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'Medicine in Japan and Germany'

Friday, April 30, 1999

Moderation: Dr. Uwe Czarnetzki, Chairman of Deutsche Gesellschaft der JSPS-Stipendiaten e.V.
14.00 Uhr Welcoming Remarks
14.30 Uhr Prof. Dr. Kumao Toyoshima, Professor Emeritus, University of Tokyo; Director Sumitomo Hospital
..........'Proposal for prevention and treatment of cancer based on recent progress of cancer research'
15.30 Uhr Coffee Break
16.00 Uhr Prof. Dr. Erhard Rosner, University of Gﾃｶttingen, Institute for East-Asian Studies
..........'Chinese Medicine in Japan from its Beginnings to the 20th Century: Convergence and Irritation'
17.00 Uhr Dr. Christian Oberlﾃ､nder, The University of Tokyo, Faculty of Medicine
..........'The Japanese Health Care System between Aging and Internationalization: Opportunities for German-Japanese Cooperation'
18.00 Uhr Break
19.00 Uhr Transfer by bus to restaurant 'Rathskeller'
19.30 Uhr Dinner

Saturday, May 1, 1999

9.00 Uhr Prof. Dr. Wolfgang Michel-Zaitsu, Kyushu University, Institute of Languages and Cultures
..........'Inner Landscapes - Japan's Reception of Western Conceptions of the Body'
10.00 Uhr Coffee Break
10.30 Uhr Dr. Heidrun Reissenweber, University of Munich, Dept.of Internal Medicine, Research Unit for Japanese Phytotherapy
..........'Integration of Japanese Phytotherapy (Kampo) into modern Medicine'
11.30 Uhr Mrs. Michiko Nakagawa-Fehlberg, practical doctor
..........'Delivery in Germany and in Japan'
12.30 Uhr Lunch14.00 Uhr Annual Assembly, Deutsche Gesellschaft der JSPS-Stipendiaten e.V.

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14.30 Uhr Prof. Dr. Kumao Toyoshima, Professor Emeritus
University of Tokyo; Director Sumitomo Hospital

'Proposal for prevention and treatment of cancer based on recent progress of cancer research'

During 1960's, basic research on cancer started to change from classical style to recent molecular approaches. Among various progress, three most important findings are

1. Mutagenic substances were demonstrated to cause cancer in experimental animals,
2. Highly oncogenic sarcoma virus proved to possess a gene responsible for its oncogenesis, presently called viral oncogene, and
3. Normal cells fused with cancer cells suppressed tumor forming ability of cancer cells suggesting presence of the tumor suppressor genes.

In 19970's reverse transcriptase of retroviruses was found and restriction endonucleases were also in hand. Thus there have been great strides in molecular biology. In the middle of 1970's, by using molecular biological technique, D. Stehelin, M. Bishop, H. Varmus and P. Vogt found cellular counter part of vial oncogene src, which lead the cancer research to molecular analysis of the cause of cancer in 1980's.
Thus, we gained very much on understanding of molecular mechanisms of cancer during the last quarter of the 20th century. That is,

1. Cancers are caused by multistep-mutations of the genes by mutagenes in various environment including food, air pollutions etc.
2. The primary targets of mutagenesis are proto-oncogenes and tumor suppressor genes which control cellular growth and differentiation in normal states,
3. Hereditary mutation on one of turmor suppressor genes, or on a proto-oncogene, in special cases, arise cancer prone family. In addition, mutation of genes responsible for genome repair mechanisms results in high incidence of cancers.
4. Mechanisms of resistance of cancer cells to drugs and radiations as well as molecular mechanisms of cancer metastasis are also explained step by step as the changes of cell functions. Although there are still many steps to be resolved, we now realize that cancer is caused by accumulation of mutations and thus recent higher incidence of cancer in developed country is reasonably explained by longer exposure to mutagenesis according to longer human life time.

Our experience of the society with advanced age showed us that both pains and troubles caused by cancer are less in aged persons compared to younger generations. Thus we recognize importance of cancer prevention. In spite of the effort of cancer prevention, the effect may not become apparent soon. So that improvement of diagnosis and treatment is also very important. Progress in early cancer diagnosis allows us treatment by smaller surgical regions. In addition, development of targeting method of anti cancer drugs gives us tools for treatment with smaller pain. Specific and non specific cancer immunotherapy as well as cancer gene therapy are the point of issue for development of cancer treatment in near future.

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Prof. Dr. Erhard Rosner University of G�ｺ楠ｴｩngen, Institute for East-Asian Studies 'Chinese Medicine in Japan from its Beginnings to the 20th Century: Convergence and Irritation'

The influence traditional East Asian medicine has had on Japan up to present day is often regarded in the West as a shining example of successful medical pluralism. In China many see it as a proof positive of the exportability of their own traditional medicine. Furthermore, in China as in Japan, this East Asian facet of modern-day health care is often invoked, and occasionally overused, as a symbol of common ground within the vast sphere of the "culture of Chinese characters" or of the "Confucian world", respectively. A look back through history shows that the reception of Chinese medicine in Japan was a protracted and complex process. There were many shades of eclectic assimilation of certain authors and texts; modern methods and know-how were taken up and improved upon in Japan, and important treatises from China painstakingly compiled and printed. There were phases of heavier Chinese influence, often reinforced by the appearance of Chinese refugees who were skilled in the art of healing, but there were also periods of estrangement from China, even out-and-out rejection, not only in the 19th century. The lecture draws an outline of this development, starting with the Ishin-Sho (984 AD), which forms an early point of crystallization of Japanese independence that aroused considerable attention in China as well. A knowledge of these processes, which go far back in history, sheds but a few rays of light on the marked differences between Japan and China, which are often perceived by Europeans only in the vaguest of terms. It also helps in understanding the foundations on which pluralism is sustained in present-day Japanese medicine.

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Dr. Christian Oberl莪､er The University of Tokyo, Faculty of Medicine 'The Japanese Health Care System between Aging and Internationalization: Opportunities for German-Japanese Cooperation'

The Japanese health care system is credited with providing the Japanese population with fairly equitable access to health care at relatively low cost. The Japanese population enjoys today the highest life expectancy in the world (82.9 years for women and 76.4 years for men in 1995). However, just like many other sectors of Japanese society, the foundations of the Japanese health care system are shaken by the two trends of population aging and internationalization. These trends force numerous difficult choices and reform decisions on Japanese health policy makers that challenge long-established arrangements. However, in addressing these problems, opportunities for cooperation between Germany and Japan also present themselves. This paper will first outline some basic features of the Japanese health care system, covering the structure of health care financing organizations, service providers, and their interaction. The special incentive structure caused by the lack of separation of medicine and pharmacy and the need for functional differentiation among clinics and hospitals in Japan will be addressed in particular. Then, recent reforms concerning the position of traditional medicine in the Japanese health care system will be briefly discussed. Finally, recent developments in the markets for medical technology and long-term care equipment will be examined with a view to opportunities for cooperation between German and Japanese companies.

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Prof. Dr. Wolfgang Michel-Zaitsu Kyushu University, Institute of Languages and Cultures 'Inner Landscapes - Japan's Reception of Western Conceptions of the Body'

A look back shows that it took Japanese doctors several centuries to familiarize with European medicine. For instance, even though the Jesuits founded a hospital in Funai soon after their landing in 1549, it took about two centuries before a human cadaver was opened in Japan to peer inside and to increase knowledge of the inner structure of the human body. Starting from the Eastern conceptions of the body prior to the arrival of the first Europeans, the long way is depicted which eventually led to a new view on the body in the 19th century. In Sino-Japanese medicine, diagnosis and therapy were aimed at the patient as a whole, and consequently little attention was paid to the role of specific body parts. Furthermore, this conception attached great importance to cosmic harmony and freedom from bodily harm, so little room was left for invasive surgical measures including dissection. The first century of Euro-Japanese (Ibero-Japanese) interactions showed somepromising attempts to combine Eastern conceptions with Western-style surgery, but hegemonial fights among Japanese warlords brought the hospitals and other institutions of the missionaries to an early end. With the increasing suppression of Christianity since the 1680s the reception of European medicine almost came to a halt. Despite of unrestricted trade and of comparatively low language barriers not a single Japanese reference to any Western work on medicine is known until the final expulsion of the Iberians' in 1638. Handwritings of the so-called "southern-barbarian-style-surgery" schools show Iberian elements mixed with Chinese, Japanese and Dutch elements. This casts strong doubt on the possibility that the Japanese ever came to practice something like "Iberian-style-surgery" in the sense of a paradigm that could be passed on or handed down to succeeding generations. After 1641 the Dutch trading post Dejima (Deshima) in Nagasaki became the only Western door to Japan. Now various restrictions imposed on Westerners as well as the language barrier created new obstacles to the flow of information. Euro-Japanese communication remained insufficient and unstable throughout the century, whereas educated Japanese could read the literature from China. A remarkable influx of Chinese science and technology during the 16th century had led to the adoption of a number of innovations and opened up the Japanese mind towards China. It was in the 17th century, moreover, that Chinese Confucianism was embraced as a comprehensive system. This served to enhance the prestige of Chinese medicine. Although European barber-surgeons and even some university trained physicians, who all paid great attention to human anatomy, again and again gave instructions in Nagasaki and Edo (Tokyo), the Japanese perception of Western surgery was restricted to a few subjects regarded as useful: plasters, ointments, the treatment of wounds, fractures and the like. Phlebotomy, cauterization, cystolithotomy of bladder stones, bone trepanning, amputations and other similar types of treatment were rejected. Due to the lack of sufficient information and to the overwhelming power of traditional approaches even self-proclaimed Western-style doctors sticked to Sino-Japanese pathology. The reception of Western medicine remained highly selective and additive in nature. Surgery happened only on the surface of the body. Nevertheless it was always the Japanese side that kept up these scientific contacts, persistently requesting informations, instructions, books and instruments from the rather passive Dutch East Indian Company (VOC). The signs of change appeared slowly and in many areas. At one hand there was a growing dissatisfaction among intellectuals with the rigid and often unpractical doctrines of Zhuxi's Confucianism, which formed an ideological pillar of the Tokugawa regime. On the other hand the use of imported European mirrors, lenses, spectacles, microscopes, telescopes and zograscopes had a substantial impact on the way things were seen. This was increasingly reflected both in language and in art and had its influence on scholars too. Paradoxically the new approach to the human body in the following 18th century was initiated by a physician who aimed at restoring the ancient authorities rather than revolutionizing contemporary medicine: Yamawaki Toyo. His dissection of a human cadaver in 1754 stimulated further dissections performed by Kawaguchi in the 1770's, an outstanding man solely relying on his own observations. Finally with the translation of Kulmus' "Anatomical Plates" into Japanese by Sugita and Maeno, the road was paved for a new conception of the body and of medicine. To question orthodox teachings by relying on observation and experiment rather than on the wisdom of ancient authorities could be considered a challenge to the Tokugawa system, but when none of the pioneers had met with a hostile reaction from the authorities, there was no more hesitation. Dissections ensued almost all over the country, accompanied by an intensive study of Western writings. This departure, combined with other disciplines, was at once an expression of and a stimulus to sociopolitical change, which is often referred to as Dutch learning (rangaku), and which was to lay the foundation for the rapid modernization of Japan beginning in the 19th century.

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Dr. Heidrun Reissenweber University of Munich, Dept.of Internal Medicine, Research Unit for Japanese Phytotherapy 'Integration of Japanese Phytotherapy (Kampo) into modern Medicine'

Remedies origination in the herbal sphere may still play an important role in future therapeutics, and this despite an apparent predominance of synthetic drugs in modern pharmacotherapy. Two factors account for this. First, in recent years a renewed interest has emerged to subject plants to a scientific evaluation in regard of their chemical ingredients. Obviously it is assumed that some plants may promise therapeutic potentials that have remained unknown so far. Second, plants have played an essential role in the medical systems of all cultures of the world since ancient times. The therapeutic efficacy of such medical plants has been established empirically, and it is to be asked whether an approach exists to evaluate such efficacy scientifically. One of the issues involved here touches on the question how empirically effective methods that have originated in a traditional therapeutic context, and that are closely tried to culture-specific notions of diagnosis and illness, can be integrated into cosmopolitan, i.e. modern scientific medicine. In Japan, Kampo therapy (lit. 'method from Han-period China'), defined by the administration of crude drug formulae mainly of plant origin on a rather pragmatic clinical basis, hat been the established medicine for centuries until it was replace by Western medicine towards the end of the 19th century. Recent decades saw a revival of Kampo which took place within a context completely dominated by Western medicine. The majority of Kampo specialists consider integration into modern medicine as the only way to preserve its role within the modern health care system. Main indications today are disease patterns caused by modern industrial society, such as chronic and degenerative diseases, functional and psychosomatic disorders and the multiple diseases of the elderly. The gradual integration of Kampo into modern medicine has already caused significant changes within the traditional therapeutic approach which are characterized by the following main features:

1. In contrast to other Asian countries, in Japan only examined physicians are allowed to prescribe traditional medication. In most cases Kampo drugs are applied in addition to a modern medical regimen.
2. Practitioners who during the early years of Kampo revival created the image of Kampo as an alternative treatment and claimed equal recognition with modern medicine have become a minority. Modern specialists regard Kampo as an additional therapeutic option to enhance the quality of modern health care in defined areas.
3. Recent textbooks reveal the trend to standardize traditional diagnostic procedures, to modernize the Kampo terminology and to clearly determine indications, benefits, and risks from the viewpoint of Western medicine.
4. For the past forty years, extensive research has been conducted in Japan both to identify the chemical structure of herbal drugs and the pharmacology of active ingredients of complex prescriptions, and to elucidate the dynamics of traditional therapies in general. Research interests include quality control of herbal preparations, standardizing of active ingredients within crude extracts and toxicity control. These efforts let to an acknowledgement by the Japanese National Health Insurance, covering Kampo-prescriptions since 1976. The initial pharmacological research has increasingly been followed up by clinical trials conducted in research centers of Kampo medicine as well as in university hospitals, applying established methodology of clinical research.

Integration into modern medicine is a precondition for the internationalization of Kampo therapy. Traditional experience gives valuable hints for the possible medical significance of a herbal prescription, but it cannot replace scientific evaluation and proof of efficacy. Respecting tradition means to raise the quality of herbal preparations and the level of scientific evaluation of medicinal plants with the aim that this form of therapy may preserve ist place in modern medicine and may survive economically and scientifically in times of growing competition.

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11.30 Uhr Mrs. Michiko Nakagawa-Fehlberg, practical doctor

'Delivery in Germany and in Japan'

Pregnant ladies visit the gynaecologist for regular check up and once the contraction starts, she will visit the hospital and have her baby there. After one week she will go back home. The whole process is basically the same here in Germany as well as in Japan. But still, some differences, I want to point out:

• Different health insurance systems,
• Function of the hospital,
• Cultural concept of family

Ad 1) Different Health Insurance Systems Everyone in Japan and Germany should have some kind of health insurance. In Germany, there are two very different types of health insurance: Public insurance and Private insurance. All expenses of regular check-up and delivery are covered. In Japan, there is only public insurance. The insurance does not cover the normal pregnant check-up and delivery, only when medical problems arise. Instead they will pay a so called congratulation money after delivery.
Ad 2) Function of the Hospital In Germany, patients with public insurance can visit or enter hospital only after referral from the praxis doctor. Patients with private health insurance can visit hospitals by their choice. So, pregnant woman visit the praxis doctor for regular check-up, but for delivery they enter the hospital. The role of praxis and the role of hospitals are clearly defined. In Japan, patients can visit hospitals of their choice. Hospitals have praxis function, too. In Japan, the pregnant woman can choose any doctor, as she likes. The basic rule is: From the first visit for pregnancy check up until delivery and post natal check up you should stay in the same clinic or hospital.
Ad 3) Cultural Concept of Family In Germany, everything goes as couple. Of course, the husband will accompany her to the delivery room. He will take holidays to help his wife with the household and baby care. In Japan, to have a baby is not just a matter of the couple. That is a matter of the whole family, including the parents of the couple. So, most expected person for help is the grandmother. She will visit the new mother and will even stay with them. Before, it has been common to live together as three generations. When the due date is coming closer, the wife goes to her own parents and stays there until she is recovered fully. Nowadays, living together as three generations becomes less and less. But the custom, that the new mother stays with her own parents, separating from her husband around delivery, is still common.