T. R. Reid has just published a new book called The Healing of America that compares American health care to health care in other countries. One comparison is with Japan:
The world champion at controlling medical costs is Japan, even though its aging population is a profligate consumer of medical care. On average, the Japanese go to the doctor 15 times a year, three times the U.S. rate. They have twice as many MRI scans and X-rays. Quality is high; life expectancy and recovery rates for major diseases are better than in the United States. And yet Japan spends about $3,400 per person annually on health care; the United States spends more than $7,000.
Life expectancy is better. Even though the Japanese smoke more than Americans. Is it all those MRI scans? (Which in Japan cost a small fraction of what they cost in America?) Or all those trips to the doctor (where, by American standards, nothing appears to happens — that is, expensive drugs are rarely prescribed — judging by overall costs)?
I believe that that Japanese do so much better because of a factor that Reid probably doesn’t consider: They eat tons more fermented food than Americans do. In a Tokyo restaurant, the woman sitting next to me, a nurse, said she believes that regular consumption of fermented foods is important for health. Does everyone in Japan think this? I asked. A large minority, she said.
The eating habits of the Japanese, as far as I could tell, bear this out. On a Japanese food blog, the writer described a breakfast that had five fermented foods: pickles, miso, yogurt, natto, and kimchi. The Japanese eat miso at every meal, more or less. They also eat lots of pickles. Natto is popular in some parts of the country but not others. They eat lots of yogurt; they are the country that gave us Yakult. They drink vinegar drinks. (Whereas in America only health nuts drink apple cider vinegar.) In other words, their diet is loaded with fermented foods. If I’m right about this, Japanese rates of autoimmune diseases should be much lower than American rates.
When people get sick much less, health care costs go way down.
Seth,
I think that you’ve spotted the elephant–or perhaps an elephant–in the room where the U.S. health care debate is being held. We aren’t very healthy for a variety of reasons, but if we took better care of ourselves, we’d spent a whole lot less on medical care and enjoy life more. Beyond potable water and mass inoculations, a healthy diet (we know more about what it isn’t than perhaps what it is) and even modestly more exercise are probably the greatest overall measures increasing public health. This doesn’t address the built-in biases of the health care system arising from the business angle, but it could make a huge difference, and Japan seems to provide an excellent model. Thanks for the info!
Do you know of any cross country comparisons on auto immune diseases?
If they are getting sick less often, as you suggest, why are they going to the doctor on average 15 times a year (vs. US average of 3 times per year)?
Shouldn’t “A (fermented) apple a day keep the doctor away” if your theory is right?
To follow up, your data suggests that Japanese health care utilization is much greater than US utilization, so it certainly doesn’t explain lower health care costs in Japan.
You do note that MRI scans in Japan cost a small fraction of what they do here, and cost diferences of that sort could explain lower Japanese spending on health care, but it’s hard to see why eating fermented food makes an MRI scan cost less per unit.
Are the pickles in grocery stores in the USA a good fermented food? Or have they been processed in some way that makes them less effective?
As a result of rigid cost control measures, Japanese medical device manufacturers developed the Toyota Corolla of MRI scanners. Also because of compensation practices, doctors in Japan will schedule multiple visits to cover what one visit would accomplish in the U.S. and more readily hospitalize patients and keep them there longer. The Walgreens-style dispensing pharmacy is rare in Japan (until recently did not exist), so people go to a clinic or hospital to get access to the pharmacy. Doctors in Japan still make considerably less than their U.S. counterparts, though medical students are matriculated into a six-year program straight out of high school.
Tom, I don’t know how average American pickles — the kind you get in supermarkets — are made. There may be some quick-pickling process that replaces fermentation with something else — I don’t know.
If your health depends mainly on what you eat and do (e.g., exercise, not smoke), then rigid cost control measures for medicine (which makes little difference) make plenty of sense.
Off topic (not entirely), sensible ideas slowly go mainstream
Seth, your blog post seems to suggest not that Japanese are healthier than Americans (because of their diet), but rather that the Japanese medical establishment must be much more efficient than the American system at delivering care per dollar/yen.
Ashish, how does my post suggest this? I say, or at least tried to say, that I believe Japan’s health care costs are lower than America’s because the Japanese are healthier to begin with — because they eat a better diet (more fermented food). A more complete answer would have said that Japan has cost controls.
Seth, the fact I read in your post are:
1) Japanese smoke more than Americans do.
2) Japanese make much greater use of healthcare than Americans do.
3) Japanese have greater life expectancy than Americans do.
4) Japanese spend much less on healthcare, per capita, than Americans do.
5) Japanese eat much more fermented foods.
Without any prior bias about fermented foods, my tentative conclusion would be that Japanese doctors are better, and cheaper, than American doctors. (If Japanese made much LESS use of healthcare than Americans did, while smoking more and living longer, then maybe I’d make a different conclusion.)
Ashish, you make a good point. Taken by itself my blog post would seem mysterious and illogical. I have blogged many times about the benefits of fermented foods — not small benefits, big ones — and in the context of those posts this one makes more sense. I believe we need bacteria in our food just as much as we need vitamins.
Eugene’s comments are correct. My experience, however, was that Japanese doctors are not superior to American doctors as Ashish surmises. There seems to be greater variability in training and knowledge among Japanese doctors. I believe that residency requirements are less stringent for new doctors in Japan, which could be the reason. I know there are some excellent doctors in Japan, but outside of the best hospitals the care could be pretty hit or miss. I have a lot of sinus and allergy problems and I was unable to find adequate care when I lived there 15 years ago and I ultimately had to return to the States to get proper treatment.
While it is true that Japanese eat a lot of fermented food and that probably makes a difference, personally I think the largest factor in better health among Japanese is that people walk a LOT more. Everyone uses public transportation and walks/bikes to and from train stations everywhere they go. Also, you often need to use stairs to get to your train, sometimes at a sprint to catch your connection. So the daily commute is a bit of a workout and the correlation between regular exercise and health is pretty well established.
Another big difference is that Japanese have nearly universal health insurance, either through employers or the national plan and people freely visit a doctor for just about anything little thing – stuff that we in the States would just go to a pharmacy for. Maybe all of those doctor’s visits for small things like a common cold means better preventative care?
It is interesting how culturally influenced the practice of medicine really is. And cost consciousness is important in Japan. People are always looking for ways to pinch pennies, especially in the workplace, so that must influence how medicine is practiced. You would think that medicine is very scientific and would be more standardized. But in reality culture influences the patient-doctor relationship, the willingness to takes risks with new treatments and what treatments are prescribed. Japanese doctors may not prescribe a lot of expensive pills, but they do prescribe a lot of pills and usually do not tell you what they are. So maybe Japanese doctors are prescribing a lot of inexpensive placebos and it works well in many cases because patients have absolute faith in their doctors?
Interestingly, when I lived in Japan there was much less awareness of allergies, especially food allergies. However, on a more recent trip back to Japan food allergens were listed on menus of all the chain restaurants, so now there is much more awareness of food allergies as a problem. So, have food allergies increased as the diet has become more factory-produced or is it just that awareness has increased?
Anyway, I would attribute the better health/lower cost in Japan to a combination of factors, with excellent public transportation being a very important one. I’m curious to read that book now, I’ll have to look for it.
Here’s another correlation that comes from living in a country with an efficient mass transit system: along with all that walking, exposure to sunlight. I wonder how natural vitamin D levels compare? Japan doesn’t go on daylight saving time, so in summer you get a pretty good blast of sunlight walking to the subway station in the morning. Almost all elementary school students walk to school.