- Japanese children are recognized as among the healthiest in the world, while American children compare poorly, despite the U.S. spending more than any other country on health care.
- Japan’s vaccine policy is non-compulsory, with vaccines considered either “routine” or “voluntary” but never forced.
- High rates of adverse events following MMR and HPV vaccinations led to major vaccine policy changes in Japan and parents and their physicians make personalized decisions about vaccination for each child.
Children in Japan are among the healthiest in the world, while children in the United States rate low on the list of developed nations for health outcome measures. Given that the U.S. spends more than any other country on health care to ensure the health and well-being of its children, what is behind this discrepancy?
Differences in Infant Mortality
One of the measures used to determine a nation’s overall health ranking is infant mortality, which is the number of infants dying before their first birthday per 1,000 live births. Among 223 nations, Japan ranks second, with an infant mortality rate of just 2.2/1,000. Only the tiny country of Monaco boasts a lower rate, at 1.8/1,000. The infant mortality rate for infants born in the U.S. is 5.8/1,000, on par with Serbia, and much higher than Cuba, South Korea and European Union countries.1 2
Several factors have been cited to try to rationalize some of the discrepancies. An increased number of pre-term births and differences in reporting methods may affect the numbers. Extremely premature infants, born far too early to survive, are counted as live births in the U.S. if they are born alive, whereas they may be considered and reported as miscarriages or stillbirths in other countries.3
Regardless of pre-term births and differences in reporting, the large gap between a 2.2 infant mortality rate in Japan and the 5.8 infants mortality rate in the U.S. cannot be explained. The reality is that efforts to improve rates of infant mortality in the U.S. lag far behind those of other developed nations.4
Cultural, Educational and Economic Influences
It is not only in minimizing infant mortality that Japan has surged ahead of the U.S. in child health rankings. Japan’s overall life expectancy—and, more importantly, a healthy life expectancy—is also much higher in Japan than in any other country. At the end of World War II, Japan had an abysmal health and life expectancy rate, with an overall life expectancy of just 50.1 years for men and 54.0 years for women. Those numbers increased by 13.5 years for males (to 63.6 years) and 13.8 years for females (to 67.8 years) in the 10 years following the end of the War.
In comparison to Japan, the U.S. has a lower life expectancy and it is getting worse. A U.S. government report published at the end of 2018 revealed that life expectancy in the U.S. dropped in 2017 to 78.6 years, with young adults in their 20s and 30s dying prematurely from drug overdoses and suicide contributing to the dropping life expectancy.7 The top five leading causes for death in the U.S. are heart disease, cancer, unintentional injuries, chronic lower respiratory disease and stroke.
Much credit has been given to Japan’s vastly improved economy compared to pre- and immediate post-war periods, but the rapid increase in life expectancy was apparent well before the country’s economic recovery. Medical advances certainly played a big role, but a new national emphasis on education, improved health laws, and community-based initiatives designed to address quality of life in rural areas were also largely responsible.8
The seeds of these social improvements were planted in the early 1900s, with free compulsory education and newly available social services, and furthered in 1961 with the introduction of universal health insurance.9
Healthy Daily Practices
Some of the simplest, most obvious factors in keeping Japanese children healthy are a seemingly nationwide emphasis on exercise and good nutrition, as well as a commitment to hygienic practices and regular health screenings.
The vast majority of Japanese schoolchildren (98.3 percent) either walk or bike to school, which has been linked to the low rate of childhood obesity in the country. School lunch programs in Japan also help set the stage for a healthy relationship with food, with most foods locally sourced and prepared fresh at the schools.10 Unhealthy choices are not offered, and children take part in planning, preparing, serving and cleaning up after meals, as well as learning about nutrition.
Naomi Moriyama, author of “Secrets of the World’s Healthiest Children,” stresses that it isn’t necessary to switch to a diet of “seaweed, sushi, and tofu to nourish a healthy child–just tweak your family food habits in a more healthy direction. Serve more plant-based foods like fruits, vegetables, beans, whole grains, and healthy fats, like heart-healthy omega 3-rich fish, and less processed food with added sugars and salt.”11
Another piece of the puzzle that may contribute to the healthy status of Japan’s children is the government’s policies on vaccination. Unlike the U.S., Japan does not mandate vaccines, but categorizes available vaccines as “routine” or “voluntary.”12 13 14 15 16 17 18 Routine vaccines are covered under the government’s universal health plan if given within a specific timeline, while voluntary vaccines are available for self-pay.
It hasn’t always been that way. Although Japan led the way in improving the safety of the whole cell pertussis (DPT) vaccine by licensing a less reactive acellular version (DTaP) in 1981,19 prior to 1994, vaccination was considered a social obligation and was paid for by the government, with fines for those who refused. After losing a series of lawsuits for victims of vaccine injuries, the government revised their vaccine policies, doing away with mandated vaccinations given in public health centers, and giving the responsibility for vaccination to parents and their personal physicians.20
One of the vaccines that prompted the 1994 revision of the Vaccination Act was the MMR (measles, mumps and rubella) combination vaccine. Introduced in 1989, the vaccine was associated with thousands of serious side effects, including aseptic meningitis. Data showed over one three-month period, one in 900 children had an adverse reaction, more than 2,000 times the expected rate of one in 100,000 to 200,000. Even after switching to a different type of MMR, the high incidence of severe reactions continued and the triple combination vaccine was banned.21 22
Japan still recommends a combination measles and rubella (MR) vaccine, which is on the non-compulsory routine schedule, while the separate mumps vaccine is on the voluntary schedule. According to Hiroki Nakatani, MD, Director of the Infectious Disease Division at Japan’s Ministry of Health and Welfare, the individual vaccines cost twice as much as MMR ‘but we believe it is worth it’.23
Another controversial vaccine no longer on the government recommended schedule in Japan is the human papilloma virus (HPV) vaccine. Introduced in Japan in 2009, the HPV vaccine was added to the list of recommended vaccines in April of 2013. However, the vaccine was quickly associated with a high number of reports of severe side effects after it was given widely to young girls and women and, by June 2013, recommendation for routine HPV vaccination had been suspended. Subsequently, the HPV vaccination rate fell from 70 percent to one percent. The government has also set up advisory panels to evaluate HPV vaccine adverse events.24
An attorney group representing some of the victims of HPV vaccination in Japan, who are suing HPV vaccine manufacturers, claims that several studies have made solid progress in clarifying the biological mechanisms for some of the adverse reactions. They are calling for “the government and drugmakers not to spread harm any further…”25
Countering some who suggest that Japan’s vaccination policies should more closely match those of the U.S., Hiroko Mori, former head of the infectious diseases department at the National Institute of Public Health and author of the Guidebook on Vaccines for Children and Parents, believes there is too much pressure for everyone to get vaccinated and no one should be forced into vaccinating themselves or their children. She is quoted as saying, “Some of these diseases may have been devastatingly fatal in the past, but we live in a day and age where they aren’t nearly as fatal … especially with the high standards of health here, it’s not necessary for everyone to be forced into getting immunized against all such diseases.”26
Should Japan Be the Role Model for the U.S.?
It should be noted that there’s another side to Japan’s current status at the top of the health and wellness charts: As many Japanese move toward a more Western diet and more sedentary lifestyle, obesity and related health issues are creeping up. Considerable social stressors such as long, six-day workweeks (suicides and death from overwork are serious issues), as well as the common use of such unhealthy stress reducers such as alcohol and cigarette smoking, are also creating new public health challenges.27
Nevertheless, the evidence is pretty compelling that, as a nation, the U.S. is not doing nearly enough to protect the health of our children. In side-by-side snapshots of the U.S., where “Half of America’s Kids Suffer from Chronic Illness and It’s Getting Worse,”28 and Japan, where children can expect to grow and lead long, healthy lives, it may be time to take a closer look at and learn from Japan’s more holistic, personalized public health policies.
This article or commentary provides referenced information and perspective on a topic related to vaccine science, policy, law or ethics being discussed in public forums and by U.S. lawmakers. The websites of the U.S. Department of Health and Human Services (DHHS) provide information and perspective of federal agencies responsible for vaccine research, development, regulation and policymaking.
1 Shesh K. Infant Mortality Rate by Country. World Atlas Aug. 14, 2018.
2 Centers for Disease Control and Prevention. Infant Mortality. CDC.gov March 27, 2019.
3 Raines K. Why is the U.S. Infant Mortality Rate So High? The Vaccine Reaction May 9, 2016.
4 CDC, MacDorman MF et al. International Comparisons of Infant Mortality and Related Factors: United States and Europe, 2010. National Vital Statistics Reports Sept. 24, 2014.
5 Pitofsku M. What Countries Have The Longest Life Expectancies? USA Today July 27, 2018.
6 Ikeda N, et al. What Has Made the Population of Japan Healthy? The Lancet Aug. 30, 2011.
7 Dywer C. U.S. Life Expectancy Drops Amid ‘Disturbing’ Rise in Overdoses and Suicides. NPR Nov. 29, 2018.
8 Sugiura Y, et al. Rapid Increase in Japanese Life Expectancy After World War II. BioScience Trends 2010; 4(1).
9 See Footnote 6.
10 Douglas L. 6 Reasons That Japanese Children Are The Healthiest In The World. HealathyWay June 7, 2017.
11 Why Japanese Kids Are Destined For Long, Healthy Lives. World Tribune Mar. 12, 2019.
12 Doshi P, Akabayashi A. Japanese Childhood Vaccination Policy. Cambridge Quarterly of Healthcare Ethics July 2010; 19(3): 283-289.
13 Kristen K. Japan Leads the Way in Child Health: No Compulsory Vaccines. Banned Measles Mumps Rubella (MMR) Vaccine. Global Research Apr. 28, 2019.
14 Kuwabara N, Ching MSL. A Review of Factors Affecting Vaccine Preventable Disease in Japan. Hawaii J Med Public Health December 2014; 73(12): 376–381.
15 Nakatani H. Sano T, Iuchi T. Development of Vaccination Policy in Japan: Current Issues and Policy Directions. Japn J Infect Dis 2002; 55: 101-111.
16 Sentaku Magazine. Japan’s backward vaccination policy. The Japan Times June 26, 2018.
17 Shimazawa R, Ikeda M. The vaccine gap between Japan and the UK. Health Policy October 2012; 107(2–3) 312-317.
18 Appendix 4, 5, 6: Vaccine Damage Payment Act; NVICP; Japan ranks highest in health; GMC & doctors’ suicides. Alliance for Human Research Protection.
19 Sato Y, Sato H. Development of acellular pertussis vaccines. Biologicals 1999; 27(2): 61-69.
20 Nakayama T. Vaccine chronicle in Japan. J Infect Chemother 2013; 19(5): 787-798.
21 Hope J. Why Japan Banned MMR Vaccine. Daily Mail 2019.
22 Ito M. Vaccination: A Choice Between Two Unknowns. Japan Times Oct. 4, 2014.
23 See Footnote 21.
24 Normile D. Japanese Court Rules Against Journalist In HPV Vaccine Defamation Case. Science March 27, 2019.
25 Five Years Since the Suspension of Proactive Recommendation of the Human Papillomavirus (HPV) Vaccine in Japan. National Attorneys Association for the HPV Vaccines Lawsuits in Japan June 14, 2018.
26 Murakami S. Japan Struggles To Ditch ‘Vaccine Backwater’ Image Due To Policy Gaps. Japan Times May 10, 2019.
27 See Footnote 6.
28 Cáceres M. Half of America’s Kids Suffer from Chronic Illness and It’s Getting Worse. The Vaccine Reaction June 27, 2019.