<POINTS>

• Discover and develop patient advocate leaders for dementia to reinforce civil society organizations.
• Redefine the concept of “health as a matter of personal responsibility” to revitalize discussions on dementia prevention.
• Demonstrate legislative leadership to hold full-fledged discussions on benefits and burdens to sustain the social security system.

 

The significance of including the dementia agenda at the G7 Summit 2023

In 2023, the G7 Summit will be held in Japan. Following the G7 Ise-Shima Summit in 2016, this will mark the seventh time for this event to be held in Japan. The G7 Leaders’ Summit will be held on May 19 in Hiroshima (where Prime Minister Fumio Kishida’s family is originally from) and the G7 Health Ministers’ Meeting will be held in Nagasaki City on May 13 and 14.

Over the past few years, the entire world has been working to overcome the Coronavirus Disease 2019 (COVID-19) pandemic, making infectious disease control a key theme not only at the Health Ministers’ Meeting, but at the Leaders’ Summit as well. Devoted efforts from the international community to end the pandemic have resulted in it taking precedence over other themes in the field of health and medicine.

As we discussed in this column every year (2022, 2021, 2020), the policy survey report “From Plan to Impact” published by Alzheimer’s Disease International shows that efforts to formulate national strategies for dementia according to objectives set by the World Health Organization (WHO) have not been advancing. To meet objectives for 2025 set by the WHO in 2017, it will be necessary for 35 additional countries and territories to formulate new national dementia strategies every year for the next three years. Given current progress, it is extremely difficult to say that this objective will be met. (By May 2022, only 39 Member States of the WHO had formulated national strategies for dementia.)

As we mentioned in the title of this column, Japan is not only the president of the G7 Summit in 2023, it is also the world’s leading super-aging society. (As of 2022, the rate of population aging in Japan was 29.1%.) While it goes without saying that the infectious disease agenda is important, in its role as G7 President, Japan must remind the international community of the importance and urgency of the aging agenda, starting with dementia. The G8 Health Ministers’ Meeting held ten years ago in 2013 in the U.K. is known as the “G8 Dementia Summit,” where dementia was the central topic of discussion. That event provided an opportunity to build momentum for joint efforts to address dementia from the international community. Given this context, it is highly significant that the summit to be held ten years later, in 2023, will take place in Japan.

Recognizing this significance, in July 2022, Health and Global Policy Institute (HGPI) presented comprehensive dementia policy recommendations titled, “The Future of Dementia Policy 2022: Deepening Dementia Policies Centered on People Living with Dementia and their Families to Lead Global Society.” Those recommendations evaluated past efforts made for dementia in Japan and indicated a direction to take moving forward from the four perspectives of the social environment, care, research, and political leadership, and have earned high recognition both in Japan and overseas.

Necessary steps for Japan to lead the international community – Our responsibilities as the world’s leading super-aging society

As host of the G7 Summit in 2023, high expectations are being placed on Japan to demonstrate leadership to the international community. To meet those expectations, I believe Japan has responsibilities it must fulfill as the world’s leading super-aging society. In particular, there have been growing expectations for innovations in the field of dementia in recent years, particularly for new diagnostic techniques and disease modifying therapies (DMTs). While it gives me no pleasure to say so, the introduction of such innovations will not instantly transform current circumstances surrounding dementia. For example, if we consider newly-developed diagnostic techniques, it is not necessarily the case that those techniques will be equally accessible in every region of Japan. As for DMTs, they may not be available for all forms of dementia or may only target a select few. Finally, to implement the use of such innovations, it will also be necessary for us to consider how to best structure society as well as systems for disseminating those innovations that will operate in a sustainable manner.

Recognizing this need, we would like to point out three responsibilities for Japan to fulfill as the world’s leading super-aging society.

1. Discover and develop patient advocate leaders for dementia to reinforce civil society organizations.
2. Redefine the concept of “health as a matter of personal responsibility” to revitalize discussions on dementia prevention.
3. Demonstrate legislative leadership to hold full-fledged discussions on benefits and burdens to sustain the social security system.

Regarding the first responsibility, HGPI has a long history of emphasizing the importance of promoting participation from affected parties throughout the policy formulation process in every disease area. In July 2022, we presented policy recommendations entitled “Further Promoting Patient and Public Involvement in the Policy-Making Process Steps for Achieving Healthcare Policies That Are Truly Centered on Patients and Citizens.” Recent years have seen increasing participation from the patients and those close to them in policy-making processes as well as in policy decision-making alongside the Government, academia, and healthcare professionals. Healthcare policy is a public issue, but at the same time, it is also an area of policy that impacts the private lives of individuals and families. This is why it is essential for patients, affected parties, and members of the general public who may someday be patients themselves to be involved in the creation of policies as something that concerns them (Kurita, Noritake, 2021). However, even if someone is a patient or an affected party, it is not possible for them to suddenly begin taking part in the policy-making process out of the blue. To promote Patient and Public Involvement (PPI), it will be necessary to increase the absolute number of patient advocate leaders who can guide such activities. In addition, when we say “reflect the voices of the parties most affected,” we must also consider how many people can be considered as members of that group. Estimates show that approximately 6 million people in Japan are living with dementia. If we include each of their voices as well as the voices of their family members and partners, we might be referring to as much as 10% of the population of Japan. If that is the case, then it is naturally difficult to identify a single voice for which we can say, “This is the voice of an affected party.” To gather as many such voices as possible and reflect them in the policy-making process, we must create a prevailing atmosphere in society where even more patient advocate leaders than exist today can take action, collaborate with various stakeholders, and have their voices be heard.

“Dementia prevention,” the second point described above, will be an unavoidable topic in future discussions on dementia policy. During the formulation of the National Framework for Promotion of Dementia Policies in 2019, there was a debate over whether the pillar for dementia prevention should be “prevention and inclusion” or “inclusion and prevention,” as well as how to handle key performance indicators (KPIs) and numerical targets for dementia prevention. In that series of discussions, some were of the opinion that “Promoting dementia prevention will result in stigma toward the people who develop dementia because they failed to prevent it.” Regarding the definition of “prevention,” the National Framework for Promotion of Dementia Policies states “Prevention does not mean ‘preventing dementia;’ it means ‘delaying the onset of dementia’ or ‘slowing the progression of dementia when people do develop it.’” (While this explanation communicates the intended meaning of “prevention,” it is safe to say there was room to consider the frequent use of the word “prevention” from a communication standpoint to determine if its intended meaning would be accurately understood throughout society.) In the international community, the term “risk reduction” is currently being used more frequently than “prevention.” While it may not exactly roll off the tongue, “risk reduction and the prevention of exacerbation” may be a more accurate reflection of the actual content of the policy.

I have given this topic a great amount of consideration over the past few years, and I think this debate is rooted in prevailing attitudes toward health in Japanese society. Here, people tend to believe “Experiencing poor health is a matter of personal responsibility, so people have to take responsibility for their own health.” One aspect in which we could observe this tendency was in discussions held during the early stages of the COVID-19 pandemic, in which people seemed to view infections as being the fault of the people who got infected. Reports in the news also showed that the percentage of the public that expressed the view that “Infected people only have themselves to blame” was much higher in Japan than in the U.S., the U.K., Italy, and China (Yomiuri Shimbun Online, June 29, 2020. “Survey led by Osaka University team shows 11% of people in Japan feel ‘Getting infected with COVID-19 is your own fault,’ which is ten times higher than in the U.S. and U.K.”).

Advances in technology have made it practical for each person to be able to check their own health conditions and take preventive measures (as a form of primary prevention) and, after the onset of a disease, track its progression and prevent recurrence (as forms of secondary and tertiary prevention). However, we must be careful to distinguish between “having one’s health fail due to inability to take preventive action” and “being personally responsible for that” (Yascha Mounk, The Age of Responsibility). Rather than just merely criticizing inappropriate health-related behaviors a person may have taken in the past, emphasizing personal responsibility can also result in moral condemnation toward an individual’s character. Furthermore, some have expressed the opinion that the line between what even falls under personal responsibility in the first place is arbitrary, and that it is nothing more than a prejudice based on “what is desirable socially” (Shintaro Tamate, The Ethics of Public Health).

The modern age has been called, “The age of personalized risk.” Technological advances have made it possible for us to accurately predict various risk factors and understand the characteristics of the individuals that each risk is associated with. These risks were originally supposed to be shared across the population as a whole, however, and it has been pointed out that the certainty provided by technological advances has led to a more prominent divide between high-risk groups and low-risk groups (Tatsuya Mima, The Riskification of the Body). Recently, a number of insurance products that personalize risk have appeared on the market. These include telematics insurance, a form of car insurance in which premiums reflect the risk of accidents based on driving habits; as well as forms of private medical insurance in which premiums are influenced by exercise history. Yet, one purpose of social security systems, including policies for dementia, is to distribute risk. Social security systems are frameworks to enable mutual support through various systems to everyone living in society without having to rely on factors like individuals or families. It goes without saying that many people want to lead long, healthy lives, and efforts to help them do so are important. Nonetheless, when working to advance such measures for prevention and health promotion, it seems safe to say it is more desirable to encourage the individual to exercise personal responsibility for their future actions (“prospective responsibility”) than require them to shoulder the losses incurred through their past actions on their own (“retrospective responsibility”) (Shintaro Tamate, The Ethics of Public Health). These sorts of perspectives are one theme I would like to incorporate into future discussions at HGPI.

The third responsibility encompasses the perspective of systems that will be required to uphold these “risk-sharing social policies.” Japan’s public Long-Term Care Insurance System is the foundation of dementia care, while its public National Health Insurance system supports dementia treatment today and will play a key role in providing society with the new diagnostic and treatment technologies that will emerge in the future. It is urgent that Japan finds ways to make these systems sustainable. Maintaining adequate benefits, however, will require reasonable burdens. The ratio of the burden of national social security to GDP in Japan is low compared to other OECD members, and considering the fact that Japan faces additional challenges due to a declining birthrate and population aging, the benefits and burdens must be rebalanced to ensure these systems can be made sustainable. Looking back on history, though, we can observe a tendency in the legislature to avoid discussions on increasing the burden because doing so can have a major impact on Cabinet approval ratings and elections. While social insurance premiums have been increased according to increases in benefits (which has been labeled an “invisible tax hike”), aside from increases in consumption tax, the tax burden has remained the same. Achieving dementia inclusivity does not necessarily mean building awareness and establishing living environments will be sufficient. Discussions should also address how to maintain social policies and the social security system so inclusivity can be possible. Demonstrating a promising future outlook for financial resources in terms of prospects for Japan’s dementia policy that includes healthcare and long-term care is also likely to enable Japan to show leadership to the international community through its policies.

In this column, we shared our expectations for Japan as host of the 2023 G7 Summit from the perspective of dementia policy as well as opinions on the responsibilities Japan must fulfill as the world’s leading super-aging society to provide guidance to the international community. It is our hope to continue speaking up about Japan’s duties in our capacity as a non-profit, independent, non-partisan policy think tank that is firmly rooted in civil society so the upcoming G7 Summit can be taken as an opportunity for Japan to demonstrate leadership to the world.

(This column is a revised version of an article titled, “Our Responsibilities as the World’s Leading Super-Aging Society Looking Ahead to the G7 Health Ministers’ Meeting in 2023,” which appeared in the January 24, 2023 edition of “Health and Welfare” from Jiji Press Ltd.)

Works Referenced
Kurita, S. and Noritake, R. 2021. “The Social Value of an Independent, Non-Profit, Non-Partisan Think Tank -Bringing Together Diverse Stakeholders for New Partnerships.” The Japanese Journal of Clinical Psychiatry, Vol. 50, No. 9. 943-948
Tamate, S. 2022. The Ethics of Public Health. Chikumashobo Ltd.
Mima, T. 2012. The Riskification of the Body – The Technologies of Modern Medicine and Governance. Seidosha.
Mounk, Y. Kimura, A. and Nasu, K., trans. 2019. The Age of Responsibility – Luck, Choice, and the Welfare State. Misuzu Shobo.

About the author
Shunichiro Kurita (HGPI Manager; Steering Committee Member, Designing for Dementia Hub)

 

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