1. Innovative policies, programs, projects, and best practices
2. Obstacles and how they are being overcome
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In light of the Japanese government's response in April 1999 to the questionnaire on the implementation of the Beijing Platform for Action distributed by the UN Division for the Advancement of Women, we observed three major advances taking place from the viewpoint of women NGOs. First, "The Plan for Gender Equality 2000" formulated by the Office for Gender Equality, the Prime Minister's Office, in December 1996 became the first government document to incorporate the notion of reproductive health/rights under the title of "Chapter 9: Supporting Life-long Health for Women, (1) Spreading awareness of reproductive health/rights," in "Part II: Basic Direction of Measures and Concrete Measures." Second, we greatly appreciate the deletion of the section concerning people with disabilities from the Eugenic Protection Law in 1996, because this is likely to eliminate discrimination against people with disabilities. Enacted in 1948, the Eugenic Protection Law specified the conditions under which induced abortions and fertility operations can be performed for purpose of preventing "birth of undesirable offspring" and promoting family planning. Third, at the International Conference on Population and Development (ICPD) held in Cairo in 1994, the Japanese government proposed the Global Issues Initiative (GII) in connection with population and HIV/AIDS, and further at the Fourth World Conference on Women in Beijing held in 1995 it proposed the WID Initiative concerning women and development, thereby intensifying international cooperation. Moreover, the linkage between the government and the NGOs has been promoted to a certain extent since the ICPD.
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(1)Budgets for women's health
In keeping with "The Plan for Gender Equality 2000," "support of life- long health for women" has been included as a budget item since 1997 in Ministry of Health and Welfare budget bills. In reality, however, government policies and budget allocations remain biased toward maternal and child health (MCH), with children's well-being given the top priority. Furthermore, the fact that the government measures for the health of other age groups are not well-developed, with the exception of osteoporosis prevention in aged women, suggests an absence of the notion of women's life-long health, as stipulated in the Beijing Platform for Action. It is also important to point out that the 1997 revision of the Maternal and Child Health Law, coupled with the integration of local public health centers, was a serious setback for women. These two changes are creating regional imbalances in available benefits, by giving local governments more leeway to decide the allocation of health-related budgets.
(2) Inadequate legal systems concerning women's health
There were no legal changes or revisions made regarding women's rights of self-determination, one of the key components of reproductive health/rights, even after the Japanese government adopted the Platform for Action at the Beijing Conference in 1995. In fact, under the Mother's Body Protection Law (translated as the Maternal Protection Law in the government's report in April, 1999), which is the 1996 revision of the Eugenic Protection Law, no amendment has been made to the part requiring a woman wishing to have an induced abortion to obtain permission from her spouse (husband or partner). In addition, various aspects of women's life-long health from the viewpoint of women's reproductive health/rights are not yet legally guaranteed. More importantly, the eugenics philosophy remains deep-rooted in the Japanese society as a whole, together with discrimination against people with disabilities. This is evident in the recent increase in prenatal testing and other reproductive technologies, which drives pregnant women to have an abortion if the fetus is found to have abnormalities. Chapter 29 of the Criminal Code, which holds only women and medical doctors and other medical workers involved punishable for induced abortions, has not been amended and is in effect to this day, even though the Mother's Body Protection Law laid down the conditions for induced abortion.
(3)Unsatisfactory medical conditions for women
a. Lack of informed choice
At present, women's informed choice is not guaranteed. One reason is that in general, doctors have power over their patients and do not necessarily explain details of the condition/symptoms and choices available in treatment; furthermore, in many cases, doctors act much more authoritatively over their female patients than over male patients.
b. Low fertility rate and fertility treatment
Alarmed by a drop in total fertility rates, the Japanese government is advancing fertility treatment in order to raise the rates. In the area of reproductive engineering including fertility treatment, there are many cases where informed choice is not guaranteed between the doctor and the patient. As long as the conventional belief which holds that "Women are not mature unless they give birth to a baby" prevails, women seeking help concerning their fertility are "pressured" to undergo fertility treatment.
c. Breast cancer and other gynecological cancers
According to reliable sources, 30,000 women are diagnosed with breast cancer, and 7,000 women die of this disease every year in Japan. This is three times more than in the 1970s. On top of this, while Japan is among the countries with the lowest incidence, the percentage increase of breast cancer incidence in Japan is the highest in the world. Keeping in mind that early detection is crucial to the eradication of breast cancer and other gynecological diseases, the government should carry out more research and formulate more policies on the causes of the increase in these diseases and on medical options available.
d.Endometriosis and fibroid tumors
The majority of endometriosis patients, who are rapidly increasing in number, are not properly diagnosed using laparoscopy or laparotomy, but only by ultrasonic imaging. Moreover, they are treated by pharmacotherapy using expensive drugs called GnRH-a, which are known to have detrimental side effects, including headaches and hyposexuality. The low-dose contraceptive pill, which is believed to be effective for the treatment of endometriosis, is not covered by health insurance. Considering that there are numerous cases in which endometriosis is misdiagnosed as fibroid tumors, further advances in research and treatment of these two diseases are needed.
e. Contraceptive choices
Until recently, contraceptive choice has been very limited in Japan. In June 1999, nine years since the first application for official approval, the Ministry of Health and Welfare finally approved the low-dose contraceptive pill along with medicated IUD with copper. Previously, condoms were most widely used. The only option for women experiencing unwanted pregnancies was induced abortion often with serious physical and psychological consequences. Not a few women in Japan maintain that the use of the low-dose pill exacts a heavy toll on their body, saying that it is likely to disrupt women's hormonal balance. At the same time, some seek immediate development of drugs which enable sexually active males to reversibly adjust their sperm count. More importantly, many women do not have correct information about emergency contraception for use in case of rape or unwanted pregnancies. People's awareness of the prevention of sexually transmitted diseases is also generally low; therefore, it is a matter of urgency to inform people of the importance of wider use of condoms. In addition to wider contraceptive choices, immediate action should be taken to disseminate information, including appropriate information on the side effects of contraceptives; promote informed choice; and improve services such as counseling clinics, provision of information, etc.
f. Increase in HIV/AIDS infection and other sexually transmitted diseases
The government should immediately make more efforts in the research, treatment, and prevention of HIV/AIDS infection and other sexually transmitted diseases which have been increasing during the past decade.
g. Inappropriate mental care
It is necessary to pay more attention to the mental health care of female patients, especially those with breast cancer and other gynecological diseases, and women victims of violence by improving education, training, and information offered.
h. Widening of regional gaps in health services and high medical cost
Because of nationwide decentralization policies, local public health centers in underpopulated areas are being closed, which in turn prevents an easy access to health care services and increases the amount of medical expenses to be paid by the individuals. On top of this, in the face of the current economic recession, underprivileged women, including aged women, are suffering enormous disadvantages. Also, it is estimated that a high percentage of buraku (a category of Japanese subject to discrimination in employment and marriage) women, single mothers, and non-registered non-Japanese women, are unable to fully enjoy insurance benefits, either because they cannot afford to be entitled, or because they cannot make the payments not covered by health insurance.
(4)Adolescents and youth
Many problems--particularly unwanted pregnancies of adolescents and youth, insufficient sex education, drug abuse, smoking, and commercial sexual exploitation of children--remain unsolved. For details, see "L. Girls" in this report.
The average life expectancy of Japanese women as of 1997 is 83.82, while that of men is 77.19. The percentage of elderly people aged 65 and over is on the rise. It has just exceeded 16% and is expected to reach 17.3% in 2000. Sixty percent of these people are women. Health policies for elderly women especially have much room for improvement. In fact, 85% of family members who take care of the aged at home are women, and most of such responsibilities lie with daughters-in-law. Due to their advancing age and heavier workloads in terms of time and energy required, women who take care of the older members of their family are risking their own health. There are few professional elderly care workers, so the burden falls on family members. In accordance with the Long-Term Care Insurance Scheme, which will come into force in April 2000, elderly people who have been officially designated as in need of care will have to shoulder 10% of the cost of the services received from designated professional elderly care workers. Many more elderly women rather than men are facing financial problems, which might lead to what we call "the aging feminization of poverty." Special programs, including care insurance schemes, should be created for low-income elderly people, where women predominate, since 80% of elderly people living alone are women. Present welfare policies and research are not effective enough to enable women to live a healthy long life without becoming bed-ridden or afflicted with senile dementia.
(6)Women with disabilities
a. The reproductive health/rights of women with disabilities
The government needs to understand that women with disabilities are much more vulnerable than other women. In Japan, there is a widely held view that women with disabilities should not have children. Many disabled women are reportedly urged to undergo sterilization operations or ovariectomy. As long as society abides by a eugenics philosophy and treats disabled people differently from others, the reproductive rights of women with disabilities will never be guaranteed. What is more, since there are more mentally disabled men than women, mentally disabled women are increasingly left out of special facilities designed for the disabled, including workplaces.
b. Japan's segregated and separate educational system
By offering children opportunities to be in contact with diverse people and have enriched experiences, women would be able to accept their bodies as natural and value them as their own. Yet, many obstacles should be overcome in order to achieve this aim.
(7)Violence against women
As "D. Violence against women" in this report shows, adequate measures to deal with violence against women have not been implemented. Often women victims are not able to make a living and to receive proper therapy and support, which amounts to the infringement of the principles of reproductive health /rights.
(8)Women and labor
The problems of long working hours and health of women in charge of family labor, such as self-employed business and farming; female non-regular employees, including temporary workers and part-timers; divorced women; and migratory female workers are critical, and the health care services provided for them are insufficient. Further, there is an urgent need for more studies on women's occupation-related health in a changing working environment. By reason of sexual division of labor, women who have to be responsible for childcare and care for the elderly are facing the problems of long working hours and health.
(9)Degradation of global environment
Environmental degradation arising from the breakdown of nutrient cycles and ecosystems and other related causes has created many health problems. For example, studies show that many synthetic chemicals could disrupt the endocrine and reproductive systems and hinder normal sexual development. Research should be conducted to determine what link exists between gynecological diseases--such as endometriosis, breast cancer, and uterine cancer--in women, fetal abnormalities, and endocrine disrupting chemicals (EDCs). The EDC levels in the Japanese environment are rising due to massive use of herbicides and pesticides and the poorly maintained incineration facilities. Hence, many women wishing to breastfeed fear that their milk is contaminated. At the same time, a considerable amount of genetically modified agricultural products are being imported, although extensive studies have not been carried out to confirm their safety.
(10)The falling birthrate
Japan's birthrate continues to drop; 1998 statistics released by the Ministry of Health and Welfare shows that the number hit a record-low, 1.38. In view of the rapid aging of the Japanese population, the government fears that this might reduce society's vitality and makes it difficult to maintain the present social security system. To increase the birth rate, the government is advocating shorter work hours, improvement of childcare leave, a variety of childcare services and consciousness-raising, all of which are intended to make it easier for women to manage outside work and childcare, but to no avail. The national and local governments are also offering economic incentives to encourage couples to have more children, but they are not effective in the face of high educational expenses and the current economic recession. In the meantime, budgets for medical research into fertility are on the rise, while social pressures on women to have children remains high. However, the odds are that many couples will remain childless, unless they can enjoy life with their children and expect a better future for them. In order to enable women and couples to go through childbirth safely and care for their children, social support, including promotion of equal participation of men and women at home, should be extended so that having children would not work to parents' disadvantage.
Of most importance is the report titled, "Shaping the 21st Century: the Contribution of Development Co-operation," adopted by OECD/DAC in May 1996, which aims to ensure universal access to reproductive health services in the form of basic health systems as early as possible but not later than 2015 and to reduce maternal mortality rates by a quarter by 2015. In light of this document, the Japanese government should promote international cooperation to upgrade comprehensive reproductive health services, not confined to MCH. Partnership between governments and NGOs in the field of international cooperation should be further strengthened, allowing NGOs to participate in all processes of project cycle management, from needs assessment to evaluation of projects related to women's health as well as in the review and discussion on the formulation of general policies.
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Recognizing the present situation where women are at a greater disadvantage than men, the administration should further promote holistic measures addressing women's life-long health, including development of the legal system, improvement of medical and welfare services, extensive dissemination of information, and reformation of training programs for medical workers, focusing on the principles of reproductive health and women's rights. As yet, few wide-ranging policies have been developed in the area of women's health that contribute to contraceptive services for adolescent girls, prevention and treatment of gynecological diseases, such as breast cancer and endometriosis, research on menopausal disorders and their prevention, care of the elderly as well as occupation-related health in a changing working environment.
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