Current Status and Future Issues on Public Health of Kobe

Administrative Bodies Responsible for Public Health

The national, prefectural and city governments all conduct public health measures. The national government is responsible for gathering information on regional health activities, providing training, technical and financial support to prefectural and municipal governments. The prefectural government is responsible for establishing and improving facilities, for technical support to municipal governments, both to municipal governments and over a wider area. The municipal government is responsible for establishing and improving facilities in each municipality, improving the quality of human resource, and carrying out the public health projects that are close to citizens.

Three Areas of Public Health Projects

Because Kobe is quite large, it has a somewhat unique structure. Public health projects in the city of Kobe are divided among three main areas:

1. Public health center, municipal health centers
2. Kobe Institute of Health
3. Mental Health Center

Kobe has one public health center, on the ninth floor of the Chuo Ward office. The center is responsible for planning and coordinating programs, which are then implemented by the municipal health centers. It plays the role usually performed by the prefectural health center, overseeing the health and risk managements systems of Kobe. It includes five offices for food and health standards.

Kobe has nine wards, with a public health and welfare office in each one. Citizens visit the municipal health centers for direct delivery of services.

The Kobe Institute of Health deals with regional and environmental issues. It also supports the municipal health centers on scientific and technical matters. It is involved with inspections, studies, examinations and analysis of regional and environmental public health issues.

The Mental Health Center offers administrative services concerning mental health, and provides citizens with accurate information and counseling services related to mental disorders.

Current Issues on Public Health

The public health issues in Kobe include merging the public health organization with welfare services. The division between these two fields has become increasingly blurred. Nursing care, for instance, is merging with general public health care. And general health care provides preventive services to help reduce future nursing care. The City has to figure out which organization should be responsible for what. It is important that the administrative activities of the City should be directed to its citizens. Public health services are mainly preventive. They can run for long periods and sometimes it is difficult to see the immediate outcomes and fruits of the services. Good examples are vaccination and immunization programs. It is difficult to measure the output, and also difficult to convince citizens of the benefit of public health services.

Public health services are getting more public attention recently. This is partly because of diseases likes SARS, and also because of new types of food that are becoming available. It has given us a chance to be more visible, and public health risk management is more of an open concern for citizens.

In line with "Healthy Japan 21," a national campaign to promote health, Kobe created its own "Healthy Kobe 21" program in 2002, to help citizens enjoy good health throughout their lives.

Eight Categories of Public Health Services

Public health services promoted by Kobe are roughly divided into the following categories:

1. maternal and child health
2. adult and elderly health
3. management of intractable diseases
4. infectious disease control
5. tuberculosis control
6. mental health
7. environmental health
8. medical and pharmaceutical affairs

Material and Child Health Project

There are several issues that are addressed in the strategies of Kobe and the larger nation alike. These include a dwindling birthrate and an aging population, women's social advancement (women are getting higher education and jobs outside the house), an increase in child abuse (physical, mental and sexual abuse as well as negligence), and a shift from extended families toward nuclear families.

Childcare is a major concern in families where both parents work. The mother often works long hours and the father even longer hours.

The fertility rate is decreasing, and a population pyramid clearly shows the change in population structure. In 1930 the pyramid was very broad at the bottom and narrowed steadily toward the top. By 1950 it had begun to bulge slightly in the middle. By 1960 and 1970 the bulging in the center continued, almost completely eliminating the pyramid shape. By 1980 and 1990 a pyramid was no longer recognizable, as the bulk of the population moved upward without corresponding replacements at the bottom. Projections for 2020 show the widest part of the graph at the top, instead of the bottom. Viewed in a series, it provides a shocking image, and helps show the serious problem we are facing.

There were sharp changes in both the birth rate and the infant mortality rate from the period 1900 to 2000. The birth rate in 1900 was just over 30 births per 1,000 people. By 2003, it had fallen to about 8.6 per 1,000 people. The infant mortality rate in 1900 was just under 160 per 1,000 births. By 2000 it had fallen to 2.6 per 1,000 births.

There has been a steady development of a maternal and child health care system. Significant dates include:

1937 - Health Care Center Law - enforcement of health guidance for pregnant women and their babies
1942 - Establishment of the maternity handbook.
1958 - Nursing care for premature babies.
1961 - Health checkups for three-year-olds.
1965 - Maternal and child health law.
1974 - Research into treatment for chronic childhood diseases
1977 - Health checkups 18-month-old babies
2003 - Funding of infertility treatment projects

The Maternal and Child Health Handbook is issued to women who register their pregnancies. It is used for recording health information about the pregnancy, birth, and care after birth.

There is a project in place to expand visiting to all newborn children, by a maternity nurse or hygienist. They will weigh the baby, give childcare advice, respond to concerns the mother might have, and give information on other resources available. There are separate guidelines for visits to babies who were born prematurely.

Health check-ups for babies are scheduled at four months, nine months, 18 months and three years. These will confirm proper growth, provide early detection and treatment of diseases and disabilities, and provide support for parents with childcare anxieties and difficulties.

For the four-month checkup, the compliance rate in 2003 was 96 percent. For the nine-month check-up, it was 91 percent. For the 18-month check-up and the three-year check-up, it was 97 percent. These check-ups are often carried out in one location, on the same day, and help create a community center type of atmosphere. It provides a good opportunity for us to give information to parents, and it is also a good opportunity for them to exchange information with each other.

Classes on childcare are also held. Few young mothers today have enough chances to care for or even hold infants, and to learn about diaper changing, clothing, skin care, etc. The classes also allow parents to share problems such as, multiple pregnancies. They also help prevent parents from caring for children in isolation, without support from other parents, and help promote community support for childcare. The classes include:

1. Bringing up babies:
   For parents of babies of five to six months old, information on accident prevention, play, baby food, dental care, sanitation, making friends, and reading picture books, are provided.
2. Continued Care:
   For children over 18 months with continuing need for support in regard to areas like speech or social skills. Instruction by hygienists, childcare workers, and psychological counselors will be given, on group play and maternal concerns about raising children. Opportunity for Information exchange among parents facing similar problems will also be created.
3. Child Abuse Prevention:
   Group counseling to support families who cannot establish proper parent-child relationships. Other classes include parenting for very low-birth-weight infants, and classes for parenting a handicapped child. There are also classes for expectant mothers and/or their husbands, about pregnancy and fathers' responsibilities for childcare. These classes are offered on Saturdays or holidays. Other classes focus on health care programs for adolescents. They are offered, when requested, by professionals. The classes include sex education for seventh-graders, taught by qualified midwives, and a class on sexually transmitted diseases, for ninth-graders, taught by doctors.
   The city also operates a hotline for adolescent problems, and an automated answering service for common adolescent concerns.
   The city has hospital programs for premature baby care (babies under 2,000 grams), for nurturing treatment, and for research into chronic diseases, such as leukemia, kidney disease, and cancer.
   The city also has a program for fertility treatment, including aid for in-vitro fertilization or micro-insemination. These treatments cost a lot, and often have to be repeated multiple times.

Other Services

1. Adult and elderly health:
   The city provides the following services to citizens over 40 years old: a) a health handbook, b) health education, c) health counseling, d) health examinations (cancer screening, etc.), e) functional training program and f) home-visit guidance. The city also cooperates with private facilities providing services to prevent people from being bedridden, and to assist those who are bedridden.
2. Management of intractable diseases:
   Public financial support for medical expenses, and other support and advice on receiving medical care at home are given to those suffering from certain intractable diseases.
3. Infectious disease control:
   Provides accurate information about infections, promotes screening and immunization programs, mounts awareness campaigns, and carries out surveillance on infectious diseases. It is especially important to prevent influenza, in particular among the elderly.
4. Tuberculosis control:
   The national rate for tuberculosis infection is 24.8 per 100,000 people, while in Kobe it is 35.9 per 100,000. This year the city started a project to reduce the incidence of infection to below 30 per 100,000 people by promoting early detection, appropriate treatment and by improving the patient support system.
5. Mental health:
   Programs offered by the city include social and vocational rehabilitation, the provision learning opportunities about mental health issues for affected families, legal and administrative assistance, and awareness campaigns.
6. Environmental health:
   The city issues business licenses for eating establishments, inns and hotels, public baths, barbers and beauty salons, and performs inspections of these businesses. It also offers animal protection, including advice on how to raise and train pets, and vaccinations to control rabies and other infections.
7. Medical and pharmaceutical affairs:
   The city issues licenses to dentists and other clinics, performs on-site inspections at medical facilities, helps reduce medical accidents and hospital-acquired infections, and provides high-quality medical services giving due consideration to the convenience ofits citizens. In 2003, the city started an advisory service to receive inquiries and hear complaints on medical services from citizens. The goal is to build trust between patients and their families and medical staffs and their institutions, and to improve the quality of medical services.

Health Risk Management System

The Public Health Center plays a leading role in preparing manuals and guidelines for risk management. It works with the municipal health centers to implement the guidelines. With SARS in 2003, and avian influenza in 2004, the city prepared an action plan and manuals for dealing with these diseases. The city also set up a contact office to respond to questions. This office is open on holidays and at night, in addition to regular hours.

Future Commitments

The city will continue to promote "Healthy Kobe 21" and will conduct an interim review to assess the program. The city will also start a new prostate cancer screening program. Other existing screening programs will be upgraded: mammography examination will be introduced; the minimum age for uterine cancer will be lowered, and a gastric cancer screening unit will tour the city, usually at the municipal health centers.

The budget for the Public Health and Welfare Bureau in 2005 is 18 percent of the city's general account spending.

Questions and Answers

-Public Health Generally-

Q: The rate of divorces is very high. What are the causes of that?

A: Yes, there are many divorces. There are no concrete measures to deal with this.

Q: Do you refer children in divorced families to the welfare department? What department cares for them?

A: We do not refer them to the welfare department. The child-home section, in another department, takes care of them. A foster-parent type program is also in place.

Q: How are the activities in the municipal health centers coordinated?

A: By the Public Health Center, which supervises the municipal health centers.

Q: How is cancer screening for a large city promoted?

A: There are many public relations activities, and the screening unit makes tours of the city, to raise awareness of the citizens. But the rates of screening are still quite low. We would like to raise them higher. We follow national guidelines for cancer screenings.

Q: Is the screening free for citizens?

A: It is not free.

Q: Is the screening free for those who can't afford it?

A: The poor can receive screening free of charge.

Q: Are tuberculosis patients treated at home or in a hospital?

A: They are mainly treated at a hospital. We get better compliance with the treatment regimen that way.

Q: What steps did you take in regard to SARS and Asian flu?

A: With these two diseases, we performed some complete sterilizations at some facilities, and also performed health checks of vulnerable populations.

Q: How do the different government levels of health care deal with each other and communicate?

A: We are in very frequent phone contact. The governments are close. We have not felt a communication problem in our case.

-Maternal and Child Health-

Q: What is the maternal mortality rate in Japan?

A: Three years ago, the rate was 7.3 per 100,000 births. Two years ago, the rate was 6.9 per 100,000 births. Factors for this usually include complications during birth, leading to hemorrhage and/or infection. A mother can suffer an amniotic embolism, something that happens in about one per 100,000 births. This can lead to respiratory failure, when water fills the lungs. It is important to watch for fetal heart rate drops, difficulty in breathing and chest pain during delivery.

Q: Are breast-feeding practices an issue here?

A: It is up to the mother to decide which method to use. We encourage breast feeding, because of the good nutrition and the good communication with the baby that it offers.

Q: Do you provide induced abortions for HIV-infected pregnant women?

A: I am not an expert in that field, and do not have an answer for you.

Editor's Note: This article is a summary of the following presentations delivered at the First 2005 Workshop. AUICK takes full editorial responsibility for the content.
* "Current Status and Future Issues on Public Health Administration of Kobe City" by Mr. Hiroshi Terada, Manager of Health Promotion and Planning Division, Public Health Department, Public Health and Welfare Bureau, Kobe City Government.
* "Maternal and Child Health Services of Kobe City" by Ms. Mihoko Higashisaka, Chief of Child Rearing Support Department, Public Health and Welfare Bureau, Kobe City Government.