Long-term care in Japan

What is a long-term care (Kaigo) model?

Section 1 The process of a long-term care model

1. What is a medical model?

Since 1982 as a doctor working for a hospital, I have diagnosed and treated patients of all ages and both sexes. However, as for the elderly and the disabled, there were few cases where disease improved dramatically after diagnosis and various treatments. There were many cases where disease remained the same or became worse. As far as the elderly and the disabled were concerned, they could not go back home and had to stay in the hospital even after treatment. People who stayed in the hospital for a long period of time made repeated visits termed "social hospitalization" or moved to an institution for health and welfare after some time. Faced with such a reality, I had the feeling that there was a limit to medical care, that it was not only medical care that could heal a disease grew within myself gradually. (See Fig. 1.)

Fig. 1 Network and approach which support the elderly

Until the mid 1970’s within a medical care facilities, there used to be a tendency of "giving good medical care for patients without consideration of medical care insurance". Gradually, there came a time with an excess of doctors and our situation became severe. Around the mid 1980’s there came an age of "no medical treatment without consideration of medical care insurance." In August of 1986, medical care plan became effective based on partial revision of the medical care law. Medical care itself had restrictions as to the number of beds allowed in a hospital. The discretion of a doctor providing medical care gradually narrowed.

The country and medical facilities required measures in order to decrease social hospitalization and reduce a national medical care expenses.

From about that time "something" which lay latent and could not be solved just through medical care alone materialized as a big issue. The elderly and the disabled were not managed only in a process of "a medical model" whereby doctors make a diagnosis and determine a treatment. To make a diagnosis and treatment by a medical model just means to ask for "Length of Life." However, patients have various diseases, problems in life and social problems. They could no longer be supported only by a medical model any more. There was the realization that life does not stop for twenty-four hours period and that disease and disability coexist. With only a medical model that makes a diagnosis and treatment for the length of life, we could not expect sufficient effects of medical treatment on the elderly and disabled.

2. What is a model for disability?

Since 1981, the World Health Organization (WHO) promoted a slogan of "safe participation and equality" for the international year of the disabled, and worked on issues of the disabled internationally for over ten years. Rehabilitation was promoted in the slogan, and it was defined as "to contain all measures to improve situations for those with disability and social disadvantage and achieve social integration of the disabled." In 1980, the WHO classified disability within three levels: 1) Impairment at a hereditary level, 2) disability at a living level as an individual, and 3) socially handicapped in social life. As for rehabilitation, "a model for disability" in making an approach of each situation is developed to decrease disability in the three aspects as much as possible. (See Fig. 2.)

In concrete terms, models for disability were constructed. These included a treatment approach for impairment, an adjustment approach for disability and an improvement approach for social disability with an aim of improving "Quality of Life." In 1994, the WHO defined "Community-Based Rehabilitation" as "a way to target equal opportunity for all disabled in a community and social integration" as a model for disability in a community. Rehabilitation centers were opened all over the country. In August 1996, rehabilitation departments were admitted as affiliated departments in hospitals and clinics.

In 1994, I myself became a doctor affiliated to Japan Rehabilitation Medical Society after being approved as a clinician by the Japan Rehabilitation Medical Society in 1989. At first I had thought rehabilitation would make immediate effects like magical words. On the contrary, we often had quite a few cases where rehabilitation effects showing in a relatively short period of time were restricted to exceptions such as ①diagnosis not long after a disease first appears, ② in the young age, and ③those without organ disease complications. Especially for the elderly or the disabled who maintained a period of keeping their ability, a model for disability was not a magical word but just an approach. Great effects could not be much expected, but continued rehabilitation for a stable period in order to keep ability. I advocated that from then on we should not only provide medical rehabilitation to patients but also care rehabilitation based on the daily lives of the patients from a care approach. What the elderly and the disabled who need care want is not only the existing rehabilitation but also an independent life with care combined with rehabilitation. (See Fig. 3.)

3. What is a social worker?

In the mid 1980’s, I did not know well what was necessary to solve the problems of the elderly and the disabled and what prevented them from being solved. When I was working as the head at a hospital in Yamaguchi Prefecture in 1987, I happened to see on television that "laws for social workers and laws for care workers" were enacted. At that time I had an intuition that "this qualification system might be an approach to solving the problems." At once I submitted an application at the examination center for social welfare promotion and applied for the examination. However, I was sorry to see that my application was returned, because after looking at the application form closely, I found that "a doctor is not qualified for the examination."

all doctors including myself studied the subject of public health, which consists of medical science and health care with much time and effort in order to become doctors, but did not have an opportunity to learn about welfare at all. Doctors were totally ignorant of welfare and disregarded or ran away from it. In the future, if they did not know about welfare, they could not bridge medical care and welfare.

One of the reasons which brought about national qualifications for social workers and care workers was that only three subjects in the welfare field qualified a head social worker, and that the specialty of a head social worker as an existing qualification for appointment was not necessarily established. Also, with a rapidly aging society, individuality and variety of needs of the elderly and the disabled became hard to handle. Therefore, "laws for social workers and care workers" were enacted in 1987, and qualifications of welfare experts for welfare service in the health, medical care and welfare fields were admitted legally. (See Fig. 4)

Qualifications in order to take examination for a social worker license offered eleven routes at that time. These included graduation from a university after acquisition of credits for subjects related to social welfare. A social worker is "one whose duties are to give consultation, advice, guidance and other support concerning welfare to those who have difficulty in leading a daily life." (Article 2) He or she will perform consulting business and support business based on cooperation of the health and welfare system. That is, his or her duty is to support removal of social, economic and mental problems of a person who asks for consultation, secure his or her life appropriately and try to promote rehabilitation. Those with qualifications work for health and welfare institutions as life instructors and consultants, for home care support centers as social workers, for social welfare councils, and medical institutions, etc.

Core subjects required to be a social worker largely consist of the three groups of "the knowledge area," "the technique area" and "the area for related knowledge" as "laws enacted for social workers and care workers." The system and ideas concerning social welfare are learned from seven subjects from "the knowledge area." From lectures and practices from "the technique area," techniques necessary for consultation support are learned. From five subjects from "the area for related knowledge," a wide range of knowledge is learned.

I began to attend a correspondence university in Kyoto in 1993, and practiced at institutions. In 1995, I acquired a social worker qualification as the first doctor in the country. With qualification as social worker network of people with qualifications related to health and welfare started to suddenly grow. I heard voices from employees working in health and care at facilities in person and had consultation and support.

I had wanted to study welfare rather than a medical model or a model for disability since before I was qualified to take an examination as a social worker and care worker. Then I started to go to welfare institutions for the elderly and welfare institutions for the physically disabled self-training once a week in 1990, when doctors were experiencing fierce competition as specialists in medical care at hospitals.

Training at institutions was a constant shock. First, it was hard for me to get over "the hurdle in my mind of medical care to welfare case." A non-stop 24 hour coexistence of diseases and disability also made daily life very difficult for me. Furthermore, a measurement system which was totally controlled by administration made institutions rigid and made it difficult to run them with little flexibility. I found it hard to integrate myself with those who were institutionalized terminally, and was very puzzled. I sometimes found myself in the situation of being doctor to a patient without being conscious of it, which brought about a gap. Patients who did not expect to receive effects from a medical model before and could not depend on care by family members were in welfare institutions. I was made to realize for the first time that I had forced my patients to enter and leave the hospital, not knowing the reality. There I had no seniors and employees to teach me. Besides, at a welfare facility, there were few places where we could study. Therefore, I was educating myself by repeatingly asking myself what I could do as a doctor.

With the approach of a longevity society, the demand for people engaged in welfare for the elderly was rapidly increasing. To deal with this, a qualification system for welfare experts was organized, which had been a long-pending issue. In 1987, laws for "social workers and care workers" were proclaimed. Whereby, a care worker is defined as "a person whose business is to provide care by helping people who have a disability in order to help them with daily functions such as bathing, excreting and eating, and to give instructions to those people and the people who care for them (Article 2)." About that time I happened to start in a new post in the Junior College Department of Okayama Prefectural University which was started in 1993. I had an opportunity to educate and train "a care worker." (See Fig. 4.) At that time most of schools for training care workers all over the country were professional schools or private junior colleges. Then, a department for training care workers was to be opened for the first time in the country at a public university.

As learning in a medical model for dealing with the elderly, there is geriatric medicine. For learning in areas other than medical science, there is gerontology. However, at that time in Japan, there were few institutions where one was able to study gerontology systematically. In December, 1989, to promote the organizing of a foundation for social service in the health and welfare area for the elderly, a "ten-year strategy for the promotion of health and welfare for the elderly (gold plan)" was decided. It was when I started to study gerontology as a general study about longevity science in a ten-year project for the promotion of study about longevity science (welfare science study subsided by the Welfare Ministry) that I started to be involved in gerontology. My share was a study about joint diseases of the aging in a general theory of senile diseases. Then with an electronic microscope I studied a hyperfine configuration about deformed joint diseases caused by aging and made a molecular biological analysis. Before that, for about three years at the Cancer Research Institute, I had done a molecular biological study about cancer cells which were hard to find. I was fortunate to see the dawn of this study of longevity science, and I attended meetings of the study group. I was sure that a general study of longevity science would be a study in Japan in the twenty-first century.

Then I went to the U.S.A. to receive training in gerontology at the medical department of the University of Michigan in August, 1994. What amazed me the most in the training there was that they had managed the elderly and the disabled by "a team approach" for ten years. This was a perspective which doctors in Japan lacked the most. In the future to manage people by a team approach will be surely necessary for any expert engaged in health, medical care and welfare (See Fig. 3). Until only recently, a medical model superceded part of welfare; but from now on the time will come when welfare will superceded part of a medical model. Knowledge and techniques of a team approach became necessary so that we would not concentrate only on the specialty of our own special works but would cooperate with the other various fields. In an aging society in the twenty-first century, unless specialists in various fields cooperate with those from other fields, there will be no solutions. To not have the lead as a specialist but to act as a coordinator will become important. To switch to the idea that each one's specialty is one branch and to cooperate is a trunk is necessary, and to be aware of it is required. (See cover.) A concrete proposal was made by the Welfare Ministry about care insurance in "Aiming at constructing a new care system for the elderly (Research Society of Care Support System for the Aged by the Welfare Ministry) for the first time in December, 1994. The report proposes that "care should be provided by a team." In other words, in a public care insurance system for the future, we need to think of care for the elderly and the disabled with the concept of a team beyond the types of jobs of works. One specialist can not only give care. For that purpose, exchange with other kinds of work in health, medical care and welfare will become more and more necessary.
The national research study center of medical care for longevity, whose foundation was proposed in the ten-year strategy for the promotion of health and welfare for the elderly, was opened in the Central Japan Hospital of the National Sanatorium in July, 1995. "Longevity Science" which comprises geriatric medicine and gerontology with an ideal of a "happy long life" is expected to achieve much. Part of this study has been performed from a result of a study from "a study about the construction of a general treatment system for the elderly (9ko-01)." It is supported by a study commission expense for longevity medical care. The money was provided by the Welfare Ministry in the fiscal year of 1997 .

I started to think very much of studying for the examination as a social worker, which is a qualification in welfare because of the experience at the University of Michigan. Then I made up my mind to try an examination for the qualification as a social worker. However, the certificate of graduation from a social welfare department in a university was necessary to be eligible for the examination. Therefore, I decided to pursue correspondence education from a social welfare department in a university. I maintained attendance at a university in Kyoto from Okayama from 1993, and had practice living in welfare institutions. This living-in practice made it possible for me to contact people in the institutions, taking my time and getting in touch with their lives and ways of living.

A welfare model in Japan is treated in a measurement system. An individual has an administrative measure based on his or her application. A measurement system as a welfare model with a public source of revenue has played an important part in social security as care service of the elderly since the law for welfare of the elderly (1963) was proclaimed. However, it is now pointed out that "the existing measurement system lacks induction to encourage the efficiency of business and creativity on the whole. Also, there are problems in the choice of service and ease with which to use it from a user's point of view" (About a Reform of Basic Structure for Social Welfare, 1997). Furthermore, it is said that "it is necessary to pay attention to the service offered to users like the ideas about a public care insurance system." The reform from "a measurement" system to "a contract and use" system, has been investigated now by the Welfare Ministry. A welfare model can not cope with the times any more, and in the meantime a measurement system will be changed to a contract and insurance system by the twenty-first century (See 11, Section 5, Chapter 5).

Various models for social welfare support techniques in a welfare model are proposed, and they are classified largely as "a medical model" and "a living model". This medical model excessively makes much of a disease aspect as is shown above, and aims to proceed with the viewpoint of a direct causal relationship, looking for a single cause of a disease (Contemporary Social Welfare Dictionary by National Social Welfare Council, 1993). With criticism of this model, a living model started to take over as a new model. A living model made by C. Meyer and C. Germain in the 1970s has intended to introduce the result of ecology science and self-psychology. The model's aim is to bring about interaction between humans and the environment, and reorganize social welfare practice based on a viewpoint and a concept on human growth and development unfolding through the interaction (abovementioned). However, a welfare model has not yet been systematized as a persuasive and concrete model.

Before a public care insurance system starts, now is the time to construct a system in which people from various teams in the community interact in many ways and can perform a team approach.

In 1992 when I was informally designated to educate and train "social workers" in a university, I looked for an academic society where I could learn about care. To my great surprise, there was not even a research society or an academic society where I could study care. Although there were innumerable different academic societies in the medical science field. As of 1992, five years had passed since the materialization of "the laws for social workers and care workers", and five national examinations were given. Still, there was no academic society on care. It was not until in May, 1995 that the national research society for social workers and care workers was founded. I contacted its executive office, and went out to have a discussion with several care workers in the prefecture who belonged to the society. Then I listened to stories at facilities told by actual home helpers. I was very surprised at the reality of appalling care as if were it were in another world, which I had never expected, compared with my experience in a hospital where I was working and the training I got at welfare institutions. The helpers had no place for training in their communities, and so they went to many places around the country to study at their own expense. They had not yet realized the difference among academic societies, research societies and training assemblies and their necessity. On that point, with my clinical experience in the medical field and my research experience at graduate school, I asked care workers to acknowledge that research societies and academic societies in care were absolutely necessary, and we started an activity in order to first found a research society.

A care worker is a specialist, but the role and the position remain ambiguous. Thereafter, I appealed to those who aimed to be care workers to take part in the care and welfare research society in Okayama Prefecture, and tried to motivate them to work by making a place for study.

A meeting for a preparation committee for the founding of the care and welfare research society in Okayama Prefecture was held at Okayama Prefectural Junior College in August, 1992. Care workers and home helpers in health and welfare institutions, including voluntary doctors for community medical care in the prefecture gathered. Seeing the enthusiasm of those present, I felt sure that the research society would be founded. I paid my respects to care workers who gave their opinions, clearly saying to doctors who wished for good reputations in care at the meeting, "Please let us care workers deal with care." Until then care kept being thought of as general work which anybody could do. I realized the time had come when its specialty should be proclaimed by those who put care into practice at facilities. The participants in the meeting lost no time in making a preparation committee, and started an activity for enlightenment in the prefecture.

However, the number of voluntary care workers in the prefecture was very small, and most of them were confined to institutions and work facilities after getting qualifications. There were few learning assemblies and research societies at the welfare facilities. Furthermore, the research society often had received disregard and interference. Health and welfare institutions made a fuss, suspecting the founding of a group of care workers. At the end of October, 1992 when the founding of the research society itself was in danger, an article on "the research society for care in the prefecture in the process of being founded" was presented in a column for the prefecture in the Sanyo Shimbun. This publication was the largest newspaper in the prefecture. Then a lot of care workers in the prefecture who had kept themselves quiet sent yells to us all at once. We celebrated on the founding of "the Research Society for Care and Welfare in Okayama Prefecture," which we spent much time on preparation, with more than 150 care workers on November 14, 1992. It was started in Okayama Prefectural Junior College. Then, one month later, the care workers association in Okayama Prefecture was founded not by care workers but by the heads of welfare institutions. Its founding was also quickened as a result of our research society.

The first research society's bulletin in the country, "Study About Care and Welfare (ISSN 0919-2492)" has been published twice a year since April 1993, and has a published number 11 as of April, 1998. The research society has already met eleven times. With interest in the law for public care insurance increasing, the number of members is more than 300. At each meeting with attendance of more than 100 people, a presentation about care practice and a symposium are given. Further, a lecture is presented by an acclaimed lecturer as an open course.

Once we succeeded in founding the Research Society for Care and Welfare in the Okayama Prefecture in November, 1992, an opportunity for founding a national academic society became ripe. With an appeal from members of research societies throughout the country and people of learning and experience in social welfare, a meeting for an appeal was held in December of the same year. The meeting took place at the Sunshine Social Welfare Professional School, which was an executive office. We sent a prospectus about the founding of the Japan Research Society for Care, asking volunteers all over the country to be promoters. With enthusiasm mainly from those people, a meeting of promoters for Japan Research Society for Care and Welfare was held in January, 1993.

However, as in Okayama Prefecture, there were few study assemblies and research study societies at work facilities in institutions for health and welfare. We had disregard toward an academic society all the more for that. Especially, we fought for leadership with the Japan Association for Training Care Workers, which was comprised of professional schools, and we did not have enough cooperation. However, in the meantime, Japan Academic Society for Education of Care and Welfare was materialized in February, 1995. Furthermore, we were warned by the Welfare Ministry that the time for founding might be too soon, but founding of Japan Care Workers Association was planned with the leadership of the Welfare Ministry, League for Welfare Institutions for the Aged, and the Japan Association for Training Care Workers. Japan Care Workers Association was founded along with care workers associations in twenty-four prefectures in February, 1994. Members of the Research Society for Care and Welfare were between the academic society and Care Workers Association, and they started to split. I found it hard to see fellow care workers with the same thoughts accuse one another, trapped by various rights and interests, which lasts even to this day to some extent.

More than two-hundred promoters were collected. The preparation meeting for founding the Japan Academic Society for Care and Welfare was held in April, 1993. Five hundred fellows gathered from all over the country and made an oath to found the academic society.

I went to Tokyo many times to work without pay for the preparation meeting of the foundation. Then, finally, in October, 1993, the Japan Academic Society for Care and Welfare was founded at Japan Women's University. I was much moved to see the founding of an academic society for care making history. Five years have already passed since then, and the number of members has become nearly 1,000. Study, education and learning about care and welfare science have been actively performed all over the country. I, as a director of the academic society took part as an editor for a bulletin of Japan Academic Society for Care and Welfare, "Care and Welfare Science (ISSN 1340-8178)." It was very moving that care insurance was taken up first in the open course and that opinions were given at all times during the places of meeting. However, I was sorry that Japan Academic Society for Care and Welfare failed to catch the trend of care insurance, probably because the founding of social care science had priority.

With the revision of eight laws related to welfare such as that of the welfare law for the elderly in 1992 and the materialization of the community health law in 1994, in health and welfare service, power was delegated to the prefectures. The demand to construct a community's own health and welfare system was increased. Since care varies according to a community, we need to share many problems and let others know about such problems. In November, 1995, the Chugoku and Shikoku Academic Society for Health and Care was founded, and places for which exchanges and visits to community blocks were made. With the concept of care by a team, the places for people to gather freely have developed in my office as an executive facility (see the colophon). I think that it is because the specialization of "care worker" was produced and cooperation was given, that we were able to found this research society and academic society.

When we were organizing a research society and an academic society, many people behaved as if to say, "I have nothing to do with care." However, now in the face of public care insurance, everybody is excitedly trying to take measures for the qualification examination , saying "I am a care manager." Why didn't you think about the specialties of health, medical care and welfare and the team approach together before? The cooperation of health and welfare has gradually developed in reforms: an administrative structure and a health and welfare project for the elderly. However, as for the cooperation of medical care and welfare which belong to totally different structures, an appropriate system has still not been constructed. We will have to work on this as our future task toward the aging society in the twenty-first century.

I started to educate students who aimed to be care workers with the major field of study as living welfare in the health and welfare course in the Junior College Department of Okayama Prefectural University. We investigated the content and the method of education taking into account the current situation of care and welfare. The department was opened in April, 1993. At the same time that the department was opened, the education and research society for care and welfare was organized into a major to work on "duties and education of a specialist, a care worker" for a special study in Okayama Prefectural University for three years.

We asked agencies related to institutions for health, medical care and welfare in Okayama Prefecture to perform "a survey concerning support service for the elderly and disabled (including children). "A survey study was done on employees who dealt with treatment directly in the agencies where special activities for health, medical care and welfare were conducted. The survey concerned the contents of care service, the extent of involvement, the difficulty in being involved, etc. Comparing and investigating the content of the survey through the kinds of institutions and the differences between jobs made it possible to grasp the range of care service and the actual situation. We had already started a basic study of a public care insurance system before it became a national issue. The result of the survey was reported in the "Survey Report on Support Service for the Elderly and the Disabled (Including Children) (March, 1994)", and the "Survey Report on Support Service for the Elderly and the Disabled (Including Children) (March, 1995)." Continuing the study, I fostered its development with the publication of The General Study of Care Insurance ― Theory and Practice of a Care Model with a subsidy for science-study expenses by the Ministry of Education in the 1997 fiscal year, "expenses for the promotion of making the result of a study public." (See Section 2, Chapter 2.)

On the other hand, the existing public-welfare department related to welfare and the environmental health department related to health and medical care were united in the neighboring prefecture, Hiroshima Prefecture, for the first time out of all the prefectures in the country. This was done by an administrative reform because of reorganizing of administrative organizations. In April, 1992, "the welfare and health department" was born. In addition, a preparation office was started for founding Hiroshima Prefectural Health and Welfare Junior College in the welfare and health department to train people for its health and welfare field. It was decided to open it in Mihara City, my hometown in Hiroshima Prefecture, in April, 1997, and I was to be invited to teach there. I started to commute from Okayama and teach at Hiroshima Prefectural Health and Welfare Junior College which was trying to deal with an aging society in the twenty-first century, which had a history and a tradition in health, medical care and welfare. Continuing this effort, I edited The General Study About Health and Welfare: Toward a Health and Welfare System (Under the supervision of Atsuo Tsubokura and edited and written by Hiroshi Sumii, Daiichi Houki, 1996) I made a report, "Survey Concerning Care of Daily Life in the Field of Health and Welfare for the Elderly and the Disabled (March, 1997)," with science-study expenses by the Ministry of Education in the 1996 fiscal year. Further, I developed and studied the degree of care by a care model.

I started a volunteer circle, "Himawari," with my students without knowing much at the same time Okayama Prefectural University was opened. Meeting with people through volunteer work brightened the students most. I think the results of volunteer work will give them something positive to live with for the rest of their lives. Though young people are said to be self-centered and indifferent to society, I thought they could be changed if they were given an opportunity. Volunteer work has been paid attention to since the Hanshin Awaji Great Earthquake in January, 1997. We also started a volunteer circle club in Hiroshima Prefectural Health and Care Junior College, and took part in bon-dancing of "Yassa Odori" with bed-ridden people around the Buddhist All Souls' Day.

The volunteer circle, "Himawari" provided "activities to send stationery to unfortunate children in Asia and Africa." A mountain of stationery was collected, but it was hard to deliver to the children because of customs duties. However, we found out that the AMDA (Asia Medical Doctors Association) performed international medical care cooperation in Asia and Africa, and they were willing to deliver stationery to those children. We attended the AMDA every month for over one year, and received training about a Nepal study tour among international volunteer cooperation programs. Then we visited a foreign country, Nepal, for the first time in our lives. The sights we saw with our eyes were all fresh and natural. The people in Nepal can not even go to a hospital because of their poverty. All over the world, there are severe realities we cannot imagine in Japan. Fifty years after the war, countries in Asia and Africa are trying to repeat the post-war history of Japan. In the process, Japan is expected to offer international cooperation concerning care.

April 25, 1997 was my forty-first birthday, and on that date, my mother died. My mother had been in a hospital receiving terminal care since the end of 1996. In the meantime I compiled her huge record of readings in a book, Memorable Novels: the Best Works That I want to Read Again (by Naoko Sumii, Itto Henshu-shitsu, 1997), though it was not finished when she was alive.

I started to write in the beginning of the book, memorable novels like this: "I was quietly watching my mother who lay in a bed in the hospital and in pain beside me. Facing the coming death of my mother, I am marveling now how important her existence is in my family. Even now when each member of the family is independent and lives his or her own life, it is the mother who keeps the bond in the family. However, her existence may look trifling to others, because the history of each family cannot be shared with them."

It was not until I was in a position to deal with terminal care that I fully realized that I had held only the viewpoint of a specialist in health, medical care and welfare before. I had been sure before that if the specialty of care by a specialist was increased, the quality of care would improve, but it was only an illusion. Discussion about care insurance and organizations related to care took rights and interests from people in need of care and those who gave it. After an examination system for receiving training as a specialist for care support (care manager) was publicly announced, the interest of care workers at facilities moved from a public care insurance system itself to the examination system. After all, what was left behind was people in need of care and those who cared for them.

Around that time, in September, 1996, "A Million-Citizens Committee for Promoting the Socialization of Care" was started in Tokyo. They proposed a revised plan of a care insurance law by citizens, and were working hard to make it work out, centering around Itto Henshu-shitsu. With the connection of having my mother's Memorable Novels edited, I took part in a network to work on care problems in communities of citizens who have care. I was recommended to be a councilor of the committee in September, 1997.

I started to attend a liaison conference for Hiroshima Northern MSW (Medical Social Workers) every month from 1995, and study medical care and welfare. We had a presentation meeting for materials from social sources about medical care and welfare which we collected every month for three years. I recommended that the materials be gathered and published. Everybody was dubious because he or she had not published a book. However, once the materials started to take the form of a book, we poured enormous passion and energy into it. In July, 1997, the Guidebook About Medical Care and Welfare Guided by Medical Social Workers (Hiroshima Medical Care and Welfare Research Society, University Education Press, 1997) was published, and began to sell well all over the country. In this effort, I felt the same enthusiasm that we had when we founded the Care and Welfare Research Society in Okayama Prefecture five years before in 1992.

I was sure that we would be able to start "A Million-Citizens Committee for Promoting the Socialization of Care" in Hiroshima. We were able to hold a conference on December 6, 1997 for founding with an attendance of almost 300 citizens in the Memorial Hall of the Hiroshima Municipal Peace Memorial Museum. This site, the symbol of the peace city, Hiroshima, had a deep connection with my mother. She had also suffered illnesses caused by atomic-bomb radiation. In the symposium, urgent appeals for care insurance did not stop coming. Three days later, the "care insurance law" was approved by the Diet. Since care insurance will be enacted in April, 2000, I am thinking of networking people who think of a care system in communities. We started "A Million-Citizens Committee for Promoting the Socialization of Care" in Okayama, centering around members in the Okayama Care and Health Research Society. Furthermore, the law for mental health care workers was approved by the Diet on December 12, 1997, which became a national qualification for social workers of mental health and a wish of which medical social workers poured their energy into. Taking this opportunity, we founded the Japan Medical Care Social Work Research Society in the Japan Education Hall on May 23, 1998. We focused on members of the Hiroshima Medical Care and Welfare Research Society. We prayed for a new qualification for medical social workers who had been left behind and were networkers to connect medical care and welfare.

From 1996, I received schooling. I submitted a report every day and received practice at care institutions by correspondence education from the community school in the postgraduate part of NHK Gakuen High School. I was determined to have more special study and practice in care. In 1998 I was able to get qualification as a care worker after succeeding in passing the national examination and practice examination.

If we are only in the circle of a huge tower of medical care and the field of health and welfare, we sometimes can not see fields other than our own. Just with the traditional vertical connection in an academic clique, a medical office and a work facility, we cannot deal with the elderly and the disabled. As only highly advanced medical technology and a system within health and welfare are pursued, interest in other areas has become too thin. There are not a few experts who know just part of a system for health, medical care and welfare. First, they should reach out from their side, and go into the circles of other areas. It is not too late to claim cooperation after one knows the system very well.

I think that my mission as a doctor, social worker, and care worker is to bridge medical care and health and welfare. I am also considering the construction of a new care system, starting in Japan and providing international cooperation with the care system. Whether a new care system by a public care insurance system will work well depends on the cooperation and unification of health, medical care and welfare.

Now the construction of a new care system is at hand, and there may be some puzzles at facilities. At present real experts in care have not been developed as of yet. I would like people working at facilities to be experts of care in the true sense of the word. For that I think that an academic society, a research society and citizens groups active in care are necessary, and I will continue working on that. Please go forward step by step to aim at the establishment of a new care system in aging society of the twenty-first century. Do it with courage for the future, not only for yourselves but also for people in need of care and those who care for them with a wider view of international health and care. Then I would like to work on care with people from all over the country and people from countries all over the world. I would use a team approach as a doctor, social worker and care worker after again going to the geriatric medicine center of the University of Michigan as a research worker living abroad and with approval by the Ministry of Education in the summer term of 1998.

Hiroshi Sumii, MD, CSW, CCW, professor at the Hiroshima Prefectural College of Health and Welfare, TEL & FAX +81-484-60-1211, sumii@hpc.ac.jp

	Number of persons who have received qualification (the end of March, 1997)			Fixed number for admission into training institutions (in April, 1996)
Social worker	7,587			1,915
Care worker	89,032			13,936
		Among them, the number of people who have received qualification by a national examination: 46,021	Among them, the number of people who have received qualification at training institutions: 43,011	13,936