A living tradition [full issue]

The magazine of the World Health Organization April 1970 UK:2/3d USA:0.50 WORLD HEALTH A living tradition. contents The secret of the ten rice bowls, by John Taylor 4 The white death, by Prince Tadatsugu Shimazu 12 The Japanese disease, by Frank Shore 15 World Health Day posters 21 Stress and the pachinko syndrome, by James Magee 22 Around the world 30 2 tomorrow is today "To cure the patient of smallpox, take some roasted beans and bury them in the sacred ground of the temple . . ." So runs the advice to physicians in an ancient Japanese medical text. Whatever its efficacy, the treatment has not been required in recent years, because there has not been a single recorded case of the disease in Japan since 1956. In fact, for the last five years, Japan, alone among Asian countries, has been free of all the quarantinable diseases, including plague, epidemic typhus and relapsing fever. Two cholera cases occurred in 1964, but are thought to have been imported. Malaria cases have dropped to a handful. Tuberculosis, which was causing the death of one person every four minutes at one period after the war, has been reduced to a level that compares with any of the most advanced countries. This is remarkable progress in the face of many difficulties, and is fully recorded in public health statistics. But figures are only part of the story. The health of a nation is interwoven with social and economic patterns, climate, geography, with the massive shifts in population generated by 20th century technology, with work and leisure, with both the physical and mental stresses engendered by the man-machine symbiosis on which civilization depends. This is what the present issue of World Health is about. It is not a picture of Utopia—disease sometimes has a way of exchanging one mask for another. A change in diet may help the Japanese to fight gastric cancer, but it brings the risk of heart disease. Tuberculosis is in decline, but traffic accidents are increasing steadily. To put all this in perspective, it must be drawn to scale. In spite of the fact that the birth rate fell by half from 1950 to 1966, the population of Japan is now over 100 million, and they live in a land area which is in effect much smaller than some single American states. The cities are growing swiftly— Tokyo has almost doubled in size over the past two decades. At the turn of the century almost two-thirds of Japan's popu- lation lived on the land. By 1965 the situation had been reversed, and two thirds now live in urban areas. It is within this context that the achievements of the postwar period are to be measured. There is also a wider signifi- cance. Japan's cities and crowds and shoulder-to-shoulder way of life are for many other countries but a glimpse of their own future. To read about Japan is to read tomorrow's newspaper—today. ■ 3

the secret of the ten rice bowls by John Taylor Sumo wrestling, an ancient Ja- panese sport. After five hours of intensive training, the wrest- lers enjoy a traditional Chanko Nabe meal (right). The veteran Sumo wrestler moved his bare feet on the clay floor, settling his more than 200 lb bulk firmly in position. From their positions on the rim of the circle, marked by a straw-plaited rope, two young novitiates hurled themselves towards him with a shout that merged into the thud of bodily contact with solid flesh and bone. Then they were flying through the air, landing catlike, unhurt, and rolling back onto their feet, seeking vainly for openings in their master's defences, hopeful pupils in an art that counts no less than 48 sepa- rate techniques of defeating an opponent. It was nearly 11 a.m., and the group of men in training at the famous Kasugano- Beya club in Tokyo were coming to the end of a session of gruelling physical exercise that had begun before dawn with only a cup of milk to break their fast. Watching with appraising eyes were men whose wide, muscled shoulders and bull necks were scarcely concealed by well-cut sports clothes; even though in retirement, the ex-champions of the Sumo cult visit the club training sessions regularly. But other men were watching too, with the observant eyes of trained scientists. One of them was Dr Toshio Oiso, director of Japan's National Institute of Nutrition— another was Dr Minoru Hara, a member of an expert committee studying food in relation to Antarctic research. Although Dr Hara and Dr Oiso appre- ciate the subtleties of wrestling, their inter- est was focused on the meal that was served in another room of the club a few minutes later. Known as chanko-nabe, it is the basic diet that helps to build the strength and weight of the Sumo wrestler to a point where he may tip the scales at anything up to 300 lb. Served in steaming dishes, it is a meal with an appetizing aroma dished out in gargantuan portions to the ravenous athletes—yet in essence it con- sists only of rice, fish and vegetables. "To some extent, the size and strength of the Sumo wrestler are due to selection," 1 I. "Breakfast is good for you" says this health education poster. A balanced diet is recommended and the calorie values of breakfast foods are listed. Two thousand five hundred tons of fish are handled every day in Tokyo's main fish market. Chief inspector Dr T. Katoh (white cap) looks at some fresh tuna. A cabbage farmer in his plot enjoys fresh air and a view of Fujiyama. Part of the year he works in a factory. Modern hygiene prevails in Japanese food factories. Dr Oiso told me. "Just as in baseball, scouts seek out young men of exceptional physique even in high school and try to interest them in the sport. Training is also very important in body-building. But the chanko-nabe is associated with Sumo as the traditional way of building up the great weight which is fundamental to this type of wrestling, in which the aim is to push your opponent, or some part of his ana- tomy, outside the circle." He opened the sliding door leading to the dining room, and pointed to the shelves on which dishes of food were standing ready. "There is no beef in the traditional chanko-nabe," Dr Oiso pointed out. "In- stead, the men eat great quantities of rice. Ten bowls of rice at a sitting is considered about the right amount. They also eat fish. Tuna is popular, and roasted salmon. There are lots of vegetables, some pickled the way we Japanese like them, with big helpings of cabbage, and also horse radish and red beans." As we talked, the wrestlers came from their hot baths, obviously ready to eat. But the Sumo discipline is rigid. Seniors come first, whether reigning or ex-cham- pions, or even in retirement. The young wrestlers are obliged to serve the older men, and must wait until the most tasty morsels have been eaten before they can sit down. Our daily rice Rice, fish and discipline . . . It seemed to me that I was making contact, if fleet- ingly, with the ethos of Japan, that highly- organized nation of more than 100 million people who from meagre resources have created the world's third economic power. Today the Japanese industrial machine produces by itself almost as much as the rest of Asia put together, including China and India. That kind of achievement can be analyzed by the economist in terms of growth rate and capital investment. But the full answer must also take into account the high national level of health and energy that is required to fuel economic progress. For Dr Oiso and other experts, not only chanko-nabe but what the ordinary Japa- nese puts on his plate is of considerable significance in this regard. At a deeper, more emotional level, the ten rice bowls of the chanko-nabe are also a token of security, the reassuring proof that Japan's new affluence is the harvest of her own traditional resources. At a time when the search for low-cost protein is a major preoccupation of the developing regions of the world, it is important to remember that Japan main- tains her population successfully on a diet 6 still based, in spite of post-war changes, on boiled rice. The Japanese way of eating is evidence of this—rice is a main dish and is accompanied by side plates of soup, vegetables, fish, poultry and meat. The side-dishes may vary according to income, the season of the year, and the demands of flavour, taste and presentation, but rice almost always holds the centre of the stage. Rice is so intertwined with Japanese modes of thinking that the cost of one barrel is regarded as the base for calcula- ting the cost of living. In the average meal, rice provides 57% of total calories, 32% of the protein, 9.9% of the fat, and 69.5% of the carbohydrates. With present-day agricultural subsidies, it offers a meal at a price that tempts the most slender budget. One Japanese magazine recently calculated that, per 100 calories, rice is still six times cheaper than pork, the meat most popular in Japan. For animal protein, Japan relies heavily on fish, which is logical for an island race. The search for food from the sea has sent Japanese fleets to the corners of the earth; with a total annual catch of nearly eight million tons, Japanese fishermen are second only to Peru in the world ratings, and expect to move into first place this year. Slithering mountains of tuna fish, bonito, saury, squid, prawns, lobsters in the Tokyo central wholesale fish market offer a pre- dawn sight for the tourist and bear witness to the skill of the offshore and deep-sea fleets. Japan is orientated toward fish; it provides not only the day-to-day meal but also the gourmet's repast for honoured guests or for family celebrations. One great delicacy is shiokara, which consists simply of pickled bonito guts. Another is sushi, which are slices of raw fish placed on top of small balls of vinegared rice. As in so many other areas of Japanese life, the considerations are not all purely economic. Quality of life counts in Japan. Rice and fish lend themselves to the artistic arrangements so dear to the heart of the Japanese chef; a sprig of celery can symbolize a garden. To a steelworker in Europe, say, such visual nourishment might appear to be of secondary impor- tance, compared with a plate of ham and sausages and a glass of beer. Japan is one of the world's most techno- logically advanced nations, with a leading position in a range of industries that in- clude not only textiles and electronics, but also shipbuilding and motor manufactur- ing. In a recent study, an American busi- ness magazine singled out the productivity of the Japanese worker for special mention, pointing out that this, and not the myth of cheap labour, was the key factor in the national economic advance, now growing at 10% annually. There is no lack of Sumo- This mobile kitchen brings home the prin- ciples of better cooking habits and a more balanced diet, and is part of the Japanese health education drive. A practical demonstration is watched by a group of housewives. Tasting the finished product. type muscle to back up such growth. Production of crude steel was only five million tons in 1950; by 1967 output had risen to 62 million tons, making Japan the third largest producer. At the same time, the health picture in Japan is favourable. Health is a story of steadily improving conditions. As recently as 1940, there were more than 7,000 deaths from beriberi heart disease, which results from vitamin B, deficiency. By 1964, deaths from this cause had fallen to just over 100, a measure of the success of the health authorities in persuading the nation to eat rice enriched with thiamine. (Polished rice, the type favoured by the Japanese, is deficient in vitamins.) By 1967, the expec- tation of life at birth was 69 years for men, and 74 for women, compared with 47 for men and 50 for women in the years just before the war. There are other factors at work in this equation including vigorous public health services, medical care and better sanitation, but diet is obviously an important element. It is a dynamic element which, as in every other country in the world, is under- going a process of adaptation and change, mirroring the rapid modernization of many aspects of life in Japan, offering a subject of study that has interest for the develop- ing and the advanced countries. At a time when nutrition is regarded as the key to the poverty-low-production cycle in many parts of Asia, Africa and Latin America, what Japan has achieved on a staple diet of rice and fish is, to say the least of it, instructive. But Japan is not only a land of paddy fields, it is a country of super-highways, trains that run at 200 kilometres an hour, glittering department stores, glass-walled office blocks, multi-level shopping and transport complexes, colour television, computers, hooting traffic jams and push- ing, shoving commuter crowds in subways and on railway platforms. It is a land of temples and contemplative monks, but it is also a land of dark-suited technocrats and managers, Japan's new Samurai class, ruled by the demands of achievement and status, frenetically active in their high-rise, earthquake-proof executive suites over- looking the pulsating streets and futuristic concrete sculptures of the urban centres. Office to armchair They work hard and they buy hard— jamming the tiny rooms of their apartments with refrigerators, washing machines, hi-fi equipment, baby grand pianos. A lot of their leisure is swallowed up in entertain- ing business clients in smart downtown supper clubs and restaurants, to the tinkle of the guitars of geisha hostesses. Tele- vision (available on eight channels) gobbles up much of what is left. "I spend my time between the office desk and my armchair," one department head admitted. In Europe and North America, this way of life is loaded with danger signals— tension, competition, alcohol, over-eating, lack of physical exercise. Sooner or later, such an environment seems to become associated with heart disease, one of the major health threats to 20th century man. Yet mortality from heart disease in Japan is among the lowest in the world, and is now running at about one-fifth of the figures for countries like the United States and Britain. It does not appear to be a question of genetics, of some kind of built-in resistance in the Japanese arteries: "Japanese who emigrate to the United States show a higher incidence of arteriosclerotic heart disease than those at home," Dr Oiso told me. "The altered diet and environment seem to have the effect of bringing into line with the rest of the people living in the United States." The answer in fact seems to lie at the end of the chopsticks, so well adapted to Japan's largely vegetarian diet. Cholesterol content, for instance, is very low, and although it has doubled in the past twenty- five years is still only at about 255 mg per head daily. The fat content in the blood is apparently an important factor in the problem of atherosclerosis. Animal fats, which figure largely in European and North American diets, raise the fat content of the blood—vegetable fats, those favou- red by the Japanese, tend to lower it. Unfortunately, the food eaten by the Japanese brings other health problems. "The leading causes of death in Japan include cerebral apoplexy, which covers cerebral thrombosis and haemorrhage, and cancer of the stomach," points out Dr Ta- kemune Soda, Director of Japan's Institute of Public Health. "Cerebral apoplexy has a correlation with the very high intake of 9

The school furniture here is too small. In fact, the average Japanese is four inches taller today than twenty years ago. In the Tokyo area, 65,000 meals are provided daily for children in 1000 pri- mary schools. A meal costs 40 yen ($0.12) and parents pay between 800 to 1000 yen ($2.40 to $3) a month. School lunches are the responsibility of the Ministry of Education and are su- pervised by the Tokyo health authorities. salt in the Japanese diet. We also suspect a link between diet and gastric cancer. We are encouraging people to take more milk and meat, and it is possible that this `westernization' of the diet may reduce the incidence of hypertension, and perhaps also of stomach cancer. But perhaps we will then find that we have more heart disease." Those are questions for which only the future can provide an answer. Meanwhile, Japan's public health authorities are watch- ing closely all the changes that modern life is bringing about in eating habits. In an industrialized society, time is always at a premium, even for cooking, and this has brought about a sharp increase in pur- chases of "instant" foods and snacks. "Some of these instant foods can be prepared literally in seconds," comments Dr Oiso. "But the food often consists largely of flour, and is of little nutritive value." Guidance on nutrition is available at the health centres in each of the 46 pre- fectures, and to reach the more stay-at- home wives the health centres operate a fleet of mobile kitchen cars. The school lunch now reaches more than 80% of children in primary schools, and also helps to maintain the programme of nutrition planned by the Ministry of Health and Welfare. How effective the kitchen car can be I saw for myself in a Tokyo suburb. I went with the car and its team of nutritionists from Shibuya health centre to a middle- class district about two miles away. We manoeuvred through the narrow streets, and then the driver swung the big vehicle skilfully into an open space behind a small factory. Quickly the woman leader of the team opened up the front canopy, switched on a microphone, and within minutes a group of housewives, some in kimonos, others in western dress, were gathered round watching a demonstration of how to prepare an economical, well-balanced and appetizing meal for New Year's Day, which was only a few days away. With the help of the director of the health centre, Dr Hiroshi Shimizu, I talked to the women standing in the crowd, and gained an inkling of the difficulties invol- ved in making changes in Japan's eating habits. "Do you like milk ?" I asked a young mother. "I don't like the smell of it," she said flatly, and added that her six-months- old baby boy did not like bottle milk either. In contrast, I talked to a 66-year-old grand- mother, who told me proudly that she had acquired a taste for milk, took meat every day, and had no interest in instant foods. The pattern changed again when I spoke to a young mother of 35. She lived with her parents, who would eat only one kind of meat, chicken. "But we also get lots of fresh fish," she volunteered, "because we have relatives who live near the sea and who bring us some quite regularly." The movement is almost contrapuntal. While the achievements of the Japanese on rice and fish and their general level of health have interest for other nations, the Japanese themselves are adapting foreign types of food to their national diet to meet their own problems. Dr Oiso showed me figures indicating that the quantities and proportion of protein, fat and sugar in the diet are increasing, while the amount of carbohydrate is falling. "More people now own refrigerators, so they are buying meat, butter, milk and eggs," he observed. As a result, Japanese children are be- coming a race of young Gullivers, with height, weight and chest measurements well above the traditional norms. Between 1949 and 1966, for example, the average height of a 15-year-old schoolboy rose from 4' 11 " to 5' 4 ", a gain of 5 " (151.3 cm to 163 cm, a gain of about 12 cm). Body weight increased by about 18 lb (about 9 kg). Girls showed proportionately similar increases, and there have been steady gains in all age-groups up to the age of 20. In 1966, it was found that American Japanese students at the University of California, who had spent their entire lives in the United States, were the same average height, 5' 61/2 " (169.4 cm), as students at Keio University in Japan. For these young people, standard Japanese washbasins are too low, bath-tubs too short, seats and tables at the wrong height. Already school chairs and desks are being made to new dimensions—the dimensions of the new Japan. ■ 11 by Prince Tadatsugu Shimazu The success of the campaigns against the acute communicable diseases is one of the most striking features of public health in Japan, the only Asian nation that is free of cholera, smallpox, plague, epidemic typhus, relapsing fever and yellow fever. In at least one area, the fight against tuberculosis, known in Japan as "the white death", progress has been dramatic. Here, in a World Health interview, the situation is reviewed by Prince Tadatsugu Shimazu, President of the Japanese Anti- Tuberculosis Association (DATA), a voluntary body which works closely with the Ministry of Health and Welfare. World Health: How was JATA founded? Prince Shimazu: The Association was set up 30 years ago, and celebrated its 30th anni- versary in April 1969. Its creation was made possible by a donation from Her Imperial Highness Princess Chichibu. Her husband, the younger brother of the Emperor, had died of tuberculosis, which at that time was widespread at all levels of society. W.H.: Has the Imperial Family continued the association with JATA? Prince Shimazu: Our work has always received strong support from this direction, and in fact the Empress also gave a donation at our foundation. Since then, both the Emperor and the Empress, and the Princess have made annual contributions. Much of our work consists of persuasion, and, aided by the patronage of the Princess, we have gained powerful support from the women of Japan in this task. W.H.: How successful have you been in combating tuberculosis? Prince Shimazu: A few statistics will make the position clear. In the years after the war, tuberculosis, which had been with us for a long time, became rampant. There was a shortage of food, particularly milk, and living conditions were very congested. At that time it was estimated that at some periods one person was dying every four minutes from tuberculosis. But by 1967, the death rate had come down to well under 20 per 100,000 of the population W.H.: What were the main elements in this success? Prince Shimazu: Apart from advances in medical treatment, the fall in tuberculosis cases is mainly due to laboratory diagnosis, BCG vaccination and mass X-ray. I feel I should pay tribute here to one man who greatly influenced us in the early days, Colonel William Sams of the Department of Health and Welfare of the United States Forces in Japan. He worked very hard to promote BCG vaccination at that time. W.H.: Can you tell me something about the organization of the campaign? Prince Shimazu: JATA itself consists of a central and 46 prefectural associations, and the central body directly operates six institu- tions, namely, a research institute, two sanatoria and three dispensaries. Throughout Japan are more than 800 health centres operated under the direction of the Ministry of Health and Welfare, and the mass case- finding programme is carried out by the health centres, JATA and other medical institutions, on a cooperative basis. The operation is on a big scale, and in 1967, for example, more than 42 million people were surveyed. Of these more than 37 million were examined by radiophotography. Among tuberculin non-reactors, about 4,500,000 persons were immunized with BCG vaccine. W.H.: What was JATA'S contribution in this huge effort? Prince Shimazu: Of the more than 37 million people examined by radiophotography, just over 12 million were surveyed by JATA, or about one-third. In most cases, we carry portable X-ray apparatus to the spot, but our fleet of X-ray cars is steadily growing. We now own 189. W.H.: How have you financed your operations? Prince Shimazu: Fund-raising is a problem, but we are always seeking new ways. The 12 Home visit by health worker (right) making sure that baby has been vaccinated with BCG against tuberculosis. I> profits from special bicycle races helped to buy 160 of the X-ray cars, and we bought another 29 with the money from sales of envelope seals. We have two kinds, a large sheet of fifty seals and a small sheet of four. The big sheet is sold by mail, and the small one is meant for distribution through the schools and the women's societies, usually in combination with envelopes. Schoolchildren have helped us greatly, and we make a special effort to teach them the importance of the work. W.H.: You have mentioned the help you have received from the women of Japan. It would be interesting to know more about this. Prince Shimazu: We have strongly encour- aged the formation of women's anti-tuber- culosis societies in the communities. This is because, apart from the routine mass checks of employees in large firms, school-children, and so on, the level of response to chest X-ray by the general public, especially the elderly, is still not satisfactory. The women can influence their neighbours and thus help to improve the response. They also assist by checking community lists, and by organizing things on the day of the examination, looking after children and old people, and carrying out similar duties. Princess Chichibu joins in the programmes every year. W.H.: Is this part of what you called "the task of persuasion"? Prince Shimazu: Very much so. A great deal of our work consists of public relations. We not only produce informational material for medical staff, nurses, health officers and the JATA prefectural associations, but also seek to attract the interests of the public by lectures, film shows, exhibitions, pamphlets, articles in newspapers and magazines, and radio and television programmes. We stress three main aspects—health examinations, adequate medical treatment, and rehabilita- tion services. Young people get a lot of our attention, and we consider it very important that the pupils of junior high schools should be well informed on this subject. We produce about 44,000 copies of a teacher's manual each year which is distributed through prefec- tural school boards to the teachers in charge of health at some 14,000 national, public and private schools. W.H.: I see that you make use of television and radio. Is this not very expensive? Prince Shimazu: The major communications media have always been most cooperative, and we do not pay for the publicity we receive in this way. We have meetings with social commentators, public health officers, tuber- culosis experts, our own public relations staff, and the journalists and radio and television programme producers, to produce data and topics. Press and radio are also willing to cooperate with us in contests in connection with Tuberculosis Prevention Week. This is held each year in cooperation with the Japan Medical Association and the Ministry of Health and Welfare. W.H.: Are you aiming at the whole popu- lation, or at certain segments? Prince Shimazu: Because of the success that has been recorded in reducing tuber- culosis among the younger age-groups, there is now an urgent need to concentrate on those segments of the population where prevalence is still high. There are three main groups, first, the elderly, second, the employ- ees of small firms, and third, contacts of tuberculous patients, especially small children. Health education is a "must" if we are to advance in this programme. I myself am examined every year, and I draw attention to the fact. W.H.: "Know your enemy" is an old pre- cept. What does JATA do in the field of research and training? Prince Shimazu: The scientific and socio- economic basis for the tuberculosis campaign is provided by our research institute. It has six sections, epidemiology, bacteriology, bio- chemistry, pathology, clinical research and radioactive isotopes, and they work in cooperation with the sanatoria and dis- pensaries belonging to JATA. We also have a research committee, dealing through sub- committees with medical treatment, surgical treatment, non-tuberculous chest diseases, epidemiology, X-ray diagnosis and radiation hazard protection, and lung function and rehabilitation. There is a joint research committee on chemotherapy, and the JATA central office also provides accommodation and staff for the Tuberculosis Research Committee, which is supported by the Ministry and includes more than 170 experts from universities, research institutes, sanatoria and JATA, apart from a number of special study groups. We provide a lot of training, both short and long-term, in Japan, and help other countries in South and South-East Asia under the Colombo Plan. W.H.: What do you consider the next most urgent problem in the fight against tubercu- losis in Japan? Prince Shimazu: A challenge facing us now is the regional difference in incidence of the disease. This is very marked, for example, at New Year, when many seasonal workers in the cities return to their homes. Though from a scientific point of view we know little about the influence of climatic factors, we have noted that those who live in the north, where the winters are cold and snowy, seem less subject to reactivation of the disease than workers returning home to the warm, wet, southern regions. We also find differences in incidence between prefectures, and this is strongly linked with the response rate to our educational campaigns. These differences in incidence become stronger every year. To show you what can be done, I would mention that in Akita Prefecture, which has a well-organized movement, the death rate from tuberculosis dropped from 25.1 to 11.4, a reduction of over 50 %, within five years. We have still a long way to go, but such results give us encouragement. ■ Mothers and children at Nihonbashi, one of Tokyo's 66 health centres. Dr Yamashita (right) explains the importance of BCG vaccination. ffi 41';', " • the Japanese disease by Frank Shore Japan's National Cancer Centre in Tokyo. Inner space, the grottoes and caves and recesses of the body, is as dark as outer space. Then comes a luminescence behind the flesh of the distended stomach, and then another and another, and it is like the game a child plays when he puts a lighted electric torch in his mouth and puffs up his cheeks. But this is not a game. Instead it is a way of finding a suspected cancer while there is still time to operate, and the flashes of light come from an ingenious little camera lowered into the patient's stomach at the end of a flexible, vinyl-covered tube. This is the gastro- camera, a Japanese invention born of the necessity to find new weapons against gastric cancer, the leading national cause of death between the ages of 35 and 54. The investigation began when the pa- tient, a 45-year-old factory worker, was picked out by mass X-ray screening, the major front-line method used against the disease by the Ministry of Health and Welfare in association with volun- tary organizations. Holding a leaflet that had been distributed in advance, the man presented himself for examination when the mobile X-ray unit of the Japan Cancer Society arrived on its six-monthly visit to his neighbourhood. He was later called in to hospital for a closer examination. He was again X-rayed in the thoracic and cardiac regions as a precaution against possible difficulties in inserting the camera, and then the thin tube with its tiny "explo- rer" was passed skilfully into his stomach. This took only a minute or two, and when the camera was in position the operator fed air until the stomach was just suffi- ciently distended to allow the instrument to turn freely. The colour pictures taken by the camera are as dramatic in their way as the images transmitted from the moon by the Ame- rican cosmonauts during the Apollo land- ings. They provide material for diagnosis at a new level of accuracy, and a glimpse of the sheer complexity of the obstacles facing medical science in the search for effective cancer treatments. In the stomach area, the disease has an uncanny gift for camouflage, particularly because of the resemblance between benign and malign- ant ulcers of certain types. In the case of the factory worker, the camouflage oper- ated at a deeper level—his ulcer healed following treatment. But the gastrocamera maintained its vigil over the small shallow depression that remained, like a patient detective on the trail of an exceptionally clever criminal. The follow-up continued for some months until the doctors studying the pictures ordered a fiberscopic biopsy, the removal of a tiny piece of tissue by an equally microscopic pair of surgical for- ceps attached to a control wire passed through a tube. Analysis of the tissue revealed malignancy, which was confirmed under the blazing lights of the operating table in time to save a human life. "Of all our techniques against stomach cancer, early detection is the most effect- ive," says Dr Takeshi Hirayama, head of the Epidemiology Division of the National Cancer Centre in Tokyo. "We estimate that surgery is successful in 80% to 90% of cases if we get there in time, that is, when the invasion is still confined to the mucous and submucous layers." Recent statistics show that his estimate is, if any- thing, on the modest side. Dr Takeo Haya- shida, head of the surgery department at the University of Tokyo Branch Hospital, found that of 2,364 cases of early cancer 15 The gastrocamera. Introduced into the patient's stomach, it takes colour pho- tographs of the stomach walls. This Japanese invention greatly facilitates diagnosis and treatment of stomach cancer. encountered from 1962-68 in 22 leading institutions, a total of 366 were operated on more than five years ago. The survival rate in this group after five years was as high as 92.5%. Japan is now spending heavily on early detection programmes. In 1952 there were only 12 gastrocameras in use—today there are more than 10,000 in over 4,000 hospi- tals and clinics that have mobilized to seek out malignancies in the first stages of deve- lopment. "An X-ray car costs as much as a Cadillac," says Dr Harayama, "but screening techniques are tremendously effective. We use direct X-ray for the ini- tial information, and then the gastro- camera to check what we find. It is a pro- cedure that we recommend strongly to other countries, although at the moment it is not widely used elsewhere. Screening of this type is used in the USSR for oeso- phageal cancer, but not, I think, for gastric cancer. There is also a need for it in the Philippines, where X-ray is not readily available in the rural health units." Probing for clues While this work of finding gastric can- cer cases continues, other researchers are probing the nature of the disease to dis- cover why it attaches itself with such fide- lity to the islands of Japan. Cancer ranks second in the list of major causes of death in Japan, and the stomach is the most common site in both men and women. In 1960, a morbidity survey conducted by the Ministry of Health and Welfare in four prefectures showed that per 100,000 popu- lation there were 86.6 male cases and 47.7 female cases. Of more than 15,000 adults examined by mass stomach X-ray by the Japan Cancer Society between 1961 and 1965, as many as 65 (or 430 per 100,000) were found to be suffering from gastric cancer. Of autopsied cancer cases between 1958 and 1963, one-quarter of the males and one-sixth of the females were affected by a malignancy in this part of the body. The frequency of stomach cancer in Japan is among the highest in the world on a com- parison of age-specific death rates, and carries off its victims as much as two deca- des earlier than among whites in Australia and the United States. There are a number of suspected causat- ive factors, including diet, the environ- ment, climate. Scientists look at rice fields and volcanoes with suspicion, noting that the frequency of gastric cancer may be correlated with low, waterlogged and allu- vial land, and that Iceland, Chile and Japan, three of the countries with the highest frequency of the disease, are also areas with volcanic activity. No one is yet in a position to make a definite statement, but there seem to be links between soil acidity, frequently caused by flooding, and stomach cancer prevalence. A stomach cancer prevalence map would show that the main concentration of the disease is in the island of Honshu. One of the districts with notably high death rates faces the Japan Sea in northern Honshu. The disease is very prevalent between the 400 and 36° parallels, centering on Yama- gata Prefecture, the prefecture with the highest death rate. The area is one of the most important in Japan for rice produc- tion, although there are a few other crops. Winters are severe, with much snow and with very little sunshine, and the soil is humid. In an area like this, where snow lies throughout the winter, there is usually a single crop of rice in the autumn, and nothing else is grown in the paddy-fields. The farmer and his family tend to rely too heavily on rice as their staple food, and diet gets out of balance, with a shortage of green vegetables, and deficiencies in protein and vitamins. But rice cannot be incriminated, according to two leading pathologists, Dr Mitsuo Segi and Dr Mi- noru Kurihara, of the Tohoku University School of Medicine in Sendai. They cite as a counter-argument the fact that rice consumption is high in neighbouring Tai- . wan (Formosa) and in Ryukyu (Okinawa), two areas where the incidence of gastric cancer is low. In any case, gastric cancer is also very high in the Tokyo area, which produces not only rice but also wheat, barley and green vegetables. But it is difficult to avoid the conclusion that the food the Japanese eat plays a role in cancer development. Approaching the problem from the cultural standpoint, Japanese scientists found that foreigners living in Japan and eating western food are less likely to get stomach cancer than the Japanese themselves. Highest salt intake A vital clue is mouth saliva. For centu- ries the Japanese have considered rice as sweet, probably because of the action of mouth saliva in producing maltose, or malt sugar, during chewing. To balance it, the Japanese eat salt, in flavoured sauces, shoyu and miso, pickled vegetables, or salted fish. A joint study by an American, Dr William Insull, and two Japanese, Dr Toshio Osio, Director of the National Institute of Nutrition in Tokyo, and Dr Kenzaburo Tsuchiya, of Keio Univer- sity, came to the conclusion that salt intake by the Japanese is probably the highest in the world. Miso, which is made from soya beans, yeast and salt contains about 12% salt; shoyu, which is a most popular season- ing, contains about 18% salt. Pickled veg- etables are served with almost every meal. What is it—an instinctive search for chemical equilibrium? According to one theory, the over-reliance on vegetable foods creates a need to consume salt to maintain the balance of potassium and sodium in the body. But there are impor- tant variations in the amount of salt eaten in different areas, and seasonal differences. In Yamagata Prefecture, salt consumption actually amounts to as much as 140% of the national average. In Tokyo, however, and in the Osaka-Nara area, where the gastric cancer rate is as high as in Yamagata, salt consumption, while still high, is well below the national average. "The fact that salted food can cause damage to the stomach lining has been proved by animal experiment," Dr Hira- yama points out. "During a series of exper- iments at the City of Hope Cancer Insti- tute in Los Angeles, in the United States, Dr Ryojun Kinochita fed animals with salted pickles and found that the frequency of stomach ulcers was much higher. But if the animals were given enough milk, the change was prevented." Here was a pointer that the Japan health authorities have been following up. With A mobile X-ray unit in action. Japan is spending a lot of money on the early detection of cancer. A crater on Mount Me-Akan. The volcanic nature of Japan's soil is suspected by some investigators as a possible factor in gastric cancer. the help of the Japan Cancer Society, 454 stomach cancer patients were matched by sex, age and occupation with healthy adults, and tests were run for cigarette smoking, and salt and milk consump- tion. No significant difference was found in regard to smoking habits between the study and control groups, but far more of the controls drank milk every day, and much fewer ate salty food regularly. "If we could only get our people to eat more ice-cream," sighs Dr Hirayama, as he looks at tables showing the fall in the stomach cancer rate among Japanese living in Cali- fornia. From 1935 to 1959, it declined by three-quarters. "Our basic strategy should be focused on changing the eating patterns of the Japanese, with special emphasis on the promotion of drinking milk and the reduction of the intake of salty food, wherever possible. The daily intake of meat and green-yellow vegetables also lowers the risk." Behind all this is a framework of patient research—what Dr Hirayama calls "vote counting". It is a story of mounting effort not only against cancer but the whole group of "adult" diseases, including cere- brovascular and cardiovascular affections, reflecting the lengthening life expectancy of the Japanese, and the retreat of tuber- culosis and the acute infectious diseases. It is a framework into which the tantaliz- ing problem of the relation between diet and stomach cancer fits like a piece but only one piece—in a huge jigsaw puzzle. The three Ms Another way of looking at the puzzle is to see it in terms of what Japanese doc- tors call "the three Ms"—the multidisci- plinary, multidisease, multifactor ap- proach. It involves an administrative chal- lenge, the task of finding out what are the effects on Japan's population of migration shifts, urbanization, cigarette smoking, the adoption of westernized foods. Ciga- rette-smoking, for example, was almost nil in Japan during the war because of shortage of supplies. The curve of tobacco consumption started climbing steeply as soon as cigarettes became available, but there is a 20-year lag in the consumption figures. There is also a 20-year lag in the lung cancer incidence curve, and epide- miologists are watching it with some anxiety. Oesophageal cancer is frequent among Japanese who eat hot rice gruel or drink hot green tea, but the geographical distri- bution does not resemble the pattern for gastric cancer. Where the main gastric cancer area faces the Japan Sea, for exam- ple, the area with the highest rate of oeso- phageal cancer is on the east coast facing the Pacific. Yet there are puzzling cross- links In Nara Prefecture, for instance, the death rates for both stomach cancer and oesophageal cancer are high. To find some of the answers, Japan's National Cancer Centre is now carrying out a survey. It covers 265,000 people in 29 health centres all over Japan, detailed information being supplied by the national census. The health centres return infor- mation about the life progress of these people, informing the Cancer Centre if any of them leave the district, and supplying death certificates. With the help of a com- puter, which maintains a watch on the basic denominators, it is possible to build up information on causes of death, and 18 The Japanese liking for salted food is incriminated as a possible cause of gastric cancer. Milk is given with school meals as a counter-measure against very salty food. 4A(vtalisit risk levels. Already it has been established that about one-fourth of deaths from lung cancer, for example, are influenced by, or caused by smoking. Tobacco with alcohol "We have also found that cancer of the oesophagus is high among smokers who also drink," reports Dr Hirayama. "It would appear that the carcinogen must be dissolved in alcohol in order to be absorbed by the oesophagus wall. Smok- ing alone, or drinking, is not in itself enough, but the combined habit is the trigger. This is a situation which is almost unique in cancer research, and is part of what we mean by the multi-factor aspect of disease." The survey has now been fol- lowing milk-drinkers for four years, col- lecting data and plotting graphs as part of a study of eating habits in connection with gastric cancer. "There is nothing concrete about the survey yet," explains Dr Hira- yama. "We are gathering information, and then we will wait and see what develops on our graphs." One of the graphs shows that the dietary habits of the Japanese, particularly the younger age-groups, are evolving rapidly. Milk consumption per head of population shot up ten times from 1949 to 1963. Another graph shows that the age-adjusted death rate of gastric cancer in Japan has been on a downward trend since 1959. "We have noticed the effect of this, in an oblique way, during tests of therapeutic drugs," says Dr Hirayama. "Our idea was to have the computer select certain drugs, on the basis of the known information, and that these would be available to doc- tors in sealed envelopes, so that selection would be scientifically 'at random'. Using this method we have been testing drugs for 10 years, but suddenly we have found that both our study patients and control patients have improved in quality. We can certainly assume that we have some drugs that are effective, but there are clearly other causes at work, associated with both mass screening and changes in food habits." But the probing goes on, patiently and methodically. Some scientists are looking for the presence of strong carcinogens in the environment. They argue that the A doctor examining the X-ray of a patient who is also to be photographed by gastrocamera. latent tumour can begin at the intra-uter- ine or neo-natal stage of human life, and that such factors as diet and geographical location are only modifiers of the risk. Synthetic carcinogens have been created that attack both DNA and the protein in the living cell and which, although appar- ently they are not found in the environ- ment, can offer models, "identi-kits", of an as yet unidentified substance which might cause certain types of cancer, including gastric cancer. "Apart from the search for chemical carcinogens in the environment, we are also looking for viral agents," Dr Hira- yama comments. "I am working with a study group of the International Agency for Research on Cancer (IARc) on this question, with special reference to cancer patterns in Taiwan. There is also a Japan-Taiwan cooperative study in pro- gress. We are working on the same lines The effects of a highly salted diet on mice being investigated in a Japanese laboratory. as researchers in the United States and elsewhere on the herpes-type virus and viral particle that have been found in human leukaemia cells and one type of tumour cell cultured in vitro. In Taiwan, most of the clinical cases of nasopharyn- geal cancer occur after a sharp rise in one kind of viral infection. From the epidemio- logical aspect, the correlation is as strong as that established between lung cancer and smoking, and between radiation and leukaemia. What we have to establish now is that the onset of cancer begins after the viral infection, and on an individual basis." Since research into virology points the way towards possible vaccines, it is an exciting new avenue of study. What are the chances of success? "Today," Dr Hira- yama said, looking at the calendar on his office wall, "is the anniversary of the day that Buddha achieved satori, enlightment. Perhaps it is a good omen." ■ JOURNEE MONDIALE DE LA SANTE 7AVRIL 1970 Ihrld Health Day 7,1pril 1970 CBOEBPEMEHHOE AELIEHHE nosEIKA,AET PAK World Health Day Posters Four posters—in English, French, Russian and Spanish—brought out for World Health Day, 7 April 1970. They all-carry the message that early detection of cancer saves lives. CANCER la deteccion temprana salva vidas MA MUNDIAL DC lA SALVO - 1970 stress and the pachinko syndrome by James Magee At a street corner, a fortune-teller plies her trade. N ight is falling in Tokyo. In the soft dusk the neon signs flare into life outside cinemas and coffee bars, and the human tide in the city's subways and railway stations rises to a flood. Japanese crowds make little noise, so you can hear the slight shuffle of feet more accustomed to the thongs of the geta or wooden-soled sandal, than to western shoes. Ribbons of colour flow down narrow side-streets as the night- spots and jazz-clubs open up. To lure the tourist and the visitors from out of town, a musician strikes chords from a samisen, a three-stringed traditional guitar, outside a smart restaurant. Again, the ear registers a tell-tale sound, the hypnotic click of the little white plastic ball in the serried rows of slot-machines in the pachinko parlours. The name is onomatopoetic. Pachinko, as the lever of the machine goes down. Pachinko . . . pachinko . . . Then the roar of the traffic washes all other sounds away, and the great grinding-machine of a city of 11 million people reasserts its presence. But at the feet of a great dark-windowed building, a merchant bank, there burns a lantern. Two lanterns. Soon a dozen. In the alley the fortune-tellers are setting up their tables and stools, faces imperturb- able, their eyes remote from the hustle and bustle of the streets, ready with pocket- torches and bamboo rods for the first troubled clients of the evening. "I have difficulties in the office," says the well- dressed young man. "One of my colleagues has been promoted to a job that I wanted, and I am worried about being passed over " With the pocket-torch the fortune- teller peers at the tell-tale lines on his client's palm. The customer wants to know more, and the bamboo rods fan out in agile fingers. The portents are favourable, and the client is advised to place his trust in the company for which he works, and to concentrate his energies on doing his work well. "My eldest boy is sick, and the doctors are very worried," the woman murmurs anxiously. From an inlaid box the fortune- teller takes strips of carved wood, mani- pulating them in mathematical combina- tions laid down by savants in China several thousand years ago. "You must be patient a little longer, because the signs are not yet clear. But your boy is young and strong. There are many powerful influen- ces on his side." The woman's seamed face relaxes as she stands up, bowing courteous- ly. "Whom shall I marry?" a girl asks. Skilful questions produce enough infor- mation to indicate that her parents have a possible husband in view, but that she has a boy-friend at the factory where she works. The situation is as old as the fortune-teller's art, and the advice no less so. "Don't make a hasty decision." It is the advice of a latter-day Confu- cious, a rope-ladder over the chasm that has opened out between old Japan, with its hierarchical structures and emphasis on authority, and the steamrolling new society of this second half of the 20th century, where everything is in flux, where type- writers have 3,000 letters and learning to read and write is a painfully complex pro- cess, and where at the same time the omni- present television set offers McLuhan-style electronic communication in images over eight channels, where a man may spend his working day among faceless machines and whirring computers and his evenings in a kimono, eating cross-legged from a table almost level with the floor as his ancestors before him, where all human relationships are still governed by the im- mutable laws of duty and obligation and yet traffic accidents per vehicle are among the highest in the world, where tiny, high- walled gardens shut out the world with a fence of reeds and aeroplanes zoom over- head on Sunday afternoons blaring adver- tisements for Monday's sales in the depart- ment stores. Over the neat, patchwork fields ofJapan's rural areas lies the great shadow of mega- </ The pachinko obsession. 23 Rural Japan: cauliflowers, each protected against the cold, but the number of farm workers is constantly decreasing. lopolis. In one of the most progressive population shifts of our time, the industries of the cities have steadily drawn the farmer and landworker from the village to the assembly-line. With jobs and higher wages as the magnet, about 67 million people, or almost 68% of the total population, now live in the urban areas, an almost complete reversal of the situation at the turn of the century. The machine is the engine of change at all levels. Using the Japanese-made mini-tractor, the farmer's wife can do most of his work on the land, releasing him for seasonal jobs in the city. He finds himself alone in a new environ- ment, rootless, disorientated, cut off from his family and community, subjected to the inexorable rhythms of the factory, and many machines. His daughter or son comes to the city too, and as often as not is attracted by the welfare facilities offered by the big companies, the "perks" that go with the city job. That can mean board and lodging, subsidized recreational acti- vities, even medical care. Life in the dormi- tories and club-rooms provided by the factory is cheerful and well-regulated, but again, a different environment. In the heart of the city other communi- ties are under assault. Although the hous- ing shortage in Japan is still acute, urban redevelopment is pushing on. New apart- ment blocks are rising in the suburbs of every city, drawing away the young families who formerly lived with their parents, breaking up the tightly-knit units that provided reassurance, certainty, terra firma. This affects, in turn, the local communities, the sense of being a neighbour, of being part of an ordered system. "The old days of the city festivals are declining," com- plained the president of one such com- munity association. "Everyone used to turn out for the ceremony of carrying the shrine on festival days. Now young people are less interested in these local customs, or else they have moved away. And anyway we can't get through the streets because of the cars, which block our processions." Static crackled in a policeman's radio- telephone as he sat in the local police box. "We used to know everyone in the area," he said thoughtfully. "All we had to do was to walk around the streets every so often to get acquainted. Now we rely on maps, and even then . . . " He shrugged and turned away to his transmitter. The sense of uncertainty emerges suddenly at un- expected places. A top businessman de- scribed with enthusiasm how rapidly an urgently-needed fly-over road had been built between Osaka and Kobe, boom towns of the postwar era. "It was put up in 18 months," he said eagerly. "That's the speed we do things at nowadays. We've got to keep up with the expanding econo- my. Sometimes I'm not sure that I can keep up—it's so hard to understand every- thing that's happening to us." Ancestor worship That helps to explain how professional fortune-tellers maintain their popularity at a time when traditional beliefs and religions are losing support steadily. Most Japanese houses used to possess a small Shinto shrine, for ancestor worship, the traditional religion of Japan; not a few would maintain a Buddhist shrine as well. But the rites are seldom practised. In fact, in the view of one commentator, Dr Kichi- nosuke Tatai, a leading psychiatrist and former departmental chief at Japan's 24 - IF - r-ru - Cr in .11 r at/ n '7,1 " •••• TIVR 'lc" - • Pc .. • II ;:zy - 1"--- r I. t r , r -r - e . Go, - - :" VP- Br.T-Fttr It7. - Sprouting like mushrooms... Institute of Public Health, the nation is almost completely atheistic. "Most people in Japan are married by the Shinto priest, and Buddhist ceremonies are carried out at funerals," he observes, "but, as in the west, religion plays only a very minor part in daily life. The Emperor is no longer regarded as a god, and technology is cre- ating fresh problems. We are developing a type of competitive society that resembles that of the United States in many ways, with all the accompanying strains and pres- sures, and at the same time we are being cut off from the old sources of strength and renewal." So, while the ancient temples maintain themselves by turning their surrounding land into parking lots, business flourishes for the fortune-tellers. "The number of my customers increases day by day," one said. "Many of them are young people, and a very high proportion are wage- earners and businessmen. They bring me their problems, and I help to solve them. It is not always a matter of fortune-telling. Very often I can use the experience I have acquired in twenty years of listening to stories of life's difficulties to show my clients how to cope." There is a growing interest in new and exotic religions. Only a small fraction of the population practise Christianity, but sales of the Bible are run- ning at record levels. More than 170 reli- gions are at present registered with the Ministry of Education, many of them offering adapted and simplified versions of Buddhism and Shintoism, and claiming a flock of about 18 million believers all told. They have a wide base, particularly among the workers, and are well established both in cities like Osaka and Tokyo, and in rural areas, including Kyushu, Hokkaido, Oka- yama Prefecture, Hiroshima Prefecture and Yamaguchi. A significant aspect of these new religions is their optimism. "There is no room for life-pessimism and negativism," notes the missionary author Harry Thomsen. "Life is beautiful, and there is always a sun above the clouds . . . The happiness is emphasized by numerous festivals, often on a stupen- dous scale . . . Practically all the new reli- gions claim to be working for, or to be able to attain, the establishment of the Kingdom of God on earth—not in the distant uncertain future, but right here Even eight-lane highways become saturated. (The helicopter from which Eric Schwab took this photograph was kindly provided by Kaginawa Prefecture.) 1111r :13W . • • -''''t":4111)41116•■'"' _ • • ;. In the subway after a long day's work. and now." * Followers are often assured that they will be freed of sickness and poverty. One group increased its support among miners in Hokkaido by promising immunity from pneumoconiosis and safety from mine accidents. The leaders of such religious movements have their finger on the national pulse; in fact, optimism is mirrored in official statistics on suicide, for example. "After the war, when we were going through the period of post-war difficulties and the dis- integration of the old vertical structures, there was a very sharp rise in suicide cases," Dr Tatai comments. "The incidence was particularly high from 1953 to 1957, especially among the younger generation. But although we have taken no special pre- ventive measures, the curve is now going downwards quite rapidly. There may be technical reasons involved here, which could affect the statistics. For instance, the use of drugs for suicide is becoming more common, and this could have a "masking" effect, since it is often difficult to distin- guish between an accidental overdose of barbiturates and a deliberate overdose. But the overall trend is clearly downwards." From Tokyo to Osaka, it has been sug - Mass production in a transistor radio factory. gested, there may be only one vast con- urbation by the end of this century. What would this imply for its inhabitants? As experience in other countries has shown, the city symbolizes material prosperity, but a relentless impoverishment of the human spirit. Man cannot do what he pleases in an urban society. Instead, he must limit himself to doing what the city has to offer, whether that means, as in London, joining the nose-to-bumper traffic queues to the coastal towns on a Sunday morning and rejoining the same queues to return home in the evening, or, as in Tokyo, camping out at the railway stations for the chance to join a queue for places in another queue for tickets to the ski slopes at the weekend. Cities and conurbations mean crowds, and already Japan is one of the most crowded countries, with rocketing land values and over forty per cent of the population hemmed by mountains into only one per cent of the total land area. Crowds mean the disappearance of the particular and the peculiar, and the merci- less promotion of the stereotype, the uni- form, the mass production of dark rain- coats for mass sitting on the slightly soiled * The New Religions of Japan, by Harry Thom- sen. Tokyo 1963. 26 A man doing a handstand in Tokyo's central park goes un- noticed, so popular is physical exercise in Japan. seats of commuter trains, the mass pro- duction of work, the mass production of pleasure. The worker who has been con- ditioned by the assembly line walks straight out of the factory, and into the pachinko parlour to kill precious leisure time opera- ting another machine. Pachinko has become an industry of its own, with 30,000 par- lours throughout Japan, and more than fifty companies engaged in manufacturing the machines. A girl may spend all day assembling the parts of television sets, and most of her evening watching television, victim of an illusion of whose mechanics she is totally aware. Crowds mean passivity, because that is the only reaction that finds complete consensus. "We are polite and tolerant very often because there is no room to fight," a young Japanese salesman explains. In Europe and North America, the monotony that lies just beneath the glit- tering surface of urban life often produces a delinquency reaction among the young. Professor Rene Dubos of the Rockefeller University in New York City has suggested that when such a reaction occurs it is due in large measure to the fact that the modern world does not offer the human being the opportunity to exercise his physical and mental powers in a creative manner during the most active period of his development. A look at Japan's crime statistics does in fact reveal a steadily climbing delinquency rate, from a total of 720,606 cases in 1958 to a peak of 1,323,981, or almost double, in 1964. In 1965, however, the curve turned downwards again to a total of 1,309,504 cases, and the dip continued to the end of 1967, the last available year, when the total had decreased to 1,093,314. The murder wave Here again there are hopeful signs of acceptance and adjustment. It is a move- ment that traces the same outline on the graph of the juvenile crime rate, which rose steadily from 6.4 per 1000 of the population in 1956 to reach a peak of 9.7 in 1964. The rate is still high, but the peak has been passed, and by the end of 1965 had returned to the level of 1962. The pattern is not confined to juvenile offences, but applies also to certain crimes commit- ted in society at large. Murder cases in Japan increased steadily from 861 in 1945 to a total of 3,356 in 1955, and the total since then has been falling, and by the end of 1967 stood at 2,225, slightly higher than the 1947 total. Robberies shot up to un- precedented frequency in the troubled years immediately after the war, but the total cases per year have been steadily decreasing since 1949, and are now run- ning at about one-fourth the number recorded in that year. (The amounts stolen have been increasing, however, no doubt because of the greater amount of money in circulation.) Clearly there are release mechanisms at work, physical and mental. The writer Nada Inada, who in private life is Dr Hori- uchi Shigeru, a practising psychiatrist, points out in this context that the worker in Japan has a frame of reference to a less affluent past, and this may help him to maintain a balanced outlook. His earlier ways of life may have been disrupted, but his wage packet gets fatter every year. "For many workers," Nada Inada com- ments, "the factory is better than the fields." This idea has even been carried to the point, in at least one factory, of leaving the worker completely without supervision, with the aim of creating self-motivation. It is an idea that seems to have possibilities —Japanese workers sometimes remain in the factory after hours to suggest ways of boosting production. Sometimes the modern worker, and his boss, can tap spiritual resources that are scarcely known or understood outside 27 Bowling is almost a national sport in Japan and provides for more physical activity than pachinko. Japan. It is not unknown for high-school baseball teams in Japan who have reached the finals in competitions to go into seclusion at a Zen temple in order to achieve tranquillity. Executives with a heavy burden of responsibility will do the same, and on occasion the president and all the members of the board of a com- pany will go into a temple for a "retreat" which may last as long as a fortnight. A 59-year old insurance company executive (who, in fact, looked hardly more than 50) chuckled at the idea of nervous wear and tear, in spite of the fact that his job was obviously quite demanding. "I use Zen," he said. "The discipline of Zen enables me to keep my mind calm and free from stress." * * Zen Buddhism, which seeks a harmonious balance of physical and mental training, has been used in Japan as the basis of a therapy for certain neuroses. Next in importance the insurance chief ranked sports as a means of freeing the mind and body of the effects of stress, and third, contact with nature and the open countryside. This love of sport works itself out at all levels of income, from the fantastically expensive golf clubs of Japan to the open air gymnastics that office wor- kers indulge in during lunch-time in city parks. A middle-aged man doing hand- stands on a park bench would attract attention in most countries. In Tokyo's Hibiya Park he passed almost unnoticed among a flock of young men "working out", sometimes stripped to the waist, on the rings and parallel bars provided by a thoughtful municipal government. A desk clerk in a nearby office, he explained that he came into the park almost every day for about 15 minutes' strenuous exercise. A 22-year-old employee of a broadcasting organization willingly demonstrated his skill in exercising on the rings. He added that he was in the habit of coming to the park at lunch-time with a group of friends to take exercise. "I have the feeling that I am escaping from desk work, from the electric lights in the office," he said. Love of nature is, of course, also an eternal theme in Japanese life and an important source of renewal. Picnics and trips to the countryside are a regular part of the recreational programmes of many business firms. An enterprising farmer recently sold off his land in parcels 3.3 metres square to city dwellers, and did a roaring trade. Each Sunday the owners of the tiny allotments visit their plots and cultivate them with minute attention, faith- ful to the dimensions imposed by the conditions of life on a group of islands which supports, on a land area which is 28 considerably smaller than the state of Montana, a population almost half that of the entire United States. "In the Japan of today, the Japanese have to learn to survive as individuals," says Professor Hitoshi Aiba, of Waseda University, a psychoanalyst with a keen interest in social problems. "Instead of acting in groups as in the past, they must learn to find solutions by themselves. There is a risk of over-adaptation in the younger age-groups (a situation in which the ab- normal is accepted as the normal) and a need for discipline. Sometimes at present the younger generation tend to act out what they read in cheap magazines about sports, cars—which few of them can yet afford—and sex. If they are to survive the pressures of modern life, they must keep the initiative." The taxi bearing me away from my Practising soft ball in the school playground. meeting with Dr Aiba bored ruthlessly through several lanes of dense traffic, then zoomed down the middle lane of the free- way shaving the giant wheels of a line of heavy lorries by a fraction of an inch. "Please," I said to the driver, "go more slowly—I do not want to go as fast as the kamikaze, the divine wind !" He grinned at me cheerfully, and slackened speed slightly. Then it was cut-and-thrust again at a busy intersection, until he emerged victorious from a duel with a battle-scarred pickup van and swung into the lead down a wide boulevard. It was quite evident that he was a man who liked his work. "What do you do in your spare time?" I asked curiously. "I go rock climbing— very dangerous," he explained as I paid the fare. Then he drove off, eager for more combat, a young man perfectly at home in modern Japan. ■ 29 around the world Doctors of Europe The wHo Regional Office for Europe—serving 31 Member States from Copenhagen —looked into the question of where doctors are most plentiful. The graph given here shows the number of physicians per 100 000 population in countries in the WHO European region in 1965 or about that date. For Austria, Belgium and Italy, the statistics exclude physicians specialized in dentistry. Outside Europe in the same year, there were 148 doctors per 100 000 inhabitants in the USA and 109 in Japan. Country Physicians pe 100 000 population Number per 100 000 population USSR 210 Czechoslovakia 185 Bulgaria 166 Hungary 159 Austria 158 Fed. Rep. of Germany 157 Malta 147 Greece 141 Switzerland 141 Belgium 140 Denmark 135 Iceland • 135 Italy 133 Romania 131 Norway 127 Poland I 126 Spain 126 France 121 ■ 119 Northern Ireland Scotland 119 Netherlands 117 Eastern Germany 115 England and Wales 115 Sweden 110 Ireland 105 Luxembourg 99 Yugoslavia 83 Portugal 81 Finland 77 Albania 48 Turkey 35 Algeria 12 Morocco 8 150 200 Nutrition in Costa Rica In Costa Rica, nutritional evaluations of pre-school children and infants under one year of age show that 60% of those visiting the health units are suffering from malnutrition, are under the normal weight and height, are retarded in their psycho- motor development, and are extremely susceptible to infectious disease. A scheme is being put into practice in the country to cope with maternal and child malnutrition. It is based on a net- work of health units-104 nutrition centres giving monthly treatment to some 13,000 unweaned children, 30,000 pre-school children, and 2,500 pregnant women; 4 nutrition rehabilitation centres with a capacity to treat simultaneously 80 child- ren over a 10-hour stay; and a nutrition rehabilitation clinic capable of treating 40 children simultaneously during a 24- hour stay. Pilgrims' progress Despite a vertiginous increase in the number of pilgrims going to Mecca in the past few decades (in 1924 there were 30,000; in 1965 the number rose to as many as 283,319 plus some 800,000 from inside the country), sanitary conditions have improved spectacularly in Saudi Arabia which is now anxious to develop further protection against the reintroduc- tion of communicable diseases such as smallpox. Jeddah, which is the principal port of entry into the country by sea and by air, therefore occupies a strategic position as far as disease transmission is concerned. The port's Quarantine Laboratory had as its main function the screening of pilgrims for quarantinable diseases, especially cho- lera, during the pilgrimage season. New diagnostic services have been introduced and efforts are being made to improve measures against the introduction of smallpox by pilgrims from countries where the disease is still present. Preventing goitre A new method of preventing goitre is giving good results in Latin America where an estimated three to five million people suffer from this disease. In certain areas where iodization of salt is impractical, trials have shown that intramuscular injections of iodized oil can be an effective preventive measure for young children. 0 50 100 Children play outside in the Arctic despite very low temperatures. "Fight Cancer" stamp NaD NACIONES UNIDAS Goitre and the cretinism associated with it, primarily caused by dietary iodine deficiency, is one of the greatest nutritional problems of South America. The Pan American Sanitary Bureau, wHo Regional Office for the Americas, is running a research programme on endemic goitre concerned with its prevalence and characteristics, and with prevention. Iod- ized oil injections, already used successfully in New Guinea, have also been tried in this programme. Pilot studies in Ecuador and Peru indi- cate that iodized oil is not only effective in reducing the incidence of endemic goitre and preventing its appearance in the new- born, but also in reducing the number of deaf persons and cretins in the population groups studied. Statistics also suggest that intellectual performance may be improved. This green stamp to commemorate World Health Day, April 7, 1970, devoted to the early detection of cancer, will be issued by the United Nations. Designed by Leonard Mitchell of New Zealand, it will also be issued in a blue six cent denomination. Children of the North Because of the lack of sunlight during the long Arctic winters, prevention of ricketts is a leading worry for health authorities in the far north. Vitamins A and D have to be supplied continuously to children during the dark months of the year. As a result, ricketts have almost com- pletely disappeared from the area. Even very young babies are able to support low temperatures and are taken out in cold weather. Provided the temper- ature does not fall below —15 0 C, it is considered safe to take infants out, for a short time at least, if their faces have been rubbed with a waterless cream. In the summer, all vaccinations against smallpox are stopped between the middle of June and the end of August on account of the mosquito plague. Mosquito bites cause severe itching and if children scratch the vaccination spot the risk of pustules spreading all over the body is considerable. One result of the light summer nights is that children never want to go to bed but stay out until late in the evening. It is not an uncommon sight in the summer to see children playing out-of-doors at mid- night. It seems well established that child- ren do not get enough sleep in the summer but on a purely empirical basis it has been found that sleep requirements appear to be smaller during the lighter months of the year. Health helps productivity The following examples, which strik- ingly show the relationship between occu- pational health and productivity, were presented at the Joint International Labour Organisation/World Health Organization Regional Seminar on Occupational Health in Manila. In a large sugar mill a combination of sulphur dioxide gas and high humidity was responsible for many cases of con- junctivitis requiring hospitalization; when ventilation in the mill was improved production increased by one third. An owner of a factory manufactur- ing jewellery contemplated retirement because he felt overwhelmed with business worries. In reality, he was suffering from occupational mercury poisoning. The owner of a very large sheep farm developed dieldrin poisoning and was forced to sell out. Yet simple hygienic precautions whilst dipping sheep in the disinfectant could have prevented this. A rapid but physiologically incorrect way to pack cigarettes by hand caused numerous cases of tenosynovitis (inflam- mation of the tendons) and reduced out- put. Studies showed that, although the work seemed light, the girls on the job actually were lifting several tons each day. When a radioactive isotope is used industrially for the first time, production is sometimes stopped because of the workers' fears. Proper education and assurance that adequate safety provisions have been taken will prevent this. photo-credits INFORMATION SERVICES, CONSULATE GENERAL OF JAPAN, GENEVA ©: p. 2 WHO/KAKUN SHO: pp. 8, 9 WHO/BREITENBACH: pp. 16, 17, 20 H. HAMAYA ©: p. 18 p. 21 WHO/E. SCHWAB: front and back cover pp. 4, 5, 6, 7, 10, 11, 13, 14, 15, 19, 20, 22, 23, 24, 25, 26, 27, 28, 29 WHO/P. ALMASY: p. 31 31