu members of t h e p o p u la tio n .^ ®
At t h e o t h e r end o f th e s c a l e of r e s i s t a n c e a r e
t h e Jews who h a v e n o t o n ly a much lo w e r m o r t a l i t y r a t e b u t
a l s o a much g r e a t e r f r e q u e n c y of c h r o n i c and p h y s i o l o g i c a l
in v o lv e m e n t s . V a r i a t i o n s i n r e s i s t a n c e w i t h i n r a c i a l
g ro u p s h a v e a much l e s s a d e q u a t e l y docum ented r e c o r d b u t
i t h a s b e e n s u g g e s t e d , f o r ex am p le , t h a t th e I r i s h and
S c a n d ia n v ia n s have a r e l a t i v e l a c k o f r e s i s t a n c e a s com
p a r e d w i t h o t h e r E u ro pean g r o u p s .
T h is b r i n g s up t h e o ld s u b j e c t of h e r e d i t y and e n
v ir o n m e n t. In o t h e r w ords th e p ro b lem i n v o l v e s t h e c o n
t r o v e r s y of n a t u r a l r e s i s t a n c e v e r s u s a c q u i r e d r e s i s t a n c e .
To s a y t h a t t h e Ja p a n e s e p e o p le h a v e l i t t l e n a t u r a l r e
s i s t a n c e t o t u b e r c u l o s i s o r much l e s s r e s i s t a n c e t h a n a
w h i t e p o p u l a t i o n would be i n c o r r e c t b e c a u s e t h a t f a c t h a s
n o t b e e n p r o v e n . I t w ould be w i s e r t o t a k e t h e view t h a t
b o t h n a t i v e and a c q u i r e d r e s i s t a n c e a r e f a c t o r s of im
p o r t a n c e i n d e te r m i n i n g t h e r e s u l t s of a t u b e r c u l o s i s i n
f e c t i o n , and t h a t a v a r i e t y of o t h e r i n f l u e n c e s a r e h i g h l y
i m p o r t a n t i n d e te r m i n i n g w h e th e r a g i v e n i n h e r i t e d o r
a c q u i r e d d e g re e of r e s i s t a n c e w i l l b e m a i n t a i n e d o r d e
p r e s s e d t o a d a n g e ro u s l e v e l .
W hile h e r e d i t a r y o r n a t u r a l r e s i s t a n c e i s a
^®B. A. D orm er, " T u b e r c u l o s i s i n S o u th A f r i c a , "
B r i t i s h J o u r n a l of T u b e r c u l o s i s , L ( J a n u a r y , 1 9 5 6 ), p . 5 2 .
u — J
r 19 ^
d e b a t a b l e q u e s t i o n , i t i s a g r e e d t h a t e n v ir o n m e n ta l c o n d i
t i o n s p l a y an im p o r ta n t r o l e i n th e l i f e of p e r s o n s who con
t r a c t t u b e r c u l o s i s . I t i s t h e p o s i t i o n of t h i s p a p e r n o t
t o a tte m p t t o e v a l u a t e a l l of t h e m u l t i p l e f a c t o r s w hich
e n t e r i n t o th e c a u s a t i o n o f t u b e r c u l o s i s b u t t o p r e s e n t some
of th e i n f l u e n c e s of t h e s o c i a l en v iro n m en t upon t u b e r c u
l o s i s in c i d e n c e and m o r t a l i t y r a t e fo und among t h e p o p u la
t i o n o f J a p a n . T h is i s o n ly one of many means of m aking a
c o n t r i b u t i o n t o a p r e c i s e e v id e n c e a s a f i n a l v e r d i c t on
t h e e p id e m io lo g y of t u b e r c u l o s i s in t h a t c o u n tr y .
Y oshioka h a s s u g g e s te d t h i s i n t e r e s t i n g p a t h of
s t u d y :
re i s no su c h d i s e a s e , w hich h a s c l o s e r e
l a t i o n w ith s o c i a l e n v iro n m en t a s t u b e r c u l o s i s . The
h i s t o r y of t u b e r c u l o s i s i n a c o u n tr y t e l l u s t h e h i s
t o r y of i t s s o c i e t y . The h i s t o r y of i t s p r e v a l e n c e
b e g a n one c e n t u r y l a t e r ( i n Ja p an ) th a n i n E uropean
c o u n t r i e s and f o llo w e d them r a p i d l y . T h is f a c t i s
a l l th e same l i k e o t h e r s o c i a l and c u l t u r a l phenom
e n a in our c o u n t r y .
At p r e s e n t , when t h e wane of t u b e r c u l o s i s a p p e a r s ,
we want t o know t h e t r u e f a c t s a b o u t i t i n Japan and
th e h i s t o r y o f ^ c o n f l i c t b e tw e e n t u b e r c l e b a c i l l u s and
human s o c i e t y .
M i l i t a r i s m and I n d u s t r i a l i s m
The e f f e c t s of w ar c o n d i t i o n s ,on th e s p r e a d of
t u b e r c u l o s i s a r e of m ore th a n t o p i c a l i n t e r e s t . T hese
17
H ir o to Y o sh io k a , " T u b e r c u lo s is S t a t i s t i c s i n
J a p a n ," Yokohoma M edical B u l l e t i n , IV ( F e b r u a r y , 1 9 5 3 ),
p . 16.
J
20 "
e f f e c t s i l l u s t r a t e t h e im p o r ta n c e o f t h e p a r t p la y e d b y
u n s a t i s f a c t o r y e n v ir o n m e n ta l c o n d i t i o n s i n r e d u c in g r e
s i s t a n c e t o t h e d i s e a s e .
A s t u d y of t h e f i g u r e s r e l a t i n g t o W orld War I r e
v e a l s t h a t t h e m o r t a l i t y r a t e of p u lm o n ary t u b e r c u l o s i s
c a s e s i n E n g lan d and W ales r o s e d u r i n g th e w ar c o n f l i c t .
T h ere was a l s o c o n s i d e r a b l e i n c r e a s e i n H o lla n d , I t a l y ,
Germany and A u s t r i a a t t h e same t im e In t h o s e c o u n
t r i e s , t h e p e a k y e a r of i n c r e a s e f o r t h e w a r - tim e p e r i o d
was 1 9 1 8 , b u t i n Denmark, t h e r a t e had begun t o f a l l b y
t h a t y e a r , h a v in g re a c h e d t h e p e a k i n 1917. The i n
c l u s i o n o f H o lla n d and Denmark i n t h i s l i s t , d e s p i t e t h e
f a c t t h a t t h e y rem a in e d n e u t r a l , e x e m p l i f i e s t h e v a s t
d im e n s io n s o f t h e w a r.
H o lla n d was a d v e r s e l y a f f e c t e d by t h e b l o c k a d e f o r
t h e w hole war p e r i o d , w h e re a s Denmark had a r r a n g e d a
f a i r l y s a t i s f a c t o r y s u p p l y and d i s t r i b u t i o n o f fo o d by
1 9 1 8 . I t may t h u s b e i n f e r r e d t h a t one v e r y i m p o r t a n t
b e a r i n g of w ar upon t u b e r c u l o s i s i s t h e e f f e c t i t h a s u p
on n u t r i t i o n a l l e v e l s and t h a t when n u t r i t i o n f a l l s b e
low a c e r t a i n s t a n d a r d , r e s i s t a n c e t o t h e d i s e a s e becom es
im p a i r e d . Comments upon t h e n u t r i t i o n a l and d i e t a r y c o n -
. d i t i o n s i n Ja p a n w i l l be m e n tio n e d l a t e r . At t h e moment,
p n l y t h e m i l i t a r y s i t u a t i o n in J a p a n w i l l be c o n s i d e r e d .
^®McDougall, o p . c i t . , p p . 1 5 3 -1 6 1 .
i_ -J
21 ^
U n t i l t h e m i d - n i n e t e e n t h c e n t u r y Ja p an h ad b e e n a l l
b u t h e r m e t i c a l l y s e a l e d from th e r e s t of t h e w o rld and was
r e s o l u t e l y i s o l a t e d . B e g in n in g i n 1 8 9 4 -9 5 , Japan s t r e t c h e d
out b y l e a p s r a t h e r t h a n b y a g r a d u a l , w ary c lim b . Jap an
expanded i n e v e r y d i r e c t i o n , th e p o p u l a t i o n , eco n o m ics,
and t e r r i t o r y . Jap an r a p i d l y em erged a s one of th e h a l f
d ozen l e a d i n g pow ers o f th e w o r ld . By 1931 t h i s n a t i o n of
i s l a n d s h ad one o f t h e l a r g e s t a r m i e s , t h e t h i r d l a r g e s t
navy of t h e g l o b e , and b o t h u n d e f e a t e d . ^ ^
The u p s and downs of t h e t u b e r c u l o s i s d e a th r a t e
fo llo w e d a lo n g w i t h v a r i o u s w ar e v e n t s and w ith i n d u s t r i a l
e x p a n s io n . T h is peak o f th e d e a t h r a t e d o es n o t c o in c id e
w ith th e p o p u l a t i o n e x p a n sio n b e c a u s e a c c o r d in g t o
L a t o u r e t t e t h e g ro w th of p o p u l a t i o n was m ost n o t i c e a b l e i n
on
t h e 1920*8. However, t h e i n c r e a s e of t u b e r c u l o s i s i n
c id e n c e d o es c o i n c i d e w ith war e v e n ts and w ith w artim e
I n d u s t r i a l i s m .
The 1909 d e a t h r a t e p e ak c o r r e s p o n d s w ith th e
p o s t- w a r i n d u s t r i a l boom. S t e i g e r w r i t e s ;
A f t e r th e R u ss o -Ja p a n e se War, Ja p an q u ic k e n e d
t h e pace of m o d e r n iz a tio n b y a d o p tin g W estern
m ethods o f t r a n s p o r t a t i o n , f a c t o r y p r o d u c t i o n ,
b u s i n e s s o r g a n i z a t i o n and f i n a n c e . ^ !
^^K enneth S c o t t L a t o u r e t t e , A S h o rt H i s t o r y of th e
F a r E a s t (Mew Y ork: The M acm illan Company, 19515, p . 563.
20
P* 507.
Mye S t e i g e r , A H i s t o r y of th e F a r E a st (New
JTork: Ginn and Company, 1 9 3 6 ), p . 740. ^
22 ^
In th e f o l lo w in g s ta te m e n t Ogawa c o n c u r s ;
The war m arked a t u r n i n g - p o i n t i n e v e r y b r a n c h o f
ou r i n d u s t r i a l and com m ercial g ro w th , f o r e i g n t r a d e
and t r a n s p o r t a t i o n s e r v i c e in p a r t i c u l a r h a v in g b e e n
c o m p le te ly r e o r g a n i z e d th ro u g h t h e w ar. I f we may
jud g e by s u p e r f i c i a l o b s e r v a t i o n , i t may be s a f e l y
s a i d t h a t a s r e s u l t of t h e war I n d u s t r y i n Ja p an
p r o g r e s s e d w ith l e a p s and b o u n d s.
B orto n w r i t e s a b o u t th e g ro w th a f t e r th e R usso-
Ja p a n e se War and a b o u t th e i n f l u e n c e of World War I on
Jap an :
Between 1890 and 1916, i n d u s t r i a l i z a t i o n , b o t h a s
a c o n t i n u a t i o n of th e t r a d i t i o n a l p o l i c y o f s t r e n g t h
e n in g t h e s t a t e and a s r è s u l t of th e s t i m u l u s of th e
two w a rs , i n c r e a s e d a t an am azing p a c e . J u s t when a
d e p r e s s i o n seemed i n e v i t a b l e , th e a c u t e demands of th e
A l l i e d pow ers f o r m u n i t i o n s , s h ip p in g and s u p p l i e s
d u r i n g World W arl e n a b le d Japan t o s o l v e , a t l e a s t
t e m p o r a r i l y , i t s m a jo r econom ic and f i n a n c i a l p ro b le m s.
So lo n g a s t h e f o r e i g n m ark e t f o r J a p a n e se g o ods and
s e r v i c e s h e l d , t h e c o u n t r y ’s econom ic f u t u r e c o u ld be
l e f t t o ta k e c a r e of I t s e l f . 23
The m ain o b j e c t i v e of Japan a f t e r th e R usso-
J a p a n e s e c o n f l i c t was t o d e v e lo p a s e l f - s u f f i c i e n t economy.
T e r r i t o r i a l e x p a n s io n lo o k e d p ro m is in g a s t h e m i l i t a r y
s t r e n g t h grew and t h e f o r e i g n t r a d e i n c r e a s e d a n n u a l l y .
The t e x t i l e I n d u s t r y a c c o u n te d f o r n e a r l y h a l f of th e
n a t i o n a l o u tp u t a s Osaka became M a n c h e s te r ’ s r i v a l .
Ja p a n e se t e x t i l e s com peted w ith C h in e s e , B r i t i s h , A m erican,
and I n d ia n g o o d s. C r o f t s and Buchanan v e r y c l e a r l y
22
G o ta ro Ogawa, E x p e n d itu r e s of th e R u ss o -Ja p a n e se
War (New Y ork; O xford U n i v e r s i t y P r e s s , 1 9 2 3 ), p p . 2 5 1 -2 5 2 .
23
Hugh B o r to n , J a p a n ’s Modern C e n tu ry (New Y ork;
Ronald P r e s s , 1 9 5 5 ), p p . 2 6 0 -2 6 1 .
i_ j
23
d e s c r i b e t h i s r i v a l r y :
Though i n 1901 th e U n ite d Kigdom o p e r a te d n e a r l y
t h i r t y tim e s a s many s p i n d l e s a s Jap an — 40 p e r c e n t
of t h e e n t i r e w o r l d ’s s u p p ly — J a p a n ’ s low c o s t c l o t h
was w i t h i n a d e ca d e t o e q u a l B r i t i s h e x p o r t s t o E a s t
A sia a n d , b y 1929, t o o u t s e l l them t e n f o l d * ^ ^
I r o n and s t e e l f o llo w e d th e same p a t t e r n . B a t t l e
s h i p s , s te a m s h i p s , and steam lo c o m o tiv e s were no l o n g e r
p u r c h a s e d a b ro a d b u t made a t home. The Yawata I r o n Works,
b u i l t i n 1901, o p e r a te d a t f u l l b l a s t t o r a i s e t h e 1906
25
p r o d u c t i o n from 1 4 5 ,0 0 0 t o n s t o 2 4 3 ,0 0 0 t o n s b y 1913.
Even a t t h a t p a c e , b e c a u se g e n e r a l demands of i n d u s t r y f o r
i r o n i n c r e a s e d w ith o v e r - a l l e x p a n s io n , d o m e s tic s m e ltin g
p l a n t s c o u ld m eet o n ly 48 p e r c e n t of d o m e s tic r e q u i r e
m e n ts .
The Ja p a n e se Empire e x te n d e d a n d c o n s o l i d a t e d a s
i t e x e r t e d a l l e f f o r t s t o e s t a b l i s h t h e i r c o u n tr y a s t h e
u n d i s p u t e d l e a d e r of t h e P a r E a s t. D uring th e f i r s t y e a r
of W orld War I t h e y moved q u i c k l y t o r e p l a c e Germany i n
C hina and t h e P a c i f i c Ocean. However, w ith t h e e x p a n s io n
of th e m i l i t a r y and th e e x p a n s io n of i n d u s t r y Ja p an f a c e d
t h e p ro b lem of f o o d , e s p e c i a l l y r i c e .
A f t e r t h e R u ss o -Ja p a n e se War th e p o p u l a t i o n i n
c r e a s e d more th a n i t h a d i n p r e v i o u s y e a r s . Many o f t h e
2 4 A lfre d C r o f t s and P e rc y B uchanan, A H i s t o r y of t h e
F a r E a s t (New Y ork: Longmans, G reen and Company, 1 9 5 ë ) ,
p . 272.
25
B o r to n , o p . c i t . , p . 2 7 0 .
i_ J
24 ^
p e o p le went i n t o f a c t o r i e s o r th e m i l i t a r y s e r v i c e and
th o s e who rem a in e d on t h e fa rm s c o u ld n o t s u p p ly amply fo o d
f o r th e n a t i o n . As of th e y e a r 1915 th e y met demands f o r
e x t r a r i c e b y im p o r tin g from a b r o a d . However, w ith th e
h ig h r a t e of p o p u l a t i o n i n c r e a s e th e p e r c a p i t a p r o d u c t i o n
s t e a d i l y d e c r e a s e d d e s p i t e l a r g e r im p o r ts from a b ro a d . In
d e s c r i b i n g th e i n d u s t r i a l and m i l i t a r y p re d ic a m e n t B o rto n
e x p l a i n s :
The p o p u l a t i o n and fo o d p ro b lem s c o u ld o n ly be
s o l v e d , t h e r e f o r e , by t h e i r c l o s e c o r r e l a t i o n w ith
t h e o v e r - a l l i n d u s t r i a l p ro g ram . C ontem porary w r i t e r s
and g overnm ent o f f i c i a l s , how ever, f a i l e d t o re c o g
n i z e th e d a n g e r s i n h e r e n t i n th e n a t i o n ’s dem ographic
t r e n d . They w ere f u l l y c o g n iz a n t of th e f a c t t h a t
t h e r e was l i t t l e hope of m a t e r i a l i n c r e a s e s i n th e
p r o d u c t i o n of s t a p l e f o o d s , y e t d i d l i t t l e t o d i s
c o u ra g e o r t o p r e v e n t r a p i d p o p u l a t i o n i n c r e a s e s .
On th e c o n t r a r y , t h e y c o n s i d e r e d a l a r g e popu
l a t i o n a b o o n r a t h e r th a n a h in d r a n c e t o th e g ro w th
of th e n a t i o n . I t was a rg u e d , f o r exam ple, t h a t a
l a r g e p o p u l a t i o n made p o s s i b l e a l a r g e army and hence
augm ented t h e n a t i o n a l s t r e n g t h . The C h ie f of th e
C o l o n ia l B ureau s u g g e s te d t h a t th e i l l ’s from any
s u r p l u s p o p u l a t i o n c o u ld be re m e d ie d b y i n d u s t r i
a l i z a t i o n and by t h e f u l l e s t p o s s i b l e u s e of th e new
c o l o n i a l t e r r i t o r i e s such a s K o rea, Form osa, and
S o u th e rn S a k h a lie n ( K a r a f u t o ) . I t was n o t , t h e r e f o r e ,
u n t i l a f t e r W orld War I t h a t Ja p a n e se e c o n o m is ts and
d em o g rap h ers r e g a r d e d t h e i n c r e a s e s i n p o p u l a t i o n as
an e s s e n t i a l l y a n t a g o n i s t i c f a c t o r i n t h e i r c o u n t r y ’s
econom ic w e l f a r e . But by t h a t tim e , t h e i r p ro g n o s
t i c a t i o n s had l i t t l e e f f e c t on n a t i o n a l p o l i c y . A
m i l i t a n t n a t i o n a l i s m had become t h e a c c e p te d p o l i c y
and f o r e i g n n a t i o n s were t o l d t h a t p o p u l a t i o n p r e s
s u r e made i t i n e v i t a b l e and n e c e s s a r y f o r Japan t o
expand on t h e A s i a t i c m a in la n d .
The J a p a n e se p e o p le f a c e d m a l n u t r i t i o n , p h y s i c a l
B ^B orton, op. c i t . , p . 264.
i_ J
r 25 ^
e x e r t i o n i n f a c t o r i e s and f i e l d s , lo ng w orking h o u r s , i n
a d e q u a te f u e l and c l o t h i n g d u r in g th e w i n t e r m o n th s, a lo n g
w ith econom ic r e c e s s i o n s and r i c e r i o t s . I t i s no wonder
t h a t d u r in g t h i s p e r i o d t u b e r c u l o s i s d e a t h i n c r e a s e d and
re a c h e d i t s h i g h e s t p o i n t of th e c r e s t .
A f t e r World War I e c o n o m is ts and d em o g rap h ers to o k
tim e from t h e i r war economy to lo o k a t th e n a t i o n ’ s h e a l t h .
They n o te d t h a t d u r i n g th e war p e r i o d th e t u b e r c u l o s i s
d e a t h r a t e had r e a c h e d a l e v e l e x c e e d in g t h a t o f any o t h e r
i n d u s t r i a l i z e d c o u n tr y i n t h e w o rld . I n 1919 th e y p a s s e d
t h e T u b e r c u l o s i s P r e v e n t i o n Law. However, I t was t h e
e a r th q u a k e of 1923 w hich awakened Jap an t o an a c t i v e
a w a re n e s s of th e n a t i o n ’ s n e e d s .
The e a r th q u a k e o f 1923 w ith i t s t r a i n o f d e s t i
t u t i o n on a l a r g e s c a l e gave a s t r i k i n g im p e tu s t o
e f f o r t s to m eet n o t o n ly th e a c u te b u t a l s o th e
c h r o n ic n e e d s of J a p a n . B e fo re t h a t d a te t h e r e had
b e e n l e g i s l a t i o n f o r t h e im provem ent of i n s a n i t a r y
h o u s in g , f o r th e p r e v e n t i o n of t u b e r c u l o s i s and f o r
employment a g e n c i e s . W orld War I had a l s o s t i m u l a t e d
e f f o r t s f o r p o o r r e l i e f , f r e e m e d ic a l a t t e n t i o n ,
b e t t e r h o u s in g , and t h e p r o t e c t i o n of c h i l d r e n . In
much of t h i s th o s e r e s p o n s i b l e f o r th e m i l i t a r y power
of Ja p a n were c o n c e rn e d , f o r b e t t e r h e a l t h and l i v i n g
c o n d i t i o n s would make f o r more a b le b o d ie d r e c r u i t s
and h i g h e r i n d u s t r i a l e f f i c i e n c y . However, p u r e l y
p h i l a n t h r o p i c m o tiv e s a l s o e n t e r e d . C h r i s t i a n m is
s i o n s and c h u rc h e s and many B u d d h is ts o r g a n i z a t i o n s
w ere a c t i v e i n r e l i e v i n g and p r e v e n t i n g p o v e r t y and
s u f f e r i n g .
L a t e r i n 1925 th e minimum age f o r w o rk e rs was
r a i s e d from tw e lv e y e a r s t o f o u r t e e n y e a r s of a g e . I n 1927
^ ^ L a t c u r e t t e , op. c i t . , p . 560.
L J
r
26
th e h e a l t h i n s u r a n c e a c t e n f o r c e d s a n i t a r y r e g u l a t i o n s f o r
i n d u s t r i a l d o r m i t o r i e s and o t h e r k i n d s o f g ro u p l i v i n g
q u a r t e r s . U nder t h e s e c i r c u m s t a n c e s , t u b e r c u l o s i s d e a t h
r a t e d e c r e a s e d s l i g h t l y . The r e s u l t s do n o t show com
p l e t e l y i n t h e s t a t i s t i c s . The q u e s t i o n i s : what w ould
have b e e n t h e r a t e i f t h e s e m e a su re s had n o t b e e n t a k e n t
M o reo v er, Ja p an d i d n o t a llo w much tim e f o r th e
r e s u l t s t o become known. V ery soon t h e p r e p a r a t i o n s b e g a n
f o r t h e n e x t m a jo r m i l i t a r y p ro g ra m . A p ro gram w h ich
b e g a n i n M a n c h u ria , e x te n d e d i n t o C h in a , and f i n a l l y
r e a c h e d P e a r l H a rb o r. In a r e a l s e n s e , t h e 1931 Mukden
i n c i d e n t opened t h e g l o b a l c o n f l i c t known a s W orld War I I .
W hile t h e i n d u s t r i a l r e v o l u t i o n b r o u g h t a n im
p ro vem ent i n t h e s t a n d a r d of l i v i n g and a l a t e b u t e f f e c
t i v e h e a l t h p ro g ra m , t h e w a rtim e i n d u s t r i a l i z a t i o n b r o u g h t
lo w e r l i v i n g s t a n d a r d s w i t h many k i n d s of d e p r i v a t i o n s .
P e rh a p s t h i s i s t h e r e a s o n t h a t s e v e r a l i n v e s t i g a t o r s h o l d
i n d u s t r i a l i s m c o m p le te ly r e s p o n s i b l e f o r t h e s p r e a d of
t u b e r c u l o s i s . Long i s one i n v e s t i g a t o r who s t a n d s on t h a t
p r e m i s e .
I t i s now g e n e r a l l y a g r e e d t h a t th e m ost p o w e r f u l
f a c t o r i n i t s e f f e c t on t u b e r c u l o s i s i n th e l i f e of
an y n a t i o n i s i t s i n d u s t r i a l r e v o l u t i o n s . The r e
v o l u t i o n h a s come t o d i f f e r e n t n a t i o n s a t d i f f e r e n t
t i m e s . . . .W henever r e c o r d s a r e a v a i l a b l e a f a i r l y
u n if o r m p a t t e r n i s e v i d e n t . F a c t o r i e s l e d t o d e
v e lo p m en t of g r e a t e r c i t i e s . W orkers were a t t r a c t e d
from r u r a l a r e a s t o t h e c i t i e s f o r h i g h e r w ages.
At f i r s t s o c i a l and econom ic c o n d i t i o n s were g o o d .
Soon, im m ig r a tio n became e x c e s s i v e , wages f e l l and
J
27 ^
28
s o c i a l c o n d i t i o n s d e t e r i o r a t e d .
Y o sh io k a c o n c u rs w i t h t h i s :
As r e g a r d s t o th e c a u s e s of th e phenomena b e f o r e
th e w ar, i t i s n o t e a s y to e x p l a i n them b i o l o g i c a l l y ,
b u t r a t i o n a l t o e x p l a i n them s o c i o - e c o n o m i c a l l y . By
t h i s e x p l a n a t i o n we r e c o g n iz e t h a t th e " J a p a n e s e
c h a r a c t e r i s t i c " of th e c u rv e o f t u b e r c u l o s i s mor
t a l i t y became more a c c e n t u a t e d i n p r o p o r t i o n t o th e
i n c r e a s e of t h e num ber of f a c t o r i e s and com panies a s
th e " I n d u s t r i a l R e v o lu tio n " of o u r c o u n tr y .
B oth of t h e s e i n v e s t i g a t o r s m e n tio n I n d u s t r i a l i s m
a s th e m a jo r f a c t o r i n r e f e r e n c e t o th e I n c id e n c e of t u
b e r c u l o s i s . T h is p a p e r t a k e s th e p o s i t i o n t h a t i n d u s
t r i a l i s m d o e s n o t d e s e r v e t h i s p la c e as much as o t h e r
f a c t o r s w hich d i r e c t l y p r e v e n t s th e body f r o m b e in g a b le
t o overcome a t t a c k s made by t h e t u b e r c u l o s i s b a c i l l i .
I n a n o t h e r s e c t i o n o f t h i s p a p e r a t t e m p t s w i l l be made t o
d e m o n s tr a te how o t h e r f a c t o r s , e x p e c i a l l y n u t r i t i o n , can
e f f e c t i v e l y i n f l u e n c e th e h o s t d e s p i t e o v e r-w o rk , i n d u s
t r i a l i s m , o r m i l i t a r i s m .
Takayama c o n c u r r e d w ith th e w r i t e r i n h i s t h r e e
e x t e n s i v e s t a t i s t i c a l s t u d i e s .
Betw een t h e t r e n d of t u b e r c u l o s i s m o r t a l i t y and
i n d u s t r i a l i z a t i o n and b etw een t h a t and u r b a n i z a t i o n ,
no s i g n i f i c a n t v a lu e of c o r r e l a t i o n c o e f f i c i e n t was
o b t a i n e d .
28
Esmond R. Long, " T u b e r c u lo s is i n Modern S o c i e t y , "
B u l l e t i n of t h e H i s t o r y of M e d ic in e . XXVII ( J u l y , 1 9 5 3 ),
p . 301.
pQ
Y o s h io k a , 0£ . c i t . , p . 1 6 .
^^Takayama, o p . c i t . , p . 111.
i_ J
^ 28 ^
In one of h i s o t h e r s t u d i e s Takayama c o n c lu d e d :
I n th e p e r i o d b e tw e e n 1930 and t h e end of t h e l a s t
w ar, b o t h t u b e r c u l o s i s m o r t a l i t y and th e r a t i o above
m e n tio n e d i n c r e a s e d , p a r t i c u l a r l y m arked i n young
m a le s . I t i s r e a s o n a b l e su p p o sed t h a t d e c l i n e i n th e
l i v i n g s t a n d a r d u n d e r m i l i t a r i s m m ight have an u n
d e s i r a b l e i n f l u e n c e upon t u b e r c u l o s i s d e a th s o v e r
whelm ing th e i n f l u e n c e o f s e l e c t i o n o r t u b e r c u l i z a - ‘ <
tion.*^*^
^^rbld.. p. 21.
J
r
n
CHAPTER I I I
COMMUNITY PROBLEM
Urban and R u ral
The s o u rc e of th e s p r e a d of t u b e r c u l o s i s i n a
community I s th e sum t o t a l of a l l c a s e s of th e d i s e a s e in
th e l o c a l i t y , and t h e g r e a t e r th e o p p o r t u n i t i e s f o r e x
p o s u re t o open c a s e s o r c o n ta m in a tio n b y t h e s e c a s e s , th e
h i g h e r th e p r e v a l e n c e of t u b e r c u l o s i s i n c i d e n c e and mor
t a l i t y i n a com m unity. H ence, t h e l a r g e c i t i e s have more
p e o p le and a l s o h ave more open c a s e s and g r e a t e r in c i d e n c e
of t u b e r c u l o s i s . Sm all c i t i e s and v i l l a g e s have few er
p e o p le and fe w e r open c a s e s and lo w e r i n c i d e n c e of t u b e r
c u l o s i s .
Imamura c o l l e c t e d th e m a t e r i a l f o r T ab le 1 and
co n clu d ed :
(The m o r t a l i t y of t u b e r c u l o s i s ) was showing a
te n d e n c y of d e c r e a s e a f t e r 1920, b u t w i t h th e o u t
b r e a k of th e C hina em ergency i t i s s lo w ly i n c r e a s i n g .
In c i t i e s w i t h p o p u l a t i o n of o v e r 5 0 ,0 0 0 , t h e m or
t a l i t y I s h i g h e r t h a n t h a t i n v i l l a g e s . As th e s t a
t i s t i c on d e a t h i n Japan i s b a s e d m e r e ly on m e d ic a l
c e r t i f i c a t e s , th e r e a l number i s s u s p e c t e d t o be f a r
m ore th a n t h a t r e p o r t e d by th e g o v e r n m e n t.52
^^A. Imamura, The E p idem iolo gy and P r e v e n t i o n of
T u b e r c u l o s i s i n Ja p a n l R e p o rte d i n th e G e n e ra l M eeting of
tL e i l Japanese M ed ical A s s o c i a t i o n , Tokyo, 1942, p . 1 .
29
L -
r ~l
30
The M i n i s t r y o f H e a l t h and W e lfa re i n J a p a n ob
s e r v e d t h a t :
3 . 4 ^ o f t h e u r b a n p o p u l a t i o n and 1 . 7 ^ o f t h e r u r a l
p o p u l a t i o n show a d e f i n i t e o r s u s p i c i o u s c a v i t y . The
r a t e f o r a d e f i n i t e o r s u s p i c i o u s c a v i t y i s h i g h e s t
f o r t h e r e s i d e n t i a l and com m ercial a r e a s and th e low
e s t f o r t h e f a rm in g and f a r m i n g - f i s h i n g a r e a s * I t i s
3 . 2 ^ f o r t h e f o r m e r and 1 . 6 ^ f o r t h e l a t t e r .
The M i n i s t r y of H e a l t h and W e lfa re a l s o r e p o r t e d t h a t : 2 5 .9
p e r c e n t o f a l l h o u s e h o ld s had a t l e a s t one c a s e o f t u b e r
c u l o s i s and 3 .6 p e r c e n t had a t l e a s t two c a s e s . Of t h i s
2 5 .9 p e r c e n t , t h e r e w ere 4 . 7 p e r c e n t o f t h e u r b a n h o u s e
h o l d s and 2 . 7 p e r c e n t of t h e r u r a l h o u s e h o ld s w h ich h ad
a t l e a s t two c a s e s o f t u b e r c u l o s i s and 3 0 .5 p e r c e n t and
2 2 .5 p e r c e n t o f th e r u r a l h o u s e h o ld s w h ich had a t l e a s t
one c a s e of t u b e r c u l o s i s . " I n o t h e r w o rd s, one o u t of
t h r e e u r b a n h o u s e h o ld s and one o u t of f i v e r u r a l h o u s e -
34
h o l d s c o n t a i n e d a t l e a s t one c a s e of t u b e r c u l o s i s . "
The U n ite d S t a t e s P u b l i c H e a l t h S e r v i c e r e p o r t s :
The t u b e r c u l o s i s d e a t h r a t e i n c r e a s e s w ith u r b a n
c o n c e n t r a t i o n . C i t i e s w i t h a p o p u l a t i o n of 5 0 0 ,0 0 0
o r m ore have t h e h i g h e s t t u b e r c u l o s i s d e a t h r a t e s .
They a r e f o l lo w e d b y c i t i e s w ith 1 0 0 ,0 0 0 t o 5 0 0 ,0 0 0
p o p u l a t i o n . The r e m a in d e r o f t h e U n ite d S t a t e s h a s
th e lo w e s t d e a t h r a t e . T hus, g e n e r a l l y s p e a k i n g , th e
more d e n s e l y p o p u l a t e d an a r e a i s , t h e h i g h e r - t h e
t u b e r c u l o s i s d e a t h r a t e . A lth o u g h c i t i e s w i t h a
^^The Ja p a n A n t i - T u b e r c u l o s i s A s s o c i a t i o n , R epo rt
on t h e T u b e r c u l o s i s P r e v a le n c e S u rv ey i n J a p a n , C om piled
by M i n i s t r y o f H e a l t h and W e lfa re Government o f Ja p a n
(T okyo: The Jap an A n t i - T u b e r c u l o s i s A s s o c i a t i o n , 1 9 5 5 ),
p . 4 7 4.
p p . 4 6 8 -4 6 9 .
i_ -1
r 1
31
p o p u l a t i o n of 5 0 0 ,0 0 0 o r more hav e a d e a t h r a t e
a lm o s t d o u b le t h a t of t h e U n i t e d S t a t e s , e x c l u s i v e
o f l a r g e c i t i e s , o n ly o n e - f o u r t h o f a l l t h e t u b e r
c u l o s i s d e a t h s in th e U n ite d S t a t e s o c c u r i n t h e
c i t i e s , t h e a g g r e g a t e of a l l t h e s m a ll p l a c e s co n
s t i t u t e a s u b s t a n t i a l p r o p o r t i o n o f th e w hole p r o
b le m . 55
The q u e s t i o n o f m i g r a t i o n i s m ost I m p o r ta n t i n t h e
s t a t e m e n t s J u s t q u o te d . P e o p le who d i e d o f t u b e r c u l o s i s
i n t h e s m a ll c i t i e s and r u r a l a r e a s c o u ld have h ad t h e i n
f e c t i n g c o n t a c t i n t h e l a r g e r c i t i e s and th e n moved t o l e s s
c o n g e s t e d a r e a s " b e c a u s e o f i l l h e a l t h o r f o r o t h e r r e a s o n s .
The s o u r c e of c o n t a c t i s n o t g i v e n and may n o t be known.
I n o r d e r t o make an y ju dgem ent a b o u t th e s o u rc e o f c o n
t a c t , f u r t h e r i n v e s t i g a t i o n i s n e c e s s a r y .
Oka, K a s a i, and Kanno have i n t e r e s t i n g r e s u l t s
from t h e i r s u r v e y made i n s e v e n r i c e f a rm in g v i l l a g e s i n
t h e n o r t h e a s t e r n d i s t r i c t of J a p a n . I n t h e s e f a rm in g
v i l l a g e s t h e y p e rfo rm e d t h e t u b e r c u l i n t e s t f o r t h e p r e
s e n c e of t u b e r c u l a r i n f e c t i o n and r e p o r t e d t h a t t h e r a t e
of p o s i t i v e r e a c t i o n s i n t h e fa rm v i l l a g e had i n c r e a s e d
40 p e r c e n t t o 70 p e r c e n t i n t h e l a s t t e n y e a r s . They
^ P u b l i c H e a lth S e r v i c e , R e p o rte d T u b e r c u l o s i s D a ta :
1 9 5 6 , Second M i t i o n (W a s h in g to n : U n ite d S t a t e s D e p artm en t
oŸ H e a l t h , E d u c a tio n and W e lf a r e , 1 9 5 6 ), p . 2 8.
Oka, S. K a s ia , and I . Kanno, " S tu d y on t h e
T u b e r c u l o s i s S u rv e y of Farm V i l l a g e s i n N o r t h e a s t e r n D i s
t r i c t of J a p a n , " Ja p a n e s e J o u r n a l of T u b e r c u l o s i s . I
(November, 1 9 5 3 ), p . 6 0 .
u J
p ~ 1
32
a c c o u n te d t h i s i n c r e a s e to th e m i g r a t i o n from t h e c i t i e s t o
t h e v i l l a g e a f t e r W orld War I I . Oka, e t t h e n make a
c l o s e r o b s e r v a t i o n :
Only 10% of th e v i l l a g e r s , i n c l u d i n g th o s e who
l e f t th e v i l l a g e s t o w ork, t h o s e who were r e p a t r i
a t e d , d e m o b iliz e d s o l d i e r s , th o s e who w ere t r a n s
f e r r e d d u r in g t h e w ar, had e v e r l i v e d o u t s i d e of
t h e i r v i l l a g e s b u t i t sh o u ld be n o te d t h a t th e r a t i o
of d e t e c t i o n from t h e s e g ro u p s ( 2 .9 - 3 ,9 ^ ) was
h i g h e r t h a n t h a t of t h e p e o p le s who l i v e d i n t h e i r
own v i l l a g e s ( 1 . '
C i t y d w e l l e r s m ig r a te d t o t h e v i l l a g e s b e c a u s e of th e
bombing and o t h e r t i m u l t s of th e w a r. R e p a t r i a t e s .from
M a n ch u ria , Form osa, and e ls e w h e re fo u n d th e v i l l a g e s
c o n d u c iv e f o r l i v i n g on r e t u r n i n g t o th e hom eland b e c a u s e
most of th e v i l l a g e s were l e f t i n t a c t p h y s i c a l l y and
a d m i n i s t r a t i v e l y by th e war and by t h e O c c u p a tio n F o r c e s .
The p ro b lem of m e d ic a l c a r e i n t h e r u r a l a r e a s i n
c o n t r a s t t o t h a t in t h e c i t y had a g r e a t i n f l u e n c e on th e
t u b e r c u l o s i s r a t e . Oka, e ^ al<, fo u n d t h a t more th a n 61
p e r c e n t of th e t u b e r c u l o u s p a t i e n t s in t h e fa rm v i l l a g e
w ere n o t aw are of h a v in g th e d i s e a s e *and h ad n e v e r r e
c e iv e d any t r e a t m e n t f o r i t P e r h a p s m ost v i l l a g e s had
no d o c t o r o r im m ediate m e d ic a l f a c i l i t i e s . I t i s q u i t e
p o s s i b l e t h a t t h e v i l l a g e r s went a b o u t t h e i r d a i l y a c t i v
i t i e s w ith o u t g i v i n g much a t t e n t i o n t o an i n f e c t i o n su c h
37
Oka, ^ a l . , 0£ . c i t . , p . 60.
. p . 68.
u J
r ^
33
a s t u b e r c u l o s i s u n t i l t h e i l l n e s s had d e b i l i t a t e d t h e
p a t i e n t . By t h a t tim e many members of t h e f a m i l y , c o
w o r k e r s , and o t h e r s h ad b e e n i n f e c t e d .
O c c u p a tio n , Age, and Sex
Numerous a n a l y s e s have a tt e m p t e d t o d e m o n s tr a te
t h e r e l a t i v e f r e q u e n c y w ith w hich p r o g r e s s i v e t u b e r c u
l o s i s o c c u rs i n i n d i v i d u a l s a c c o r d in g to t h e i r d i f f e r e n t
o c c u p a t i o n s . However, i t i s d i f f i c u l t t o e v a l u a t e t h e
r o l e of t h e o c c u p a tio n i t s e l f a s a c a u se f o r t h e i n c i
d en ce of t u b e r c u l o s i s . P e rh a p s t h e ty p e of o c c u p a tio n
d o e s n o t have any g r e a t e r i n f l u e n c e th a n t h e econom ic
s t a t u s and l i v i n g c o n d i t i o n s o f t h e i n d i v i d u a l s i n t h e
d i f f e r e n t o c c u p a ti o n a l g ro u p s . D i f f e r e n c e s i n e co n o m ic
s t a t u s , s a n i t a t i o n , h o u s i n g , and such e n v ir o n m e n ta l con
d i t i o n s have g r e a t l y i n f l u e n c e d t u b e r c u l o s i s r a t e s i n a l l
c o m m u n itie s . The l i t e r a t u r e on t u b e r c u l o s i s h a s many
r e f e r e n c e s t o t h e p o s s i b l e e f f e c t s of h o u s in g on t u b e r
c u l o s i s , y e t , i t i s n e v e r p o s s i b l e t o d i s s o c i a t e t h e
h o u s in g o f th e p e o p le from t h e econom ic p o s i t i o n . The
two u s u a l l y go hand i n h and and g i v e a f a i r i d e a o f th e
s t a n d a r d o f l i f e i n th e community.
Oka, a t aL, have p r e s e n t e d i n t e r e s t i n g o b s e r v a
t i o n s r e g a r d i n g t h e econom ic s t a t u s and t u b e r c u l o s i s i n
t h e r i c e fa r m in g v i l l a g e s . 59 They a rr a n g e d t h e f a m i l i e s
i_
I b i d . , p . 61 . J
r 34 ■ ’
i n t o t h r e e c l a s s e s , n am ely, t h e u p p e r c l a s s who had more
th a n two chohu of l a n d , t h e m id d le c l a s s w ith one t o tw o
chobu of l a n d , and th e lo w e r c l a s s w ith l e s s th a n one
chobu o f l a n d . The chobu c o n s i s t s o f 9920 s q u a re m e t e r s
o r 2 .4 5 a c r e s . U sin g t h i s c l a s s i f i c a t i o n t h e y r e c o rd e d
t h e i n c i d e n c e of t u b e r c u l o s i s a s f o l l o w s : r a t e of t u b e r
c u l o s i s of u p p e r c l a s s , 7 .1 9 p e r c e n t ; m id d le c l a s s , 5 .6
p e r c e n t ; lo w e r c l a s s , 7 .2 p e r c e n t . About h a l f , o r 62
p e r c e n t , of t h e p a t i e n t s s t u d i e d l i v e d i n h o u se s w ith
l e s s t h a n t h r e e room s, and on t h e b a s i s of th e t a t a m i ,
l e s s th a n h a l f , o r 4 0 .8 p e r c e n t , l i v e d on l e s s th a n t h r e e
t a t a m i . The t a t a m i i s t h e s tra w m a t, a b o u t 18 s q u a re
f e e t i n s i z e , w hich i s u se d t o c o v e r th e f l o o r . O b v io u sly ,
more t h a n h a l f o f th e p a t i e n t s in t h e farm v i l l a g e s l i v e d
i n c o m p a r a t i v e l y sm a ll h o u s e s .
T hese i n v e s t i g a t o r s a l s o o b s e rv e d t h a t th e d e a t h
r a t e o v e r a p e r i o d of 10 y e a r s among th e m id d le c l a s s and
t h e u p p e r c l a s s d e c r e a s e d y e a r a f t e r y e a r . Lower c l a s s
d e a t h r a t e showed no d e c r e a s e b u t a te n d e n c y t o i n c r e a s e
i n r e l a t i o n t o p e r c e n t a g e of t h e e n t i r e number of p a
t i e n t s . No r e a s o n was g iv e n f o r th e c h a n g e s in t h e r a t e s .
R e g a r d le s s of t h e a r e a , i t i s u n u s u a l f o r th e
u p p e r c l a s s t o have th e h i g h e s t t u b e r c u l o s i s in c i d e n c e or
m o r t a l i t y r a t e . The i n v e s t i g a t o r s m e n tio n e d t h a t th e s u s
p e c t e d s o u rc e of i n f e c t i o n was n o t i n t h e v i l l a g e s . The
^ a r g e s t num ber o f p a t i e n t s came from th e p e o p le who had ^
^ 35 ^
a c t i v i t i e s o u t s i d e t h e v i l l a g e s , su c h a s t h e s o l d i e r s ,
t e a c h e r s , and t h e com m uters who w orked i n t h e c i t y .
The t e a c h e r s i n Ja p an u s u a l l y l i v e i n one v i l l a g e
f o r t h r e e o r f o u r y e a r s and th e n t h e y m i g r a t e t o o t h e r
p l a c e s a s s i g n e d h y t h e g o v e r n m e n t N o t o n ly do t h e y have
num erous p o s s i b i l i t i e s f o r i n f e c t i o n b u t once t h e y become
i n f e c t e d , t h e y may c a r r y t u b e r c u l o s i s b a c i l l i t o one o r
m ore c o m m u n itie s .
A lth o u g h a c o n s i d e r a b l e number of s t u d i e s have b e e n
made in Ja p an and i n o t h e r c o u n t r i e s c o n c e r n i n g t u b e r c u
l o s i s among v a r i o u s o c c u p a t i o n a l g r o u p s , i t i s s t i l l n o t
p o s s i b l e t o g i v e an a d e q u a te c o m p a ra tiv e p i c t u r e b e c a u s e
o f o c c u p a ti o n d i s s i m i l a r i t y i n th e E a s t and th e W est.
F o r ex am p le, t e a c h e r s i n t h e West do n o t change r e s i
d ence e v e r y t h r e e o r f o u r y e a r s a s t h e t e a c h e r s i n Ja p a n .
A know ledge of many s o c i a l f a c t o r s i n Ja p a n must
b e c o n s i d e r e d w henever su c h a s tu d y i s d o n e , b u t now su c h
f a c t o r s a p p e a r t o be unknown o r known o n ly b y a few who
have n o t d i s s e m i n a t e d th e i n f o r m a t i o n . T hese f a c t o r s
m ust be s u f f i c i e n t l y u n d e r s t o o d in o r d e r t o r e c o g n i z e
t h e s i m i l a r e l e m e n t s , t o know how t o re c k o n w ith t h e r e -
I
s u i t s when t h e e le m e n ts do n o t c o i n c i d e , and t o know what
i s o c c u r r i n g w i t h i n t h e s o c i a l s t r u c t u r e w hich would cau se
John F . Embree, Suye Mura: A J a p a n e s e V i l l a g e
(C h ic a g o ; C hicago U n i v e r s i t y P r e s s , 1 9 3 9 ), p . 1 6 2 -1 6 3 .
r 36 ^
t h e i n c o n g r u i t y . B ecause of t h e u b i q u i t o u s c h a r a c t e r o f
t u b e r c u l o s i s , such a s tu d y would have u n l i m i t e d v a l u e .
I t h a s b e e n e s t a b l i s h e d in many c o u n t r i e s t h a t
w o rk e rs i n c e r t a i n d u s t l a d e n a tm o sp h e re s a r e e s p e c i a l l y
l i a b l e t o d e v e lo p p ulm o nary t u b e r c u l o s i s c a u s e d b y t h e
i r r i t a n t p a r t i c l e s w hich e n t e r t h e l u n g s . G r i n d e r s ,
t i n m i n e r s , and t h o s e who work i n d i f f e r e n t t y p e s of
s i l i c a d u s t o c c u p a tio n s hav e a h ig h t u b e r c u l o s i s m or
t a l i t y r e g a r d l e s s o f th e econom ic s t a t u s and l i v i n g
c o n d i t i o n s and r e g a r d l e s s o f th e s tr e n u o u s p h y s i c a l ex
e r t i o n r e q u i r e d . The v e r y s t r e n u o u s p h y s i c a l e x e r t i o n
of t h e m in e r or t h e f a r l e s s p h y s i c a l s t r a i n o f th e
p o t t e r , t h e c u t l e r g r i n d e r o r p o l i s h e r seems t o have no
i n f l u e n c e on th e i n c i d e n c e of th e r a t e of i n f e c t i o n .
I t i s t h e o c c u p a ti o n a l e n v iro n m e n t w hich p r o v i d e s th e
o p p o r t u n i t y f o r i n h a l a t i o n of s i l i c a d u s t . T h is a p p l i e s
t o Ja p a n e s e m in e rs and w o rk e rs i n d u s ty e n v iro n m e n ts i n
J a p a n .
Volumes have b e en w r i t t e n in many c o u n t r i e s and
e s p e c i a l l y i n th e U n ite d S t a t e s c o n c e rn in g t h e c o m p a ra tiv e
m o r t a l i t y from t u b e r c u l o s i s i n b o t h se x a t v a r i o u s age
l e v e l s . Records and s t u d i e s from Ja p a n a lth o u g h l i m i t e d ,
f o l lo w t h e t r e n d i n th e U n ite d S t a t e s . F o r i n s t a n c e , th e
^^R. Y. K e e r s , B. G. R igden, and P . H. Young,
P ulm onary T u b e r c u lo s is (E d in b u rg h : E. & S. L iv i n g s t o n e
L im i te d , 1 9 5 3 ), p . 62^
i_ J
37
t o t a l t u b e r c u l o s i s m o r t a l i t y r a t e o f m a le s i n p r a c t i c a l l y
a l l l a r g e p o p u l a t e d a r e a s i s h i g h e r th a n t h a t of f e m a le s
b u t t h e d i f f e r e n c e s a p p e a r when t h e two s e x e s a r e com pared
a t v a r i o u s age p e r i o d s .
I t i s g e n e r a l l y a c c e p t e d t h a t t h e m ost d a n g e ro u s
age p e r i o d f o r becom ing i n f e c t e d and succunibing t o t u b e r
c u l o s i s i n f e c t i o n i s d u r in g t h e f i r s t y e a r of l i f e . ^ ^
The f o l l o w i n g f o u r y e a r s of t h e l i f e s p a n , up t o t h e f i f t h
y e a r , a r e much l e s s d a n g e ro u s b u t t h o s e f o u r y e a r s a r e n o t
a s " s a f e " a s th e p e r i o d b e tw e e n f i v e y e a r s of age and
p u b e r t y . From p u b e r t y onward, th e ch an ce of d y in g i f i n
f e c t e d i n c r e a s e s r a p i d l y u n t i l a p e a k h a s b e e n r e a c h e d .
The p r e c i s e age p e r i o d f o r r e a c h i n g t h e peak i s i n c o n s t a n t
f o r d i f f e r e n t p e r i o d s of t im e , f o r e a c h se x , and f o r e a c h
c o u n tr y .
D e s p ite t h e h ig h s u s c e p t i b i l i t y of t h e i n f a n t , w i t h
t h e g e n e r a l d e c l i n e i n th e t u b e r c u l o s i s m o r t a l i t y r a t e i n
t h e U n ite d S t a t e s , t h e r e have b e e n r a d i c a l ch an g e s in i n
f a n t m o r t a l i t y r a t e s . F o r i n s t a n c e , i n 1900 i n t h e U n ite d
S t a t e s t h e t u b e r c u l o s i s m o r t a l i t y r a t e among m ale i n f a n t s
u n d e r one y e a r o f age was 350 p e r 1 0 0 ,0 0 0 p o p u l a t i o n and
was th e h i g h e s t a t t h a t tim e i n any age g r o u p . ^5 gy 1940
th e r a t e had d ro p p e d t o 25 p e r 1 0 0 ,0 0 0 p o p u l a t i o n in
^ ^ R ic h , o p . c i t . , p . 221.
^ ^ D r o l e t , o p . c i t . , p . A -46.
i_ J
38 ^
c o m p a riso n w ith th e p e ak of 110 p e r 1 0 0 ,0 0 0 p o p u l a t i o n
among th e men 55 t o 65 y e a r s of a g e . In 1946 th e lo w e s t
d e a t h r a t e among t h e b o y s 5 t o 15 y e a r s of age re a c h e d
5 p e r 1 0 0 ,0 0 0 p o p u l a t i o n , and th e h i g h e s t among th e m ales
was i n t h e g ro u p of 55 t o 65 y e a r s of a g e . The f i g u r e s
i n T a b le 3 show a s i m i l a r age grou p s h i f t i n J a p a n .
TABLE 3
YEARLY TUBERCULOSIS DEATH RATE BY AGE GROUP®
Year
1943 6 6 .0 4 0 3 .8 6 1 7 .4 2 0 3 .7
1947 6 4 .5 2 0 3 .2 4 2 4 .0 1 8 8 .1
1951 5 1 .1 7 4 .0 1 5 8 .7 1 5 9 .1
1955 1 4 .8 1 8 .1 4 3 .5 9 8 .6
D eath r a t e p e r 10 0 ,0 0 0 p o p u l a t i o n
^From: " T u b e r c u lo s is i n Ja p an " (The
Ja p an A n t i - T u b e r c u l e s i s A s s o c i a t i o n , Tokyo,
1 9 5 6 ), p . 3 . ( T y p e w r i t t e n . )
D r o l e t a c c o u n ts t h i s d e c r e a s e among c h i l d r e n i n
t h e U n ite d S t a t e s t o th e i n c r e a s e d i s o l a t i o n i n s t i t u t i o n s
f o r open c a s e s , th e a g g r e s s i v e cam paign f o r e r a d i c a t i o n
of b o v in e t u b e r c u l o s i s , and t h e p a s t e u r i z a t i o n 6f d a i r y
44
p r o d u c t s . J u d e f in d s u g g e s t s t h a t c h i l d r e n up t o th e
^^G odias J. D r o l e t , Los A ngeles County-W ide C hest
X-Ray S u rv ey of 1950 (Los A ngeles : T uber c ü ï o s i s C o n tr o l
P o u n d a tlo n , 1 9 5 3 ), p . 2 .
^ 39
age of two y e a r s a r e h i g h l y s u s c e p t i b l e t o t u b e r c u l o s i s i f
ex p o sed t o m a ssiv e i n f e c t i o n su c h as would r e s u l t from
l i v i n g i n th e same home w ith a c a se o f t h e d i s e a s e w hich
had any d e g re e of a c t i v i t y . C h ild re n o f t h a t age d e
v e lo p v e r y s e v e r e i n f e c t i o n s , f r e q u e n t l y t u b e r c u l o s i s men
i n g i t i s . Along w ith o t h e r i n v e s t i g a t o r s , J u d e f i n d s t a t e s
t h a t t h e n a t u r a l im m unity of t h e c h i l d i s r e l a t i v e l y h i g h
b e tw e e n t h e a g e s of f i v e 'and f i f t e e n y e a r s and u n l e s s th e
e x p o s u re i s m a s s iv e and c o n ti n u o u s , t h e s e o l d e r c h i l d r e n
seldom d e v e lo p th e d i s e a s e . Then a t p u b e r t y th e n a t u r a l
im m unity d e c l i n e s b u t r e v i v e s a g a i n p a s t m id d le l i f e when
t h e r e seems t o be g r e a t e r r e s i s t a n c e .
T u b e r c u l o s i s m o r t a l i t y r a t e i n Ja p an f o l lo w s
J u d e f i n d ’s o b s e r v a t i o n r a t h e r c l o s e l y . However, t h e r e
c o r d s f o r Ja p a n e se c h i l d r e n u n d e r two y e a r s of age f a i l t o
b e a c c u r a t e enough t o come t o any d e f i n i t e c o n c l u s i o n s .
O f te n , t h e d e a t h s o f such young c h i l d r e n a r e n e v e r d e t e r
m in e d . Embree m e n tio n s , "Then comes a c r i t i c a l p e r i o d of
w eaning a t w hich s t a g e c h i l d r e n f r e q u e n t l y d ie ." ^ ®
These c h i l d r e n c o u ld have succumbed t o t u b e r c u l o s i s
I
b e c a u s e o f m a l n u t r i t i o n . P o s s i b l y t h e s e c h i l d r e n had been
b r e a s t f e d f o r a y e a r or more and d i d n o t d i e b e c a u s e of
^^T. P. J u d e f i n d , " L e c tu r e Notes f o r B a c t e r i o l o g y
and Immunology" (Los A n g e le s : C o lle g e of M e d ica l Evan
g e l i s t s , 1 9 5 7 ), p . 130. (M im eographed.)
^ ^ E n b re e , Suye M ura, p p . 1 6 2 -1 6 5 .
J
r 40 ^
t h e w eaning p r o c e s s b u t b e c a u s e of m a l n u t r i t i o n c a u se d b y
d e l a y in w ean in g . And t u b e r c u l o s i s f o l lo w s v e r y c l o s e l y
upon t h e h e e l s of m a l n u t r i t i o n . E a r l y c h ild h o o d m alnu
t r i t i o n i s n o t uncommon in many c o u n t r i e s where w eaning
d o e s n o t b e g i n w i t h i n t h e f i r s t n i n e m onths of l i f e .
Young c h i l d r e n who have b e e n b r e a s t f e d f o r n i n e m onths o r
m ore o f t e n d e v e lo p i l l n e s s e s a lo n g w ith m a l n u t r i t i o n . T h is
h a s b e e n o b s e rv e d i n t h e U n ite d S t a t e s e s p e c i a l l y among r e
c e n t im m ig ra n ts o r p e o p le i n th e lo w e r econom ic g ro u p s who
f o l lo w t h e p a t t e r n of lo n g te rm b r e a s t f e e d i n g . I t i s n o t
u n u s u a l t o f i n d t h e s e c h i l d r e n i n p e d i a t r i c w ards o f t h e
c i t y h o s p i t a l s b u t once th e m a l n u t r i t i o n h a s b e e n o v e r
come, t h e c h i l d r e n a r e a b le t o le a v e th e h o s p i t a l im
p ro v e d and grow ing a c c o r d in g t o norm al h e a l t h p r e s c r i p
t i o n s .
S e v e r a l i n v e s t i g a t o r s i n Ja p an have made s u r v e y s
of t u b e r c u l o s i s i n c i d e n c e among v a r i o u s age g ro u p s and of
d i v e r s e d i s t r i b u t i o n b e tw e e n m ale and fe m a le p o p u l a t i o n a t
d i f f e r e n t age l e v e l s . ^9 f a b l e 4 on page 41 c o n t a i n s
s t a t i s t i c s r e l a t i n g t o t h e p r o p o r t i o n of i n f e c t e d p e r s o n s
Imamura, o p . c i t . , p p . 3 -1 0 .
48
Takayama, o£. c i t . , p p . 21 ^ s e q q .
^^T . E b in a , e t a l . , "U ber d i e R e ih e n u n te rsu c h u n g d e r
g a n z e n B evB ikerung e i n e r k l e i n e n S t a d t i n N ordj a p a n , " Das
F o r s c h u n g s - I n s t i t u t f u r T u b e rk u lo s e und L e p r o s i e . V
T P e b ru a ry , 1 9 5 3 ), pV 5 1 -6 2 . ~
J
^ 41 ^
TABLE 4
MORTALITY FROM TUBERCULOSIS AT DIFFERENT AGE
PERIODS IN JAPAN® AND THE UNITED STATES^
Ja p an U n ite d S t a t e s
D e a th s p e r 1000 D e a th s p e r 1 0 0 ,0 0 0
Age Mgle Fem ale Male Fem ale
0-1 2 4 .8 2 4 .3
0 -4 1 8 .7 1 8 .8
1 -4 1 2 .6 1 2 .0
5 -9 8 .9 1 4 .7 4 .6 4 .2
10-14 2 2 .0 7 0 .5 5 .0 8 .2
15-19 1 6 2 .0 2 3 2 .7 1 9 .7 3 5 .1
2 0 -2 4 2 1 6 .2 2 2 0 .7 4 1 ,5 5 7 .5
2 5 -2 9 1 6 3 .8 1 4 9 .9 5 2 .7 5 9 .7
3 0 -3 4 1 0 3 .1 8 8 .1 6 0 .3 5 2 .6
3 5 -3 9 7 2 .0 5 6 .1 6 7 .0 4 7 .3
4 0 -4 4 5 4 .0 3 8 .4 8 3 .2 4 0 .4
4 5-49 4 7 .8 3 0 .3 9 0 .6 3 4 .8
50-54 4 2 .4 2 6 .3 1 0 1 .3 3 5 .8
55-59 3 6 .8 2 2 .4 1 0 9 .9 3 8 .9
6 0 -6 4
6 0 -6 9 4 1 .5 2 3 .8
1 1 0 .3 4 2 .8
7 0 - 1 0 .8 7 .1 9 0 ,3 6 6 .8
®Prom: Im am ura, op. c i t . , D i s t r i b u t i o n of t u b e r c u
l o s i s d e a t h s by^ a g e ; a v e r a g e number i n y e a r s 1 9 3 4 -1 9 3 8 , p . 3.
^Prom : R ic h , o p . c i t . , M o r t a l i t y from t u b e r c u
l o s i s a t d i f f e r e n t age p e r i o d s , and i n t h e e s t i m a t e d i n
f e c t e d p o r t i o n of t h e p o p u l a t i o n (U .S . R e g i s t r a t i o n A re a,
1 9 4 0 ), p . 220.
u J
^ 42
in t h e p o p u l a t i o n a t e a c h age p e r i o d . W hile t h e s e s t a t i s
t i c s a r e a d m i t t e d l y b a s e d upon d a t a w hich l e a v e much t o be
d e s i r e d , t h e y g iv e a r e l a t i v e view of th e r a t e i n t h e two
c o u n t r i e s .
At d i f f e r e n t p e r i o d s o f t h e l i f e sp a n t h e r e a p p e a r
t o be v a r i o u s c l i n i c a l m a n i f e s t a t i o n s , l e s i o n c h a r a c t e r
i s t i c s , and o t h e r i n c o n s t a n t e le m e n ts w hich a r e n o t t h o r
o u g h ly u n d e r s t o o d . P r e c i s e know ledge of t h e s e d i f f e r e n c e s
would b e m ost e f f e c t i v e i n t h e c o n t r o l of t h e d i s e a s e .
S t a t i s t i c s show t h a t t h e m o r t a l i t y r a t e i n Japan
and i n th e U n ite d S t a t e s i s h ig h among i n f a n t s and c h i l d r e n
up t o f i v e y e a r s of age i n c o m p a riso n w i t h t h e 5 -9 y e a r o ld
g ro u p . The m o r t a l i t y r a t e among t h e i n f e c t e d p o p u l a t i o n
d u r i n g th e p e r i o d b e tw e e n f i v e y e a r s and p u b e r t y i s m ark
e d l y lo w e r th a n t h a t i n any o t h e r d e cad e of th e l i f e s p a n .
The r e a s o n f o r t h i s i s n o t known b u t h a s b e en fou nd t r u e
f o r e v e r y c o u n tr y i n w hich s u r v e y s have b e e n made. Much
more m ust be l e a r n e d a b o u t th e u l t i m a t e f a t e of th o s e who
become i n f e c t e d f o r th e f i r s t tim e a t any of t h e age
p e r i o d s .
In b o t h c o u n t r i e s , a c c o rd in g t o t h e s t a t i s t i c s i n
T a b le 4, t h e t u b e r c u l o s i s m o r t a l i t y c u rv e b e g i n s to r i s e
s h a r p l y a t th e p e r i o d of p u b e r t y . F a c t o r s w hich a r e r e
s p o n s i b l e f o r t h e d i f f e r e n c e s b e tw e e n th e m ale and fe m a le
p o p u l a t i o n c a n n o t be s a t i s f a c t o r i l y d e f i n e d b u t s e v e r a l
f a c t o r s a r e w o rth y of m e n tio n . ^
r 1
43
O b s t e t r i c i a n s and t u b e r c u l o s i s s p e c i a l i s t s have
lo n g b e l i e v e d t h a t c h i l d b e a r i n g e x e r t s u n f a v o r a b l e i n
f l u e n c e upon t u b e r c u l o s i s . R e g a r d le s s o f t h e s p e c i f i c
e f f e c t of p re g n a n c y i t s e l f , t h e r e a r e c e r t a i n o t h e r con
d i t i o n s w hich may or. may n o t e x e r t i n f l u e n c e d e p e n d in g u p
on th e c i r c u m s ta n c e s a t th e t im e . Rich m e n tio n s :
I t i s r e c o g n i z e d , f o r ex am p le , t h a t p h y s i c a l e x
e r t i o n , m a l n u t r i t i o n , i n s u f f i c i e n t s l e e p and m e n ta l
s t r a i n a l l e x e r t an u n f a v o r a b l e i n f l u e n c e u p on t u b e r
c u l o s i s , and c h i l d b e a r i n g e n t a i l s one o r more of t h e s e
u n f a v o r a b l e i n f l u e n c e s . 50
There i s e x c e s s p h y s i c a l work i n v o lv e d i n c a r r y i n g
t h e c o n s t a n t l y i n c r e a s i n g w e ig h t b e f o r e d e l i v e r y o f th e
c h i l d and d u r i n g th e l a t t e r p a r t of p re g n a n c y w hich may
v e r y w e ll c o n s t i t u t e a n im p o r ta n t u n f a v o r a b l e i n f l u e n c e
e s p e c i a l l y f o r women who have t o do a g r e a t d e a l of work
and do n o t g e t p r o p e r r e s t .
Amount o f r e s t n e ed e d d ep en d s upon t h e h e a l t h
s t a t u s of e a c h i n d i v i d u a l woman. Many women i n Ja p a n e x e r t
a g r e a t d e a l o f p h y s i c a l e n e rg y d u r in g t h e f u l l te rm of
p re g n a n c y b e c a u s e o f t h e demands of t h e home and t h e f a m i ly .
A lso , d u r i n g p re g n a n c y , p r o p e r m e d ic a l c a r e and n u t r i t i o n
a r e m ost im p o r ta n t f o r t h e m o th e r and f o r th e c h i l d . I f
t h e y a r e n o t p r o v i d e d , th e r e s i s t a n c e i s lo w e re d and i n
f e c t i o n by t u b e r c l e b a c i l l i i s a p t t o o c c u r .
The s u b j e c t of n u t r i t i o n w i l l b e d i s c u s s e d in
®°Rlch, 0£ . c i t . , p . 1 97.
i_ J
^ 44 ^
a n o t h e r s e c t i o n of t h i s p a p e r . However, i t i s i m p o r t a n t
t o n o t e t h a t good p r e n a t a l c a r e i n c l u d e s a g o o d , w e l l -
b a l a n c e d , and n u t r i t i v e d i e t . L a t e r th e b r e a s t f e d i n f a n t
r e q u i r e s a l a r g e amount of n o u r is h m e n t w hich comes from
t h e m o th e r .
A tte n d a n t upon t h e i n c r e a s e i n t h e s i z e o f t h e
f a m i l y i s t h e added e x p e n s e . Food b i l l s add more s t r a i n
upon t h e b u d g e t and f o r f a m i l i e s i n th e low income g ro u p
th e s t r a i n i s g r e a t l y f e l t . L a r g e r l i v i n g q u a r t e r s a r e
r e q u i r e d o r o v e rc ro w d in g may r e s u l t . F o r t h o s e who do n o t
have s u f f i c i e n t income t h e r e f o l l o w s t h e n o t u n u s u a l com
b i n a t i o n o f p o v e r t y and t u b e r c u l o s i s .
G lo g a u e r p o i n t s o u t th e r o l e of b i r t h r a t e a s an
I n f l u e n c e i n fe m a le t u b e r c u l o s i s m o r t a l i t y . T h e s t u d y
shows t h e p a r a l l e l i s m s b e tw e e n a d e c l i n e in t h e b i r t h r a t e
and a d e c l i n e i n t u b e r c u l o s i s m o r t a l i t y i n v a r i o u s c o u n
t r i e s , However, G lo g a u e r d i d n o t m e n tio n w h e th e r o r n o t
l i v i n g c o n d i t i o n s had s t e a d i l y im proved a t t h e p e r i o d when
t h e b i r t h r a t e was d e c l i n i n g . As p o v e r t y and t u b e r c u l o s i s
seem t o go t o g e t h e r , so im p roved l i v i n g c o n d i t i o n s e x e r t
p o t e n t e f f e c t upon t h e t u b e r c u l o s i s m o r t a l i t y r a t e .
The p e ak of th e d e a t h r a t e o c c u rs i n Ja p a n j u s t a t
t h e tim e t h a t t h e a v e ra g e Ja p a n e se y o u th m a r r i e s . G i r l s i n
^ ^ 0 . G lo g a u e r , " T u b e r k u l o s e s t e r b l i c h k e i t und G e b u r t-
e n r d c k g a n g ," Z e i t s c h r i f t f i i r T u b e r k u lo s e , LX ( J a n u a r y ,
1 9 3 1 ), p . 14
J
45
Jap an m a rry and b e g i n work a t a v e r y e a r l y a g e . No d o u b t,
t h e y t a k e up b o t h o f t h e s e r e s p o n s i b i l i t i e s much e a r l i e r
t h a n A m erican g i r l s . T u b e r c u l o s i s s t r i k e s b o t h Ja p a n e se
m ale and fe m a le a t th e m ost p r o d u c t i v e y e a r s of t h e i r
l i v e s . Embree p o i n t s out t h a t " . . . a t t w e n t y - t h r e e o r
t w e n t y - f o u r , a young man m a r r i e s . H is w ife w i l l be s e v e n
t e e n o r e i g h t e e n y e a r s o l d . O b v i o u s l y , c h i l d b e a r i n g
b e g i n s a t a much e a r l i e r age f o r th e J a p a n e s e g i r l th a n
f o r t h e g i r l i n t h e U n ite d S t a t e s . The m o r t a l i t y r a t e
d o e s n o t b e g in t o d e c r e a s e u n t i l a f t e r t h i r t y y e a r s of
a g e , a f t e r m ost women i n Ja p an have b e e n m a r r i e d tw e lv e o r
f o u r t e e n y e a r s and p o s s i b l y have had s e v e r a l p r e g n a n c i e s .
The m o r t a l i t y r a t e f o r t h e m ale p o p u l a t i o n o v e r
t h a t o f th e fe m a le p o p u l a t i o n a f t e r t h e t w e n t y - f o u r age
p e r i o d may b e p a r t l y due to th e f a c t t h a t th e h i g h e r f e
m ale d e a t h r a t e i n th e e a r l y y e a r s weeds o ut many of t h o s e
who, b e d a u s e of u n f a v o r a b l e e n v ir o n m e n t, c h i l d b e a r i n g ,
h e r e d i t a r y s u s c e p t i b i l i t y , e t c . , would h a v e d i e d of t u b e r
c u l o s i s i n t h e l a t e r age p e r i o d . The fe m a le p i c t u r e shown
i n th e l a t e r y e a r s i s an e v id e n c e of th e s u r v i a l of th e
f i t t e s t .
M o reo v er, t h e o c c u p a t i o n a l h a z a r d s of th e m ale
w o rk e r i n t h e l a t e r y e a r s a f f e c t th e m o r t a l i t y r a t e .
O c c u p a tio n s w hich i n v o lv e e x p o su re t o th e w e a t h e r , o v e r -
52
S n b r e e , o p . c i t . , p . 2 0 3 .
L _ J
^ 46 ^
e x e r t i o n , i n s u f f i c i e n t r e s t , e t c . , make r e a s o n a b l e co n
t r i b u t i o n s t o th e t u b e r c u l o s i s m o r t a l i t y of t h o s e l i v i n g
i n h e a v i l y t u b e r c u l a r i z e d c o m m u n itie s.
I t i s d i f f i c u l t to d i s c u s s t h e s o c i a l p ro b lem s of
t u b e r c u l o s i s i n a community w ith o u t s u f f i c i e n t s o c i o l o g
i c a l i n f o r m a t i o n . S t a t i s t i c s have v e r y l i t t l e v a lu e i f
a n a l y s i s c a n n o t b e made. A n a ly s is d e p en d s upon a th o ro u g h
know ledge of econom ic s t a t u s , l i v i n g s t a n d a r d s , and o t h e r
e n v ir o n m e n ta l c o n d i t i o n s w hich a r e m a jo r e le m e n ts of t h e
com m unity. R e c e n tly P a r s o n s p o i n t e d o u t :
J u s t a s a l a r g e p a r t of " m e d ic a l" p h y s io lo g y was
t a k e n o v e r b y n a t u r a l s c i e n c e , so s c i e n t i f i c j u r i s
d i c t i o n o v e r much of th e e a r l i e r " a r t of m e d ic in e "
i s b e g in n i n g t o be t a k e n o v e r by s o c i a l s c i e n c e .
The m e d ic a l p ro b lem of t u b e r c u l o s i s d e p en d s g r e a t l y upon
s o c i a l s c i e n c e b u t t h e w r i t e r h a s n o t b e e n a b le t o l o c a t e
more of th e s o c i a l s c i e n c e s t u d i e s w hich w ould a llo w f o r
f u r t h e r a n a l y s i s o f comm unity p ro b le m s r e l a t i n g t o t u b e r
c u l o s i s in J a p a n .
T a l c o t t P a r s o n s , "Some T re n d s o f Change in
A m erican S o c i e t y , " J o u r n a l o f t h e A m erican M ed ical A sso-
e l a t i o n . CLXVII (May, 1 9 5 8 ), p . 34.
J
r ■ >
CHAPTER IV
FAMILY PROBLEM
N u t r i t i o n
What i s i t t h a t d e t e m i n o s w h e th e r o r n o t th e
b a c t e r i a w h ich e n t e r t h e b o d y w i l l o r w i l l n o t m u l t i p l y
and p ro d u ce a p r o g r e s s i v e i n f e c t i o n ? Each i n d i v i d u a l e n
c o u n t e r s a h o s t o f b a c t e r i a e v e r y d a y ; a t one tim e when
t h e b a c t e r i a e n t e r th e b ody t h e y e s t a b l i s h p r o g r e s s i v e i n
f e c t i o n and a t a n o t h e r tim e t h e y may f i n d t h e body e n v i
ronm ent a l t e r e d and u n s u i t a b l e f o r m u l t i p l i c a t i o n .
P r o g r e s s i v e i n f e c t i o n o c c u r s a f t e r th e b a c t e r i a e n t e r t h e
b o d y o n ly i f th e h o s t i s i n a s u f f i c i e n t l y s u s c e p t i b l e
c o n d i t i o n .
T h is p a p e r h a s m e n tio n e d t h a t t h e d e g r e e of s u s
c e p t i b i l i t y of a g i v e n i n d i v i d u a l v a r i e s m a rk e d ly from
tim e t o t im e , i n e a c h s e x , and i n v a r i o u s c i r c u m s t a n c e s .
The r e s i s t a n c e of t h e b o d y , e i t h e r a c q u i r e d o r n a t i v e h a s
b e e n m e n tio n e d a s an i m p o r ta n t f a c t o r i n overcom ing i n
f e c t i o n b y e n t e r i n g b a c t e r i a . C irc u m s ta n c e s w hich lo w e r
r e s i s t a n c e a r e i m p o r t a n t n o t o n ly a s a t h r e a t t o th o s e who
h a v e a c t i v e o r an a r r e s t e d t u b e r c u l a r l e s i o n b u t t h e s e
c ir c u m s ta n c e s a r e o f g r e a t im p o rta n c e a l s o to t h o s e who a r e
e x p o se d t o i n f e c t i o n .
47
i_ J
48 ^
T h is p a p e r h a s m e n tio n e d th e f a c t t h a t p o v e r t y and
t u b e r c u l o s i s go t o g e t h e r . In com m u n ities w here t h e i n
d i v i d u a l s a r e g ro u p ed a c c o r d i n g t o t h e i r econom ic s t a t u s ,
t h e t u b e r c u l o s i s m o r t a l i t y r a t e of th e d i f f e r e n t g ro u p s
t e n d s t o v a r y i n v e r s e l y w ith t h e i r econom ic l e v e l .
I n th e many s u r v e y s made i n v a r i o u s p a r t s of t h e w o rld
w h ich show t h e r e l a t i o n s h i p b e tw e e n econom ic s t a t u s and
t u b e r c u l o s i s m o r t a l i t y r a t e , t h e h i g h e s t t u b e r c u l o s i s
d e a t h r a t e s have b e e n fo u n d i n th e lo w e s t econom ic l e v e l s
56
and th e lo w e s t r a t e s i n t h e h i g h e s t econom ic l e v e l s .
M a l n u t r i t i o n need n o t accompany low income b u t i t
i s o f t e n an a d v e r s e r e s u l t of i n a d e q u a te incom e. O r d i
n a r i l y , low income a cc o m p a n ie s o t h e r su ch a d v e r s e c o n
d i t i o n s a s b a d h o u s in g , e x tre m e p h y s i c a l e x e r t i o n , o v e r
c ro w d in g , and lo n g h o u r s of work and e x p o s u re b y t h e u n
s k i l l e d w o rk e rs who c o m p rise t h e b u l k of t h e low Income
p o p u l a t i o n . B ecause o f t h e s e added f a c t o r s w hich a r e so
much a p a r t o f t h e low incom e g r o u p s , i t i s d i f f i c u l t t o
a s s e s s t h e d e g re e t o w hich m a l n u t r i t i o n I n f l u e n c e s t u b e r
c u l o s i s i n f e c t i o n and t u b e r c u l o s i s m o r t a l i t y .
The s t o r y o f t h e r e s u l t s o f w ar upon t u b e r c u l o s i s
^ ^ R ic h , o p . c i t . > p . 619
55
K e e rs , e t a l . , o p . c i t . , p . 6 3 .
J . E w a r t, "E conom ies and T u b e r c u l o s i s , " P ro
c e e d in g s of t h e Royal S o c i e t y of M e d ic in e . XVI ( J a n u a r y ,
1 9 2 3 ) , p . 1 1 .
u J
^ 49
m o r t a l i t y r a t e i n Ja p a n a s m e n tio n e d e a r l i e r i s n o t u n
common. The r a t e i n o t h e r c o u n t r i e s f o l lo w v e r y c l o s e l y
t h e a v a i l a b l e i n f o r m a t i o n r e g a r d i n g fo o d s u p p ly i n t h e i n
d i v i d u a l c o u n t r i e s . War y e a r s i n Germany d e m o n s tr a te t h e
e f f i c a c y o f fo o d u p o n t u b e r c u l o s i s .
G erm any’s m o r t a l i t y r a t e f e l l from 255 p e r 1 0 0 ,0 0 0
p o p u l a t i o n i n 1900 t o 143 p e r 1 0 0 ,0 0 0 i n 1 91 3 . A f t e r t h e
o u t b r e a k o f World War I , t h i s downward t r e n d c e a s e d and b y
1916 t h e r a t e had r i s e n t o 162 p e r 1 0 0 ,0 0 0 p o p u l a t i o n * In
1917 and 1918 when t h e b lo c k a d e h a d c a u s e d a d e s p e r a t e fo o d
s h o r t a g e , t u b e r c u l o s i s m o r t a l i t y r a t e s o a r e d t o 230 p e r
1 0 0 ,0 0 0 p o p u l a t i o n - t h e h i g h e s t f i g u r e f o r Germany i n
57
t h e p a s t two d e c a d e s .
I n A u s t r i a and B elgiu m where t h e fo o d s h o r t a g e
o c c u r r e d t o a s i m i l a r d e g r e e , t h e p i c t u r e was e s s e n t i a l l y
t h e same a s i n Germany. But i n l e s s s e r i o u s l y a f f e c t e d
c o u n t r i e s , su ch a s E n g la n d , t h e r e was o n ly a r e l a t i v e l y
s l i g h t r i s e i n t u b e r c u l o s i s m o r t a l i t y . S c o t la n d h a d no
r i s e i n t h e m o r t a l i t y r a t e a t a l l b u t t h e t r e n d w h ich h a d
b e e n downward f l a t t e n e d o u t d u r i n g t h e w ar y e a r s .
The t u b e r c u l o s i s m o r t a l i t y r a t e i n Ja p a n f o l l o w e d
t h e same t r e n d . The downward t r e n d a f t e r th e R usso-
J a p a n e s e c o n f l i c t r e v e r s e d i n 1916 a s an e f f e c t o f World
War I . In t h e same y e a r s t h a t Germany had t h e h i g h e s t
57
R ic h , 0£ . c i t . , p . 612.
i_ J
^ 50
r a t e of th e p r e v i o u s d e c a d e s , Ja p an a l s o re a c h e d t h e p e a k
r a t e of a l l t i m e s , i . e . , 253 p e r 1 0 0 ,0 0 0 . The f a c t s a b o u t
i n d u s t r i a l i s m and m i l i t a r i s m a s p o t e n t c a u s e s o f t h i s -In
c r e a s e hav e b e e n m e n tio n e d e a r l i e r i n t h i s p a p e r . 58
R ecords from n e u t r a l Denmark d e m o n s tr a te t h a t i f
a d e q u a te and p r o p e r n u t r i t i o n p r e v a i l s , t h e n t h e b o d y can
w i t h s t a n d t u b e r c u l o s i s d e s p i t e lo n g w orkin g h o i ^ s , h e a v y
w ork, e t c . Denmark p ro d u c e d and e x p o r t e d d a i r y p r o d u c t s
and m eat d u r i n g World War I . I n th e f i r s t y e a r s of th e
w ar, t h e demand f o r th o s e p r o d u c t s b y th e w a r r in g coun
t r i e s i n f l i c t e d a g r e a t s h o r t a g e f o r t h e w orking c l a s s
p e o p le in Denmark. P a r a l l e l w ith t h i s fo o d s h o r t a g e t h e
t u b e r c u l o s i s m o r t a l i t y r o s e . Then th e c o m p lete b lo c k a d e
of G erm any’s u n r e s t r i c t e d su b m arin e w a r f a r e came and
Denmark c o u ld no l o n g e r e x p o r t and im p o rt and t h e p e o p le
l i v e d on t h e i r own p r o d u c t s and m e a t. C o n s e q u e n tly , th e
c o n su m p tio n of fo o d p e r c a p i t a i n c r e a s e d and t h e t u b e r
c u l o s i s m o r t a l i t y r a t e d e c l i n e d and c o n tin u e d t o d e c l i n e
when t h e r a t e i n t h e n e ig h b o r i n g w a r r in g c o u n t r i e s had an
i n c r e a s e d d e a t h r a t e .
A p o i n t e d a n a l y s i s o f Denmark made b y F a b e r shows
t h a t f a c t o r s o t h e r th a n n u t r i t i o n , su c h a s em ploym ent, f u e l
s u p p ly , and h o u s i n g , w hich u s u a l l y c o m p lic a te th e p i c t u r e
i n t h e w a r r in g c o u n t r i e s , h a d v e r y l i t t l e I n f l u e n c e i n t h e
S u p r a , p p . 2 2 -2 5 .
i_ J
r n
51
o b s e rv e d f l u c t u a t i o n of th e t u b e r c u l o s i s I n c i d e n c e i n
5 9
Denmark.
Most im p o r ta n t i s th e f a c t t h a t Denmark h ad t h e
p r o p e r n u t r i t i o u s f o o d s , m eat and p r o t e i n s and f a t s .
P r o t e i n s a r e e s p e c i a l l y e s s e n t i a l i n r e s t o r i n g th e t i s s u e
d e s t r o y e d b y t h e b a c i l l i . P r o t e i n s o f c e r e a l s and v e g e t a
b l e s do n o t , a s a r u l e , s u p p ly t h e e s s e n t i a l amino a c i d s
i n t h e p r o p o r t i o n s o f f e r e d b y t h e p r o t e i n s i n m i l k , e g g s ,
and m e a t. F o r t h i s r e a s o n t h e soy bean o f Ja p an h a s lo w e r
b i o l o g i c v a lu e t h a n m e a t .5 0
The Ja p a n e s e d i e t i s b a s i c a l l y composed o f r i c e ,
f i s h , and f r e s h s e a s o n a l v e g e t a b l e s . They have a v e r y
m eager q u a n t i t y of a n im a l p r o t e i n s and f a t s . The a v e r a g e
J a p a n e s e e a t s a b o u t s i x t y - f i v e pounds o f f i s h b u t o n ly
61
f i v e pounds of m eat p e r y e a r . The a v e r a g e f i g u r e s f o r
t h e U n ite d S t a t e s p o p u l a t i o n a r e tw e lv e pounds o f f i s h and
a b o u t 140 p ounds of m e a t.
A n o th e r s o u r c e o f f a t l i e s i n su c h f o o d s a s b u t t e r ,
c r e a m , , c h e e s e , and v a r i o u s o i l s . These i m p o r ta n t fo o d s
a r e v e ry m eag er i n th e d i e t of th e a v e r a g e w o rk ing p e rs o n
K. F a b e r , " T u b e r c u l o s i s and N u t r i t i o n , " A cta
T u b e r c u lo s e s S c a n d i n a v i a . X II (1 9 3 6 ) , p . 2 8 7 .
James M c L e ste r, "The norm al D i e t , " D i e t o t h e r a p y :
C l i n i c a l A p p l i c a t i o n of M odem N u t r i t i o n , e d . M ichael G.
Wohl ( P h i 1a d e 1p h i a : W.B, S a u n d e rs Company, 1 9 4 5 ), p . 8 .
^ ^ H e r s c h e l Webb, An I n t r o d u c t i o n t o Jap an (New
York : Colum bia U n i v e r s i t y P r e s s , 1 9 5 7 ) , p . 6 6 .
L _ J
52 ^
i n J a p a n .
Nakamura com pared th e d i e t s of v a r i o u s c o u n t r i e s
w h ich w ere i n v o lv e d i n W orld War I and d e c i d e d :
In c o n c l u s i o n , we w ould t h i n k t h a t th e f e a t u r e s of
th e J a p a n e s e t u b e r c u l o s i s depend l a r g e l y upon th e
Ja p a n e s e f o o d . S tu d y in g t h e r e l a t i o n b e tw e e n t h e fo o d
and t u b e r c u l o s i s i n t h e c h i e f c o u n t r i e s of th e w o r ld ,
we m ig h t c o n c lu d e t h a t t h e s m a ll m o r t a l i t y from t u b e r
c u l o s i s i n E n gland i s c a u se d b y t h e f a c t t h a t - th e
E n g l i s h p e o p le ta k e much p r o t e i n , e s p e c i a l l y a n im a l
on e, and much f a t , t h a t t h e m o r t a l i t y of I t a l i a n p e o
p l e from t u b e r c u l o s i s i s n o t s m a ll , th o u g h t h e y t a k e
much f a t , b e c a u s e t h e y a r e v e g e t a b l e p e o p le and f o r c e d
t o r e l y upon v e g e t a b l e p r o t e i n and l a s t l y t h a t t h e
f a c t t h a t t h e J a p a n e s e p e o p le t a k e v e g e t a b l e p r o t e i n
a lm o s t e x c l u s i v e l y and l i t t l e f a t , i s th e r e a s o n why
t h e m o r t a l i t y from t u b e r c u l o s i s i s g r e a t i n J a p a n .
W hile m a l n u t r i t i o n a n d / o r u n d e rn o u r is h m e n t u s u a l l y
accom pany i n a d e q u a t e in co m e, t h e r e i s a l s o t h e g e n e r a l
p ro b le m of t h e p re d o m in a n t a v a i l a b i l i t y of f o o d . H i s t o r i
c a l l y , Ja p an h a s f o r many y e a r s had a fo o d d e f i c i e n c y . The
p ro b lem o f such a l a r g e and a lw a y s grow ing p o p u l a t i o n on a
l i m i t e d p r o d u c t i v e la n d a r e a ( o n ly 16 p e r c e n t a r a b l e ) u n
d o u b t e d l y e m p h a siz e s t h e fo o d n e e d s . Ja p an h a s b e e n d e
p e n d e n t upon fo o d Im p o r ts a m o u n tin g t o a t l e a s t 15 p e r
c e n t o f t h e r e q u i r e m e n t s b e f o r e World War I I , and t h e po p
u l a t i o n c o n t i n u e s t o i n c r e a s e . R e p a t r i a t i o n from K o re a ,
M a n c h u ria , and China h a s a c c o u n te d f o r much of t h e p o s t
war i n c r e a s e , b u t , i n t h e m ean tim e, t h e num ber of b i r t h s
® ^Takashi Nakamura, " T u b e r c u l o s i s and N u t r i t i o n , "
S c ie n c e R e p o rts o f t h e R e se a rc h I n s t i t u t e f o r T u b e r c u l o s i s
and L e p ro s y , I I (1 9 5 0 ), p . 47I
i_ J
r -i
5S
s t e a d i l y g ro w s.
A v a i l a b i l i t y of in d ig e n o u s fo o d c r o p s h a s s e a s o n a l
l i m i t a t i o n s b e c a u s e th e p e o p le do n o t make u s e of any k in d
of p r e s e r v a t i o n su c h a s c a n n in g , f r e e z i n g , e t c . Canning
r e q u i r e s p r o p e r and e x t e n s i v e s t e r i l i z a t i o n w hich i s n o t a t
t h e i r d i s p o s a l . F r e e z i n g r e q u i r e s r e f r i g e r a t i o n , an u n
common l u x u r y i n J a p a n . T h e r e f o r e , i n t h e autumn and w in
t e r m o n th s f o l l o w i n g t h e h a r v e s t of r i c e and sw eet p o t a t o
c r o p s , fo o d c o n su m p tio n i s h i g h b u t d u r i n g th e summer
m o n th s, fo o d i n t a k e f a l l s o f f s h a r p l y w i t h t h e d e p l e t i o n
o f stoc/ks o f s t a p l e fo o d s t u f f s .
C a l o r i c i n d i c a t i o n s v a r y g r e a t l y i n i n d i v i d u a l
c a s e s and i n d i f f e r e n t g e o g r a p h i c a l a r e a s . G e n e r a l l y , a
l a b o r e r n e e d s a b o u t 3000 t o 3500 c a l o r i e s p e r d a y ; a
c l e r k n e e d s o n ly 2500 c a l o r i e s p e r d a y . An i n d i v i d u a l
w e ig h in g 150 pounds a t c o m p le te r e s t i n b e d s h o u ld have
a p p r o x i m a t e l y 2250 c a l o r i e s p e r d a y . A cco rd in g t o t h e
N a t i o n a l N u t r i t i o n S u rv e y , J a p a n e s e p e r c a p i t a c a l o r i c i n
t a k e f o r 1947 was 1857 c a l o r i e s . T h e h i g h e s t a v e ra g e
was i n May, 1949 when t h e p e r c a p i t a i n t a k e r e a c h e d 2033
c a l o r i e s . The w ar r e c o r d s show t h a t J a p a n e s e p e r c a p i t a
^ ^ l ^ i n i s t r y of L a b o u r, A n a l y s i s of L abour Economy
i n 1949 (T okyo: L ab o u r S t a t i s t i c s and R e se a rc h D i v i s i o n .
1 9 5 0 ), p . 4 9 .
64
I b i d .
J
54
I n t a k e re a c h e d a s low a s 1500 c a l o r i e s i n May 1946*®^ A l
th o u g h t h i s i s n o t s u f f i c i e n t n o u ris h m e n t f o r t h e a v e ra g e
r e s t i n g b o d y , p e o p le i n Ja p an worked and l i v e d u n d e r t h e
s t r e s s o f war c o n d i t i o n s w ith t h i s k in d of v e r y low c a
l o r i c i n t a k e .
I t i s n o t c l e a r w h e th e r m a l n u t r i t i o n a n d / o r u n d e r
n o u r is h m e n t d e p r e s s s p e c i f i c a l l y t h e r e l a t i v e l y l i t t l e u n
d e r s t o o d m echanism s of n a t i v e and a c q u i r e d r e s i s t a n c e t o
t u b e r c u l o s i s , o r w h e th e r t h e y m e r e ly i n t r o d u c e f a c t o r s
w hich ham per t h e a c t i v i t y o f th o s e m ech an ism s. However,
i t i s g e n e r a l l y a g r e e d t h a t th e J a p a n e se d i e t f a l l s b e
low t h e a c c e p t e d r e q u i r e m e n ts f o r a h e a l t h y and w e l l - n o u r
i s h e d p e o p le . The common d i e t i n Ja p an c a u s e s a m a jo r p r o
b lem o f n u t r i t i o n , b o t h u n d e r n u t r i t i o n and m a l n u t r i t i o n .
H a b i t a t i o n
T u b e r c u l o s i s i s o f t e n c a l l e d a " h o u s e h o ld i n f e c -
t i o n . " P ro lo n g e d and i n t i m a t e c o n t a c t i n a h o u s e h o ld
w i t h a p e r s o n h a v in g an open c a s e of t u b e r c u l o s i s i s a
m a jo r s o u rc e of i n f e c t i o n . In homes w here o v e rc ro w d in g
o c c u r s , i n f e c t i o n o f o t h e r members of t h e f a m i l y i s a l
m ost i n e v i t a b l e . T h is p a p e r h a s m e n tio n e d how an i n
n o c e n t c a r r i e r c a n p i c k up th e i n f e c t i n g o rg a n is m , b r i n g
^^Supreme Commander o f A l l i e d P ow ers, 0£ . c i t . ,
p . 1 66.
66
W ilson G. S m i l i e , P r e v e n t i v e M e d icin e and P u b lic
H e a l t h (New Y o rk : M acm illan Company, 19SSV, p . 161.
55 ^
I t i n t o t h e h o u se and v i c t i m i z e many o t h e r s i n th e h o u s e
h o l d . Overcrowded c o n d i t i o n s make t h i s e v en more l i k e l y .
F a m ily and home c o n t a c t s e n d a n g e r e v e r y member o f th e
h o u s e h o ld , i n f a n t s , c h i l d r e n , and a d u l t s .
The b a s i c s o c i a l u n i t i n Ja p an i s t h e f a m i l y . I t
c o n s i s t s o f th e f a m i l y h e a d and h i s w i f e , t h e e l d e s t son
and h i s w ife and c h i l d r e n and a n y u n m a rrie d c h i l d r e n of
t h e m a s t e r . T hus, n o r m a l ly one Ja p a n e se h o u s e h o ld i n c l u d e s
two e le m e n t a r y f a m i l y u n i t s . L iv in g i n t h e h o use w i t h t h e
s m a ll f a m i l y may b e a r e t i r e d f a t h e r o r m o th e r , o r b o t h ,
o f th e m a s t e r . However, i t i s n o t u n u s u a l t o f i n d t h e o ld
r e t i r e d c o u p le l i v i n g on t h e p re m ise i n a s e p a r a t e h o u s e .
In i t s p h y s i c a l a s p e c t s t h e J a p a n e s e home v a r i e s
g r e a t l y from t h e sim p le t h a t c h e d - r o o f e d h o u se of a f a r m e r
t o t h e e l e g a n t t i l e - r o o f e d d w e l li n g w i t h e x p e n s iv e i n t e
r i o r woodwork and b e a u t i f u l s l i d i n g s c r e e n s p a i n t e d b y f a
mous a r t i s t s . Rooms of t h e h o u se a r e m ea su re d a c c o r d i n g t o
th e num ber of t h r e e - b y - s i x - f o o t t a t a m i o r s tra w f l o o r m ats
w hich t h e y c o n t a i n . S l e e p i n g rooms c o n t a i n no b e d s . When
n i g h t comes, q u i l t s a r e p l a c e d on t h e f l o o r t o fo rm m a t
t r e s s and c o v e r s . The k i t c h e n u s u a l l y h a s a d i r t f l o o r .
I t may o r may n o t b e an i n t e g r a l p a r t of t h e h o u se b e c a u s e
t h e r o o f o f t h e k i t c h e n c o n n e c ts on t h e o t h e r p a r t of t h e
h o u se a s a l e a n - t o .
I n a d d i t i o n t o t h e m ain h o u s e , t h e r e a r e s e v e r a l
^ u t - h o u s e s such a s t h e b a r n , b a th h o u s e , t o i l e t , w oodshed ^
r 56
and som etim es t h e r e i s an o u td o o r o ven. The h o u se y a r d , a s
im p o r t a n t t o e v e r y day l i f e a s t h e h o u s e , a f f o r d s a p l a c e
f o r a l l k i n d s of women’s w ork, f a m i l y e n t e r p r i s e , and
n e ig h b o rh o o d e n d e a v o r s . Y ards in t h e r u r a l a r e a s , r e g a r d
l e s s of s i z e , a lw ay s manage t o p r o v id e a f l o w e r g a rd e n f o r
t h e h o u s e h o ld gods and a v e g e t a b l e p l o t f o r t h e h o u s e h o ld
so u p .
I t h a s b e e n s a i d f o r c e n t u r i e s t h a t t h e Ja p a n e s e
b u i l d t h e i r d w e l l i n g s f o r c o m f o r t a b l e l i v i n g i n th e summer.
The d a y s f o l l o w i n g ’* t s u y u " , th e r a i n y s e a s o n , a r e n o t o n ly
h o t b u t a l s o v e r y hum id. F o r t h i s r e a s o n , c o o l v e n t i l a
t i o n i n summer seems t o t a k e p r e c e d e n t o v e r th e need f o r
warm th i n w i n t e r .
These more .or l e s s summer c o n s t r u c t i o n s become i n
a d e q u a te f o r c o ld w i n t e r d a y s and n i g h t s . They do n o t h o ld
t h e h e a t s a t i s f a c t o r i l y and h e a t i n g d e v ic e s do n o t s u p p ly
enough h e a t e v en f o r t h e b e s t o f c o n s t r u c t e d h o u s e s . U su
a l l y i n r u r a l a r e a s t h e f a m i l y s i t s a ro u n d a f i r e p i t
( i r o r i ) and p o r t a b l e c h a r c o a l h e a t e r s (h l b a c h i ) .
A n o th e r h e a t e r i n g e n e r a l u s e i s th e k o t a t s u , a
l a t t i c e - l i k e wooden s t r u c t u r e p l a c e d o v e r t h e i r o r i and
c o v e re d w ith a h eavy b l a n k e t and q u i l t . A ll th e p e o p le i n
t h e h o u s e h o ld s i t a ro u n d t h i s h e a t e r w ith f o l d e d k n e e s
5*^Housing B u re au , P u b l i c - O p e r a t e d A partm ent House
of P o st-W a r Ja p a n (T okyo: M i n i s t r y of C o n s t r u c t i o n o f
J a p a n e s e G overnm ent, 1 9 5 1 ), p . 8 .
i _ - I
57 "
u n d e r t h e q u i l t e d c o v e r i n g . Hone o f t h e s e h e a t e r s p r o v id e
s u f f i c i e n t h e a t f o r t h e tim e - h o n o r e d t a t a m l c ro u c h in g l i f e
of t h e J a p a n e s e . The f l o o r s re m a in c o ld from t h e end of
one hum id summer t o t h e b e g in n i n g of th e n e x t .
L iv i n g on t h e f l o o r i n such a m anner f i t s v e r y w e l l
i n such t r o p i c a l r e g i o n s a s I n d i a , w here a s i m i l a r ty p e
o f l i f e on t h e f l o o r i s p r a c t i s e d . But t h i s k in d of l i f e
i n t h e c o ld c l i m a t e o f Ja p a n c r e a t e s a m ost u n c o m f o r ta b le
and u n h e a l t h f u l l i f e . Such a l i f e c o n t r i b u t e s t o t h e h i g h
i n c i d e n c e o f t u b e r c u l o s i s and t o o t h e r d i s e a s e s . D e s p i t e
t h e f a c t t h a t t h e sh o e s a r e rem oved i n t h e h o u s e , th e
t a t a m i c o l l e c t s d u s t and t h e d u s t becom es a p e r f e c t c a r
r i e r of t u b e r c l e o rg a n is m s .
As an a d d i t i o n t o t h e h e a l t h p ro b le m , a t n i g h t t h e
wooden s h u t t e r s a r e c l o s e d f o r t h e p u r p o s e o f k e e p in g o u t
b o t h t h e r o b b e r s and t h e n i g h t a i r . H ig h t a i r i s b e l i e v e d
t o be d e t r i m e n t a l . T h e r e f o r e , r e g a r d l e s s o f th e number of
p e o p le who a r e s l e e p i n g i n t h e same room; t h e windows a r e
t i g h t l y c l o s e d . U nder t h e s e c o n d i t i o n s , any p e rs o n w i t h
an unknown i n f e c t i o n of t u b e r c u l o s i s p o t e n t i a l l y can i n
f e c t many p e o p le v e r y q u i c k l y .
B e fo re t h e w ar th e l a r g e num ber of p e o p le i n one
house u s u a l l y c o n s i s t e d of th e f a m i l y o n ly . S t u d e n ts and
m i g r a n t s of d i f f e r e n t o c c u p a ti o n s l i v e d t o g e t h e r b u t n o t
f o r lo n g p e r i o d s o f t im e . A f t e r th e w ar many p e o p le l i v e d
^ o g e t h e r b e c a u s e o f th e h o u se s h o r t a g e . The s t r e s s o f ^
58
m i l i t a r y c o n f l i c t s i n M a n c h u ria , C h in a, and l a t e r i n th e
U n ite d S t a t e s , r e s u l t e d i n a g r e a t l a c k of r e p a i r on t h e
h o u s e s . Money sa v e d from h o u s in g r e p a i r went t o s u p p ly
fo o d and o t h e r w i s e su p p le m e n t th e b u d g e t . M an-power f o r
h o u s in g r e p a i r w ent t o t h e arm y o r i n t o am m unition f a c t o
r i e s . S u p p l i e s f o r h o u s in g r e p a i r w ent i n t o w a r im p le ^
ment s .
I n o r d i n a r y d a i l y l i f e t h e f a r m e r ’s h o u s e h o ld i s
t o g e t h e r a lm o s t e v e r y h o u r i n th e d a y . T o g e th e r t h e y e a t
b r e a k f a s t , l u n c h , and s u p p e r , and s i t a ro u n d t h e f i r e i n
t h e e v e n in g . D u rin g t h e h a r v e s t , t h e e n t i r e f a m i l y w orks
t o g e t h e r . F r e q u e n t l y t h e y work i n t h e y a rd t o g e t h e r , e ac h
d o in g a s p e c i a l c h o r e . The women do su c h work a s silk w o rm -
r e a r i n g and walshing c l o t h e s w h ile th e men work a t m aking
b a s k e t s o r m aking c h a r c o a l .
The m a s t e r and h i s w if e have one s l e e p i n g room t o
g e t h e r b u t i f t h e r e a r e c h i l d r e n , th e m a s t e r s l e e p s w ith
t h e n e x t y o u n g e s t c h i l d w h ile t h e m o th e r s l e e p s w i t h th e
b a b y . A ll t h e o l d e r c h i l d r e n s l e e p t o g e t h e r , u s u a l l y i n
one o f t h e s le e p in g - r c o r n s o r i n th e d a i d o k o r e , t h e m o s t-
l i v e d - i n room.
E venin g b a t h p l a y s a v e r y i m p o r ta n t r o l e i n t h e
68
Economic S t a b i l i z a t i o n B oard , Economic S u rv e y of
-Japan (Tokyo: S t a b i l i z a t i o n Board of th e J a p a n e s e G overn-
m e n t, 1 9 5 1 ), p . 1 8 2 .
^^Em bree, Suye M u ra, p . 90.
J
^ 59
h o u s e h o ld l i f e i n e v e r y p a r t of J a p a n . The p u b l i c b a t h ,
known t o e v e ry o n e a s t h e s e n t o h . c e n t - b a t h , a v a i l s c i t y
d w e l l e r s t h e o p p o r t u n i t y of h a v in g r e g u l a r e v e n in g b a th s *
M u l t i p l e d w e l l i n g s i n t h e c i t y hav e no b a t h rooms n o r can
m o st o f t h e sm a ll c i t y h o u s e s b o a s t such l u x u r y . B a th
p l a c e s i n t h e c i t y o r i n t h e v i l l a g e h e l p t o s e a l i n t i m a t e
a s s o c i a t i o n w i t h i n t h e f a m i l y and among f r i e n d s who v i s i t
t o g e t h e r b e f o r e , a f t e r , o r d u r i n g a b a t h .
The e v e n in g b a t h aim s t o c l e a n b u t i n t h e w i n t e r i t
s e r v e s m a in ly t o warm and t o r e l a x t h e b a t h e r . D u rin g t h e
w i n t e r i t i s t h e one p l a c e and p e r h a p s th e o n ly tim e o f t h e
d a y t h a t one f e e l s w arn . B e fo re s t e p p i n g i n t o t h e deep and
v e r y h o t w a t e r , th e p e rs o n i s e x p e c te d t o wash and r i n s e
t h e b o d y . I n h o t e l and p u b l i c b a t h p l a c e s , s e v e r a l p e o p le
occupy a l a r g e b a t h a t o n c e, t a l k i n g and r e l a x i n g t o g e t h e r .
A m o th e r w i t h two or t h r e e c h i l d r e n of b o t h sex u s u a l l y
s i t t o g e t h e r i n t h e t u b . F r e q u e n t l y , two o r t h r e e women
w i l l b a t h e t o g e t h e r , one b e in g i n th e tu b a t a tim e w h ile
t h e o t h e r s s t a n d by t a l k i n g . T hus, t h i s one s i n g l e l a r g e
tu b of w a t e r can s e r v e many p e o p l e .
P o s s i b l y , t h e h ig h t e m p e r a t u r e o f t h e w a t e r d e
s t r o y s many h a rm f u l b a c t e r i a , b u t t h e e f f e c t s o f e x p o s u re
d u r i n g t h e w i n t e r r a i s e s a p o i n t f o r f u r t h e r s t u d y . Y e t,
no one w ould d a r e c o m p la in a b o u t t h i s p r a c t i s e b e c a u s e
c o ld and d i s c o m f o r t c o n t r i b u t e g r e a t l y to w a rd d e v elo p m e n t
o f d i s c i p l i n e , a c c o r d i n g t o t h e J a p a n e s e way o f t h i n k i n g . ^
60 ^
T hese m e a s u r e s h e l p t o " h a r d e n o n e s e l f " and B e n e d ic t
m e n tio n s :
To h a r d e n o n e s e l f , one may e x p o se o n e s e l f t o any
c o ld and i t i s r e g a r d e d a s p a r t i c u l a r l y v i r t u o u s f o r
c h i l d r e n p r a c t i c i n g c a l l i g r a p h y t o f i n i s h t h e i r p r a c
t i c e p e r i o d s w i t h t h e i r f i n g e r s numb and c h i l b l a i n e d .
M odem e le m e n ta r y s c h o o ls a r e u n h e a te d and a g r e a t
v i r t u e i s made of t h i s f o r i t h a r d e n s t h e c h i l d r e n
f o r l a t e r d i f f i c u l t i e s of l i f e . W e s te r n e r s have b e e n
more im p r e s s e d w i t h t h e c o n s t a n t c o ld s and s n o o ty
n o s e s w hich t h e custom c e r t a i n l y d o e s n o t h in g t o
p r e v e n t .
The f a m i l y i s a m ain s o u rc e of t u b e r c u l o s i s i n f e c
t i o n and i n Ja p a n i s a g g r a v a t e d b y t h e c u sto m s of l i v i n g ,
e s p e c i a l l y some o f t h e custom s of s l e e p i n g , b a t h i n g , and
e a t i n g , and t h e m ere f a c t t h a t many p e o p le do n o t even
know t h a t t h e y have t h e d i s e a s e m akes t h e c h a n c e s f o r i n
f e c t i o n u n l i m i t e d . Oka, elb a l . c o n c lu d e d and r i g h t l y s o :
As many p a t i e n t s l i v e i n a s m a ll h o use u n d e r such
u n d e s i r a b l e c ir c u m s ta n c e s and u n d e r b ad h o u s in g con
d i t i o n s , t u b e r c u l o s i s , once i t m akes i t s e n t r y i n t o
a fa rm v i l l a g e , t a k e s r o o t i n t h a t e n t i r e v i l l a g e
t h r o u g h f a m i l y i n f e c t i o n w hich was and i s t h e g r e a t
e s t s o u r c e of i n f e c t i o n b e f o r e , d u r i n g , and a f t e r
t h e w a r .^ ^
To t h i s E bina a g r e e s :
Es i s t b e B o n d e rs i n Ja p an s e h r sc h w e r, Jede I n -
f e k t i o n s q u e l l e zu su c h e n , w e ll tu b e r k u l B s e Kranke
ü b e r a l l i n Ja p an v o rh a n d e n s l n d . . • .
. . .Und w i r w is s e n a u c h , d a s s d i e X n f e k tio n i n n e r -
h a lb d e r F a m il l e m e i s t e n f a l l s d i e H a u p t r o l l e s p i e l t . ' ^
*^^Ruth B e n e d i c t , The Chrysanthemum and t h e Sword
(B o s to n : M i f f l i n Company^ 1 9 4 6 ), p . 1 8 0.
71
Oka, ejt a l . , op. c i t . , p . 7 1 .
^ *72gbina, op. c i t . , p . 59 ^
^ 61 ^
Rehab1111 a t i on
A r t i c l e t w e n t y - f i v e of th e New C o n s t i t u t i o n of
Ja p an s t a t e s :
I n a l l s p h e r e s o f l i f e , th e S t a t e w i l l u s e i t s e n
d e a v o r s f o r t h e p ro m o tio n and e x t e n s i o n o f s o c i a l
w e l f a r e and s e c u r i t y of p u b l i c h e a l t h .
A f t e r t h e w a r, th e m a jo r problem was r e h a b i l i t a
t i o n . T hat th e " s o c i a l w e l f a r e and s e c u r i t y " of p u b l i c
h e a l t h i n Japan h a s b e e n p ro m o te d s i n c e th e w ar owes much
t o th e above p r o v i s i o n a s s t a t e d i n th e New C o n s t i t u t i o n .
T h is p a r t of th e c o n s t i t u t i o n made p r o v i s i o n f o r t h e c a r e
of p a t i e n t s who c o u ld n o t a f f o r d to rem a in i n h o s p i t a l s o r
s a n i t o r i a .
The p r o v i s i o n was g r a v e l y n eeded b e c a u s e ev en th e
s m a ll num ber o f h o s p i t a l s and s a n i t o r i a w ere o n ly 25 p e r
c e n t o c c u p ie d a f t e r t h e w a r. P a t i e n t s h ad gone i n s e a r c h
of fo o d o r t o h e lp s u p p ly t h e f a m i l y b u d g e t . T hese p a
t i e n t s e n d a n g e re d t h e i r f a m i l i e s and t h e c o m m u n itie s to
w h ich t h e y r e t u r n e d * They n e e d e d t o be i s o l a t e d b u t c o u ld
be e n c o u ra g e d t o s t a y i n i s o l a t i o n o n ly b y p r o v i d i n g p r o p
e r fo o d and n u r s i n g c a r e i n t h e h o s p i t a l s and b y g i v i n g
s e c u r i t y t o t h e p a t i e n t ’ s f a m i l y .
The problem o f f a m i l y r e s p o n s i b i l i t y h a s t o be
f a c e d i n e v e r y c o u n t r y . Lack o f f i n a n c i a l re p la c e m e n t t o
'^^Yoshitome U sh im aru , " P r o g r e s s i n S o c i a l S e c u r
i t y , " C o n tem po rary J a p a n . X X III ( 1 9 5 5 ) , p . 6 9 3 .
L _ J
r 62 ^
th e f a m i l y b u d g e t f o r t h e h o s p i t a l i z e d member of th e f a m i l y
p l a c e s g r e a t s t r e s s on many f a m i l i e s . O b v io u sly , i n t h e
low income g ro u p s w here t u b e r c u l o s i s h a s i t s h e a v i e s t t o l l ,
t h e n e e d i s more a c u t e .
I n 1950 t h e g overnm ent o f Jap an i n c r e a s e d fo o d r a
t i o n i n g and f i n a n c i a l m e d ic a l a i d f o r t u b e r c u l o u s p a t i e n t s .
In some i n s t a n c e s t h e f i n a n c i a l c o n d i t i o n s re a c h e d a p o i n t
w here t h e m e d ic a l a i d p r o v id e d b y t h e governm ent e x c e e d e d
t h e l i v i l i h o o d aid.*^^ By 1954, when t u b e r c u l o s i s m o r t a l
i t y r a t e had d e c l i n e d so m a rk e d ly , t h e m e d ic a l a i d c la im s
f o r c a r e o f t h e p a t i e n t s am ounted t o 53 p e r c e n t of th e
t o t a l c l a i m s .
Governm ent a s s i s t a n c e e n c o u ra g e d c a s e r e p o r t i n g
and l a c k o f h o s p i t a l sp a c e a g a i n p r e s e n t e d a p ro b le m . The
t o t a l num ber o f p e o p le r e q u i r i n g Im m ediate h o s p i t a l i z a t i o n
i n 1953 am ounted t o 1 ,3 7 0 ,0 0 0 , b u t t h e number of a v a i l a b l e
75
b e d s w ere m e re ly 1 9 0 ,0 0 0 .
I n a d d i t i o n t o t h e n e e d f o r h o s p i t a l s , t h e r e was
a l s o a n e ed f o r n u r s e s and d o c t o r s . B e fo re 1930 none of
t h e J a p a n e s e d o c t o r s had b e e n t r a i n e d i n p u b l i c h e a l t h
w ork. The R o c k e f e l l e r F o u n d a tio n became i n t e r e s t e d i n
p u b l i c h e a l t h p ro b lem s i n Ja p a n and h e l p e d t o e s t a b l i s h
t h e I n s t i t u t e of P u b l i c H e a l t h w hich was co m p lete d i n 1 938 .
74
U sh im a ru , o£. c i t . . p . 698.
7 5 « ^ l:)0 P C u lo sis i n Ja p an " (The Ja p a n A n ti- T u b e r c u
l o s i s A s s o c i a t i o n , 1 9 5 6 ), p . 3 . ( T y p e w r i t t e n , )
L J
63
The I n s t i t u t e of P u b l i c H e a l t h , h o w e v er, d id v e r y l i t t l e
t e a c h i n g o f p u b l i c h e a l t h . As w i t h so much o f t h e work i n
th e m e d in a l f i e l d i n Ja p a n and e s p e c i a l l y w i t h work regarding
s o c i a l p ro b le m s , t h i s o r g a n i z a t i o n c o n f in e d i t s a c t i v i t i e s
l a r g e l y t o r e s e a r c h . S in c e t h e r e was a g r e a t need i n Ja p a n
f o r d o c t o r s e d u c a te d i n p u b l i c h e a l t h , e a r l y i n 1946 a p r o
gram was p ro m o te d t o r e - e s t a b l i s h t h e I n s t i t u t e a s a
t e a c h i n g i n s t i t u t i o n .
The f i r s t c o u r s e s i n p u b l i c h e a l t h b e g an i n 1947.
A m odel n u r s i n g s c h o o l b e g a n i n June 1946 e n r o l l i n g h i g h
s c h o o l g r a d u a t e s f o r a t h r e e - y e a r c o u rs e i n n u r s i n g . In
1947 th e J a p a n e s e A n t i - T u b e r c u l o s i s A s s o c i a t i o n b e g a n a
c o u rs e on t u b e r c u l o s i s f o r p u b l i c h e a l t h n u r s e s .
I t i s g e n e r a l l y a g re e d t h a t t h e J a p a n e s e a r e w i l l
in g t o t a k e o r d e r s from th e h e a d s of th e g o v e rn m e n t. These
o r d e r s f i l t e r down t o t h e l o c a l r e g i o n s , t o t h e h a m le t o r
b u r a k u . The J a p a n e s e p e o p le a p p a r e n t l y a c c e p t o r d e r s and
w i l l i n g l y obey, b u t g i v i n g o r d e r s i s n o t enough. M e d ica l
c a r e i s n o t c o m p le te u n t i l t h e i n d i v i d u a l p a t i e n t h a s b e e n
t r a i n e d t o l i v e and t o work i n a m anner w hich w i l l p r o t e c t
t h e i n d i v i d u a l fro m d i s e a s e . P a t t e r s o n s u g g e s t :
T u b e r c u l o s i s d i d n o t a p p e a r t o y i e l d t o im proved
s a n i t a t i o n o r t o im m u n iz a tio n th r o u g h s e r o l o g i c a l
m e th o d s . The one e f f e c t i v e t r e a t m e n t seemed t o be
a lo n g t h e l i n e o f i n c r e a s i n g human r e s i s t a n c e b y more
h y g i e n i c l i v i n g . The t h r e e m ain l i n e s d e v e lo p e d i n
t h e a t t e m p t t o s o l v e t h i s p roblem w ere : 1) t h e s a n a
to r iu m m ethod ( t r e a t m e n t b y h y g i e n i c l i v i n g ) ; 2)
o f f i c i a l h e a l t h d e p a r tm e n t a c t i o n ( p r e v e n t i o n th ro u g h
o f f i c i a l a d m i n i s t r a t i o n ) ; 3) o r g a n i z a t i o n of m e d ic a l
64
V 6
and l a y f o r c e s ( i n d i v i d u a l and com m unity e d u c a t i o n ) .
The P a t t e r s o n s u g g e s t i o n c o i n c i d e s w i t h t h e prog ram
s t a r t e d by th e O c c u p a tio n F o r c e s i n J a p a n , e s p e c i a l l y th e
f i r s t tw o i t e m s . O r g a n i z a t i o n of t h e m e d ic a l and l a y f o r c
e s e x te n d s to t h e com m unity and i n d i v i d u a l l e v e l . T h is
p a p e r h a s m e n tio n e d some o f th e d i f f i c u l t i e s a t t h i s l e v e l .
T hese d i f f i c u l t i e s a r e n o t e n t i r e l y m e d i c a l b u t a r e s o c i a l
a l s o .
O b serv a n t s t u d e n t s have n o t i c e d t h e r e f l e c t i o n of
a d e q u a te t r e a t m e n t i n h o s p i t a l s o r s a n i t o r i a . M atsuda ob
s e r v e s " . . . i t i s b eyon d d o u b t t h a t th e p r o g n o s i s of t h e
c o n v a l e s c e n t s from t u b e r c u l o s i s a r e much a f f e c t e d by t h e i r
77
l i v i n g c o n d i t i o n s a f t e r d i s c h a r g e . " T h is f i n a l p ro b lem
of c o n t r o l and p r e v e n t i o n p r o j e c t s i n t o th e l i v i n g h a b i t s
of th e f a m i l y u n i t , t h e m o st i m p o r ta n t u n i t o f J a p a n e se
l i f e . A f t e r th o r o u g h an d a d e q u a te t r e a t m e n t t h e p a t i e n t
m u st b e p r o p e r l y r e h a b i l i t a t e d i n t h e home. T h ere i s a l s o
t h e p ro b lem of employment and e n v iro n m e n t w hich s h o u ld
p r o v i d e r e a s o n a b l e p r o t e c t i o n from t h e h a z a r d s of r e - i n
f e c t i o n * I n d i v i d u a l and community e d u c a t i o n r e q u i r e s th e
e f f o r t s o f a s t a f f h a v in g members from th e f i e l d s of
76
R obert H. P a t t e r s o n , F o u n d a tio n s o f Community
H e a l t h E d u c a tio n (Hew Y ork: M cG raw -H ill Book Company,
I n c . , 1 9 5 0 ), p . 55.
77
' Hoboru M a tsu d a , "A S tu d y of O c c a s i o n a l l y P o s i t i v e
C u l t u r e s i n A d equate T re a tm e n t of T u b e r c u l o s i s , " Ja p a n e se
J o u r n a l o f T u b e r c u l o s i s , II(D e c e m b e r, 1 9 5 4 ) , p . 533.
i_ J
65 ^
m e d ic a l an d s o c i a l s c i e n c e .
J
r
CHAPTER V
EVALUATING THE PROBLEM
" R e c o g n iz e d a s t h e g r e a t e s t s o c i a l d i s e a s e , t u b e r
c u l o s i s h a s b e e n t r e a t e d a s a n a t i o n a l p rob lem s in c e 1912,
when th e f i r s t r e g u l a t i o n f o r i t s c o m p u lso ry n o t i f i c a t i o n
78
was i s s u e d . " T h is s t a t e m e n t r e g a r d i n g t u b e r c u l o s i s i n
E n g lan d i n d i c a t e s t h a t t h e h e a l t h d e p a r tm e n t t h e r e r e c o g
n i z e d a t t h e o n s e t a v e r y i m p o r t a n t f a c t o r w hich h ad i t s
b e a r i n g on t h e c o n t r o l of th e d i s e a s e .
Ja p a n b e g a n p r e v e n t a t i v e t u b e r c u l o s i s m e a s u re s a t
t h e same tim e t h a t t h e E urop ean and W este rn c o u n t r i e s b e g a n
b u t d i d n o t k e ep p a ce i n t h i s p ro g ra m . Ja p a n c o n ti n u e d t o
l a g b e h i n d f o r a p p r o x i m a t e ly a h a l f c e n t u r y , u n t i l th e
A l l i e d Pow ers g a in e d c o n t r o l . P e rh a p s Ja p a n o v e rlo o k e d
th e im p o r ta n c e of t h e s o c i a l f a c t o r s .
I n e v a l u a t i n g t h e e x t e n t and s e v e r i t y of th e t u b e r
c u l o s i s p ro b lem i n an y com m unity, due r e c o g n i t i o n m ust b e
g i v e n t o th e l a r g e number o f f a c t o r s in v o lv e d and to th e
in n u m e ra b le i n v e s t i g a t o r s who p ro d u c e i n d i v i d u a l and d i
v e r s e t h e o r i e s on th e s u b j e c t . T here h a s b e e n l i t t l e d e
c r e e o f u n a n im i ty t h a t any one t h i n g p l a y s t h e m a jo r r o l e
*^®Keers, ©t. al• # op. cit., p. 304.
66
L _ J
67 ^
i n th e I n c i d e n c e o f t u b e r c u l o s i s m o r b i d i t y and m o r t a l i t y .
I n v e s t i g a t o r s do a g r e e ho w ev er, t h a t m e d ic a l t r e a t m e n t s and
g e n e r a l h e a l t h c o n d i t i o n s o f a p o p u l a t i o n i s g r e a t l y i n f l u
e n ce d b y s o c i a l f a c t o r s su ch a s p a t t e r n s o f l i v i n g , custom s
and h a b i t s o f i n d i v i d u a l s , f a m i l i e s , and c o m m u n itie s of th e
t o t a l p o p u l a t i o n .
T h is p a p e r h a s s u g g e s t e d some of t h e m a jo r s o c i a l
f a c t o r s w hich a p p e a r t o be r e s p o n s i b l e f o r t h e h i g h i n c i
d e n ce o f t u b e r c u l o s i s i n J a p a n . I t a d m its t h e l a c k of s p e
c i f i c i n f o r m a t i o n c o n c e r n in g J a p a n e s e c o m m u n ities and b e
l i e v e s t h a t f u r t h e r i n v e s t i g a t i o n s h o u ld be made a t th e
comm unity l e v e l i n o r d e r t o en h ance t h e pro g ram a g a i n s t t u
b e r c u l o s i s . I t a l s o t a k e s t h e p o s t i t i o n t h a t u n l e s s t h e s e
s o c i a l f a c t o r s a r e a d j u s t e d , m e d i c a t i o n , h o s p i t a l i z a t i o n ,
and o t h e r form s o f m e d ic a l t r e a t m e n t w i l l p r o v i d e o n ly
te m p o ra r y r e s u l t s .
M o r t a l i t y r a t e s h a v e shown s p e c t a c u l a r d e c l i n e s i n
Ja p a n and i n t h e U n i t e d S t a t e s d e s p i t e t h e f a c t t h a t t h e
p o p u l a t i o n i n c r e a s e d d u r i n g t h e same p e r i o d . D e c lin e i n
b o t h c o u n t r i e s h a s b e e n i n t e r r u p t e d m o s t l y b y w ar and t h e
e f f e c t s of w a r. D e s p i t e t h e d e c l i n e , t u b e r c u l o s i s i s s t i l l
a menace t o t h e human p o p u l a t i o n . R ich w r i t e s :
T u b e r c u l o s i s i s s t i l l b y f a r t h e m ost common c a u se
o f d e a t h i n t h a t v a l u a b l e age p e r i o d b e tw e e n f i f t e e n
and f o r t y - f i v e . In th e U n ite d S t a t e s , i n 1946, t u b e r
c u l o s i s was r e s p o n s i b l e f o r 16 p e r c e n t o f a l l d e a t h s
i n p e r s o n s b e tw e e n 15 and 24 y e a r s o f a g e , and f o r 15
p e r c e n t o f d e a t h s among i n d i v i d u a l s b e tw e e n 25 and
i_ J
^ 68 ^
and 40 y e a r s o f a g e . I t i s e i t h e r th e f i r s t o r th e
se co n d c a u se of d e a t h b e tw e e n t h e a g es of 15 and 45
i n more t h a n h a l f of t h e s t a t e s o f th e u n i o n .
I n o t h e r w o rd s, t u b e r c u l o s i s s t i l l p r e s e n t s many p ro b le m s
and a know ledge of th e f a c t o r s w hich a r e r e s p o n s i b l e f o r
t h e p r e s e n c e and t h e s p r e a d o f t h e d i s e a s e s t i l l h a s e x
t e n s i v e v a lu e t o p o p u l a t i o n g ro u p s i n a l l p a r t s of th e
w o rld .
Some i n v e s t i g a t o r s h a v e w anted t o c e n s u r e i n d u s
t r i a l i z a t i o n r a t h e r t h a n w ar f o r th e l a c k of d e c l i n e i n
t u b e r c u l o s i s m o r t a l i t y r a t e i n J a p a n . But t h e g ro w th o f
i n d u s t r y in o t h e r c o u n t r i e s was accom pan ied b y an i n c r e a s e
i n p r o s p e r i t y f o r t h e l a b o r e r , i n c r e a s e d w ages, im p ro ved
n u t r i t i o n , and b e t t e r s t a n d a r d s of l i v i n g . C o n co m itan t
w ith t h e s e im prov em en ts t u b e r c u l o s i s m o r t a l i t y r a t e b e g a n
t o f a l l # T h is was n o t t h e p a t t e r n i n J a p a n .
A n t i t u b e r c u l o s i s c am p aig n s i n Ja p an have h a d v a l
u a b le e f f e c t s . G re a t s e r v i c e h a s u n d o u b te d ly b e e n r e n d e r e d
b y v a r i o u s m e a s u re s su c h a s th e f o s t e r i n g of s a n a t o r i a ,
l e g a l p r o v i s i o n f o r p r o t e c t i o n i n p u b l i c p l a c e s , s p e c i a l
c a s e f i n d i n g s u r v e y s , and g o vern m ent a s s i s t a n c e an d m e d ic a l
c a r e t o p a t i e n t s and t h e i r f a m i l i e s . These m e a s u re s have
h e lp e d t o remove and c o n t r o l in n u m e ra b le s o u r c e s of i n
f e c t i o n from t h e com m unity. Y e t , w i t h a l l of t h e s e p r e
v e n t i v e m e a s u r e s , t u b e r c u l o s i s d i d n o t d e c l i n e a s r a p i d l y
^ ^ R ic b , op. c i t . , p . 914.
u J
69
i n Ja p a n a s i t d i d i n W e ste rn and E u ro p ea n c o u n t r i e s .
C ould t h e e x p l a n a t i o n depend upon r a c i a l r e s i s
t a n c e ? T h is l i n e of th o u g h t h a s b e e n u s e d on t h e b a s i s
t h a t i n t u b e r c u l a r i z e d r a c e s a g r a d u a l i n c r e a s e i n t h e g e n
e r a l l e v e l o f n a t i v e r e s i s t a n c e h a s p r o b a b l y o c c u r r e d a s a
r e s u l t of n a t u r a l s e l e c t i o n a c t i n g o v e r a p e r i o d of c e n
t u r i e s . But how can n a t u r a l s e l e c t i o n e x p l a i n th e i n t e r
n a t i o n a l p e r s i s t a n c e o f t h e h i g h e s t t u b e r c u l o s i s d e a t h '
r a t e s i n t h e lo w e s t econom ic l e v e l s an d t h e lo w e s t d e a t h
r a t e i n t h e h i g h e s t incom e g ro u p s ? N a t u r a l s e l e c t i o n d o e s
n o t a c c o u n t f o r t h e r i s e i n th e m o r t a l i t y i n th e b l o c k a d e d
c o u n t r i e s d u r i n g W orld War I and t h e c h an g e i n t h e r a t e i n
Denmark when th e f o o d b lo c k a d e s i t u a t i o n c h a n g e d . The
t u b e r c u l o s i s m o r t a l i t y r a t e s o b s e r v e d i n b o t h W orld War I
and W orld War I I h a v e d e m o n s tr a te d t h a t n a t u r a l r e s i s t a n c e
and a c q u i r e d im m unity r e a d i l y succumb t o o t h e r e n v i r o n
m e n ta l f a c t o r s .
O p p o r t u n i t i e s f o r c o n t a c t i n f e c t i o n i n th e l a r g e
c i t i e s e x c e e d th e o p p o r t u n i t i e s f o r c o n t a c t i n f e c t i o n i n
t h e v i l l a g e s o r th e r u r a l a r e a s . The d e n s i t y o f p o p u l a t i o n
i n t h e c i t i e s o r i n t h e r u r a l a r e a s g i v e some i n d i c a t i o n
o f t h e p r o x i m i t y o f p e o p le t o e a c h o t h e r . The number of
p e o p le l i v i n g i n one room i n th e r u r a l a r e a may be J u s t
t h e same a s t h e num ber of p e o p le l i v i n g i n one room i n t h e
c i t y b u t th e p r o x i m i t y o f p e o p le t o e a c h o t h e r in th e t o t a l
com m unity i s n o t t h e same an d t h e p o s s i b i l i t i e s f o r i n -
L _ J
^ 70 ^
f e e t i o n d ep en d upo n a l l known f a c t o r s .
I t i s g e n e r a l l y a g r e e d t h a t th e s o u r c e o f a t u b e r
c u l o s i s i n f e c t i o n i s o f t e n fo u n d i n th e f a m i l y . The g e n
e r a l l i v i n g c o n d i t i o n s of t h e J a p a n e s e f a m i l y a r e ev en
m ore h a z a rd o u s th a n the f a m i l y l i f e I n many o t h e r c o u n t r i e s .
Y e t, much more s tu d y m ust be g i v e n t o t h e s o c i a l p ro b le m s
i n f a m i l y l i v i n g b e f o r e t h i s can b e a d e q u a t e l y d i s c u s s e d .
More m u st be known a b o u t t h e a t t i t u d e s to w a rd members of
t h e f a m i l y who h av e t h e d i s e a s e ; t h e i d e a s a b o u t th e
s l e e p i n g h a b i t s o f t h e f a m i l y and a b o u t i s o l a t i o n of t h e
member who may b e i n f e c t i o u s ; t h e r e a c t i o n of t h e f a m i l y
t o t h e s u g g e s t i o n o f i s o l a t i o n o f d i s h e s and p e r s o n a l a r
t i c l e s of i n f e c t e d members o f t h e f a m i l y ; o t h e r s o c i a l
e le m e n t s i n t h e f a m i l y p a t t e r n a b o u t w hich n o t enough h a s
b e e n w r i t t e n f o r m e a n in g f u l q u e s t i o n s t o b e a s k e d a t t h i s
w r i t i n g . B ecause t h e f a m i l y u n i t i s th e b a s i c u n i t i n
J a p a n , m ore s tu d y s h o u ld b e g i v e n to i t i n o r d e r t h a t i t s
V
r e a l v a lu e c a n be r e v e a l e d a s a n i n f l u e n c e on th e i n c i d e n c e
of t u b e r c u l o s i s m o r b i d i t y and m o r t a l i t y . P a u l h a s p u t i t
v e r y w e l l i n t h e s e w o rd s : " B e fo re t e a c h i n g p e o p le new
h e a l t h h a b i t s , i t I s w is e t o l e a r n th e e x i s t i n g h a b i t s ,
and how t h e s e a r e l i n k e d t o one a n o t h e r , w hat f u n c t i o n t h e y
p e rf o r m , and what t h e y mean t o t h o s e who p r a c t i s e them ."® ^
80
B enjam in P a u l , " S o c i a l S c ie n c e i n P u b l i c H e a l t h , "
A m erican J o u r n a l o f P u b l i c H e a l t h , XLVI (Novem ber, 1 9 5 6 ) ,
p . 139 6.
i_ J
71 ^
The b i r t h r a t e i n Ja p an h a s b e e n a pro b lem f o r
t h o s e who s tu d y dem ography, and e con om ics a s w e ll a s f o r
t h e m e d ic a l and s o c i a l w o r k e r s . The a d v e r s e e f f e c t of
p re g n a n c y upon t u b e r c u l o s i s was d i s c u s s e d and i t i s ob
v io u s t h a t a d e c l i n e i n t h e b i r t h r a t e c a n a c t t o s p a r e
many t u b e r c u l o u s women t h e h a z a r d of c h i l d b e a r i n g . A d e
c l i n e i n t h e b i r t h r a t e a l s o means s m a l l e r f a m i l i e s , w h ich
i n t u r n m eans a l e s s e n i n g o f t h e num ber of f a m i l y c o n t a c t s
aS a s o u r c e o f i n f e c t i o n , m ore a v a i l a b l e fo o d f o r b e t t e r
n u t r i t i o n , and b e t t e r s t a n d a r d s of l i v i n g .
N u t r i t i o n i n Ja p a n h a s assum ed a s much im p o rta n c e
a s an y o t h e r f a c t o r w hich e f f e c t s t u b e r c u l o s i s . Summons
r e p o r t e d t h a t "one of th e m a jo r p u b l i c h e a l t h p ro b lem s of
t h e P a r E a s t i s , w ith o u t d o u b t , n u t r i t i o n - b o t h u n d e r -
n u t r i t i o n and m a l n u t r i t i o n . "
I t i s g e n e r a l l y a g r e e d t h a t t h e p r o t e i n i n t a k e i n
Ja p an i s v e r y low and t h a t t h e d a l l y t o t a l c a l o r i c i n t a k e
f a l l s s h o r t of minimum r e q u i r e m e n t . How can t h e fo o d v a l
u e s fo u n d i n m i l k , e g g s , and b u t t e r g a i n e n tr a n c e i n t o t h e
d i e t p a t t e r n o f Jap an ? The w hole p ro b le m of n u t r i t i o n f o r
J a p a n p l a y s an i m p o r t a n t p a r t i n th e s p e c i f i c p ro b lem o f
t u b e r c u l o s i s and m ust t a k e i t s p l a c e i n th e program o f
h e a l t h .
81
James S. Summons, P u b lic H e a l t h i n th e W orld Today
(C am b ridge, M a s s .: H a rv a rd U n i v e r s i t y P r e s s , 1 9 4 9 ),
P . 2 0 9 .
i_ J
^ 72 ^
E v id e n ce shows t h a t t u b e r c u l o s i s m o r t a l i t y r a t e r e
f l e c t s t h e l i v i n g s t a n d a r d s o f a p o p u l a t i o n w h e th e r i n
d i f f e r e n t d i s t r i c t s o f a s i n g l e c i t y a t a g iv e n p e r i o d o f
tim e o r i n a n a t i o n - w i d e p o p u l a t i o n a t d i f f e r e n t p e r i o d s of
t im e . P o v e r t y shows a m arked s t a t i s t i c a l a s s o c i a t i o n w ith
t u b e r c u l o s i s i n Ja p a n j u s t a s i n o t h e r c o u n t r i e s . P o v e r ty
l e a d s t o t u b e r c u l o s i s r a t h e r th a n t u b e r c u l o s i s l e a d i n g t o
p o v e r t y . The p r i n c i p a l m eans b y w hich p o v e r t y i s fo u n d t o
c a u se t u b e r c u l o s i s a r e o v e r-c ro w d in g an d u n d e m u t r i t i o n
w hich a r e th e c h i e f d i s t i n g u i s h i n g f e a t u r e s b e tw e e n th e
p o o r and t h o s e who a r e n o t p o o r . U n d e m u t r i t i o n i s d i f f i
c u l t t o a s s e s s a s a f a c t o r i n t h e c a u s e o f t u b e r c u l o s i s on
a c c o u n t o f t h e a b s e n c e of an a c c e p te d s t a n d a r d i n d i f f e r e n t
g e o g r a p h i c a l a r e a s and c l i m a t e s .
W hile t h e r e i s i n c o n t r o v e r t i b l e e v id e n c e t h a t fo o d
d e f i c i e n c i e s and c a l o r i c e x p e n d i t u r e s a r e g r e a t e s t i n t h e
p o o r e s t c l a s s e s , i t i s n o t b y an y means unknown f o r p e o p le
i n th e m id d le and u p p e r econom ic l e v e l s of s o c i e t y t o
s u f f e r from th e d i s e a s e * Som etim es t h e y have an a c u te
fo rm , n o t b e c a u s e t h e i r fo o d co n su m p tio n i s n e c e s s a r i l y
i n a d e q u a t e , a s ju d g e d b y n orm al c a l o r i e i n t a k e , b u t b e
c a u se of e x c e s s i v e e x p e n d i t u r e o f e n e rg y , e s p e c i a l l y i n
l a c k of s l e e p , r e s t o r o t h e r t y p e s of o v e r i n d u l g e n c e .
T hese p e o p le s t a r v e j u s t a s s u r e l y a s t h o s e who a r e , from
p o v e r t y o r o t h e r r e a s o n , d e p r i v e d of e s s e n t i a l fo o d su p
p l i e s . ^
^ 73
The e v id e n c e t h a t t h e t u b e r c u l o s i s m o r t a l i t y r a t e
r e f l e c t s s e n s i t i v e l y t h e l i v i n g s t a n d a r d s of a p o p u l a t i o n
g ro u p i s now so c o m p le te t h a t one c a n f e e l c o n f i d e n t t h a t
t h e m o st d i r e c t and e f f e c t i v e way i n w hich t h e t u b e r c u l o s i s
m o r t a l i t y r a t e can be d e c r e a s e d i s b y a program o f h e a l t h
e d u c a t i o n and an im provem ent i n t h e s t a n d a r d s of l i v i n g of
t h e p o p u l a t i o n g ro u p i n q u e s t i o n . A side from t h e a l t o g e t h
e r i m p r a c t i c a b l e p r o c e d u r e o f a c o n tin u o u s sw eeping cam
p a ig n of d e t e c t i o n and c o m p u lso ry s e g r e g a t i o n of a l l open
c a s e s , and p u b l i c s u p p o r t and c a r e o f t h e d e p e n d e n ts of
t h e i n d i v i d u a l s t h u s f o r c e d t o l e a v e t h e i r hom es, t h e r e i s
no known a n t i - t u b e r c u l o s i s m e a su re w hich can hope t o b e
v e r y e f f e c t i v e i n any com m unity a s lo n g a s t h e h e a l t h e d
u c a t i o n i s i n a d e q u a t e and t h e l i v i n g s t a n d a r d s o f t h e
p e o p le a r e lo w .
The J a p a n e s e m e d ic a l s c i e n t i s t s have a th o r o u g h
k n ow ledge o f t h e t h e o r y of t u b e r c u l o s i s . They have made
many s t u d i e s o f t h e d i s e a s e and hav e s e t down p l a n s and
p ro g ram s t o f o l lo w i n th e f i g h t a g a i n s t t h e d i s e a s e . B a t
how much i s p r a c t i s e d an d f o l lo w e d i s n o t e a s y t o d e t e r
m in e . M o reo v er, t h e s e p l a n s r e q u i r e a g r e a t d e a l of
f i n a n c i n g . The m a t t e r o f h a v in g enough f i n a n c e s t o f o l
low th r o u g h w ith recommended p ro g ra m s b e a r s c o n s i d e r a t i o n .
M a t e r i a l s s e n t f o r t h i s s tu d y from th e h e a l t h i n
s t i t u t e s i n J a p a n , th e M i n i s t r y of H e a l t h , m e d ic a l s c h o o l s
^ n d m e d i c a l o r g a n i z a t i o n s a r e num erous and w e l l - w r i t t e n . ^
r 74 ^
However, m ost of t h e m a t e r i a l s p e r t a i n e d t o t e c h n i c a l and
e x p e r i m e n t a l s t u d i e s o f th e d i s e a s e . They d i s c u s s e d i n
g r e a t d e t a i l v a r i o u s t e c h n i c a l s u b j e c t s a lo n g w i t h e x
t e n s i v e s t a t i s t i c a l i n f o r m a t i o n and many c h a r t s . T h ere i s
no d o u b t t h a t t h e y h a v e a c o n s i d e r a b l e amount o f t h e o r e t
i c a l i n f o r m a t i o n . But t h i s i s o n ly h a l f o f t h e p ro b le m .
M e d ic a l p e r s o n n e l who h a v e w orked w i t h d i s e a s e i n o t h e r
c o u n t r i e s know t h a t t h e c o m p le te program m ust i n c l u d e
s o c i a l d im e n s io n s a lo n g w i t h m e d ic a l i n f o r m a t i o n . P e r
h a p s t h e l a c k o f t h i s d im e n s io n h a s b e e n t h e r e a s o n t h a t
Ja p a h h a s l a g g e d b e h i n d o t h e r i n d u s t r i a l i z e d c o u n t r i e s i n
t h e i r t u b e r c u l o s i s cam p aig n .
One of t h e m o st r e c e n t r e p o r t s from Ja p a n r e m a r k s :
D e s p i t e t h e u s e o f PAS, s t r e p t o m y c i n , i s o n i a z i d ,
and h i g h l y p e r f e c t e d c h e s t s u r g e r y , m o r b i d i t y from
t u b e r c u l o s i s h a s n o t shown any s i g n o f d i m i n u t i o n ,
a l t h o u g h t h e d e a t h r a t e h a s d e c r e a s e d . In o t h e r
c o u n t r i e s s a n a t o r i u m s a r e b e i n g c l o s e d o r u n d e r
g o in g a change o f f u n c t i o n f o r l a c k o f t u b e r c u l o s i s
p a t i e n t s . The c a u s e s f o r t h i s s i t u a t i o n w i l l be
fo u n d i n t h e l a c k o f p u b l i c fu n d s a p p r o p r i a t e d f o r
t u b e r c u l o s i s c o n t r o l . L e s s t h a n 3 0 ^ of t h e p a t i e n t s
w i t h a c t i v e c a s e s a r e b e in g t r e a t e d i n s a n a t o r i u m s ,
and o n ly s l i g h t l y o v e r 2 0 ^ o f a l l t u b e r c u l o s i s
p a t i e n t s r e c e i v e a d e q u a te t r e a t m e n t . Mass s u r v e y s
a r e made o n ly once a y e a r and o n ly a b o u t 3 3 ^ o f th e
p o p u l a t i o n a r e i n c l u d e d i n su c h s u r v e y s . As a con
se q u e n c e t h e num ber o f a c t i v e c a s e s d o e s n o t d im in
i s h . Each y e a r an e s t i m a t e d 3 3 0 ,0 0 0 new c a s e s d e
v e l o p . T u b e r c u l o s i s h i n d e r s t h e n a t i o n ’ s econom ic
g ro w th and i s p o t e n t c a u se o f k e e p in g t h e p e o p le im
p o v e r i s h e d , t h u s s e t t i n g u p a v i c i o u s c i r c l e , ® ^
^ ^ F o re ig n L e t t e r s , " S t a t u s o f T u b e r c u l o s i s , " J o u r -
h a l of th e A m erican M e d ic a l A s s o c i a t i o n , CLXVII ( J u n e ,
1 9 6 8 ) , p . 11 46.
j
75
H e r e in l i e s th e b a s i c r e a s o n s f o r t h i s s t u d y . T h is m ost
r e c e n t r e p o r t i n d i c a t e s t h a t d e s p i t e t h e e x c e l l e n t l y
t r a i n e d m e d ic a l p e r s o n n e l and d e s p i t e th e e x t e n s i v e u s e of
r e c e n t l y d e v e lo p e d c h em o th e rap y and s u r g e r y , th e number of
new c a s e s of t u b e r c u l o s i s c o n t i n u e s a t a r a t e f a r b eyon d
t h a t o f o t h e r c o u n t r i e s . T h is p a p e r t a k e s t h e p o s i t i o n
t h a t t h e m a jo r r e a s o n f o r t h i s " v i c i o u s c i r c l e " i s th e f a c t
t h a t Ja p a n h a s n e g l e c t e d t h e s o c i a l f a c t o r s w hich so g r e a t
l y i n f l u e n c e t u b e r c u l o s i s . T h is p a p e r h a s e n d e a v o re d t o
e x p l a i n t h a t th e p e o p le have t u b e r c u l o s i s b e c a u s e t h e y a r e
im p o v e r is h e d and a r e n o t im p o v e r is h e d b e c a u s e of t u b e r c u
l o s i s . Low s t a n d a r d s o f l i v i n g , m a l n u t r i t i o n and u n d e r -
n u t r i t i o n , and u n h y g ie n ic l i v i n g h a b i t s c o n t r i b u t e d t o t h e
p r o d u c t i o n of t h e a n n u a l 3 3 0 ,0 0 0 new c a s e s .
T h e r e f o r e , i t i s n e c e s s a r y t o s t u d y th e r e l a t i o n
of th e s o c i o - c u l t u r a l f a c t o r s i n t h e c o u n tr y t o t u b e r c u
l o s i s i n o r d e r t o f i n d a means of w eaving t h e r e c e n t
s c i e n t i f i c know ledge i n t o t h e d a i l y l i v i n g o f e a c h member
o f th e s o c i e t y , e a c h u n i t o f t h e f a m i l y . These i n d i v i d u a l s
a r e t h e p r i n c i p a l s u b j e c t s of i n t e r e s t . I t i s f o r them
t h a t th e d i s c o v e r i e s w ere m ade, f o r them th e s k i l l s w ere
l e a r n e d . Adding t h e know ledge of t h e s o c i a l f a c t o r s t o t h e
s tu d y of t u b e r c u l o s i s i n Ja p a n w i l l change th e m e d ic a l p r o
gram t o a h e a l t h p ro g ram , l ; e i , a p rogram of d i s e a s e p r e
v e n t i o n , a d e q u a te r e h a b i l i t a t i o n a lo n g w i t h e f f i c i e n t and
m o d e m , s c i e n t i f i c t r e a t m e n t . ^
SUMMARY
1* Ja p a n b e g a n s t u d y of t u b e r c u l o s i s and s e t
o r d i n a n c e s f o r t h e p r e v e n t i o n of t h e d i s e a s e a t a b o u t th e
same tim e a s E n g land and U n ite d S t a t e s .
2 . The i n c i d e n c e o f t u b e r c u l o s i s i n Jap an co n
t i n u e d h i g h e r t h a n t h a t o f any o t h e r i n d u s t r i a l i z e d
n a t i o n .
3 . T h ere i s n o t s u f f i c i e n t e v id e n c e t o p ro v e t h a t
J a p a n e s e p e o p le have l i t t l e n a t i v e r e s i s t a n c e t o t u b e r
c u l o s i s ' b u t t h e r e i s e v id e n c e t o p ro v e t h a t t u b e r c u l o s i s
i n c i d e n c e i s i n f l u e n c e d b y s o c i a l e n v ir o n m e n t.
4 . M i l i t a r i s m and t h e e f f e c t s o f w ar seemed t o be
f a c t o r s w hich h e lp e d t o i n c r e a s e t h e i n c i d e n c e of t u b e r
c u l o s i s i n J a p a n . I n d u s t r i a l i s m may o r may n o t s t i m u l a t e
t h e r a t e o f t u b e r c u l o s i s d e p e n d in g upon w h e th e r o r n o t
l i v i n g s t a n d a r d s and im p ro v ed s o c i a l c o n d i t i o n s p ro c e e d
s i m u l t a n e o u s l y .
5 . T u b e r c u l o s i s i n c i d e n c e i s h i g h e r i n th e c i t i e s
t h a n i n r u r a l a r e a s i n J a p a n and i n o t h e r c o u n t r i e s .
6 . U s u a l l y t u b e r c u l o s i s i n c i d e n c e i s h i g h e r among
r 77 ^
low econom ic g ro u p s t h a n among h i g h e r econom ic g r o u p s .
T h is was n o t a s e v i d e n t i n Ja p a n a s i n W estern c o u n t r i e s
b u t p e r h a p s t h i s i s b e c a u s e of t h e l a c k o f u n d e r s t a n d i n g
a b o u t s o c io -e c o n o m ic s t a n d a r d s i n J a p a n .
7 . T u b e r c u l o s i s s t r i k e s a t an e a r l i e r age i n Ja p a n
t h a n i t d o e s i n W estern c o u n t r i e s .
8 . T u b e r c u l o s i s i s h i g h among t h e fe m a le popu
l a t i o n i n J a p a n . P e rh a p s t h i s i s t h e r e s u l t of e a r l y
m a r r i a g e s , h i g h b i r t h r a t e , and h e a v y h o u s e h o ld d u t i e s .
9 . M a l n u t r i t i o n and u n d e r n u t r i t i o n d e p r e s s t h e
n a t i v e and a c q u i r e d r e s i s t a n c e t o t u b e r c u l o s i s . D i e t a r y
h a b i t s of Ja p a n a r e v e r y I n a d e q u a t e i n t h e e f f o r t s a g a i n s t
t u b e r c u l o s i s .
1 0 . T u b e r c u l o s i s , known a s a "h o u s e h o ld i n f e c t i o n , "
r e a c h e s a l a r g e number of c h i l d r e n and a d u l t s i n t h e home
e s p e c i a l l y u n d e r t h e i n t i m a t e an d u n h y g ie n ic c ir c u m s ta n c e s
of J a p a n e s e l i v i n g .
1 1 . R e h a b i l i t a t i o n f o r t u b e r c u l o u s p a t i e n t s i s a
m a jo r c o n ce rn .. The f i n a n c i a l p r e s s u r e i s g r e a t l y f e l t and
was n o t e f f e c t i v e l y met u n t i l O c c u p a tio n a l F o r c e s came i n
c o n t r o l . H o usin g and h e a l t h e d u c a t i o n i s s t i l l a p ro b lem
t o b e s t u d i e d and m anaged.
i_ J
78
1 2 . T u b e r c u l o s i s I s a s o c i a l d i s e a s e and c o n t r o l
o f t h e d i s e a s e d e p e n d s u p o n and m ust b e p ro m o te d b y a n
u n d e r s t a n d i n g o f t h e s o c i o - c u l t u r a l f a c t o r s , t h e i r f u n c t i o n
and t h e i r m e a n in g s t o t h e i n d i v i d u a l , th e com m unity, and
t o t h e s o c i e t y a s a w h o le . F u r t h e r s tu d y o f t h e s e f a c t o r s
i n J a p a n m ust b e made i n t h e same d e t a i l e d and th o r o u g h
m an ner a s h a s b e e n done i n o t h e r s c i e n t i f i c f i e l d s .
i_ J
r ~ i
CHRONOLOGICAL REPORT OF MEASURES FOR PREVENTION AND
CONTROL OF TUBERCULOSIS IN JAPAN
1890 D e c re e from J a p a n e s e M i n i s t r y o f Home A f f a i r s
c o n c e r n i n g u s e o f K o ch ’ s t u b e r c u l i n
1904 O rd in a n c e c o n c e r n in g t u b e r c u l o s i s p r e v e n t i o n
1911 J a p a n e s e W hite C ro ss S o c i e t y fo u n d e d
1913 J a p a n e s e Red C ro ss fo u n d e d
J a p a n e s e A s s o c i a t i o n f o r P r e v e n t i o n o f T u b e rc u
l o s i s fo u n d e d
1914 E s t a b l i s h e d s a n a t o r i a i n c i t i e s of 5 0 0 ,0 0 0 p o p
u l a t i o n o r more
1919 E s t a b l i s h e d s a n a t o r i a i n c i t i e s o f 5 0 ,0 0 0 pop
u l a t i o n o r more
1925 Minimum age f o r w ork r a i s e d fro m 12 y e a r s t o 14
y e a r s o f age
1927 H e a l t h i n s u r a n c e and s a n i t a r y r e g u l a t i o n s f o r
i n d u s t r i a l d o r m i t o r i e s
1929 M id n ig h t l a b o r p r o h i b i t e d f o r women and b o y s
1938 Began 5 y e a r p l a n w i t h BCG v a c c in e
1943 BCG m ass v a c c i n a t i o n
1947 J a p a n e s e A n t i - T u b e r c u l o s i s A s s o c i a t i o n b e g a n t u
b e r c u l o s i s n u r s i n g c o u r s e f o r p u b l i c h e a l t h n u r s e s
1954 J a p a n e s e A n t i - T u b e r c u l o s i s A s s o c i a t i o n b e g a n c o u r s e
f o r s u rg e o n s o f t u b e r c u l o s i s p a t i e n t s
r 1
BIBLIOGRAPHY
A n d e rso n , R. J . , e;t a l . " T u b e r c u l o s i s C o n t r o l : A T o t a l
P ro b le m ," P u b l i c H e a l t h R e p o rt, LX ( F e b r u a r y , 1 9 5 1 ),
1 3 2 -1 3 8 .
A sano, K. " F i g h t i n g T u b e r c u l o s i s i n J a p a n ," J o u r n a l of
I n d i a n M e d ic a l A s s o c i a t i o n . XX ( S e p te m b e r, 1 9 5 1 ),
453— 454.
B a l f o u r , M a r s h a l l , e t a l . P u b l i c H e a l t h and Demography i n
th e F a r E a s t . Hew Y o rk : The R o c k e f e l l e r F o u n d a tio n ,
1950.
B e n e d i c t , R u th . The Chrysanthem um and t h e Sw ord. B o s to n :
M i f f l i n Company, 1946.
B o r to n , Hugh. J a p a n ’s Modern C e n tu r y . New Y o rk : The
R onald P r e s s Company, 1955.
Brown, R. Gow. " I n f l u e n c e o f S o c i a l F a c t o r s on th e I n
c id e n c e of E x tra p u lm o n a ry T u b e r c u l o s i s I n f e c t i o n , "
J o u r n a l of H y g ie n e , XL (May, 1 9 4 7 ), 2 37.
C r o f t s , A l f r e d , and B u chanan, P e r c y . A H i s t o r y o f th e F a r
E a s t . New Y ork: Longmans, G reen and Company, 195 8.
D a v ie s , R obert J . " T u b e r c u l o s i s , " Pulm onary D i s e a s e s ,
E d it e d b y Roscoe L. P u l l e n . P h i l a d e l p h i a : Lea &
F e b i g e r , 1955.
D orm er, B. A. " T u b e r c u l o s i s i n S o u th A f r i c a , " B r i t i s h
J o u r n a l of T u b e r c u l o s i s , L ( J a n u a r y , 1 9 5 6 ), 5 2 -6 0 .
D r o l e t , G o d ia s J . Los A n g e le s C oun ty-w id e C hest X-;
S u rv ey of 1 95 0. Los A n g e le s : T u b e r c u l o s i s C o n t r o l
F o u n d a t io n , 1953.
"E p id e m io lo g y o f T u b e r c u l o s i s , "
C l i n i c a l T u b e r c u l o s i s . E d it e d b y B enjam in G o ld b e rg .
P h i l a d e l p h i a : ï". A. D a v is Company, 1946.
DuBos, R. J . " B i o l o g i c a l and S o c i a l A s p e c ts o f T u b e r
c u l o s i s , " B u l l e t i n o f t h e New York Academy of
M e d ic in e , jCXVYl 1 J u n e , 1955/), 3 5 1 -3 6 9 .
80 J
^ 81
E b in a , T. © 1^ "V ber d i e R e ih e n u n te r s u c h u n g d e r g a n z e n
B ev B lk eru n g e i n e r k l e i n e n S t a d t i n I f o r d ja p a n ," Das
F o r s c h u n g s - I n s t i t u t f ü f T u b e r k u lo s e und L e p r o s i e . V
( F e b r u a r y , 1 9 5 3 ) , 4 7 -6 3 .
Economic S t a b i l i z a t i o n B o a rd . Economic S u rv e y of J a p a n .
Tokyo: S t a b i l i z a t i o n B oard o f t h e J a p a n e s e G overn
m e n t, 1 9 5 0 -5 1 .
Erabree, John F , The Ja p a n e s e N a tio n - A S o c i a l S u r v e y .
New Y ork: F a r r a r and R i n e h a r t , I n c . , 19 45.
Suye M ura: A J a p a n e s e V i l l a g e . C h ic a g o :
C h icag o U n i v e r s i t y P r e s s , 1939.
E w a rt, R. J . "E conom ics and T u b e r c u l o s i s , " P r o c e e d i n g s _of
t h e Royal S o c i e t y o f M e d i c i n e . XVI ( J a n u a r y , 1 9 2 3 ),
1 1 -1 8 .
F a b e r , K. " T u b e r c u l o s i s and N u t r i t i o n , " A c ta T u b e r c u lo s e s
S c a n d i n a v i a , X I I (1 9 3 8 ) , 2 8 7 -3 3 4 .
F o r e i g n L e t t e r s . " S t a t u s o f T u b e r c u l o s i s , " J o u r n a l o f t h e
A m erican M e d ic a l A s s o c i a t i o n , CLXVII ( J u n e , 1 9 5 8 ),
1146Ï
G i t o , T e ru o k a . "An E ssa y on t h e P o p u l a t i o n Problem of
Ja p a n i n L ig h t of S o c i a l B i o l o g y ," J a p a n e s e J o u r n a l
of M e d ic a l S c i e n c e , I (M arch, 1 9 3 0 ) , 3 .
G lo g a u e r , 0. " T u b e r k u l o s e s t e r b l i c h k e i t und G e b u r te n -
r û c k g a n g , " Z e l t s c h r i f t f d r T u b e r k u lo s e , LX ( J a n u a r y ,
1 9 3 1 ), 7 -1 4 :
H ousing B u re a u . P u b l i c - O p e r a t e d A p a rtm e n t House o f P o s t -
War J a p a n . Tokyo: M i n i s t r y of C o n s t r u c t i o n o f th e
J a p a n e s e G ov ern m en t, 1 95 1 .
H u ls e , F r e d e r i c k S. " C o n v e n tio n and R e a l i t y i n Ja p a n e s e
C u l t u r e , " S o u th w e s te r n J o u r n a l of A n th r o p o lo g y . IV
( W in te r , 1 9 4 8 ), 3 4 5 -3 5 5 .
Im am ura, A. The E p id e m io lo g y and P r e v e n t i o n o f T u b e rc u
l o s i s i n J a p a n . R e p o rte d i n th e G e n e r a l M e etin g o f
th e 1 1 t h J a p a n e s e M e d ic a l A s s o c i a t i o n . Tokyo, 19 4 2 .
J u d e f i n d , T. P . " L e c tu r e N o tes f o r B a c t e r i o l o g y and
Im m unology." Los A n g e le s : C o lle g e o f M e d ica l Evan
g e l i s t s , 1957. (M im eog rap hed.)
L J
r " 1
82
Kamada, T. War Damage and R e h a b l t l t a t l o n of J a p a n . Tokyo:
M i n i s t r y of C o n s t r u c t i o n o f t h e J a p a n e s e G o v e rn m e n t,
1951.
K e e r s , R. Y . , R ig d en , B. G . , and Young, P . H. P u lm o n ary
T u b e r c u l o s i s . E d in b u r g h : E. & S. L i v i n g s t o n e
L i m i t e d , 1953.
L a t o u r e t t e , K enneth S c o t t . A S h o r t H i s t o r y o f t h e F a r
E a s t , New Y o rk : The M a c m illa n Company, 1 9 5 1 .
Long, Esmond R. " T u b e r c u l o s i s i n M odem S o c i e t y , " B u l l e -
t i n o f t h e H i s t o r y of M e d ic in e , XXVII ( J u l y , 1 9 5 3 ),
S o n ,
L o w e ll, A nthony M. T u b e r c u l o s i s i n New York C i t y . New
York* New York K b e r c u l o s i s and H e a l t h , 1 9 5 6 .
M a tsu d a , N oboru. "A S tu d y of O c c a s i o n a l l y P o s i t i v e C u l
t u r e s i n A deq uate T r e a tm e n t o f T u b e r c u l o s i s , "
J a p a n e s e J o u r n a l of T u b e r c u l o s i s , I I (D ecem ber,
1 9 5 4 ), 3 2 3 -3 3 3 .
M eD ougall, John B. _ T u b e r c u l o s i s : A G lo b a l S tu d y i n S o c i a l
P a t h o l o g y . E d in b u rg h : Ë. & S. L i v i n g s t o n e L i m i t e d ,
19 4 9 .
M c L e s te r, Jam es. "The Normal D i e t , " D i e t o t h e r a p y : C l i n
i c a l A p p l i c a t i o n of Modern N u t r i t i o n . E d i t e d b y
M ic h a e l G. Wohl. P h i l a d e l p h i a : W. B. S a u n d e rs
Company, 1945.
M i n i s t r y o f L a b o u r. A n a l y s i s of L ab o u r Economy i n 1 9 4 9 .
Tokyo: L abour S t a t i s t i c s and R e se a rc h D i v i s i o n ,
1 9 5 0 .
M isono, K e is u k e . " I n c i d e n c e o f T u b e r c u l o s i s i n J a p a n ,"
1 ’Union I n t e r n a t i o n a l e c o n t r e l a T u b e r c u l o s i s
B u l l e t i n , XX^i ( J u n e , 1 9 5 6 ) , 6 4 5 -6 8 0 ;
M yers, J . A r t h u r . " H i s t o r y o f T u b e r c u l o s i s , " The F u n d a
m e n t a l s of P u lm o n ary T u b e r c u l o s i s . E d it e d b y
Edward H ay es. S p r i n g f i e l d , 1 1 1 . : C h a r le s C.
Thomas, 1949.
Nakamura, T a k a s h i . " T u b e r c u l o s i s and N u t r i t i o n , " S c ie n c e
R e p o r ts of t h e R e s e a r c h I n s t i t u t e f o r T u b e r c u l o s i s
and L e p r o s y , I I ( 1 9 5 0 ) » 3 8 - 4 7 .
Ogawa, G o t a r o . E x p e n d i t u r e s o f t h e R u s s o -J a p a n e s e W ar.
New Y ork: O xford U n i v e r s i t y P r e s s , 1923.
^ 83 ^
Oka, S . , K a s i a , S . , and Kanno, I . " S tu d y on th e T u b e rc u
l o s i s S u rv e y of Farm V i l l a g e s i n N o r t h e a s t e r n D i s
t r i c t o f J a p a n ," J a p a n e s e J o u r n a l o f T u b e r c u l o s i s ,
I (Novem ber, 1 9 5 3 ) , 6 0 - 7 1 .
P a r s o n s , T a l c o t t . "Some T ren d s of Change i n Am erican S o c i
e t y , " J o u r n a l o f t h e A m erican M e d ic a l A s s o c i a t i o n ,
CLXVII ( May , 1958 ), 3 1 - 3 6 .
P a t t e r s o n , R o b e rt G. F o u n d a t io n s o f Community H e a l t h Edu
c a t i o n . New York ; M cG raw -H ill Book (Company, IncTT*
19 50.
P a u l , B e n ja m in D. ( e d . ). H e a l t h , C u l t u r e , and Community.
New Y o rk : R u s s e l l Sage F o u n d a t io n , 1955.
" S o c i a l S c ie n c e i n P u b l i c H e a l t h , "
A m erican J o u r n a l o f P u b l i c H e a l t h , XLVI (November,
1 9 5 6 ), 1 3 9 0 -1 3 9 6 .
F o t t e n g e r , F r a n c i s M. T u b e r c u l o s i s . S t . L o u is : The
C. V. Mosby Company, 194 8 .
P u b l i c H e a l t h S e r v i c e . R e p o rte d T u b e r c u l o s i s D a ta ; 1 9 5 6 .
Second E d i t i o n . W ashington : U n ite d S t a t e s D e p a r t -
m ent o f H e a l t h , E d u c a tio n and W e l f a r e , 1956.
R ic h , A r n o ld . The P a t h o g e n e s i s of T u b e r c u l o s i s . S p r i n g
f i e l d , 1 1 1 . , C h a r le s C. Thomas, 1951.
Sams, C raw fo rd P . "M e d ic a l Care A s p e c ts o f P u b l i c H e a l t h
and W e lfa re i n J a p a n , " J o u r n a l of t h e A m erican M edi
c a l A s s o c i a t i o n , CXLI ( O ctobe r , 1 9 4 9 ) , 5 2 7 -5 3 1 .
S a tow , T. " P r e v e n t i o n o f T u b e r c u l o s i s i n J a p a n ," 1 ’U nion
I n t e r n a t i o n a l e c e n t r e l a T u b e r c u l o s i s B u l l e t i n , I I I
( J u l y , 1 9 2 6 ), 3 3 - 4 8 .
S a u n d e r s , L y le . C u l t u r e D i f f e r e n c e s and M e d ic a l C a r e . New
Y ork: R u s s e l l Sage F o u n d a tio n , I 9 54 .
S c h e e l e , L e o n a rd A. " O p p o r t u n i t i e s i n T e a c h in g of P r e v e n t
a t i v e M e d i c i n e ," J o u r n a l o f t h e A s s o c i a t i o n o f Amer-
i c a n M e d ic a l C o l l e g e s . YÔCV~(JuïyV~l9~507 . 2 4 1 -2 4 7 .
S m i l i e , W ilson G. P r e v e n t i v e M e d ic in e and P u b l i c H e a l t h .
New Y o rk : M a cm illa n Company, 1952.
S t e i g e r , G. Nye. A H i s t o r y of t h e F a r E a s t . New Y o rk :
G inn and Company, 1936.
L J
^ 84 ^
Summons, Jam es. P u b l i c H e a l t h I n t h e W orld T o d ay . Cam
b r i d g e , M ass. ; H a rv a rd U n i v e r s i t y P r e s s , 19 49.
Supreme Commander of t h e A l l i e d Pow ers G e n e r a l H e a d q u a r
t e r s . P u b l i c H e a l t h and W e lfa re in J a p a n . A nnual
SummaryT T okyol Supreme Commander o f th e A l l i e d
Pow ers G e n e r a l H e a d q u a r t e r s , 1948.
______ . P u b l i c H e a l t h and
W e lf a r e i n J a p a n . Annual Summary. Tokyo: S uprem e"
Commander of t h e A l l i e d Pow ers G e n e r a l H e a d q u a r t e r s ,
19 4 9 .
T ak a n o , R okuro. "The P r e v a l e n c e o f T u b e r c u l o s i s and t h e
A n t i - T u b e r c u l o s i s Campaign i n J a p a n ," J a p a n M e d ic a l
W o rld . V II ( J a n u a r y , 1 9 2 7 ) , 1 6 -1 9 .
Takayama, Y asu o. S t a t i s t i c a l S t u d i e s on T u b e r c u l o s i s
M o r t a l i t y i n "Japan, D e p a rtm e n t o f P u b l i c H e a l t h .
O saka, J a p a n : Osaka U n i v e r s i t y M e d ic a l S c h o o l, 1 9 5 3 .
The J a p a n A n t i - T u b e r c u l o s i s A s s o c i a t i o n . R e p o rt on t h e
T u b e r c u l o s i s P r e v a l e n c e S u rv e y i n J a p a n . C om piled
b y M i n i s t r y of H e a l t h and W e lfa re G overnm ent of
J a p a n . Tokyo : The Ja p an A n t i - T u b e r c u l o s i s A s s o c ia
t i o n , 1 9 5 5 .
________________ . " T u b e r c u l o s i s in
J a p a n .^ TokyoT The J a p a n A n t i - T u b e r c u l o s i s A s s o c i
a t i o n , 195 6 . ( T y p e w r i t t e n . )
U sh im aru , Y o sh ito m e . " P r o g r e s s i n S o c i a l S e c u r i t y , "
C o n tem p o rary J a p a n , X X III ( 1 9 5 5 ) , 6 9 3 -6 9 9 .
Webb, H e r s c h e l . An I n t r o d u c t i o n t o J a p a n . New Y o rk :
C olum bia Unî ve r s i t y P r e s s , 19 57.
Y am aguchi, M. " S u rv e y of T u b e r c u l o s i s P r e v a l e n c e i n
J a p a n , " B u l l e t i n o f W orld H e a l t h O r g a n i z a t i o n , X I I I
( 1 9 5 5 ) , 1 0 4 1 -1 0 7 3 .
Y o s h io k a , H. " T u b e r c u l o s i s S t a t i s t i c s i n J a p a n , " Yokohama
M e d ic a l B u l l e t i n . IV ( F e b r u a r y , 1 9 5 3 ), 1 1 - 2 2 .
I- J
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Creator Jones, Fleda A. (author)

Core Title Social problems and tuberculosis in Japan

Contributor Digitized by ProQuest (provenance)

Degree Master of Arts

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Health and Environmental Sciences,OAI-PMH Harvest,Social Sciences

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