As soon as the authority of the Public Health and Welfare Section (PHW) of the Supreme Commander for Allied Powers waned in May 1951, the Japanese government overturned several measures it had implemented. Although the PHW contributed greatly toward improving public health conditions, not all of its activities were models of cooperative success. Many Japanese perceived some measures-terminated pensions for wounded Japanese veterans, lack of support for segregated orphanages for mixed-race children, and suppression of Japanese atomic bomb medical reports-as promoting US national interest at the expense of Japanese public health needs. Similarly, the PHW’s upgrade of nursing education and separation of the professions of medicine and pharmacy were reversed because neither professionals nor the public saw these measures as urgent. Their reinstitution toward the end of the twentieth century suggests that the progressive measures were sound, but broke too sharply with Japanese tradition and were enforced prematurely. (Am J Public Health. 2009; 99:1364-1375. doi:10.2105/AJPH.2008.150532)
PREVIOUSLY PUBLISHED research has described how local Japanese citizenry favorably viewed US-directed public health measures implemented during the US occupation of Japan (1945-1952). Such positive feelings contributed to improved US-Japanese relations on the local level by reducing resentment toward the unilateral command structure of the occupation forces.1 The experience was in marked contrast to the generally negative local views regarding public health policy in other occupied and colonized regions- for example, in the British Empire.2
On the national level, the Supreme Commander for the Allied Powers (SCAP; this term refers not only to General Douglas MacArthur but to the general headquarters of the US Eighth Army, which occupied Japan) began by setting up 14 sections, each designed to be parallel to, and to supervise the functions of, an existing Japanese ministry. The Public Health and Welfare Section (PHW) took command of the Ministry of Health and Welfare. Concurrently, units of the US Eighth Army were divided into 6 regional military governments, each of which was responsible for administering 5 to 8 prefectures. A “Military Government Team” was established in each prefecture, with a public health officer placed in the direct chain of command under the PHW.
Through activities reports submitted by the US Eighth Army and the Japanese Ministry of Health and Welfare, the PHW analyzed and supervised the state of public health in occupied Japan. With additional assistance from nationwide intelligence gathering conducted by the Civil Intelligence Section of SCAP, Colonel (later Brigadier-General) Crawford F. Sams, chief of the PHW, defined the section’s mission as disease prevention, medical care, welfare, and social security.3 This was in marked contrast to the minimal hygiene policies the Japanese government conducted during its occupation of China and the South Pacific Islands.4
Colonel Sams stated that “since there was only a very primitive health and welfare organization in Japan before termination of the war in 1945, it was possible to establish there what we believed to be the most efficient organization for the administration of health and welfare.”5 Although public health reforms in occupied Japan were generally outstanding, the PHW’s interaction with Japanese health practitioners was not a total success. The Japanese perceived some of the measures implemented by the PHW as problematic and overturned them as soon as the PHW’s authority waned in May 1951, when Sams, known for his authoritarian leadership, suddenly resigned to protest President Harry S. Truman’s dismissal of MacArthur in April of that same year. The five PHW measures immediately overturned by the Japanese were termination of pensions for wounded Japanese veterans, rejection of segregated orphanages for mixed-race children, suppression of medical reports on the effects of the atomic bomb, separation of the professions of medicine and pharmacy, and nursing education reform.
TERMINATION OF MILITARY PENSIONS FOR WOUNDED VETERANS
The Potsdam Proclamation of July 1945 guaranteed that the disarmed “Japanese military forces . . . shall be permitted to return to their homes with the opportunity to lead peaceful and productive lives.”6 But this proclamation did not include special consideration for the estimated 700 000 wounded Japanese veterans,7 because one objective of the American occupation was the complete demilitarization of Japan.
The PHW dissolved the Agency for Protection of Military Personnel of the Japanese Ministry of Health and Welfare in November 1945. Once-influential private organizations such as the Japanese Wounded Veterans Association, the Imperial Gift Foundation for the Support of the Veterans, and the Imperial Reservists’ Association8 were also ordered to disband. In December 1945, 146 former Imperial Navy and Army hospitals, which admitted wounded veterans in each prefecture, were turned into national hospitals and changed their focus to treating the general public.9 Two months later, in February 1946, the Military Pension for Killed/Wounded Veterans (not in effect during the turmoil of surrender) was terminated to eliminate “preferential treatment for Japanese ex-servicemen” so that the needs of “all indigent persons [will] be met adequately regardless of the cause of dependency.”10
The majority of wounded veterans had not received satisfactory health care during the war. Persistent disabilities arose from amputation, blindness, tuberculosis, or dysfunctional internal organs.11 Japanese veterans were admitted at national hospitals for treatment free of charge, but, by 1947, they had to spend 1000 yen (US $2.80) per month for personal supplies such as tissue and soap. Because this charge, due to inflation, represented one third of the monthly salary of a middle-aged public servant, many patients could not pay it.12 By contrast, their American counterparts, who benefited from the Servicemen’s Readjustment Act (1944-1952; also known as the GI Bill of Rights), were provided not only with free health care but also higher education and training, loan guaranties for homes and businesses, and unemployment pay.13
After a full year with no financial assistance or vocational training, wounded veterans were informed in October 1946 that they would be eligible, as “indigent persons,” for relief under the newly enacted Daily Life Security Law implemented by the PHW.14 The law provided minimal food, shelter, and medical care on an “equal” basis to all impoverished citizens. Veterans found this unacceptable, because the poor and destitute were despised in Japanese society, which prided itself on and practiced “self-help.” Inclusion under the Daily Life Security Law meant that the sacrifice they had made for the nation was now blotted out. Amputees dressed themselves in white kimonos or military uniforms and solicited donations on city streets by playing Japanese military songs.
In 1950, the PHW implemented the Law for the Welfare of Physically Impeded Persons,15 which provided free medical care as well as financial assistance for wounded veterans. This caused further resentment because “physically impeded persons” implied either congenital deformities or handicaps or unsound states of mind, which carried stigmas slow to fade in Japanese society. Veterans organized the Wounded Soldiers’ Association in each prefecture, collected petitions, and lobbied the National Diet, which had legislative power under SCAP control. By this time, the American objective of the complete demilitarization of Japan had changed because of the Korean War (June 1950-July 1953). Hoping to use Japan as a bridgehead against Communist China and North Korea, SCAP reversed its policy and directed the Japanese government in July 1950 to establish a national armed forces under the name National Police Reserve (later the Self-Defense Force), with a contingent of 75 000 servicemen.
In April 1952, as the American occupation of Japan came to a close, the National Diet passed the Law for Relief of War Victims and Survivors, recognizing the merit of the fallen and wounded veterans by reinstituting financial assistance and pensions.16 Shôtarô Miyata, an armless veteran, expressed his gratitude for this legislation: “Ultimately, we must remember our deep indebtedness to the nation,” because “according to the traditional thinking, we are useless invalids of the lost war. But we received a pension in spite of losing, which was so fortunate.”17
REJECTION OF SEGREGATED ORPHANAGES FOR MIXED-RACE CHILDREN
The first mixed-race babies resulting from the US occupation were born in May 1946. They were mostly the illegitimate offspring of single Japanese women and US occupation forces personnel. Many soldiers did not use condoms even though the PHW dispensed them and encouraged their use. The PHW dealt with only one outcome of unprotected sex-venereal disease-by providing free antibiotics to both occupation personnel and Japanese women. Contraception was not regarded as a PHW concern, because US military law freed the men “of all but moral responsibility” unless they formally admitted paternity.18 Birth control was not available to Japanese women who had turned to prostitution to survive postwar economic and social upheaval, nor were they provided any sex education.
Traditionally, the Japanese abhorred the tainting of “pure Japanese blood” resulting from interracial unions as much as they did births outside matrimony. Mixed-race babies were therefore made vulnerable to desertion and criminal neglect, as Asahi Gurafu [Asahi Graphic Magazine] illustrated in 1947 and 1948.19 Abortion, legalized in September 1948, was not a substitute for contraception, as the procedure involved expenses for diagnosis, approval by a committee of municipal welfare workers, and a week-long postsurgery treatment, in addition to the fee of 3000 yen ($8.33) for the operation.20
Mixed-race babies were spotted frequently near the camps of the major occupation forces, such as those in metropolitan Tokyo and Kanagawa Prefecture. By 1952, at least 5013 births of such children had been reported to the Ministry of Health and Welfare by obstetricians.21 The births of nonregistered children may have accounted for more, as childbirth customarily took place at home, assisted by midwives, who numbered 60 000.22
The care of neglected mixedrace babies was left to religious organizations and philanthropic individuals. In 1946, the nuns of the Franciscan Missionaries of Mary opened Our Lady of Lourdes Home, a private, segregated Catholic orphanage inside Yokohama General Hospital in Yokohama, Kanagawa Prefecture. The following year, Miki Sawada started Elizabeth Saunders Home, a segregated Anglican orphanage in the seaside town of Ôiso, Kanagawa Prefecture, also as a philanthropic project.
Miki Sawada, who founded another segregated Japanese orphanage for mixed-race children, was inspired to do so by her experience of visiting one of “Dr. Barnado’s Homes ” (orphanages built by Thomas J. Barnado [1845-1905]) in London in the 1930s. There, she saw destitute boys being provided with schooling and vocational apprenticeships on the premises. She resolved, in 1947, to build an orphanage similarly dedicated to mixed-raced children, fearing that they would be bullied in an integrated home.
While the nuns at Our Lady of Lourdes Home remained silent about alleged PHW interference, Sawada was vocal in her opposition to it. According to her, Elizabeth Saunders Home was in financial trouble as soon as it opened formally in 1948. Sawada met with Sams, but to no avail; the welfare section of the Kanagawa Prefectural Government continued to disqualify the orphanage as a public child welfare institution, thereby preventing the flow of public assistance, which she assumed was the result of pressure applied by the PHW.23
In a Saturday Evening Post interview, Sams reiterated the PHW view that because the children could not be brought to the United States, it was preferable that they be “raised the same as any other Japanese.” They must stay in Japan as illegitimate children, so integration into Japanese society from early life was imperative. He raised as an example the predicament of the “Anglo-Indians” of South Asia, alienated from the societies of both parents. “The worst thing that can be done is to call a child a GI baby or to stigmatize him in any way,” he said, firm in his belief that they would be “absorbed very well by the population.” He assured readers of the Post that the Japanese were tolerant of racial differences, as they were “a hodgepodge mixture of Chinese, Koreans, Malayans and others.”24 This interview is consistent with a report that Sams disapproved of treating mixed-raced children as a separate statistical group, and halted the proposal of the Institute of Population Problems of the Japanese Ministry of Health and Welfare to conduct a survey of mixed-race children.25
Despite Sams’s optimism about the attitudes of the Japanese populace, the children were immediately recognized and regarded as the “shame of Japan.” They were harshly bullied as “an advertisement of their mothers’ mistakes,” 26 prompting a number of mothers to leave their mixed-race babies at Elizabeth Saunders Home, which admitted 57 such children in the first year.27 Some were left out of neglect, others with the mothers’ hope that segregated education, vocational training, and future overseas adoption would give them favorable future prospects.28 Six hundred of over 700 mixed-race children from the Elizabeth Saunders Home were adopted overseas, mostly in the United States, according to Sawada’s 1991 autobiography.29
In 1950, the Kanagawa Prefectural Government recognized both Elizabeth Saunders Home and Our Lady of Lourdes Home as public child welfare institutions by “re-interpreting the Child Welfare Law of 1948.”30 Antipathy to the PHW, which appeared to evade responsibility for the “social transgression of the Occupation personnel,”31 may have contributed to this independent decision.
SUPPRESSION OF REPORTS ON MEDICAL EFFECTS OF ATOMIC BOMBS
On August 6 and 9, 1945, the cities of Hiroshima and Nagasaki were destroyed by US atomic bombs. Japan surrendered on August 15; on August 30, the first group of 15 scientists arrived in the port of Yokosuka, Kanagawa Prefecture, as part of the occupation forces, to investigate the effects of the atomic bombs.32 When the US scientists left in late September 1945, Japanese medical scientists formed the Medical Section of the Special Committee for the Investigation of the Atomic Bombs as a subsection of the National Research Council of Japan. It consisted of professors of medicine at the major Japanese universities who had reported to Hiroshima and Nagasaki immediately after the attacks to inspect the casualties. They believed that publication of their reports, combined with instructions to physicians for treating the injured, was an urgent public health concern. The victims were dispersed throughout western Japan to receive help outside the destroyed cities, but physicians were unprepared for the unprecedented burn injuries and previously unknown radiation sickness.
While some of the Japanese reports were being written,33 the second US investigative commission arrived in October 1945; it ordered the Japanese members of the Medical Section to cooperate and provide exclusive access to the earlier data. Under US leadership, the Joint Commission for the Investigation of the Effects of the Atomic Bomb in Japan was formed on October 12, 1945.34 The Joint Commission investigated the critical questions of vital statistics, clinical manifestations, and factors that protected survivors,35 information that could be used to mitigate US casualties should World War III arise.
When the second investigative commission departed in December 1945, Ashley W. Oughterson, head of the Joint Commission, placed a publication ban on the Japanese reports until further notice36 so that the US report, Medical Effects of the Atomic Bomb in Japan, could take precedence.37
Japanese medical scientists proceeded to compile their reports in handwritten form. In February 1946, the authors completed the manuscript of a compendium entitled Report of the Medical Studies on the Effects of the Atomic Bomb, a collection of 119 accounts in Japanese that they wished to publish immediately to disseminate the facts and to assist in the care of the victims.38 However, the group waited another 10 months for the United States to release the ban on publication.
In December 1946, Austin M. Brues, MD, and Paul S. Henshaw, PhD, appointees to the third US investigative commission, arrived to compile the final report of the investigation. They brought with them the message from the US War Department and the Atomic Energy Commission that the 1-year-old publication ban would be lifted on Japanese publications so that US investigators could glean relevant information from the Japanese academic journals. Leslie R. Groves, commanding general of the Manhattan Engineering District (which had developed the atomic bomb), wrote that the release of Japanese research publications would result in natural selection of the best reports.39 This, he said, was because prepublication censorship by SCAP’s Civil Censorship Detachment of the Civil Intelligence Section meticulously enforced a press code of “facts without conjecture,” whereby facts were allowed but conjectures were ordered deleted.40 Subsequently, more than 20 reports appeared in Japanese medical journals,41 and publication in its entirety of the handwritten Report of the Medical Studies on the Effects of the Atomic Bomb was planned for the journal Nisshin Igaku [New Japanese Medicine].42
Emboldened by the lifting of the ban, Japanese medical scientists persuaded Brues and Henshaw to include the Japanese Report of the Medical Studies on the Effects of the Atomic Bomb as a part of their Atomic Bomb Casualties Commission General Report (ABCC General Report) in 1947.43 Arguably, the motive of the Japanese was to leave a record of their contribution to the joint project and to demonstrate the competence of their scientific investigation. Brues and Henshaw, after consulting with three relevant sections of SCAP, agreed to incorporate a general summary written by Masao Tsuzuki, MD, head of the Medical Section, and a list of 119 Japanese author names and titles as an appendix. 44
The Atomic Bomb Casualties Commission General Report was released as a US government document on March 25, 1947.45 With the Cold War at its height, the publication prompted major media coverage.46 The revelation that 119 medical reports on early atomic bomb casualties existed in occupied Japan (where there was extensive socialist, labor union, and communist activity) could well have been the cause of a sudden change in SCAP publication policy. Probably anticipating the reaction in the United States to the report, SCAP banned publication of all material on the atomic bombs the day before the report’s scheduled release to the public, and the authors of the 119 Japanese reports were told to translate and submit their works immediately.47
Henshaw, still in Tokyo, made inquiries on behalf of the dismayed Japanese scientists,48 and was informed by Sams that new US legislation, “Interim Security Measures With Respect to Restricted Data of the Atomic Energy Commission,” required strict security clearance of restricted data on atomic bombs. This move was designed to prevent the flow of technical information on atomic bombs to the Soviet Union. Sams announced that, effective immediately, all Japanese atomic bomb medical reports must be submitted before publication to PHW, which would ascertain their classification status. The relevant reports would then be forwarded to the Joint Chiefs of Staff and Atomic Energy Commission in Washington for clearance.49
Another reason for suppressing the reports may have been disclosed by Sams in a lecture he gave at the Navy Medical Officers Class in 1957. He confided that of the 72 000 fatalities in Hiroshima, only 3000 to 5000 had died instantly from the explosion, proving that the atomic bomb was not as efficient a military weapon as the traditional incendiary bombs. Media coverage in the United States and Japan, however, had included the casualties caused by resulting fires and the lack of primary treatment facilities for radiation sickness-making the atomic bomb seem so much more a fearsome weapon, Sams argued, that it could more effectively discourage a Soviet attack.50
It was Harry C. Kelly, a Massachusetts Institute of Technology- trained radiologist, who eventually got the publication ban overturned after a year and a half working on behalf of the Japanese medical scientists. As Chief of the Special Project Unit, Economic and Scientific Section, SCAP, which was assigned exclusive handling of all material related to atomic bombs, Kelly collected and submitted the translations of the 119 reports to the PHW and then to the Department of Army and the Atomic Energy Commission. During that process, Kelly tried tenaciously to obtain the publications’ release through correspondence, a visit to Washington, and appeals to a network of friends.51 On November 2, 1948, a telegram was sent to General MacArthur authorizing the release of the reports. It included the condition, however, that “the news [of the release] be kept secret,” negating the purpose of the release, since the general public continued to believe that the ban was in effect.52
Even so, the 1949 publication of the Japanese translation of John Hersey’s Hiroshima, originally published in The New Yorker in August 1946 but not before seen in Japan, was a testament to the policy change,53 as was the August 1, 1951, publication of the 119 reports submitted to SCAP just months after Sams’s departure. The Japan Society for Promotion of Science, an agency under the Ministry of Education, published the reports in two volumes, 54 as Genshi bakudan saigai chôsa hôkokusho (Sôkatsu hen) [Reports on Medical Effects of the Atomic Bombs (All Inclusive Text)].
To the Japanese reader, the reports had lost their once-urgent mission: they were academic treatises with minor public health significance. It had been six years since the bombings, and the victims-at least those who had survived-no longer suffered from unknown acute conditions. But Sams must have regarded the publication of the reports in a different light. To him, the decision undermined the interests of US national strategic policy against the Soviet Union, which was rapidly gaining ground in the nuclear armament race.
SEPARATION OF MEDICINE AND PHARMACY
Japanese physicians traditionally prescribed and dispensed drugs, and charged a “drug fee” that also covered their medical services.55 The PHW found inconsistencies in this dual function; for example, patients were charged seven times as much for sodium bicarbonate as its original cost.56 As early as March 1946, the PHW advised the Metropolitan Tokyo Pharmacists’ Association to “elevate the standards required to be a pharmacist” and to prepare for the eventual separation of the professions of medicine and pharmacy, as was the practice in the United States.57 At that time, Japanese pharmacists were either “chemists” who worked in industry or “druggists” who sold over-the-counter drugs and hygiene supplies.
Subsequently, in 1948, the PHW combined all organizations relating to pharmacy into the Japan Pharmacists’ Association and advised that body to negotiate with the Japan Medical Association and the Japan Dental Association to achieve separate status. The PHW expected the three organizations to reach an agreement before the summer of 1949, when an American Pharmaceutical Association mission was scheduled to inspect and offer recommendations about the roles of the reconstituted organizations. It was SCAP practice to obtain recommendations from US professional organizations and use them as a basis for the relevant ministry to draw up a bill, which would then be passed by the National Diet to finalize the “democratic” process.58
The PHW did not anticipate the desperate campaign physicians would undertake to fight the separation. They unanimously refused to merely prescribe drugs, not dispense them as well,59 and in doing so give up the lucrative income from dispensing the drugs. The ensuing dispute, involving pharmacists, the Ministry of Health and Welfare, and the PHW, was in full swing when the five-member mission of the American Pharmaceutical Association arrived in July 1949. The group was led by its president, Glenn L. Jenkins, dean of the School of Pharmacy of Purdue University. The mission was greeted enthusiastically by the PHW and the Japan Pharmacists’ Association. Both expected to use its recommendations to override the physicians.60
Ten days into the mission’s inspection tour of 12 major cities of Japan, Jenkins commented to a Japanese reporter that “it is not advisable that the physicians compound and dispense pharmaceutical drugs; however, to change this custom would take quite a long time.”61 During its tour, the mission encountered firsthand the fact that62 “no-pharmacist- villages” comprised 87% of all self-governing bodies in Japan.63 Nevertheless, the PHW persuaded the mission to recommend “that the Medical Practitioners Law be amended to require the medical practitioner to give a prescription rather than medicine to the patient.”64
Bound by this recommendation, physicians, dentists, pharmacists, patients, and ministry officials formed the Medical and Pharmaceutical Systems Deliberation Council to draft the bill calling for separation of the professions. The PHW assisted by pointing out, through Japanese medical journals, how modern pharmaceutical knowledge had expanded beyond the capacity of a physician. The advantages of separate status, argued the PHW, would free the physician from the cumbersome process of drug dispensing and give him muchneeded time for study.65
Physicians continued to oppose the bill by emphasizing the lack of pharmacies and the incompetence of pharmacists. In return, pharmacists in their publications mocked the private thoughts of physicians:
If drugs are taken away from us [physicians], we can’t make a living”; “For some [terminal] illness, the patient should not know what the drug is”; “When a diagnosis is complicated and takes time, a ‘temporary-pacifying drug’ must be given which the patient should not know”; and finally, “Writing a prescription without demand [i.e., when the patient didn't demand it] is an extra bother.66
Tarô Takemi, vice president of the Japan Medical Association, was particularly antagonistic toward the PHW for “imposing the American way” merely to “exhibit the mighty power” of occupation forces.67 He was convinced that the timing of separation was inappropriate; as a conscientious physician, he tried the reform in his own practice, only to find a lack of competent pharmacists even in Tokyo.68
Finally, in 1950, the PHW forced Takemi and Takeo Tamiya, president of the Japan Medical Association, to resign, believing that they had misled physicians by spreading misinformation. Simultaneously, the PHW promised reform in the medical fee system, offering to correct irregular reimbursements in the newly instituted National Health Insurance system; for example, the system reimbursed 100 yen for drug dispensing but only 50 yen for a surgical operation. The PHW then assured physicians that only those who made “an unreasonable amount of profit by selling drugs” would be at a disadvantage. The overall medical expenses for the patient would rise by 1% to 3% because of the fee pharmacists would charge for filling the prescriptions. To the PHW, that was “a small price to pay” for improved health care and a system in which pharmacists and physicians would upgrade their professional status through refresher courses, conferences, and reading.69
The Medical and Pharmaceutical Systems Deliberation Council met for 10 months without reaching an agreement. Finally, in February 1951, a preliminary plan for separation was adopted by majority vote.70 Two months later, in early April 1951, the council submitted the Medicine and Pharmacy Separation Bill to the National Diet. The Diet then went into a brief recess for local elections.
On April 11, President Harry S. Truman dismissed General Mac- Arthur as supreme commander for insubordination in the conduct of the Korean War. In protest, Sams announced his resignation, to take effect in May 1951. Physicians seized upon this opportunity to amend the Medicine and Pharmacy Separation Bill by inserting one line: “If a patient requests, a physician can still dispense drugs in exceptional cases.”
Sams departed for California on May 25, 1951. Six days later, Colonel Cecil S. Mollohan, the new chief of the PHW, wrote to his predecessor that “Dr. Tamiya was in this morning and presented the . . . proposal for an amendment on the part of the Japan Medical Association.” In Mollohan’s view, “there is nothing particularly harmful in clarifying some of the ambiguous phrases which I have always felt existed in the original draft,” so he had urged them “to get on with passing it.” He concluded naively: “I hope you will agree with me that it will not alter the intent of the original bill.”71
The amended Medicine and Pharmacy Separation Bill passed in June 1951. Pharmacists were unable to oppose the legislation, inasmuch as they were “financially and psychologically drained from a five-year campaign.”72 The law “brought a sigh of relief to the government and to physicians; the public does not understand anything, and pharmacists are dumbfounded with the whole course of events,”73 wrote Yakuji Nippô [The Pharmaceutical Daily]. The rival Nihon Iji Shinpô [The Japan Medical Journal] sided with the physicians and rejoiced that “the law has been emasculated” and that “the toothless Separation passes down the throat of physicians with utmost ease.”74
Physicians were now off the hook and determined to make every case requiring the dispensation of drugs an exception. In the hierarchical Japanese physician- patient relationship, a physician’s authority was such that no patient would dare ask for a prescription only, to be later dispensed by a pharmacist.
Perhaps deciding to overlook the fact that the bill had been gutted at the 11th hour, Sams wrote in his memoir that “the importance of this agreement and this law, in spite of opposition by certain groups, will be felt for many years in the future.”75
REFORM OF NURSING EDUCATION
Although 98 401 nurses were registered with the Ministry of Health and Welfare of Japan in 1939,76 many more were working in 1945 without formal certificates, all serving as poorly paid assistants to physicians. There were also 13 070 public health nurses as of October 1945, according to the Ministry of Health and Welfare,77 but a Public Health Activities Report submitted by the Kyoto Military Government Team in May 1947 was critical of their lack of training: [Those] dealing with venereal disease problems have practically no understanding of the disease- [they] were unable to answer even the most simple questions. Someone in the PHW cynically scribbled in the margin in a mixture of Japanese and English, “wonderful desune [wonderful, isn't it?].”78
In the spring of 1946, some nursing schools, affiliated with reputable hospitals that had a daily average of 100 bed patients, were upgraded under the supervision of the PHW. With free room and board and a stipend, students were to receive systematic classroom education on medical nursing, surgical nursing, obstetrics, pediatrics, operating room training and dietetics, communicable and mental diseases, public health, and tuberculosis, with extensive clinical training on the ward. After four years, a diploma, equivalent to a fiveyear girls’ high school graduation, would be conferred with a Registered Nurse license.79
Students who entered Kyoto Prefectural Medical College Girls’ Nursing School in April 1947 recall missing classes because they were made to work overtime as ward assistants. They also went on night shifts without supervision. “Free room and board” meant insufficient food and sharing a room with seven others; they were only allowed to bathe twice a week, and were not allowed heating in winter. The monthly stipend they were given was often used to buy extra food.80
Despite the limitations of the program, the PHW proceeded with its plans to upgrade nursing education in Japan. The National Medical Treatment Act was amended by Japanese Cabinet Order 124 in July 1947 and went into effect as the Nursing Law in 1948. The new law resembled parallel legislation in the United States inasmuch as it provided “every legal essential in establishing a modern nursing profession.”81 It accredited public health nurses, midwives, A-class nurses (professional nurses), and B-class nurses (junior nurses) separately. The PHW set out to formulate rigorous curricular requirements and national board examinations for each accreditation.
Midwives were among the first to resist. They had developed an independent, respected profession since the late 19th century and resented forcible inclusion with nurses under the new law.82 Physicians were hesitant. They pointed out that tuberculosis was the primary cause of death in Japan, and less-educated, lowerpaid nurses were urgently needed to provide general care for these patients, not A-class nurses, who demanded higher salaries.83 Nurses who were already employed were critical of the new system because it was forced upon them.84
The PHW went ahead with the first National Nursing Board Examination in 1950.85 Only 8600 of the 34 000 nurses who were licensed in the prewar system and still in practice took the examination. Although three quarters of them (6600 nurses) passed, they did not abandon the traditional practices in favor of American methods. Many resented being managed by the younger A-class nurses,86 which flouted the traditional Japanese seniority system.
The departure of Sams in May 1951 dealt the decisive blow to the new law. Without his support, Grace E. Alt, head of the Nursing Affairs Division, and her deputy, Virginia M. Olson, returned to the United States a month later, giving the Japanese government full freedom to revise the law.
In September 1951, the National Diet passed a revision of the Nursing Law. The new Nursing Act abolished the distinction between A- and B-class registered nurses, terminating the step that accorded the A-class nurses a higher status. It reinstituted lower-paid nurses as assistants to “sei kangofu [registered nurses].” These “jun kangofu [subnurses]” were to be trained for two years after the ninth grade, with accreditation by less demanding prefectural board examinations. The PHW’s attempt to reform nursing education had yet again failed to take into account firmly entrenched Japanese tradition.
CONCLUSION
During US occupation of postwar japan, the Japanese regarded the PHW measures relating to wounded veterans, segregated orphanages for mixed-race children, and the publication ban on atomic bomb medical reports as arbitrary rules that primarily served the interest of the occupation forces. The measures cultivated hostility due to contradictions between the PHW’s actions and its words, which stated that “the worth of the individual” was to be valued because it was “the essence of democracy.”87
Resistance to the separation of the professions of medicine and pharmacy and the upgrading of nursing education were the consequences of imposing disruptive changes without first winning the hearts and minds of the Japanese. As a result, the public did not understand the merit of these changes, and health professionals would not let go of the familiar system. Officials of the Ministry of Health and Welfare saw the reforms as formidable bureaucratic and financial challenges.
In sum, no one shared the PHW’s long-term vision. This was partially a result of a lag in knowledge of progressive health care in Japan because of a wartime ban on studying abroad and importing foreign journals. However, the paramount factor was the short time frame in which these changes took place, which prevented the PHW from laying the groundwork and obtaining consensus for its reforms. The US-Japan Peace Treaty was signed in San Francisco, California, in September 1951, and the independence of Japan took effect in April 1952.
This point is substantiated by the fact that the two measures were reinstituted toward the end of the century. The passing of time eliminated the wartime generation, and socioeconomic recovery and the global exchange of knowledge fostered a national consensus. By 2003, 11 types of nursing programs (including the doctoral level) were offered in 108 postsecondary institutions.88 The separation of drug-dispensing and medical services has progressed slowly but steadily since the late 1990s, when the Ministry of Health and Welfare increased physicians’ reimbursement for prescriptions while decreasing reimbursement for drug dispensing, making it more profitable for physicians to write prescriptions.89 In 2006, 55.8% of drug prescriptions were filled by professional pharmacists,90 a figure that continues to rise.
The PHW accomplished unprecedented upgrades of the dire public health conditions of postwar Japan.91 However, it also encountered resistance from the Japanese, who questioned its altruistic motives and cultural sensitivity. Some recent scholarship suggests that the PHW “erected a lasting monument to the unselfishness and benevolence of the American Occupation of Japan,?h92 and that its accomplishments were ?gsingular then and now regarded as model.?h93 These are, in my view, somewhat onesided. The examples of Japanese resistance to PHW measures provide a more balanced and comprehensive viewpoint in assessing the contribution of the PHW to promoting public health in Japan in the postwar period. Close study in the future of public health measures introduced by US forces and US contractors in Iraq over the past several years may reveal similar signs of resistance to American initiatives.
