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Sunday, Jan. 8, 2006
Doctor of reforms
By TOMOKO OTAKE
Even at the age of 94, Shigeaki Hinohara's mind and memory are so clear as to put some of his medical students to shame. And even despite being Japan's best-known and most highly acclaimed physician -- and chairman of the board of trustees of prestigious St. Luke's International Hospital in Tokyo -- Hinohara shows no sign at all of tiring in his pursuit of reform of the country's hidebound medical laws and systems. On the contrary, Hinohara confides, with a twinkle in his eye, that he is becoming "more and more radical" in his drive to raise standards -- declaring boldly that "laws must be broken or they will never change."
However, this charismatic physician, who still treats patients, was not drawn to medicine initially. Born into the family of a Methodist minister in Yamaguchi City in western Japan, may well have followed in his father's footsteps until being deeply moved by the kindness and professionalism of the local doctor who long tended his ailing mother.
Then, while studying medicine at Kyoto University, he himself contracted tuberculosis, which at that time was often a fatal disease. Due to his illness, he was not only exempted from military service, but he says that his experience of being bedridden for months has made it easier for him to understand his patients' feelings.
During this recent interview with The Japan Times, the father of three sons and grandfather of six, who has now been married for 64 years, expounded on his undiminished passion for medical reform and his view of Japan's war-renouncing Constitution. He also confided what it was he whispered to the education minister at an Imperial Palace ceremony in November when he received the Order of Culture, one of the nation's top honors and one that is only bestowed on five of Japan's most distinguished cultural and academic achievers each year.
The interview was conducted at Teusler House, a wooden guesthouse/administration building named after Rudolf B. Teusler, the American doctor and missionary who founded St. Luke's in 1902 in the waterfront Tsukiji district where St. Luke's Garden, comprising two modern high-rise office/hotel buildings, now towers over the hospital and the adjacent nursing college.
Tell us a little about your childhood years, and how they influenced the course your life has taken.
My father was from the city of Hagi in Yamaguchi Prefecture, and when he was 14 he was influenced by a missionary and converted to Christianity. Because of that he was disowned by his parents. However, he went to Kobe and managed to graduate from a mission school there called Kwansei Gakuin. Then he served in the Yamaguchi Regiment of the Imperial Japanese Army for two years.
In 1900, when he was around 24, he went to North Carolina and spent four years studying at what is now Duke University, through 1905. Afterward, he worked for a Methodist church in Osaka, got married, and went to the States again -- this time to study at a famous seminary in New York City called Union Theological Seminary. That was when I was born in Yamaguchi City, where my mother's family lived. Upon his return from America, my father served in a church in Oita Prefecture for two years, then moved to Kobe to serve at a church there for 15 years.
Did you ever think of following your father into the church?
Yes, my first idea was to follow in his footsteps, though I liked literature too. But my mother was very sick, and our family physician, Dr. Yasunaga, took care of her so well that I was moved by his enthusiasm and decided to become a doctor.
So, after that I went to Kyoto and entered the University of Kyoto Medical Department, but when I became a sophomore, I was afflicted with tuberculosis. There was no effective treatment for TB back then, so I just retreated to Hiroshima, where my father was the principal of a girls-only Christian school called Hiroshima Jogakuin. I stayed there for a year, during which time I was bedridden for eight months and could not even walk to a toilet.
At that time, I thought I would not be able to continue my medical study and thought about pursuing music, which I also liked. But my parents encouraged me to keep studying. So I went back to school and graduated in 1937, a year behind my class. After two years' residency training at Kyoto University, I studied at graduate level for 2 1/2 years before I was posted to St. Luke's International Hospital in July 1941. In December that year, Japan entered World War II. Because of my illness I was not drafted into the military, and spent all the wartime years taking care -- as much as I could -- of people injured in air raids. During the war, I also taught internal medicine and nursing at St. Luke's nursing school, and when a music teacher left, I taught music too, since I had started playing the piano when I was 10, after I was barred from exercise for a year due to nephritis.
What happened to the hospital after the war?
A month after the war ended, Gen. Douglas MacArthur [Supreme Commander Allied Powers] announced the requisition of St. Luke's for 10 years. The hospital building was used to treat soldiers wounded in the Korean War, and I was given a small orthopedics hospital along the Sumida River to use, and I practiced there for 10 years. But during that time, I also felt like studying more, so in 1951, when the San Francisco Peace Treaty was signed, I boarded a ship to San Francisco and studied medical education and internal medicine at Emory University in Atlanta for a year.
In 1943, I had married Shizuko, whom I had known from the same church. It was around the same time when my father retired, moved to the Den-en Chofu district of Tokyo and set up a new church. I was also teaching the choir at my father's church. I was so busy back then -- I wanted to try new things earlier than anybody. I was curious. I wanted to learn how to drive but could not afford the time to get the license, so I had my wife take the driving test instead and drive me back and forth between our home and the hospital.
After the war, I was really busy at work. I had three children, but couldn't take care of them. I hardly saw my children growing up.
After I had St. Luke's back [from the Occupation authorities], I worked very hard to make the hospital the best educational institution for medicine and nursing. As Japan's economy made a great comeback, by the time of the 1964 Tokyo Olympics I was working as an assistant to the director of the hospital.
You were a passenger on the JAL airliner that was hijacked by Japanese Sekigunha (Red Army) members in 1970. How was that?
I had boarded the flight bound for Fukuoka from Tokyo to attend an academic conference. I was 58 years old at the time. They wanted to go to Pyongyang, but ended up landing at Kimpo airport near Seoul in South Korea, where we spent three nights before being released. No one was sure if we would survive. The hijackers had dynamite strapped to them, and we were terrorized, wondering whether the negotiations might break down. The nights were the most scary, because we really couldn't tell what would happen; during the day we dozed off. Every passenger was handcuffed. We were also not given any food for two days.
Then, the terrorists said that they were willing to lend us some of their books to read, such as the Red Army newsletters and the biography of [North Korea founder] Kim Il Sung. Among their other suggested reading was "The Brothers Karamazov" by Fyodor Dostoevsky. Nobody else raised their hands, so I did. The novel was inspired by a passage in the Bible [John 12:24] that says, "Truly, truly, I say to you, unless a grain of wheat falls into the earth and dies, it remains alone; but if it dies, it bears much fruit."
In the end, lawmaker Shinjiro Yamamura came to Kimpo, offered to give himself as a substitute hostage, and flew together with the Red Army members to Pyongyang. We were released on the fourth day. When I came home, some 1,000 patients and friends of mine had worried about me and sent us flowers. My wife and I then determined that, at some point in the future, I would have to repay that kindness to someone somewhere. I was nearly 60 then, and felt that my life had ended once, and that I was given a new life -- a life that I was determined to devote to selfless love for the social good. Before that, I had been working to become a good, famous doctor, to become a famous educator.
Nonetheless, you are still passionate about reforming medical education in Japan, are you not?
In around 1970, during the student movement days, the so-called Yasuda incident took place at the University of Tokyo, when medical students used force to protest the one-year, unpaid residency required of them. But abroad, it was normal for medical students to go through two or three years of residency. The protest prompted a health ministry panel to abandon that residency system. I was the only one who argued against the ministry's move. I said . . . that Japan was moving in a wrong direction, and I proposed a paid, voluntary two-year residency training just like law-school graduates go through. The panel agreed, because it was not mandatory, but only private university students in the Kansai region signed up. I kept campaigning very hard, stating that -- if we didn't make the training mandatory -- we would produce a bunch of almost bogus doctors. That's because students have zero clinical experience, and it's reckless to have them write prescriptions and give shots right off the bat.
Last year, that was finally legislated for -- 35 years after I started advocating it. But I realized back then how hard it is to change a law.
You are also very active in the advancement of nurses, I believe.
After I learned about the U.S. system, I tried to make nursing education at St. Luke's the best in Japan. We created a four-year college of nursing in 1964. Around 1971, the hospital director became ill, so I became the acting president of the nursing college and assisted the director at the same time. When I turned 65, however -- as I had made it a rule for our staff to retire at 65 -- I officially retired from the hospital. After that, I served only as an adviser to the hospital, while continuing as head of the nursing college and pursuing my goals of creating master's and doctoral programs for nursing at St. Luke's as early as possible. Five years later, a master's program was created, and eight years after that, I created a doctoral program for the first time in Japan.
What are the key things that your leadership at St. Luke's achieved?
Twelve years ago, when the hospital was rebuilt, we decided to make it a 520-room facility comprising single rooms only. I was a key member of the reconstruction committee, and spearheaded a campaign to provide great services, while securing the privacy of patients through the single-room facility, which was unprecedented in Japan. We also built a 49-story office building housing a preventive check-up center, a nursing home and a hotel. The total construction cost was 120 billion yen.
That was when I was around 80 years old, and people wanted me to serve as director of the hospital. . . . [but] I agreed to take the post only on a volunteer basis, and I served for four years. After that, I asked Dr. Kenji Sakurai to become my successor, and since then I have been serving as chair of the board of trustees.
Now, from April last year, under the leadership of Dr. Tsuguya Fukui, St. Luke's has been embarking on another revolution.
What kind of revolution this time?
Medical education in Japan is so behind. Clinical training after schooling is behind too. Apart from the medical departments at the University of Tokyo and the University of Kyoto, all of the 80 or so medical departments in the nation have roll calls [before lectures], because they are worried that students would fail in the national qualification exam.
In America, people go to medical schools after graduating from four-year universities, so medical school is kind of a graduate-level education. Medical students are mature, because they have already finished bachelor-level study before they get into medical schools, and they are filled with a sense of mission to become doctors.
Also, everyone in America who goes to a medical school pays for their education, either through loans or scholarships. It's not like Japan, where parents pay for their children's medical schooling and even buy them cars. High-school students here don't have opportunities to enjoy themselves; they are pressured to study only and improve their hensachi [standardized test scores]. And if they excel academically, they are recommended to go to medical departments regardless of their interest. So they have no maturity as human beings. Once they get into college, they feel their future is guaranteed, so they stop studying.
I'm sincerely hoping that some university will adopt a graduate-level, four-year medical school system, instead of the current bachelor-level six-year program. But private universities generally say that a shortened program would mean less revenue.
To change the situation, I want to create my own medical college at St. Luke's, but there are lots of hurdles to overcome, including financial ones.
Do you realistically think this is likely to happen?
My dream is to buy a medical school. When I was given the Order of Culture in November, there was a ceremony with the Emperor and Empress present. I was seated next to the education minister, so I asked him to deregulate the medical education system. I pitched the idea of experimentally creating a graduate-level, four-year school and then comparing, 10 years down the road, whether it produced better doctors than the existing six-year programs.
What are your views on the training of nurses in Japan?
St. Luke's has created a doctoral program for nurses, but the law that defines their role hasn't changed. The law on nurses says their job is to "assist" doctors in performing their duties. They are regarded as being lower than doctors.
At St. Luke's, nurses graduate from college, practice for five years, go through a two-year master's program, and then get awarded a doctorate after three more years of study. They deepen their knowledge over the course of 15 years.
But then, when they are assigned to hospitals, they are regarded as being beneath doctors who are still in their residency, who have no clinical experience -- and whose practices are so dangerous that the nurses must make sure the prescriptions they write are correct.
Many nurses in Japan also give up their careers halfway through, because the working conditions are harsh and they can't balance careers with family life. They'd rather go to cleaner, better-paying jobs in areas such as computer science. There is no other country like Japan, where nurses are overworked and burned out.
In America, for 40 years, trained nurses have been able to treat patients and give diagnoses. They can even declare how many months are left for the patients.
Specialists are not required for 70 percent of illnesses -- including rashes, colds, high blood pressure and early-stage diabetes. These common diseases can be treated by nurses in America and Canada, but not in Japan. That's simply because in Japan the law has never changed -- and it's been 60 years since the law was made!
So, in practice, what can you do about this?
What I've been doing lately is teaching nurses how to treat patients -- and I urge them to practice their skills. If they are charged with violating the law, I will launch a popular movement -- because nurses have the capabilities! So I'm telling nurses, "Do what you can, then the law will change."
A case in point concerns paramedics. When no doctor is present, they save the lives of cardiac-arrest patients by inserting tubes into their mouths. In reality, fewer than 10 out of 100 doctors can insert tubes, because they just don't have the chance to learn such skills. Paramedics can do that safely, but they were attacked by those who question their legal right to do so.
Then, following a private-sector campaign, the law was eventually revised to make it legal. Laws must be broken or they will never change! So I want to break many laws from now on, because I'm 94 and I don't have much time left. I'm getting more and more radical these days.
Tell us about your response to the 1995 sarin attack on Tokyo subways by Aum Shinrikyo, which took place when you were director of the hospital.
Swedish hospitals have underground operating rooms in case of air raids. So when I rebuilt St. Luke's, I went to study the hospitals there. I studied the possibilities of earthquakes hitting Japan, and I installed oxygen tubes inside the walls of hospital hallways, lounges and the chapel. That's why a year later, when the sarin attack happened, we were able to accommodate 640 emergency patients within two hours, even though 80 percent of our 520 beds were taken. When it happened, nobody knew what substance was causing the patients to suffer, but two hours later our special team detected sarin. We lost one patient, but we managed to save all the rest of them. It was all possible because we were prepared for such an emergency.
What do you think about Japan's role in the world, now that it is 60 years since the end of World War II?
Japan should declare that it will abandon all its weapons, even the ones to protect ourselves, and it should limit the SDF's duty to disaster relief. We should declare that we won't fight back even if we get attacked. Then we will never perish.
Peace can never be achieved without sacrifice and forgiveness. Japan declared, when it created the current Constitution, that it would take the lead in advocating peace. But what has Japan done to advocate peace? Nothing!
When that Constitution was drawn up, there was an atmosphere of peace in the entire world. Japan then cooperated with America and created the SDF in a half-baked attempt at pacifism. If we are really going to take the lead, we should declare ourselves a weapons-free country. In return, we should ask other countries not to export their weapons. If there were no weapons, we would all just be throwing stones when we fight. Countries export weapons because it makes money. It was the Korean War that helped Japan's economic recovery after the war. We were making weapons in Japan.
The pacifist movement in postwar Japan failed to achieve peace. People kept saying "don't" for 60 years, yet nuclear weapons kept proliferating. What I'm trying to do these days is to tell 10-year-old kids to love the plants, the trees, the animals and other people. It is one of my dreams to teach children about the importance of life.