An Aging Population Creates a 'Nursing Hell' for Many Women

TIMES STAFF WRITER

For more than three decades, Masako Shimano has been the perfect wife, dutiful daughter-in-law, self-sacrificing mother and tireless nurse.

Now she works to spare other Japanese women the same fate.

In this farming exurb about an hour's train ride northwest of Tokyo, women like Shimano, a 58-year-old grandmother, are still referred to as yome, or brides. But these brides are not wrinkled women in wedding kimonos. In rural Japan, "bride" is a job description for the wife of the eldest son.

It might better be translated as "drudge."

As Japan's population ages, the form of the drudgery is evolving from child care to elder care. And the burden of caring for this senior population--whose numbers and longevity have never before been seen--has landed hard on the shoulders of millions of aging yome like Shimano.

Japanese live longer than anyone in the world: currently 77 years on average for men, 84 years for women. More than 13,000 Japanese are older than 100.

With the birthrate stubbornly remaining below replacement level, those older than 65 already make up 17.2% of the population, outnumbering the 14.7% who are younger than 15. The percentage of those older than 60 will nearly double to 42.3% by 2050. Demographers predict that the population will peak by 2007 and then fall continuously for the next 100 years.

Nowhere in the world are the strains of the swiftly aging population so acute. Wage structures, pension policies and retirement ages--as well as the definition of aging, the role of women and the meaning of filial devotion--are all in play.

Japanese tradition has always required the wife of the eldest son to care for her husband's aging parents as well as other disabled relatives until their deaths. Those who would put the bedridden in nursing homes faced ostracism. For many modern women, the sacrifice is too severe. Some cite this "nursing hell" as one reason for not marrying or not having as many children as they might like.

Shimano and many scholars believe that Japan's success in managing its rapid aging comes down to whether it supports or exploits middle-aged women like her.

"In Japan, the birth dearth and the aging society are inexorably linked. Both are women's problems," says Keiko Higuchi, a specialist in gender studies and aging society at Tokyo Kasei University.

About 85% of those who care for elderly relatives are women. More than half of the caregivers are older than 60. More than a third of the caregivers are women who nurse their husband's relatives, sometimes simultaneously caring for their own aging parents.

Shimano had to quit her job as a teacher when she got married. She raised three children while helping in her husband's family fields. Then she nursed her father-in-law, who was bedridden for more than a year, changing his diapers until the day he died.

"I don't know exactly what his disease was," she says. "As the bride, I was not informed."

Now Shimano looks after her 92-year-old mother-in-law while baby-sitting her 6-year-old grandson and keeping house for her husband, a widowed daughter and a son who is still in graduate school. In her spare time, she has become a grass-roots activist who champions the needs of the elderly, the disabled and their beleaguered caregivers.

Though Japan's outrageous youth pop culture receives more attention in the West, it is the aging society that dominates the bookshelves, television talk shows and intellectual debates here.

To tame skyrocketing medical costs and address the problem of nursing hell, the government introduced a public nursing insurance program in 1999. It requires all Japanese older than 40 to pay into an insurance plan that allows them to receive help with bathing, meals or medical care at home if they become feeble or disabled.

However, implementation has been plagued with problems, and even the system's defenders say it may take years to work out the kinks.

Shimano says that in her neighborhood, yome who accept public nursing help are gossiped about and even stigmatized. One of her goals is to sweep away such attitudes by using non-threatening slogans like "Brides are people too" to still the tongues of nasty neighbors.

The controversy over the nursing law goes to the heart of the evolving debate over Japanese family values.

Conservatives worry that the trend toward public involvement will undermine the moral duty most Japanese feel to take proper care of their elders. Liberals believe that the government hasn't done nearly enough.

Political scientist Yoichi Masuzoe spent five years commuting between his home in Tokyo and his hometown on the distant island of Kyushu, where he built a special house for his ailing mother.

He chronicled his family's ordeal, a struggle that many Americans would find familiar, in a much-discussed new book, "When It Comes Time to Put Mother in Diapers." When his mother was dying and the family could no longer cope, Masuzoe tried to find a good nursing home but was told the wait would be three years. He compares this to calling 911 after failing to put out a kitchen fire with a fire extinguisher and being told to wait three years.

"It is the family and the 'bride' doing the nursing who will collapse," he concludes.

The government is trying to double the number of nursing home beds by 2009. Meanwhile, families struggle on. There are frequent reports of caregivers committing suicide under the strain, or confessing to physically or mentally abusing their charges.

The pressure to care for the elderly also contributes to Japan's birth dearth. Higuchi says she knows of women who have had abortions because they could not handle a new baby along with a seriously ill parent. Older women have told their working daughters not to have another baby because they could not help care for a new grandchild on top of nursing duty.

One woman was told by her husband's relatives: "It doesn't matter if you collapse and die. You must nurse," Higuchi says.

Tomonari Inomata, a social worker at the Kagayaki nursing home in Saitama, says family counseling must address the plight of such women.

When it comes time to discharge a patient and Inomata asks the family who will take care of the person, the eldest son usually says, "I will."

"So I say, 'Oh, are you going to quit your job to stay home and look after [your parent]?' And he looks stunned and falls silent," Inomata says. "Of course, what he means is that his wife is going to do it. But he doesn't consult her."

Haruko Kadono, 63, spent 24 years nursing her parents and her in-laws. Her book about her experience has been turned into a movie titled "Elderly Parent."

In one true and painful scene, she asks her husband for a divorce to escape the hell of nursing her demanding father-in-law.

"What did I do?" asks her husband.

"You didn't do anything," comes her literal reply. She adds, "I want a divorce from your father."

"The [public] nursing system is a big scam," Kadono fumes. "In fact, women are forced to quit their jobs to take care of their relatives for free. . . . The policymakers are almost all men . . . and they haven't got a clue."

The Prime Minister's Council for Gender Equality found that nearly 11% of women ages 40 to 49 who quit their jobs cited nursing duties as the reason. That rose to 14% for women in their 50s.

By now, the stunning statistics of Japan's aging population are well known to everyone here. Yet society is only starting to come to grips with the implications and beginning to formulate policies to respond to the coming crisis.

There is broad consensus that Japan will have to keep raising its retirement age, scale back public retirement benefits and redefine its seniority-based wage structure to avoid national bankruptcy.

"Everyone understands that the current pension system will not survive," says Shinji Fukukawa, who heads the Dentsu Institute for Human Studies, a respected think tank.

But policy details raise emotional questions about financial fairness, employment traditions and family values:

How much can retirement benefits be scaled back without causing political and social instability?

How can women and elderly people be invited into the work force, instead of excluded as dependents?

How much can this xenophobic country rely on robots instead of immigrants?

How should medical care be allocated among generations? And what about the dignity, privacy and ultimately the right to life of the very old?

Economists agree that Japan will need to tap its underutilized female work force to ease labor shortages. Sixty percent of single Japanese women and half of married women are in the work force. But the vast majority of married women choose lower-paying, part-time jobs because they are also doing virtually all of their family's housework, child care and elder care.

However, if female participation in the labor force continues to rise as it has for the past 20 years, who will have time to care for ailing seniors? Can older workers, who will probably be women, accept the low wages offered for the hard physical labor of such jobs?

An estimated 1 million nursing home workers will be needed in 2025, and the Justice Ministry is moving to admit more foreign guest workers to fill the gap. But many question whether Japan will be able to control illegal immigration or tolerate large numbers of foreigners.

Higuchi, the specialist on the aging who opposes importing workers, instead proposes a "nursing draft." Since pacifist Japan has no mandatory military service, she would require all young people to spend a year at age 20 caring for seniors.

Today's problems are the legacy of Japan's extraordinary success in boosting life expectancy. In 1935, a Japanese man could expect to live only 47 years and a woman 50 years. Most parents died before they became bedridden. And if elder care became too burdensome, there was a folk tradition in some rural areas of leaving the aged to die on a high mountain, as depicted in a famous short-story-turned-film titled "Throw Away Grandma Mountain."

Japanese attribute their longevity to their diet, the habit of walking instead of driving, extremely low infant mortality, a generous universal health-care system and, of course, the care that many children lavish on aging parents.

Yet in recent years, when the nation's longevity statistics are released each Sept. 15 on Respect for the Aging Day, the tenor of the media coverage has changed from celebratory to "Oh no, it's increased again," complains Inomata, the social worker.

And longevity does not always translate into good health. In 1987, the average time that families nursed an aging relative was four years. But by 1997, it had become 7.4 years, according to a survey by Higuchi. Nearly 49% of bedridden elderly have been that way for more than three years, Health and Welfare Ministry statistics show.

The ministry estimates that by 2025, barring major progress in gerontology, Japan will have 5.2 million elderly requiring full-time care, about 2.3 million of them bedridden. If current projections hold, that would mean 2% of the entire population would be confined to bed.

Japan is already "the empire of the bedridden," says welfare policy specialist Nobuo Maeda. A professor at Seigakuin University, Maeda is sharply critical of the quality of care for elders. He says the government-run geriatric-care system has emphasized warehousing rather than rehabilitation.

Patients whose problems could have been treated with early intervention are left incontinent or bedridden because of ignorance and financial considerations at geriatric hospitals and nursing homes, he argues.

Geriatric psychiatrist Hideki Wada says doctors also tend to overprescribe tranquilizers for the elderly and underuse antidepressants. Japan does not train enough gerontologists and does not even have good gerontology textbooks, Wada says.

But with few other options, self-help is starting to flourish. A generation of vigorous seniors who were forced to retire at 60 is looking for jobs, volunteering and becoming a political force.

The percentage of Japanese elderly living with their children is declining, from 69% in 1980 to 52% in 1997, the government says. According to a Mainichi newspaper survey, the percentage of Japanese who say it's undesirable for parents to live with their adult children has more than doubled.

Many middle-aged Japanese are planning for a retirement that will ensure independence. In one telling trend, healthy midlife Japanese who remodel their homes are adopting senior-friendly features such as shallower bathtubs or hallways wide enough for wheelchairs.

The old notion that physical care by non-family members is humiliating is also starting to fade.

Shimano is determined not to be nursed by her children, and plenty of Inomata's clients also express relief not to be a burden on--or at the mercy of--their family "brides."

"People used to have the prejudice that nursing homes were all 'Throw Away Grandma Mountains,' " Inomata says. "And the elderly used to think they were being dumped here. But now they say, 'Finally, they've let me in!' "

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Skyrocketing Costs of Medical Care

Japan's burgeoning population of seniors will strain the finances of the nation's vaunted universal health-care system. The number of elderly requiring care is expected to double in 30 years.

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Notes: "Elderly" is defined as older than 70 or bedridden and age 65 to 70.

Sources: Ministry of Health, Labor and Welfare "National Medical Care Expenditure" and "Annual Report of Medical Care for the Aged," 1999, Welfare White Paper

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World Life Expectancies

Japanese live longer than anyone on Earth, thanks to their healthy diet, low infant mortality rate and universal public health care.

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Highest Life Expectancy at Birth

Japan

2000-2005: 81.5

2045-2050: 88.0

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Sweden

2000-2005: 80.1

2045-2050: 84.6

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Hong Kong

2000-2005: 79.9

2045-2050: 84.7

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Iceland

2000-2005: 79.4

2045-2050: 83.1

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United States

2000-2005: 77.5

2045-2050: 82.6

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Lowest Life Expectancy at Birth

Lesotho

2000-2005: 40.2

2045-2050: 65.1

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Malawi

2000-2005: 39.3

2045-2050: 64.0

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Swaziland

2000-2005: 38.1

2045-2050: 62.7

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Mozambique

2000-2005: 38.0

2045-2050: 62.8

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Botswana

2000-2005: 36.1

2045-2050: 63.2

The Aging Societies

Japan's society is among the fastest-aging in the world, but it will have plenty of company in Europe. The high ratio of elderly to young people in these countries is expected to burden working-age citizens.

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People Older Than 60 in 2000

Japan: 23.2%

Italy: 24.1%

Spain: 21.8%

U.S.: 16.1%

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People Older Than 60 in 2050

Japan: 42.3%

Italy: 42.3%

Spain: 44.1%

U.S.: 26.9%

Source: "World Population Prospects, the 2000 Revision," United Nations Population Division

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To read Part 1 in this series, go to http://www.latimes.com/japan.

Japan's Demography Shock

Sunday: Wrenching decisions about having children.

Today: Caring for a graying society.

Tuesday: Willing to give up on Mr. Right.

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Sonni Efron recently completed a 4 1/2-year assignment in Japan. Researchers Makiko Inoue and Hisako Ueno in The Times' Tokyo Bureau contributed to this report. Photographs for The Times by Shima Hayase.

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