INTERVIEW

Dr. Akira Ogawa

Before we consider the policy for multiple chronic diseases, first, we need to reconsider the existing healthcare system in Japan. It is crucial to achieve a basic consensus among the multi-stakeholder from various healthcare sectors in shaping the direction of the right healthcare delivery system in future Japan, so that we can start to plan from right at the beginning.
The effort of Japan Stroke Association
It is known that cerebral infarction, cerebral hemorrhage and subarachnoid hemorrhage are the three major types of stroke. Subarachnoid hemorrhage is a sudden bleeding in the compartment of the brain, symptomless before onset, and is reported with an intense headache as if the back of the head was strongly hit from behind. Normally it starts with mild attacks and followed by severe attacks. In order to help the patients and their family members to understand the symptoms better, the Japan Stroke Association (JSA) and Japan Stroke Society (JSS) had adopted active approaches to create public awareness through various campaigns.
Multisectoral Cooperation on Stroke Awareness Campaign
JSA plays a main role in engaging with social and philanthropy activities, and JSS plays a main role in the academic arena, where both emphasis on creating public awareness especially towards the major stroke event, cerebral infarction, which is considered as the most common kind of stroke. The prologue to cerebral infarction is the transient ischemic attack (TIA), where you may imagine the similarity between TIA and heart attack. Heart attack is referred as ischemic attack of the heart, and cerebral Ischemic attack in brain is called TIA. In the case of ischemic heart attack, it is often accompanied by severe symptoms such as chest pain, difficult breathing and the fear of heart failure at anytime. Therefore it is rare to have patients with ischemic heart attack to refuse hospital treatment. In the event of a heart attack where a part of the heart muscle has failed, the patients can still live a normal life as long as the heart remains its pump function. However, different parts of the brain have different functions that control speaking, seeing, thinking, and moving the limbs etc. TIA as an early stage of cerebral infarction is often neglected because the event is short and may not cause severe physical distress such as the event of ischemic heart attack. This early stage is often likely to be diagnosed of something else such as blood vessel clogged, causing the necessary primary/secondary intervention or surgeries to be delayed. Because of that, appropriate intervention is often only started after a serious attack where the patients suffered major consequences such as lost of speech or paralysis of limbs. In view of this, it is important to create a public awareness about stroke, so that primary prevention can be strategized when the symptoms is made known to each and every individual including family. However, it is often difficult to gain healthy audience in the public awareness campaign. The people who attended the campaigns were often patients who had suffered severe stroke, or their family members. Various approaches were made, where mass media including newspapers and television were engaged to spread straightforward messages, stroke campaigns, multi-sectoral collaborations campaigns, open public lectures, public approaches through television broadcasting, still the awareness in the healthy population whom also served as the potential high-risk groups for stroke is low.
Platform in seeking multisectoral approach
Japan is considering moving on to the direction where future policy proposal should consider the framework of NCD. The Ministry of Health, Labor and Welfare is also working to approach the five common diseases and five targeted healthcare areas. In the past, NCD risk factors are known to be hypertension, diabetes mellitus, hyperlipidaemia, and overweight. Today, the term of metabolic syndrome is established to conceptualize the disease. As a result of the publications of various articles concerning the comorbidities of these risk factors and their associations to severe stroke, recognition is finally gained in the society, and the term of metabolic syndrome has become established in the people’s mind. Recently, the concept of polyvascular disease has been spread to promote the understanding where cerebrovascular disease, coronary artery disease and peripheral arterial disease are under the same umbrella of vascular disease, and all of them are interrelated with one another in systemic disease.

Multisectoral approach in treating NCDs is the most important approach as NCDs share common risk factors. The approach shall seek primary prevention rather than treating the symptoms. It is often too late when the approach is targeted to the ill. Necessary approaches shall be taken before people get ill, primary prevention through health check up and lifestyle changes shall be the first step above anything else. There is nothing more that we can do with secondary prevention except in trying to prevent a severe attack after a mild transient ischemic stroke.
In anticipation of the needs in building the consensus for the future healthcare delivery system
Plenty of discussions are needed in order to build a multisectoral approach platform for treating NCDs. It shall be noted that the stands of the academic members, doctors in the hospitals and the private practitioners differ with one another. Therefore, it is important to start from the big picture of building the basic conceptual network involving relevant players from multiple sectors to anticipate what kind of healthcare delivery service is necessary for Japan. Japan has held pride in the implementation of national health insurance after the war. However, we need to understand that the healthcare delivery only requires stethoscopes, medicines and scalpels in the old days. Today, healthcare delivery becomes impossible without high cost equipments, and the people are taking healthcare delivery lightly as it doesn’t cost much. The current healthcare delivery system in Japan has not really been discussed. For example, shall we aim for a healthcare system such as the large welfare state as in Scandinavia which comprised high taxes, or shall we aim for a healthcare system as in the United States where people need to get their own health insurance policy in order to have a good quality of healthcare which comprised lower taxes. Conflicts will readily occur unless we are able to consider the whole scheme which comprised from the initial acute and chronic phases to the phase of rehabilitations. In particular to the high number of in-patient care among Japanese people because of stroke, it is indispensable to implement the national policy for primary prevention. For that reason; it is necessary to establish the basic act for stroke approach. In addition, there are others pressing issues in developing healthcare delivery system that target on multiple sectors approach of NCDs, corporations among hospitals of different sizes and telemedicine services through ICT. It is nevertheless important to overcome the differences of the different positions hold by the bureaucratic fiefdom (BF), the Ministry of Education, Ministry of Health, Labor and Welfare (MHLW), and the Ministry of Internal Affairs Communications (MIAC). If there is a plan to develop a NCD Alliance platform in Japan, I would be more than glad to take on the role!

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