“Attention residents of Matsudo! A 70-year-old, 1.70m-tall man is missing…” In 2018, 16,927 elderly people went missing in Japan, the majority of them with dementia. In a country where, at 36 million, the elderly make up 30 per cent of the population, providing them with care and assistance is a social responsibility. In Matsudo, a commuter city east of Tokyo, public announcements of this kind are made every ten days. Volunteers patrol the city in orange vests to assist disoriented grandparents. In 2019, they were able to find all but one.

During the World War II era, as described by anthropologist Ruth Benedicte, Japan’s elderly were cared for by their families. The current reality, however, is very different. The Confucian tradition of maximum respect for elders is still taught in schools and there is an annual public holiday honouring elderly citizens. But in the majority of cases, it is no longer their families who care for them but society. According to the OECD, Japan not only has the highest life expectancy in the world but also the healthiest population.

This shift from the tradition of taking care of the elderly within families to assisted care was very rapid,” explains Florentino Rodao, historian at Madrid’s Complutense University and author of La Soledad del País Vulnerable (The Solitude of the Vulnerable Country), a work that examines contemporary Japan. According to the author, Japan’s ageing population became a policy priority in the late 1980s and consumer taxes have been increasing ever since to sustain public spending on care. This social welfare system faces new challenges: a rapidly growing elderly population, overwhelmed public coffers and lonely deaths which escape the system, a tragic consequence of the isolation suffered by the elderly.

The most aged country in the world has become a ‘silver society’, a phenomenon which has its origins in the Japanese baby boom of the 1950s and 1960s. But while other countries with ageing populations such as Spain and the United Kingdom have made major cuts to their health systems over the last decade, Japan is celebrating 20 years since it introduced a social care system that provides cover in the last stages of life.

Its aim is to avoid burdening families and prevent the physical and mental deterioration of the elderly, with an emphasis on dementia, an illness that plagues nearly five million Japanese.

Naoko Hasegawa travels around Matsudo by bicycle. In 1953, this suburb of Tokyo was a farming village with a population of 40,000. Today it has close to half a million inhabitants and farmland has become a rare sight. She parks her bicycle at the home of a one hundred-year-old resident. Despite the state of emergency declared by Japan in response to the coronavirus, she cannot stop. Elderly people depend on her work as a care manager. When she is not in her office processing paperwork and contacting doctors or local care providers, she pays visits to elderly residents and monitors their care.

In this ageing city, dozens of care managers look after the health and welfare of the elderly. “We are authorised to draw from public funds. People over 65 who require assistance apply to their local government. Once approved, we manage the services [which range from] renting wheelchairs, installing handrails or ramps, grips in beds, hiring ambulance taxis to go to hospital or home visits by dentists, nurses, physiotherapists or doctors, as well as meals and bathing.”

In-home bathing has been very well received and demand continues to increase. It requires a nurse and two assistants who arrive by van and in a matter of minutes install a portable bath in the living room. The nurse takes vital signs and if everything is in order, they begin bathing. Patients are covered with a thin cloth to protect their privacy. It is also important for them to relax. The nursing team spends 45 minutes in each home and there is no time to rest. Many residents are no longer able to bathe on their own. In Matsudo, 25,000 elderly people live alone.

“Care and assistance with heart” is the city’s motto. Every day, ambulance taxis, deliveries of nutritious food, vans with baths and health professionals traverse this ‘silver city’, providing a lifeline to its residents. The care sector employs almost 11,000 workers. A total of 578 local businesses provide care at people’s homes and in senior centres. The local council provides a list of all of the authorised businesses.

At the senior centres, seniors play games, sing, garden and fight against dementia. They also bathe. Matsudo has 108 senior residences, both public and private, including for short- and long-term stays, nursing homes and facilities specialising in dementia. As Hasegawa explains, “In Japan, families are no longer able to care for elderly family members who are very frail or have dementia. We respect their wishes but if they are unable to live on their own we apply for a residence. Everything is done in consultation with the person and the family. People’s dignity is the most important thing, it is the ethics of our care system.”

The system is partially funded by co-payments. Users pay between 10 and 30 per cent depending on their pension, and the rest is paid for through a combination of national and municipal taxes.

In Matsudo, €358 million (roughly US$388 million) go to supporting the elderly, a quarter of the annual local budget. More than 20,000 elderly people use the system and there are 1,000 new applications each year. Hasegawa, 54, has seen the system evolve: “When it was set up, there was financial leeway, but not anymore. Services are becoming more expensive and are no longer accessible to everyone.” She has also seen minor generational shifts. “Before, nine out of ten were women, now there is an increase in the number of men, three out of ten. And the sector is beginning to open up to foreign employees. We are constantly recruiting,” she says. The government is seeking to address labour shortages in the sector by accepting 60,000 foreign workers, though the pandemic has stalled visa processes. As for volunteers, “They can go to the senior centres or do support work, but care requires professionalization,” she says.

Old and new challenges in the care sector

The local government is currently working hard to address the coronavirus crisis and has set up an online health clinic. City councillor Jiro Sekine is the grandson of internal migrants who came from another region to work in Tokyo and settled in the city. In a video call, he explains that the Matsudo phenomenon is new: “Like my grandparents, thousands of Japanese came [to the capital] from all over Japan. They are now the older generation.” Faced with the challenges of the care system, “the key is prevention and keeping them active, getting them to exercise in groups in the park, to participate in activities, to seek stimulation,” he says.

The rapidly ageing population brings to light another phenomenon, kodokushi, or lonely death, a consequence of the (unintended) isolation of a generation that experienced Japan’s economic growth in the 1960s but also the rapid decline of the 1990s, and has undergone dramatic lifestyle changes.

Nowhere is this phenomenon more pronounced than in Tokiwadaira, a neighbourhood of Matsudo, where 60 years ago, the countless blocks of nearly identical buildings with more than 4,000 government housing units were home to families during the country’s post-war baby boom, but where today volunteers are trying to prevent elderly people from dying alone. In 2018, 218 people died in the city without anyone noticing.

“Strange as it may seem, there are still citizens who don’t know about the existence of care insurance. We have to teach them, especially Japanese men, that needing care is nothing to be ashamed of,” says Jiro Sekine.

The pandemic has dealt a major blow to the care sector all over the world, especially to nursing homes, which have seen mass deaths in countries like the United Kingdom, France, Belgium, Ireland, Spain and the United States. The figures out of these countries, where personnel, protective equipment and hospital beds are lacking, tell a story of neglect.

On 12 February, the Japanese Ministry of Health announced measures to protect the elderly and senior residences including the use of masks, health screening for care workers, quarantine in suspected cases, ventilation of spaces and readily available disinfectants. In late February, all visits were prohibited. Although several dozen senior residences across Japan have seen infections, the contrast with figures from other countries is significant. In mid-May, with more than 16,000 people infected in Japan, 474 were residents and attendees of day care centres, while 226 were employees of nursing homes. Of those 700, 79 have died. Thirteen elderly men died at one nursing home in Matsudo. To date, Japan has prioritised old age for hospitalisation.

Senior centres and businesses operating in the sector are shutting down and caregivers are leaving their jobs because they feel they are at risk. Experts in Japan speak of finding a balance between safety measures and ensuring care. Some residences allow for family visits through glass partitions. Others have set up ‘online visiting hours’ and caregivers help residents to communicate with the outside world. When the state of emergency was declared, the Prime Minister of Japan urged young people to protect their grandparents. A new public announcement in Matsudo is urging the population to “stay home and protect lives.”