|JPRI Working Paper No. 23: August 1996
Mental Castration, the HIV Scandal, and the Japanese Bureaucracy
by Masao Miyamoto
After living in the United States for over ten years and practicing medicine and psychiatry there, I returned to Japan in 1986 and joined the Ministry of Health and Welfare. When I compare my first year in America with the first year after I returned to Japan, I am convinced that coming back to Japan was far more stressful. Americans were kind to me, but upon returning to Japan I found that bringing back foreign ways--for example, clarity in speech or an individual style of dress--was rejected. Many Japanese who have been abroad try to erase any acquired foreign habits because of their fear of ostracism.
I resisted this pressure to conform. In fact, I more or less preferred being
isolated by my ministerial colleagues, because I no longer had to dine or sing
with them at a karaoke bar, which meant my evenings were my own, to spend as I
wanted. However, I was not happy with the way the Japanese bureaucracy
functioned, and this is why I wrote Straightjacket Society (Kodansha, 1994), which is a clinical analysis of the psychology of the Japanese bureaucracy and society. Because of this book, and my refusal to apologize for having written it, in 1995 I was fired from the ministry. I am therefore impervious to further retribution in discussing the most recent revelations of its flaws.
As many of you may be aware, since early 1996 the Ministry of Health and Welfare (MHW) has come under fire because it allowed HIV-tainted blood to be used in treating hemophiliacs. Because of its negligence, 400 people have already died and over 3,000 have been infected with the HIV virus. On March 29, 1996, the ministry acknowledged it was at fault and agreed to pay compensation to the victims. This is a positive first step in overcoming this tragedy, but much more needs to be done if the pattern is not to repeat itself.
In March, 1983, the Centers for Disease Control in Atlanta issued a warning in the U.S. that blood products might be tainted with the HIV virus. Soon afterward the F.D.A. approved the use of heated blood products. As a matter of course, this information would have been reported to the Ministry of Health and Welfare by the Japanese Embassy in Washington, D.C.
In June, 1983, Travenol Japan (the former name of Baxter Ltd.) sent a report to the Ministry of Health and Welfare that Travenol America, because of findings connecting unheated blood products to HIV, had recalled their products in the United States. In that same month, the Ministry of Health and Welfare established an AIDS study group headed by Dr. Takeshi Abe, an expert on hemophilia. This study group held a meeting on July 4, 1983, at which several important issues were discussed. Unfortunately, notes taken at the meeting were thought to be nonexistent until the file magically appeared at the ministry in February, 1996, after Mr. Naoto Kan, the new minister of Health and Welfare, appointed an in-house investigative body to look into HIV-related issues. This file revealed three crucial facts.
1. Imports of heated blood products were being urgently considered.
2. Unheated blood products of non-American origin would continue to be imported.
3. The use of heated blood products from the U.S. would cause some damage to Japanese pharmaceutical companies, but this should be ignored.
In short, the ministry was aware of and had adequately grasped the danger surrounding AIDS. However, a week after the July 4th conference the AIDS study group held another meeting and decided that imported heated blood products would be subject to lengthy clinical trials, and the unheated blood products from the U.S. would not be banned. This means there was a 180-degree change in the group's position.
In the latter part of July, 1983, one of Dr. Abe's hemophiliac patients died of an AIDS-like disease. Dr. Abe consulted on this case with two physicians of the U.S.'s Center for Disease Control and both diagnosed the cause of death as AIDS. However, this was not recorded as the first AIDS death in Japan.
In February, 1984, clinical testing of heated blood products began in Japan. In March, a subcommittee of the AIDS study group recommended the use of heated blood products, and the AIDS study group was dissolved with no sense of impending crisis.
In September, 1984, Dr. Abe confirmed that 23 of his 48 patients with hemophilia had been infected with HIV, but this information was not made public. In December, 1984, the Ministry of Health and Welfare confirmed that 47 out of 183 Japanese hemophiliacs tested positive for HIV. Again, this was not made public. In March, 1985, the ministry identified a male homosexual who was living in the U.S. and who had returned to Japan temporarily as the first AIDS patient in Japan.
Given this chronology, for the ministry to assert that the first AIDS patient in Japan was a homosexual living in the U.S. seems a blatant attempt to manipulate the public into believing that AIDS is a disease prominent outside of Japan but that Japan is somehow immune to HIV. Behind this manipulation lies the protectionism of the Japanese pharmaceutical industry, designed to give Green Cross, the largest Japanese maker of blood products, sufficient time to develop heated blood products so that the Japanese market would not be inundated with heat-treated blood from the U.S.
In July, 1985, the ministry approved the sale of heated blood products. However, despite knowing that unheated blood products could lead to the spread of HIV, it did not order companies to recall unheated blood products. In May, 1989, HIV-infected hemophiliacs filed a lawsuit against the government and Japanese pharmaceutical companies. During this lawsuit the ministry maintained that it could not find any of the files of the AIDS study group. In October, 1995, the court proposed a compromise settlement indicating that the government was at fault. In January, 1996, Green Cross was found to have continued selling unheated blood products until 1988, after heated blood products were approved in 1985. This sale of unheated blood products affected not only hemophiliacs but also people who underwent surgery and received transfusions.
In January, 1996, Mr. Kan was appointed Minister of Health and Welfare and formed an in-house investigation team. On February 9, 1996, nine files of documents related to the HIV study group, long claimed to be lost or non-existent, were found. This is when the HIV scandal started to cause a public uproar. On March 29, 1996, a compromise settlement was signed by both sides in the lawsuit. On April 3, the MHW vice-minister informed Mr. Kan that seven more files had been found. These files were actually found in January, but their existence was disclosed only after the settlement. So far only two of the seven files have been made public.
These two files make it very clear that the ministry had been collecting information from around the world related to HIV-tainted blood products and AIDS, and that it was therefore certainly aware of the dangers. These files also make clear that Dr. Abe, the head of the AIDS study group, manipulated the time frame so that Japanese and American pharmaceutical companies finished their clinical trials at the same time. This meant that approval for both was granted at the same time. If the clinical trial period had not been manipulated, American pharmaceutical companies, which had a head start, would have won early approval for and could have overwhelmed the Japanese market with their heated blood products. Dr. Abe's manipulation of the clinical trial period suggests that he wanted to protect Japanese pharmaceutical companies so they could enter the market at the same time.
How the Bureaucracy Works
After going over this information, I isolated ten problems of the MHW's bureaucratic structure.
1. The harmony of the ministry or the group is more important than reality.
2. The major task of the ministry or the bureaucracy is the protection of industry, not the protection of the public.
3. The concept of continuity, which is an important dogma within the bureaucracy, clashes with crisis-management.
4. The seniority system minimizes criticism of one's superiors, obscuring the existence of problems.
5. No leadership is exercised in the decision-making process, and the public is made to pay for the bureaucrats' mistakes.
6. The system of amakudari--bureaucrats joining related industries in their field upon retirement--fosters the status quo and maintains the pre-existing regulations.
7. There is no Freedom of Information Act in Japan.
8. Individual rights are not respected.
9. Clinical trials for new drugs are a form of non-tariff trade barrier.
10. Japanese consider themselves to be very special.
I think these problems are a distillate of the Japanese bureaucracy as a whole, and they are all interrelated. I would therefore like to use the HIV scandal to explore the social psychology of Japanese society.
When I entered the Ministry of Health and Welfare I recognized that in Japan individuals should not assert their rights. Even if the rights of the individual are acknowledged by the group, one is not supposed to exercise them in front of the group. The Japanese bureaucracy is even more special in the sense that once one belongs to it, one has to embrace the myth that the system is immortal. In order to maintain this myth, it becomes important that everyone believes the group is perfect. Furthermore, the notion of tradition is reinforced, and since many bureaucrats think that the Japanese bureaucracy has reached the level of perfection, tradition equals the status quo. Therefore, major change does not take place.
There is another dogma within the Japanese bureaucracy, namely continuity. Upon entering the ministry I was told by many of my superiors that continuity was the most important concept for bureaucrats. Why is continuity so important? Because it prevents significant change and values the status quo. Given these values, the Japanese bureaucracy as an organization becomes almost impossible to restructure.
The status quo in the Japanese bureaucracy takes the form of precedence: one must always respect the precedents that have been set. In the case of the HIV scandal, in 1983 some officials of the ministry thought that it might be important to change the policy and import heated blood products in order to prevent the spread of AIDS among hemophiliacs. But the opposition to this argued that it would establish a precedent of approving drugs for sale without clinical testing. The concept of precedence was more important than human life.
In Japan, in order to market a new drug, regardless of the country of origin, it is mandatory that the drug undergo clinical trials in Japan as a regulatory measure. In the case of heated blood products, the ministry could have used its power to waive domestic clinical testing and call for emergency imports. But when precedence becomes a tradition, it overrides any emergency.
Beginning in 1987, I was seconded to the Defense Agency for two years, where I was in charge of the health problems of the entire Japanese army. At one meeting I emphasized that the armed forces should be made aware of the dangers of the HIV virus. An air force colonel, who was also a physician, said to me, "Dr. Miyamoto, is this the opinion of the Ministry of Health and Welfare, or is it your own personal opinion?" I answered that it was my own opinion. His response was, "As a bureaucrat, the most important thing is continuity. What you're saying is that once someone becomes infected with HIV there is no cure, and since the mortality rate is extremely high, extra precautions should be taken. It is my understanding that AIDS is a disease limited to homosexuals. Since the Ministry of Health and Welfare's opinion is 180 degrees different from yours, your suggestion will only provoke anxiety among armed services personnel." He further cautioned me, "As a bureaucrat, one should not make drastic changes in approach because of the important of continuity. You may not be aware of this since you have only recently returned from America. If you want to make a drastic change in policy you must have an order from the MHW."
As should be obvious by now, the concept of continuity and the importance given to precedent have severe implications for crisis management. AIDS is a big problem for all countries. When it first became recognized as a problem, it should have been a matter of crisis management. But the lack of a crisis-management mentality in the Japanese bureaucracy is revealed in the decisions made by the MHW in 1983.
In order to maintain the status quo, people must be trained not to think for themselves; they must, in effect, be mentally castrated. The Japanese bureaucracy wants the public to be as obedient as sheep, not complaining, never challenging the system. If everyone is educated to embrace these values, then Japan as a system can maintain its harmony. From the bureaucrats' point of view--from the point of view of those who control Japan Inc.--this is the ideal. However, in order to imprint these values on people a special technique is needed that halts the growth of identity integration.
Identity integration is a term used in psychoanalysis to refer to an individual's ability to distance him or herself from parental figures and become independent. All of us live in worlds of both fantasy and reality, but most of us are able to make a distinction between the two. Identity integration places a clear boundary between these two worlds, enabling individuals to control their impulses and at the same time to deal with strangers and separation anxiety. Therefore identity integration is a sine qua non for functioning in everyday life.
The Japanese bureaucracy's goal is to halt people's identity integration at the level of adolescence, a period when one still needs some dependency. This is why I say that the goal of Japanese education is psychological castration. Unfortunately the bureaucrats are also puppets of the bureaucracy, and their identity integration is the same as everyone else's. Therefore, they do not know that they hinder identity integration.
How did this sophisticated way of controlling people develop? The
responsibility goes back to the Edo period (i.e., the Tokugawa military
government). Perhaps Japanese bureaucrats also got a hint from bonsai, the Japanese art of stunting the growth of trees, because in Japan creative ability and innovation have been trimmed. Creating bonsai can be viewed as a form of castration.
The HIV scandal arose within these dynamics of Japan as a system. Since I was trained in Western psychoanalysis, I learned that in the psychoanalytic diagnostic interview one looks for contradictions in the patient's behavior. When I went over all the documents and comments released by the MHW about the HIV scandal, I found a contradiction. On the one hand, the MHW emphasizes that the safety of the people is most important. But on the other hand, according to the file of July 1983, the MHW was well aware that unheated blood products stood a good chance of being contaminated by HIV.
If you believe the MHW's official stance, you would expect an immediate ban on imports of unheated blood products and the emergency import of heated blood products. But instead the MHW reversed its original decision. It decided against a ban on unheated blood products and in favor of the regular procedure of clinical trials, which takes a long time. This allowed Japanese pharmaceutical companies to develop and market their own heated blood products while keeping American products out of the Japanese market. Note also that it was only in 1985 that the ministry approved heated blood products and that it did not order the recall of unheated blood products possibly tainted by HIV until 1988.
What this contradiction means is that the bureaucracy is not concerned about the safety of the people. Instead, the evidence clearly indicates that the MHW is concerned about protecting the pharmaceutical industry.
Let me go back to the clinical testing, which I view as a form of trade barrier. This barrier also sheds light on the bureaucrats' view that the Japanese are special. In order to be marketed in Japan, all drugs, even those developed in the U.S. and approved by the F.D.A., have to undergo years of clinical trials. Given the quality of medical care and research in the U.S., there is no reason for further Japanese clinical trials (which are often identical to those in the U.S.). But MHW officials argue they are necessary because "The Japanese are different; therefore new drugs have to undergo our own testing." The MHW officials seem to have forgotten that the U.S. is a multi-racial society and includes many people of Japanese ancestry. This is why I view clinical testing as a hidden trade barrier. What is hidden behind the word 'different' is the protection of the Japanese pharmaceutical industry.
The notion that the Japanese are different was vividly illustrated after the Kobe earthquake last year. Five U.S. physicians came to Japan to give emergency assistance but were told by the MHW that they could not treat victims because they were not licensed to practice in Japan. In addition, Americare donated a large amount of Tylenol, but the MHW would not release it because it said that the pain-killing effect of Tylenol was too strong for Japanese.
The bureaucracy's insistence that the Japanese are special is not confined to the MHW. In 1987, when there was pressure from the American government to open the Japanese beef market, a group of American politicians invited their Japanese counterparts to a luncheon of American beef. At that luncheon, Mr. Tsutomu Hata, a former prime minister and then head of the delegation representing the Ministry of Agriculture, said that it would be difficult to increase the consumption of beef in Japan because of Buddhist restrictions and because Japanese intestines are longer due to rice eating and therefore cannot digest beef properly.
Senator Phil Gramm of Texas replied that opening the market would be a good way to test whether long intestines or Buddhist teaching were preventing increased consumption of beef. Japan has since opened its market for beef and consumption has quadrupled. Mr. Hata is also known for his statement that because snow is different in Japan foreign skis have to be restricted. The reasoning behind all these restrictions on medical qualifications, Tylenol, beef, and skis is so unscientific as to be laughable.
The Issue of Amakudari
Let me now turn to the AIDS scandal and the role played by amakudari.
That Japanese bureaucrats view themselves as special is clear from the meaning
of the word amakudari, which means 'descent from heaven.' They are clearly in a
heavenly world because they do not have to take responsibility, and upon
retiring from their ministry, through amakudari, they are guaranteed a large income without much work.
Green Cross, a pharmaceutical company known for its blood products, has suffered heavy criticism in the Japanese media for having continued to sell unheated blood products until 1988, thereby causing the widespread dissemination of the HIV virus among hemophiliacs. Many senior bureaucrats from the MHW joined this company upon retirement from the ministry. For example, the then president of Green Cross was a former director general of the ministry's Bureau of Pharmaceutical Affairs.
Why does industry accept these bureaucrats? Because if the company makes a mistake or has a problem it expects the ex-bureaucrats to take care of things. In the case of Green Cross, had the ministry decided that unheated blood products should be destroyed and heated blood products imported without clinical trials, the damage to the company would have been considerable. Since the president of Green Cross was a former director general of Pharmaceutical Affairs, his influence was still quite large and one phone call to his successor at the ministry would have been enough to take care of the problem.
Of course, no one knows whether this phone call was made. There is no proof. However, it is quite clear that between July 4 and 11, 1983, there was a change in the ministry's thinking that greatly benefited Green Cross and at the same time maintained the harmony of the MHW. Harmony here means that the organization's size and jurisdiction did not decrease and that the status quo was maintained. Everyone was happy, except for the hemophiliacs who started to fall ill.
In 1989 a group of hemophiliacs initiated a lawsuit against the MHW and five Japanese pharmaceutical companies. In court, the MHW was asked to reveal internal files of the AIDS study group but continuously maintained that it had no record of such files. After seven years of investigation, and only after Mr. Kan became the Minister of Health and Welfare in January 1996 and formed an in-house body to investigate this disaster, did the missing files suddenly appear, as if Mr. Kan had waved a magic wand. Ministry officials said they 'discovered' the files, refusing to admit that the files had been hidden. Bureaucrats are trained not to take responsibility, and the use of the word 'discovered' is a typical way to avoid it.
The question is, why did these files remain hidden for seven years? Why, since they contained damaging information indicating the MHW was aware that unheated blood products could be contaminated by HIV, were the files not shredded? I believe many people in the MHW knew about the existence of these files. However, given their contents, someone who revealed their existence would put himself in the spotlight. For most bureaucrats, going up the ladder is the most important goal in their lives. In order to achieve this, taking care of their assigned duties without making any blunders is the preferred course of action. If you cause a problem, and come under fire, promotion will be closed to you. Therefore, "see no evil, hear no evil, and speak no evil" is the modus vivendi of Japanese bureaucrats. Given this mentality, it is easy to see why these internal files did not go into the shredder. The bureaucrats probably thought that none of them would ever reveal anything to an outsider, so there was no reason to destroy them.
Generally speaking, politically appointed ministers such as Mr. Kan, who became Minister of MHW in January of 1996, are outsiders and do not have any control over the system. But Mr. Kan appointed a vice minister to head the in-house investigative team, and there is a power struggle among the bureaucrats of the MHW.
The MHW is divided into three major groups: career bureaucrats, who must pass a difficult civil service exam and are guaranteed an elite career; non-career bureaucrats, who can go only halfway up the ladder and who comprise the majority of all bureaucrats; and the physicians' group, to which I belonged when I worked at the ministry. Non-career bureaucrats tend to side with the elite bureaucrats, and there is always antagonism between these two groups and the physicians' group. The reason for this antagonism is that the physicians hold medical degrees and always have the option of leaving the ministry to open a private practice, whereas the career and non-career bureaucrats do not. The physicians' group thus has more freedom, and a lack of freedom creates envy. The career bureaucrats often criticize the physicians for what they perceive as a lack of loyalty.
After being dismissed from the ministry last year, I continued to keep in touch with my friends there. According to them, the head of the investigating team--a vice minister and hence an elite bureaucrat--most likely tried to use the HIV incident as a way to increase the influence of the career bureaucrats and attack the physicians' group. This is why Dr. Atsuaki Gunji, a former director of the biological and antibiotics division, now the office of blood products management, was the first to be criticized. But the issue of seniority was also involved.
How Seniority Works
When I entered the ministry, the first piece of paper I was given was a list of physicians with their medical school and year of graduation. I noticed that many physicians carried around a miniaturized copy of this list in order to check the seniority and ranking of other physicians. Within the ministry, twice a year, graduates from the same medical school get together in order to maintain and strengthen their cohesiveness and reinforce seniority. Another twice yearly meeting to reinforce cohort solidarity brings together graduates from the same year but different medical schools.
Dr. Gunji and Dr. Abe (the head of the AIDS study group and then dean of
Teikyo Medical College) are both graduates of Tokyo University Medical College,
but Dr. Abe is 20 years senior to Dr. Gunji. So if Dr. Abe, as an expert in
hemophilia, told Dr. Gunji that he was taking a certain position, Dr. Gunji,
not being a specialist in the field, would have offered no opposition. Dr.
Gunji, upon retiring from the MHW, became a tenured professor at Tokyo
University Medical College, another amakudari position. If he had had a major fight with Dr. Abe over the marketing of heated blood products, it is doubtful that he would have received the post at Tokyo University Medical College, the most prestigious medical school in Japan.
In the same vein, Mr. Matsushita, then president of Green Cross and a former director general of MHW's Pharmaceutical Affairs Bureau, was senior to Mr. Mochinaga, the then director general of Pharmaceutical Affairs and now a member of the Diet. Both graduated from Tokyo University and were elite career bureaucrats. According to the weekly magazine [supply name], Dr. Abe and the founder of the Green Cross, Dr. Naito, were also good friends. Dr. Abe had great respect for Dr. Naito, his senior, who had been in the Japanese Imperial Army. Dr. Abe had been in the Japanese Imperial Navy, and their military careers were another bond between them. This bond is very important because in the pre-war period the military was the most respected career, whereas Japan's defeat has both distorted and strengthened the bond. This intricate web of human ties and the dynamics of the seniority system has led many people to wonder to what extent the two former directors of the Pharmaceutical Affairs Bureau are implicated in this scandal. (Dr. Abe resigned as dean of Teikyo Medical College on February 26, 1996.)
Mr. Kan, the present Minister of Health and Welfare, has achieved something that no other minister in Japanese history has, which is to take a leadership role. He has placed more importance on reality than on group harmony. He has been praised by almost all Japanese for the actions he has taken in this scandal, but his reputation suffers among the bureaucrats. Up until now ministers have been special guests of the bureaucrats, put on a pedestal and ignored, but Mr. Kan declined that special-guest status and asserted his own point of view, which has made him their enemy.
When I speak to my former colleagues I sense their underlying hostility toward Mr. Kan. What Mr. Kan has done, above all, is to reveal information to the public. Unfortunately, in Japan we do not have a Freedom of Information Act. And why not? The reason is very simple. The bureaucrats would like to maintain their power.
One of my superiors said to me when I first joined the ministry, "Do you know why we bureaucrats have so much power over the people and the politicians? We determine what information to give out and to whom, in such a way that it benefits the bureaucracy." Basically, he was saying that the Japanese public does not have a right to have access to information. Mr. Tada, the Vice Minister of Health and Welfare who was asked by Mr. Kan to investigate the AIDS scandal, commented to the press that, "The ministry's decision to reveal information at this time because so many people want to know, is an exception."
The proof that the ministry is generally unwilling to reveal information to the public became very clear when 27 more files connected to this scandal were found in mid-February but kept hidden from Mr. Kan. Their existence was only revealed after the court settlement in late March, when the government agreed to pay damages to HIV-infected hemophiliacs. Mr. Kan was apparently very angry and verbally reprimanded the vice minister. Disappointed in the way the investigation was being conducted, Mr. Kan also raised the possibility of bringing in a third party to uncover the truth. I agree with the idea of bringing in a third party because, given the dynamics of the Japanese bureaucracy, to conduct an in-house investigation is like asking a convict to be his own jailer.
Everything I have touched on here boils down to one issue, and that is the rights of individuals. The Japanese government for over 400 years has prevented the concept of individual rights from entering Japan. It is about time for the Japanese bureaucracy to accept that bureaucracy is for the people and not the people for the bureaucracy, for people to learn that individual rights are more important than group harmony, and to end the educational goal of mental castration and replace it with the development of independent thinking so that people can free themselves from governmental control.
DR. MASAO MIYAMOTO's background and career are described in JPRI's Critique,
Vol. II, No. 10 (November 1995). Parts of this Working Paper were presented as
a speech at the Massachusetts Institute of Technology, April 10, 1996.