Toshitaka Nakahara

New approaches to public health education, research and practice

The World Health Organization has defined public health as the science and art of promoting health, preventing disease, and prolonging life through the organized community efforts. In Japan, the role of the nation in promoting public health is clearly stated in the Japanese constitution, and doctors and other medical professionals learn the principles of public health as an essential part of their national qualifications. Consequently, research into education in the field of public health is extremely important. For this reason, the Faculty of Medicine in Kyoto University provides courses in hygiene and in public health, conducting both teaching and research.

When I took up my post in 1997, the work of promoting the study of public health in Japan already had the benefit of an extremely firm foundation that had been painstakingly constructed since the Meiji period, including public health administration. However, despite this foundation, not everything was straightforward and many challenges presented themselves. The challenges included actively addressing the administration's requirements, such as conducting spe-cified research, serving on government think tanks, and participating in other organized community efforts. I also became involved in education and research in peripheral areas, such as taking a role in Japanese and international academic conferences and in the activities of organizations working in public health. Training human resources has been another substantial commitment, working through the School of Medicine, School of Health Science, Graduate School of Medicine, School of Public Health, and also through education at other universities, working to reform and improve medical and public health teaching, producing textbooks, and actively participating in the national examinations for medical practitioners. I also make a particular effort to participate in environmental issues within Kyoto University, to participate in occupational safety and health issues, and to practice and improve public health education both at and outside the university.

Kyoto University Graduate School of Medicine established its School of Public Health in 2000, training public health specialists with the skills needed for a changing society. Until recently, all training of public health specialists had been handled by the National Institute of Public Health, which was established in 1938 under the government's Ministry of Health and Welfare. In today's Japan, however, it is vital for health, medicine and welfare to be properly interlinked. To achieve this and to train people who can deal with new public health issues, it was decided to establish a School of Public Health within Kyoto University that would be based on this new approach. I was personally involved in the establishment of the School, and continue to be involved in medical education, public health education and research, with the main focus being on my specialty of Public Health and International Health.

The largest public health issue we currently face is still tobacco, although Japan has made some progress by using the Health Promotion Law to take action on passive smoking, and has ratified the WHO's Framework Convention on Tobacco Control (FCTC). The economic losses incurred by Japan are significant. (See table for 2002 figures.) The nation's total medical expenditure was approximately 31 trillion yen, but reports estimate that direct excess medical expenditure due to smoking accounts for 1.3 trillion yen of that total. Our findings demonstrated that stopping smoking is effective at reducing medical expenditure, and provided the basis for 2006 revisions to the treatment fees received by medical institutions under Japan's national health insurance program. As a result, doctors are now paid for managing nicotine dependence by giving guidance to smokers and managing attempts to give up smoking. With this change in the fee structure, guidance on giving up smoking is now available at medical institutions. Another important event that has happened in 2006 is the establishment of Japanese Association for Smoking Control Science. The Association conducts scientific studies related to stopping smoking, and has the objective of securing a position for Smoking Control Science as an academic discipline.

From a practical perspective, health promotion is regarded as one of the most important approaches for public health worldwide, but in international health terms, there are suggestions that health promotion needs to be fused with primary health care, the principle behind public health work for developing countries. Local governments including Kyoto City and Kyoto Prefecture sought advice on this topic when creating their local versions of the Health Japan 21 guidelines for health promotion. The School is now collaborating with these local authorities to create such guidelines and evaluate their effect.

Turning to the system for implementing public health, we have been investigating and considering how local authorities and public health centers in municipalities around Japan should cooperate under the Community Health Act. Health education by local authorities and public health centers is important in helping people to live healthy lives, and this role is performed in Japan through the implementation of legislation such as the Law of Health and Medical Services for the Aged. Our studies have investigated the prevention of life-style diseases (hypertension, diabetes mellitus, hyperlipidemia, osteoporosis, etc.) and also examined smoking, HIV/AIDS, etc. With regard to cigarette smoking, first of all we discovered from surveys of students that smokers were already well aware of the health risks from smoking, and that the majority of smokers wanted to quit.

Total Social Loss By Smoking(2002)

Furthermore, our surveys of action taken against smoking by hospitals, companies, etc. found that 57.2% of hospitals had anti-smoking education programs for patients,that 30.1% of hospitals were taking action on smoking by hospital employees, and that 84.1% of companies were taking some sort of action against smoking. In contrast, as many as 65% of hospitals still permit smoking in doctors' rooms, demonstrating doctors' relative lack of concern about smoking. Surveys regarding the health education programs implemented by public health centers and local authorities showed that public health centers give more guidance on stopping smoking. Methods of education also differed, with 28% of public health centers offering lectures and 29 offering health classes (an average of 2.8 sessions per class) with about 26 people attending each session. Sessions sometimes incorporate practical elements, with for example, 48% of health classes measuring the concentration of carbon monoxide in the breath of each class participant. Telephone follow-ups on the effectiveness of the educational programs were conducted by 15% of the public health centers. We have also analyzed health education from a social marketing perspective with the aim of discovering even more effective methods. Regarding interrelationships with administrative entities and other organizations (hospitals, schools, etc.) on health education, 60% of public health centers had a clear grasp of health education programs provided by the local authority, but only 40% of public health centers demonstrated a grasp of programs conducted by other organizations, indicating the need for establishing a greater level of cooperation between the entities that are working to achieve widespread health education.

I am also active internationally, working as President for the Northern Part of Western Pacific in the International Union of Health Promotion and Health Education, a position from which I am involved in enhancing links and information exchange in the field of health promotion between the countries of East Asia.

These sorts of surveys and investigations on the practical aspects of the study of public health are generally focused on health promotion, and their findings form the basis of guidance given to the public health administration. One current change in Japan is a growing concern about metabolic syndrome, a composite life-style disease that includes diabetes mellitus, obesity, etc. Another change is the increasingly substantial participation by insurance authorities such as the national health insurance program in maintaining and improving health, an area where public welfare authorities have played a particularly large role to date. Meeting this sort of change in circumstances, we are investigating a wider range of methods for enhancing public health; we are aiming to establish more effective and more efficient methods; and we intend to encourage the application of those methods in the community.

Photo of Nakahara

Toshitaka Nakahara

Born in 1949
Specialized Research Field: Public Health and International Health
Graduated from the Faculty of Medicine at Kyoto University.
Master's degree in Public Health, School of Hygiene and Public Health, Johns Hopkins University
M.D., Ph.D. in Medicine (Nihon University), M.P.H. (Johns Hopkins University)
Professor, Graduate School of Medicine, Kyoto University
URL : public health and international health (External Link) (Japanese only)

"Public health has not always been seen as a big issue in Japan, but it does have a long history. When schools of medicine were first established in the Meiji era, the study of hygiene was treated as a subject in its own right and given a status alongside surgery, internal medicine, pathology, and physiology. The concept of public health reached Japan from the United States after the World War II".

Prof. Nakahara graduated from the Faculty of Medicine at Kyoto University in 1974 and got his medical license later that year. He chuckles when he says, "Although I do perform the occasional checkup, I have done almost nothing as a doctor in the area of medical treatment." Since graduating from the Faculty of Medicine at Kyoto University, he has worked for the government in the fields of maternal and child health, industrial health, health management, healthcare of the aged, building hygiene, water services, waste management, environmental conservation, and health insurance at the Ministry of Health and Welfare, and for Yamanashi and Kagoshima prefectures. In 1979, he went to study at Johns Hopkins University where he went on to get a masters degree in public health. He subsequently worked as a public health expert and researcher. In 1992, he was appointed Director of the Department of Public Health at the National Institute of Public Health, and, in 1997, he took up his current position as a Prof. at Kyoto University's Graduate School of Medicine.

Prof. Nakahara's research topics have been very diverse, but he is particularly well known for a paper published about ten years ago examining the cost to society of smoking - how much has to be paid in extra medical costs due to smoking, and how much medical costs would be reduced by promoting non-smoking. Restrictions on smoking in Japan had lagged behind the West until this point, when Nakahara's report triggered a change in attitudes that resulted in Japan finally taking the smoking issue