Japan's nursing care system on verge of breakdown

Desperation stalks the care industry. More and more people need care. Fewer and fewer can give it. It’s an impossible situation. It can’t continue. Something will have to happen. What? When? Nobody seems to know.

Once every nine days a care recipient is murdered by an exhausted caregiver, sometimes a family member, sometimes a professional. Sometimes suicide follows murder.

In February a 61-year-old man was sentenced to four years in prison for the murder in 2022 of his 91-year-old mother. Her mind was failing, her body weakening, her care needs growing, their savings dwindling.

He’d been a French chef and quit his job to care for her. They lived on her pension, but it wasn’t enough – less and less so as the cost of living soared. It’s soaring still. There was no help and no hope – or if there was he failed to connect to it. Alone, harassed we imagine to the point of madness, he strangled her. The human nervous system is not infinitely resilient; it has a breaking point. Beyond it, there’s no telling what may happen. You may have gone a lifetime without ever committing a violent act, without so much as a violent thought. But you’re no longer yourself.

Last November an 84-year-old man strangled his 81-year-old Alzheimer’s-stricken wife. “There’s no end to it,” says Josei Jishin magazine (March 4) in a report titled “Nursing Care Breakdown.” No end indeed. This is a country in which one person in five is 75 or over. If the breakdown goes much further, it will take down with it more than just one industry and its immediate beneficiaries. This is a sociological earthquake and tsunami as terrifying as the natural cataclysms those words normally describe. 

What, one asks, of social services? They are many and various: medical facilities, senior citizen residents, group homes, daycare centers, home helpers – private-sector operations for the most part, backed by government support; costly all the same and their foundation is crumbling. A record number of them went bankrupt last year – 172, up from 122 the year before. The problem is not lack of demand – very far from it: 7.07 million people require care, says the health ministry; up from 2.56 million in 2001 and 6.96 million in 2023 – but shortage of staff. It’s arduous work, with long hours and low pay, the latter, it seems, immune under government-sponsored insurance strictures to the law of supply and demand. Who would take it on, given the choice? Many who do give up. Health ministry figures for 2023 show 2.12 million employed caregivers – down 29,000 from 2022. 

If it’s a job, you can quit and look for something else. If it’s a loved one who needs care, there is no “something else.” The French chef forced to quit his job is one of roughly 100,000 a year in a similar plight. The government has taken notice and coined a slogan: Kaigo rishoku zero. “Kaigo” is nursing, “rishoku” means leaving employment. If slogans were solutions, this one would do it. But they don’t seem to be, and it hasn’t. The number continues to rise. These are people with no professional training who must cope with needs utterly beyond the imagination of those who have never faced them. The relative lenience of the chef’s sentence suggests the court’s sympathy with what the defendant was up against.

Why didn’t he seek outside help? Perhaps he did, to no avail. It wouldn’t be surprising if so. The 172 industry bankruptcies are part of the story. Rising costs are another – of the services themselves and of everything else. You call in a home helper, let’s say, two days a week. It eases the burden somewhat, onerous even so. But it costs, and as your savings shrink you cast about for economy measures. What can be dispensed with? Is home help really necessary? Can’t I manage without it? You resolve to try and do your best. But there are costs not measurable in yen. There’s a psychological toll. Unmeasurable, it can go unnoticed – until something snaps.

Kikue Tsujimoto manages care operations at the Tokyo-based NPO Wakaba – an optimistic name meaning young leaves. She’s 74. “I’ll be closing down this month,” she tells Josei Jishin. “I’m getting on myself, and it’s impossible to get staff.” Japan needs an additional 570,000 caregivers by 2040, says the health ministry. The 29,000 caregivers lost in 2023 suggest the need for drastic action – “the first priority is to get wages up,” says sociologist Shuhei Ito; “but the government is doing nothing, and last year the wages of home helpers actually fell 2 percent.”

“At our peak we were helping to care for 80 people,” says Tsujimoto. “I’m now down to 10. It’s not that fewer people than before want our service. It’s that I can’t get staff.”

“Rieko,” as we’ll call her, is 90 years old and living on her own. She broke a bone, was hospitalized, underwent rehabilitation, recovered to a remarkable degree, and returned home. She’d need help with housework and shopping and such, but otherwise she felt quite capable of taking care of herself.

Her relative health was her undoing. The shrinking care pool must prioritize patients with more urgent needs than hers. She’s waiting her turn, doing her best in the meantime, an example and an inspiration for all of us; still, notes the magazine, “it’s cruel that a 90-year-old woman living alone can’t get the support she needs.”

And this, too, is cruel: Last October the Tokyo care facility Doctor House Jardin, it is alleged, abruptly shut down operations. There was no money to pay salaries, so staff stopped showing up. Municipal authorities scrambling to resettle the 94 residents found the place littered with dirty dishes and dirty diapers. Places were eventually found for all of them, but the stress the experience put them through is easily (or rather not easily) imagined.

Does no one have an idea? Maybe Germany does, suggests Ito, the sociologist. Germany pays family caregivers as something like government employees, recognizing that the work they do is of service to society as a whole. This, he says, has eased at least financial pressures on caregivers forced to quit jobs. It’s a start. Japan, very far in the forefront of the developed world’s rapid aging, suffers the paralysis of its core problem: an instinctive resistance to change in changing – not to say lurching – times. “Breakdown” draws ever nearer.

© Japan Today