Battling for Multicultural Healthcare: A Report from the TrenchesHealth Society
A Looming Crisis
Around 2015, the staff of the National Center for Global Health and Medicine (NCGM) in Shinjuku, Tokyo, began noticing an increase in inquiries from foreign nationals searching for hospitals or clinics where their native language was spoken. Around the same time, we began receiving a growing number of queries from other area institutions that were struggling to communicate with non-Japanese-speaking patients and wondering if we could lighten their burden.
Of course, foreign tourists, students, and businesspeople have long gravitated to Tokyo, but few neighborhood hospitals or clinics had to deal with non-Japanese-speaking patients on a regular basis. When forced to do so, they relied on friends or acquaintances to interpret or simply improvised, using gestures, pictures, and so forth.
In the past few years, however, providers have begun to feel overwhelmed. At some facilities, the frequency of visits from foreign nationals surged from about one a month to one a week and then one a day. Providers were witnessing with their own eyes what government statistics only later confirmed—that the number of foreign patients was growing at an unprecedented pace. Moreover, the trend has spread from Japan’s big urban and tourism centers to the outlying regions.
Concern over the capacity of our healthcare system to accommodate foreign patients has likewise spread and escalated. The government plans to beef up medical interpreting, but this approach fails to acknowledge the breadth and urgency of the problem. Clear communication can be a matter of life and death for our patients. Here on the ground, there is a growing sense that Japan’s healthcare system must adapt quickly if we are to avert a full-scale healthcare crisis.
In Shinjuku, one of Tokyo’s most diverse municipalities, non-Japanese citizens make up a full 12% of registered residents and account for more than 60% of the community’s annual population growth. Multilingual and multicultural government and social services have become essential, not only for the working-age foreigners concentrated here but increasingly for their dependents as well. Some neighborhood elementary schools prepare informational materials in seven different languages. In the hospital where I work, foreigners account for 12% of all first-time outpatient visits. Here, interpreting for patients and their families has become routine.
But not all municipalities or facilities are so equipped. Meanwhile, demand for healthcare services from foreign nationals is expected to soar further in the coming years, as the Japanese government pursues its target of 40 million inbound tourists by 2020, while simultaneously opening the door to many more foreign workers—and all this at a time when local healthcare facilities are grappling with the shift to community-based care.
In the following, I examine in greater detail the key challenges facing the Japanese healthcare system in an increasingly multicultural society.
Japan’s Laissez-Faire Policy on Language Support
Medical communication can be challenging in the best of circumstances. A verbal explanation delivered by a Japanese physician or nurse to a Japanese patient is often insufficient to convey everything the patient needs to know. To fulfill their obligation to inform and explain, healthcare providers frequently supplement such face-to-face discussions with written materials.
Viewed from this perspective, providing a qualified interpreter seems like the bare minimum a healthcare facility should do for a patient who speaks no Japanese. Yet in many cases, the facility has neither in-house interpreting staff nor funding to pay for outside interpreters. Indeed, the kind of specialized professionals needed for the job may not even be available.
In Japan, the police and the courts are legally obligated to provide qualified interpreters for those requiring their services, yet there is no such requirement for healthcare providers. In Canada and Australia (where I have conducted research), residents deemed unable to understand or communicate adequately in English are provided with medical interpreters trained at public expense. These countries have allocated resources to train and compensate such professionals in order to protect the basic rights of foreign nationals and ensure the safety of all patients.
In Japan, where such a system is lacking, many facilities rely on local volunteers—despite the potentially dire consequences of faulty or vague communication. A growing number of hospitals contract with outside agencies for telephone interpreting, but not all facilities can afford the cost of such services. Among those that cannot, the tendency is to avoid foreign patients altogether—a trend at odds with the widely acknowledged need for greater inclusion and accommodation.
Unfortunately, simply complaining about the lack of policy support and the shortage of qualified interpreters is not a solution. Where possible, institutions themselves need to step up to the plate and address the problem proactively. The NCGM provides professional training for medical interpreters in partnership with several other healthcare institutions and organizations, and we offer training free of charge for those interested in medical interpreting between Japanese and such high-demand languages as Vietnamese, Nepalese, and Burmese (the Myanmar language). Healthcare providers can also minimize the risk of dangerous translation errors by sharing information and materials with interpreters in advance and speaking in clear, simple Japanese.
Of course, there is a limit to what we can expect from small private hospitals and clinics outside of the major metropolitan areas. But regional partnerships and alliances can make a big difference. In Ishikawa Prefecture, which has invested heavily in tourism, the prefectural chapter of the Japan Medical Association has contracted with language agencies to provide free medical interpreting for member institutions when needed. These services are available to foreign students and workers as well as tourists.
Addressing the Nonpayment Problem
Another problem frequently cited by healthcare facilities in connection with foreign patients is the issue of unpaid medical bills.
In Japan, it is almost impossible to know in advance what any given tests or procedures will cost. Neither doctors nor their nurses can provide patients with such information. The reason this is not more of a problem is that healthcare overall is relatively inexpensive (especially by comparison with the United States), and that universal health insurance covers about 70% of the total cost. There are also mechanisms to lighten the burden of costly hospitalization and treatment in cases of financial hardship. Students, trainees, and other foreigners residing legally in Japan typically enroll in the national health insurance system and enjoy the same benefits as Japanese citizens.
Most nonpayment issues involve short-term visitors who arrive in Japan without travel insurance or other coverage, experience unexpected medical problems, and return home without paying the bill, protesting that it is beyond their means. These uncollected fees are basically unrecoverable, and they can put a serious strain on the finances of local healthcare facilities.
No doubt there are instances of freeloaders who have no intention from the start paying for the services they receive, but these constitute a small fraction of the whole. Far more common are situations in which patients are unable to pay the unexpected expense in cash (as many providers still insist) or find their credit cards maxed out. Tourists covered by domestic insurance plans or travel insurance are often called on to pay upfront, especially if the facility lacks the English skills and other know-how to bill the insurer.
Accordingly, many of these cases of nonpayment could be prevented by introducing more flexible hospital practices—accepting payment by credit or debit card, arranging with credit card companies for emergency credit-limit increases, having the patient contact family to provide an alternative method of payment, hiring intermediary agencies to deal with foreign insurance companies, and so forth. The presence of competent interpreters could also help ensure that patients understand their bills and their payment options.
That said, the possibility of nonpayment remains real. In the absence of policy reform, the provision of costly treatment to short-term foreign visitors will continue to pose considerable financial risk for healthcare facilities.
Overcoming Cultural Barriers
Cultural competence is another challenge for Japanese healthcare facilities in dealing with non-Japanese patients and their families. For example, very few Japanese hospitals are in a position to accommodate a female Muslim patient who will only agree to be seen by a female practitioner. Some Tokyo hospitals can guarantee an all-female obstetrics staff for women in labor, but not many. Hospitals need to apprise women of the situation in advance, so that they can make an informed decision about whether to give birth in Japan or return home to Singapore or Malaysia.
Dietary laws create further challenges for multicultural in-patient care. In some cases, it is simply a matter of avoiding a few specific ingredients in hospital meals. (On the other hand, some patients object even to the use of rubbing alcohol as a disinfectant.) Facilities need to have a frank conversation with the patients and their families about their dietary needs and options. In some cases, having prepared meals brought in by family, friends, or caterers may be the best answer.
Controlling Infectious Disease
The increased movement of people across national borders has made disease control measures more important than ever before. Japan’s healthcare providers are trained to follow standard protocols for preventing the spread of infection, but they need to do more to enlist the cooperation of patients and their families. This can be difficult when all the relevant educational materials are in Japanese.
Immunization is a case in point. Coverage of 95% of a population is needed to prevent outbreaks of diseases like measles and rubella. Japan needs to provide clear multilingual information on its immunization requirements to all foreign nationals engaged in childcare or expecting children in Japan. Hospitals and municipalities must do their part, meanwhile, by posting clear multilingual information to help non-Japanese visitors and residents access these and other essential healthcare services.
The time has also come to require medical examinations of all students, trainees, and workers before they enter Japan for extended periods of stay. Over the past few years several outbreaks of tuberculosis have been reported at Japanese language schools in Tokyo and elsewhere in the country. This should not be particularly surprising when one considers the lack of systematic testing and the close and stressful conditions in which foreign students often work and live. There have also been reports of outbreaks among foreign “trainees” housed together in dormitories under the Technical Intern Training Program—even though participants in the program are technically required to undergo a medical examination before entering the country and periodically thereafter. Other infectious diseases, like measles and rubella, can pose risks at the local level.
Foreign students and trainees, who can ill afford to be quarantined, stand to benefit most from pre-immigration medical examinations to screen for tuberculosis and other infectious diseases. Yet the language schools and local communities that benefit from their presence seem reluctant to impose or implement such requirements for fear of discouraging applicants. So it is that in our current economy-first environment, health, safety, and humane conditions take a backseat to profit, and local healthcare facilities end up paying the cost.
A Question of Will
The failure of the Japanese healthcare system to accommodate the needs of foreign patients is nothing new. The reason it emerged in 2018 as a focus of such intense scrutiny is simply that the sense of alarm that had been building among healthcare providers finally spread to other sectors of society. With the number of foreign patients mounting and projected to grow at a faster rate than ever, the realization dawned on local community leaders, journalists, and others that we must act decisively to avert an all-out crisis.
The two critical challenges facing the healthcare system today as regards the care of foreign nationals are those of improving multilingual communication to minimize health risks to patients and avoiding nonpayment to minimize the financial risk to healthcare providers and institutions. Changes in hospital practices and public policy can go a long way toward preventing problems and reducing these risks; it is mainly a question of how quickly we are willing to act.
For too long now, initiatives and accommodations geared to the treatment of foreign patients have been left to a handful of “advanced treatment hospitals.” That approach is no longer tenable. We need to institute rigorous new systems across the board. The safety of our patients and communities and the livelihood of our healthcare providers now hinge on the will of our government and medical administrators.
(Banner photo: The author, Hori Narumi, at the entrance to the International Health Care Center, National Center for Global Health and Medicine, Tokyo.)