How Culture Makes Medicine

A chemist at a market in Pune. Photo: Reuters/Danish Siddiqui

• There are some deep-seated but seldom-discussed cultural beliefs about the relationship between healthcare providers and the individuals they treat.
• The Japanese and American systems have different strengths and pitfalls, with major ramifications for everyone who engages with healthcare.
• National personality helps explain the opioid epidemic in the United States and the suicide rate in Japan and reveals the medical landscape of the countries.

The standard American approach to preparing a young child for an MRI is simple: Knock them the hell out. MRIs require patients to remain unnaturally still for a long time in an unpleasant situation – lying down in a strange hospital room in a narrow, claustrophobic tube that makes loud banging noises. So American medicine gives children general anesthesia to prevent them from moving around and ruining the MRI images.

It’s been like that every time my children have gotten an MRI in the US. (We have a familial condition that requires monitoring through occasional scans.) When my wife, Emily, and I see one of our children after the MRI, they appear comatose, unconscious and breathing through an oxygen mask. Over the next few hours they gradually wake up, disoriented.

So when we had to take our three-year-old daughter (I’ll call her “Star”) to get an MRI in Tokyo, we expected roughly the same experience. But instead of having both of us say goodbye, the staff brought Emily into the MRI room with our daughter. The anesthesiologist gave Star a mild sedative that calmed her down; then the technician laid her on the gurney like bed and slid it into the scanner.

Every time Star budged, however minutely, the anesthesiologist leaned forward in the direction of the MRI tube and crossed his index fingers in an X, the Japanese gesture for “stop.” Emily translated the doctor’s admonishment into directions for Star, promising her ice cream and, best of all, freedom, if she would only stay still a little longer. After the better part of an hour, the tech retracted the bed and Star hopped off.

Meanwhile, I’d taken my two other kids out for a walk, wondering how I’d keep them occupied for the next few hours while we waited for the little zombie to awaken. As we returned to the hospital seating area, we saw Emily and Star, who was eating an ice cream cone they’d bought in the café. She was awake, alert, and elated to be done. I was floored.

Going into the procedure, I had known that the mechanics of Japan’s and America’s health systems were very different; most obviously, Japan has universal government health insurance. But living in Japan, I had begun to see that the differences in health care went deeper than questions of who pays the bills. It seemed to me that the divergence in the MRI protocol wasn’t random or isolated; it revealed some deep-seated but seldom-discussed cultural beliefs about the relationship between healthcare providers and the individuals they treat. The two systems have different strengths and pitfalls, with major ramifications for everyone who engages with health care – which is to say, everyone.

When we arrived in Tokyo in 2016, one of the first of many cultural shocks, right there in the airport, was seeing lots of people wearing surgical masks. After SARS broke out in 2003, Japanese, like other people in East Asia, began wearing masks when they felt sick and went out in public spaces. In wintertime, it wasn’t unusual to see a third of the people in a packed Tokyo metro car wearing masks. This proved helpful when SARS’s sequel blew up into a pandemic. And almost-universal masking helped limit COVID-19 in Japan, which has had the lowest death rate of any major developed country despite never having imposed any lockdowns.

Mask wearing is one example of a major part of Japan’s health culture: a strong belief in an individual’s responsibility to the system. According to this view, individuals are expected to handle their own problems without complaint, so as not to burden other people or the system as a whole. A survey of the research into this cultural feature concluded, “A well person is one who handles their own needs. . . . People need to be self-reliant to avoid overtaxing limited support reserves.” When facing challenges, Japanese have traditionally been told, “Ganbatte,” an exhortation to do your best while quietly enduring any unpleasantness.

Eriko Onishi, a professor of family medicine at Oregon Health & Science University who has done research on the medical cultures of Japan and the United States, first glimpsed the differences between them when she was doing an obstetrics rotation at a hospital on a U. naval base near Tokyo. She found that she could often tell whether a woman giving birth was a foreigner before entering the room. “Usually you could tell by somebody screaming that this person is not Japanese,” she says. “The cultural background will definitely play into how you manage your pain. ‘My grandpa was in pain when he was old.’” In Japan, that feeling is the norm, she says.

Japanese patients tend not to mention their discomfort, and doctors tend not to ask much about it. Japanese women are far less likely than Americans to ask for or receive epidural anesthesia during childbirth; withstanding the pain of labour is widely seen as a normal first step into motherhood. When Japanese do ask medical professionals for help, they often apologise. “I’m sorry, I’m sorry,” they say, according to Onishi. “I feel bad because I’m complaining.” Overall, Japan uses general anesthesia about one-quarter as often as the US per capita.

While the Japanese sense of responsibility can serve the system, there’s also a dark side: Swallowing the hurt can let it fester inside. The country has especially stigmatised mental health issues, says David Matsumoto, a psychologist at San Francisco State University who studies cultural differences. “There’s less reporting of symptoms, maybe downplaying of symptoms.” Resistance to getting psychological help leads to higher levels of severe psychological distress and contributes to a high suicide rate.

Mental health is also entangled with the especially Japanese problem of people living in social isolation. A survey of developed countries in 2005 found that 15% of Japanese reported rarely or never spending time with anyone, the highest rate of any country in the survey, and more recent studies find much the same. People who rarely leave their homes are called hikikomori, a well-known problem around the country. Research suggests that most hikikomori have mental illnesses or disorders, often undertreated: One study found that only 7% of hikikomori seek help themselves, and that in cases where they do receive help, usually prompted by a relative, it comes after four years of isolation, on average. Among older people, social isolation too often ends in kodokushi, a profoundly isolated death, which often isn’t noticed for a long period. A small industry has sprung up to empty the homes of kodokushi victims, since they don’t have close social contacts who will handle their affairs.

While Japan is traditionally a collectivist society, the United States is at the other end of the spectrum, arguably the most individualist country in the world. “In other countries, there’s more a sense of duty to your neighbours. In the US you have the right to improve your personal lot. Your right to pursue happiness is one that’s written into the Declaration,” says Jane Ballantyne, a retired professor of anesthesiology and author of a forthcoming book on the history of medical rights. “You have an idea of what care you have the right to receive, which might include pain relief.”

An emphasis on patient entitlement led to a more empathetic understanding of patients in pain but also contributed to the United States’ deeply tragic opioid epidemic. In the 1980s, some American pain specialists began to argue for a new understanding of and approach to patients in pain. Traditionally, medicine regarded pain as medically subordinate to the four vital signs: pulse, blood pressure, body temperature, and breathing rate. The newer view held that doctors were callously undertreating pain.

”Unrelieved pain has enormous psychological effects on patients,” says Dr Dennis S. O’Leary, president emeritus of the Joint Commission on Accreditation of Healthcare Organisations, a nonprofit that helps set important medical guidelines in the United States. “Research shows that unrelieved pain can slow recovery, create burdens on patients and their families, and increase costs of the health-care system. And we believe patients have an explicit right to effective assessment and management of existing pain,” he adds, summarising the changing view. In 1996, James Campbell, then president of the American Pain Society, gave an influential talk arguing that pain should be regarded as the “fifth vital sign,” pushing it into the pantheon of fundamental indicators of health. “Quality care means that pain is measured and treated,” he says.

To correct this neglect of Americans’ fundamental rights, pain specialists wanted to expand the use of opioids, the strongest pain medicines known. Doctors had long thought that these drugs, traditionally called “narcotics,” were highly addictive and had prescribed them reluctantly. “It was rammed into our heads: You don’t prescribe narcotics,” or if you do, you prescribe as small a dose as possible for the shortest time, says Victoria Sweet, a doctor and the author of Slow Medicine, a critique of how today’s doctors rush through treating patients rather than take the time to figure out how to handle problems like pain.

Views on opioids, however, soon underwent a major shift. In 1986, after conducting a small study of opioids, Russell Portenoy and Kathleen Foley published a report concluding that opioids were effective and safe for long-term treatment of chronic pain, with little risk of causing addiction. Other pain specialists piled on. Their argument was boosted by drug companies (most infamously Purdue Pharmaceuticals) that co-opted the movement, funding and distorting the research of opinion leaders.

Health-care institutions aligned with the new view. In 2000 the Joint Commission adopted a set of pain management standards that pushed the idea of pain as the fifth vital sign and required healthcare providers to ask patients about their pain levels, often using cartoon drawings of human faces arranged on a continuum from big frown to big smile. “It was a new thing to measure, like we had a new colour,” says Sweet. “I remember one of my patients was sitting there; he’s relaxed, leisurely sipping a Coke, and he says, ‘Doc, I got an 11.’ It didn’t take long for him to figure out that if he said that, the doctor would give him more narcotics.” Hospitals expanded on the pain question and started giving patients satisfaction surveys. Insurance companies began paying doctors and hospitals on the basis of their patient-satisfaction scores.

Legal oversight of doctors also changed: The emphasis shifted from watching for overprescription of opioids to watching for undertreatment, which came to be seen as cruel. After one physician was disciplined by the Oregon Medical Board for under-prescribing opioids in 1999, a researcher at a health and policy institute wrote, “Contemporary medical research has shown that there is no necessary upper limit on the amount of opioid medication that may be required adequately to control severe pain.”

All of these changes swirled together into a perfect storm for prescribing opioids but almost no penalties for overprescribing them. The number of opioid prescriptions skyrocketed, followed soon by addictions, overdoses, and deaths – much of it in the name of individual rights.

That storm never arrived in Japan, where opioid use per capita has remained a fraction of what it is in the United States. Onishi researched the use of painkillers in the two countries and found that 95% of American doctors thought opioids were used too often, while only 7% said the same in Japan. There are organisational differences that contribute to making opioids rarer in Japan, but arguably the most important factor is one that drives all the others: No one expects that Japanese doctors will prescribe opioids—not patients, drug companies, insurance providers, hospitals, or the doctors themselves.

“Up until the current generation of young people, it was considered a virtue to endure pain and suffering,” says Katsuyuki Miyasaka, a professor emeritus of anesthesia at St. Luke’s International University, in Tokyo, who has studied how medicine is practiced in Japan. “People did not think they had a right to be comfortable or pain-free.” The Japanese system never pushed questions about pain levels and patient satisfaction, and consequently it never pushed opioids.

How we value the individual versus the collective is one important way in which health cultures differ, but there are many more. Doctors in the United Kingdom maintain a more distant relationship with patients than do those in the US but seem to reach out to people more readily than do doctors in Japan. UK physicians have been moving toward an approach in which they treat chronic pain not just with medicine but by teaching self-management techniques that can help patients understand and alleviate the stresses in their lives. Australia and Singapore place their trust in assertive public health systems, adopting government-run electronic health recordkeeping to centralise medical information and boost research and innovation. America’s can-do, interventionist attitude has led to many new treatments but sometimes veers into overtreatment. All of these health systems have strengths – but also weaknesses that can spawn various national maladies.

In recent years, Japan and the US have begun to rip out the broken pieces of their respective systems. Japanese, especially the young, more readily discuss their problems, and the principle of ganbatte has fallen out of favour. The suicide rate has decreased in recent years. The US, responding to the horrors of the opioid epidemic, has made the drugs much harder to get, with the number of prescriptions dropping by 44% over the past decade. But neither country has fully developed new social mechanisms to replace the broken ones. Japanese are not yet very open about mental health; many Americans who used to take prescription opioids have no better way to handle their chronic pain, so they turn to illegal sources. The two countries would do well to continue their progress by learning from each other and from other countries that may have found better answers to the same questions. There’s a lot of wisdom to be gained if we can look beyond our borders with open minds.