Susan Orpett Long is a professor of anthropology and served as founding director of the East Asian Studies program at John Carroll University. Her research interests include comparative medical systems, family change, care of the elderly, and the cross-cultural study of bioethical issues. She is the author of Final Days: Japanese Culture and Choice at the End of Life (University of Hawaii Press, 2005) and Family Change and the Life Course (Cornell University East Asia Papers, 1987). She edited Lives in Motion: Composing Circles of Self and Community in Japan (Cornell University East Asia Papers, 1999) and Caring for the Elderly in Japan and the US: Practices and Policies (Routledge, 2000), and co-edited Death in the Early 21st Century (Palgrave 2017). She has authored numerous articles and book chapters.
More than a quarter of Japan’s population is age 65 and older, making elder care a pressing issue. What is the traditional image of elder care in Japan and how has the increase in the elderly population impacted this understanding?
Japanese families have changed a lot over time. What we think of as a Japanese family was only the official family system from the Meiji period, starting in 1868 lasting into the twentieth century. A lot of people who are elderly in Japan today saw this family system take hold. What they saw growing up was a traditional family and this has had an impact on their expectations. However, now that the family system has changed and the economic basis has changed, it leads to discrepancies between what the older generation expects and what the younger generation can deliver.
The older system was based on inheritance. Specifically, one child, usually the eldest son, and the spouse would inherit the family’s property. Before the 1920s, the Japanese economy was largely based on family farms or family shops and it did not make sense to break up family farms and divide them equally among kids, especially considering the small size of Japanese farms. The responsibility for caring for elderly parents was located there in part because the eldest son and his spouse were the ones who continued to live in the family home and take over the business. The assumption was that since they are living in the same house and benefitting economically from the household, they should contribute to the household through work and caregiving. With the gendered division of labor, it was the women who were doing a lot of the care-giving for kids and elderly.
The basis of the change in the family system came with the post-war occupation of Japan. The Allied Occupation, led by the U.S., came in and wanted to democratize Japan. America’s occupation leaders saw the Japanese family system as undemocratic and, as a result, they established a new family law code. In this new code, they established equal inheritance for all children and they got rid of the concept that the household continues through the generations. A nuclear family model was established by law. Not only was there legal change, but also tremendous economic change. Most people no longer owned their livelihoods; they could only work for wages. That was a huge difference because there was no family business to inherit. The inheritance system, and the sense of obligation that came with it, were undermined by the new economic system. Whatever there is to inherit is supposed to be split among the siblings, so in theory, all the siblings should be held responsible for elderly parents. But there is still this sense that the oldest son, or one child and the spouse, should take care of the older people. There are still these kinds of assumptions, but they are increasingly being questioned.
How have the gendered aspects of elder care changed with the increase in women in the workforce?
In the traditional multi-generational family, women were always engaged in some kind of productive labor. They were not officially part of the labor force necessarily, but they were farming or they were helping run a family business. This idea of the traditional housewife-mother image that some people have was not a part of the older traditional family from the early 20th century. That started changing in the 1920s. Women worked for the family, whatever the family business was. Women would help with that and they also bore most, but not necessarily all, of the responsibility for nurturing and care-giving. It did not matter whether care was needed for kids, for old people or whether the husband or younger siblings of the husband were still living at home. That was part of expectation. Officially, according to Confucianism, the son, particularly the elder son, has a responsibility to care for the parents. But the reality is that there was a couple in each generation that was a member of the household, plus miscellaneous single people. Because of the gender division of labor, the day-to-day work usually fell to the wife of the eldest son. Now that women have their own jobs, and families are more reliant on two incomes, it has become difficult for women to both work and provide the physical care-giving. In the countryside, where life is a little bit harder, women have been saying, “I don’t want to marry an eldest son. It will pile more responsibility on me.” Some people negotiate with their potential spouse about how the care-giving is going to be handled. The assumption from the older model of the live-in daughter-in-law being available may not be viable, but people still strongly believe that a primary caregiver should be identified. What you see now is that more males are involved in care-giving, both sons and especially husbands. The idea that people should rely on their spouse is really strong. Spouses have become the assumed care-giver rather than the daughter-in-law. Of course, when the person is a widow or widower, it is more difficult to determine who will care for them.
In 2000, the Japanese government created the Long Term Care Insurance System (LTCI) to support families caring for elderly relatives. What are some of the virtues and shortcomings of the system?
The LTCI has multiple kinds of services, but you can divide them into preventative care, residential services, and home-based, community-based services. It is not free and it does not cover everything, but it covers just about everything you can think of in a limited way. As the population ages and more and more people need these services, there is the question of sustainability. The government has limited resources and fewer people are paying into the system because birth rates are lower and the labor force is shrinking. How do you keep paying for it? The answer is you cut back on benefits, which now people are used to.
How has the implementation of the LTCI impacted attitudes toward government-assisted elder care?
When the LTCI was being created, one of the questions that came up was whether the payment for home helpers could go to family members who were providing care. A number of Japanese feminists argued against this idea because they believed that the money would go into the household budget while the women still needed support. They are not going to get that support if they are being paid instead. A number of Japanese feminists fought that and were successful, so family caregivers do not get paid for providing home helper-type assistance. The other thing that they thought about was whether people would use the LTCI. There was a stereotype that Japanese people do not like strangers coming into their homes. In the interviews that I conducted, there was hesitation initially in some families, but most families were so desperate for relief that they welcomed the services. It does not mean they liked all the caregivers equally, but their experience early on with this system was that the home helpers were reliable, caring, and good people, and families were happy to have them around to help. Either that concern was exaggerated or people adjusted quickly because the need was so great. The idea that it is a government program is also helpful. Rather than it feeling like charity, the system was purposefully designed such that individuals had to make contributions to the system. This care is thus something that they have earned by paying their taxes and premiums. When they need it, help comes to them.
What is the government doing to address the labor shortage in elder care?
There is a huge problem with labor force in elder care. The bigger picture solutions seem to be either technology or immigration. Immigration is not terribly welcomed, although there are some small-scale programs. The Japanese government has agreements with Indonesia and the Philippines. They are bringing over people who are licensed nurses or care-givers in those countries and there is supposed to be a training program in Japan. It is still pretty small-scale, so Japanese residents do not feel like they are being invaded. Foreign caregivers are divided up, with no more than a couple people per community. So far, the reaction has not been awful, but if you ask a person on the street what they think about any kind of large-scale importing of workers, many people are fervently against it. On the one hand, the government itself is promoting the program, and on the other, it is becoming increasingly nationalistic. Relying on foreign workers does not seem like an ideal solution. The other possible solution is robotics. The Japanese government is really pushing this one. They are putting a lot of funding into robotics research.
In recent years, there has been an increase in news stories on the topic of kodokushi or “lonely death” among the elderly, where a person passes away alone and remains undiscovered for a long period of time. Is this type of death occurring more often?
Kodokushi is increasing in the sense that more elderly people are living alone. That gets to the root cause. While the numbers have been increasing over the last few years just as the Western press discovered the phenomenon, the Japanese have been talking about kodokushi for at least a decade. The New York Times articles from a month back said about several thousand people a year die a lonely death. I am not aware whether that number has changed substantially in the last ten years. There are over a million deaths in Japan every year, so if you have a couple thousand deaths by kodokushi, it is still less than one percent. So then why is there all this attention paid to it? From my perceptive, there is more attention because dying alone is such a culturally horrible thing in Japan. The ideal death is a death where family is there. Not just one or two family representatives, but everybody. The expectation is that dying should not be something you have to do by yourself. You should have support, even to the point where some doctors will not declare somebody has died until family members have arrived. They might continue to do CPR well past hopelessness so that the person will not be dying alone.
A bad death in Japan is one where you have been a burden due to long-term illness. There is a sense that you try not to be a burden or bother other people with your problems and people feel that way with their kids too. From the elderly person’s point of view, it is better to die by a heart attack so there is no long-term bothering of people. This idea of good death and a bad death has very little impact on what actually happens, but it helps to explain to some degree why people make the choices they do. The lonely death is so awful because of the isolation and because the discovered corpse epitomizes dirt and impurity both literally and symbolically.
What are some of the root causes of this phenomenon?
In a lot of these cases, there is intersectionality with poverty and physical problems. The reason for social isolation might be that the person cannot hear or see very well, or maybe their teeth are gone, so having a conversation is difficult. Once you are dealing with these physical infirmities, to say nothing of the cognitive impairments of some elderly people, the explanation for the isolation becomes clearer. I find Western coverage of this issue frustrating because the media say “if only we can engage the seniors in the community more, check in on them more.” This seems kind of naive because the problems are really complex. Developing programs to engage seniors in the community is not a worthless endeavor, but I do not think it will completely solve the problem. We also need to keep in mind that these stories are sensationalized, both in Japan and the US. These deaths are awful, but they are still a small percentage, so keeping things in perspective is important.
By m-louis .® (桜太極拳) [CC BY-SA 2.0], via Wikimedia Commons