Medical Reform from the Front Lines: Twenty Years of Struggle in Nurturing Exceptional Talent

Masahiro Kami, M.D., Ph.D.

President, Medical Governance Research Institute, Tokyo, Japan

“Publicness that is not government” is what is missing in Japanese society today. How can it be achieved? Those directly involved must confront the problems and continue through trial and error. Through that process, concrete systems are built, and the people who will lead the next generation are also cultivated. I have called this kind of effort “medical reform from the front lines,” and have continued it for twenty years.

A commemorative photo from the 19th Symposium of Medical Reforms Promoting Practical Solutions from the Field. Hiroshi Suzuki is fifth from the left in the front row, and the author is sixth. (November 2024)

The starting point was my meeting in 2003 with Hiroshi Suzuki, then a member of the House of Councillors and now a professor at the University of Tokyo’s Graduate School of Public Policy. He had graduated five years ahead of me from my alma mater, Nada Junior and Senior High School, so I knew his name but had never met him. After we happened to attend a symposium together, he sent me an email saying, “I like your willingness to break with convention. Why don’t we work together on medical reform?”

At the time, I was thirty-five years old. I was an internist at the National Cancer Center Hospital and felt stuck in my circumstances. I had conflicts with my superiors and had been removed from ward duties. On days when I had no outpatient clinic, I would arrive at eight in the morning and spend the rest of the day with nothing to do, passing time in the doctors’ office until work ended. For someone living such gloomy days, Suzuki’s proposal was highly appealing. At that time, Suzuki himself was in the prime of his career. In 2004, together with his former students Kentaro Kawabe, now chairman of LINE Yahoo, and Daigo Sato, chairman of the NPO Dot JP, he threw himself into the effort to block the proposed merger of professional baseball into a single league. Later, in the 2009 Tokyo Metropolitan Assembly election, the Democratic Party achieved a landslide victory, helping create the momentum for the 2009 change of government.

Suzuki’s next issue was healthcare, and he was looking for allies. He and I met almost every day and continued our discussions. I will not go into detail here, but thanks to support from the people around us, in October 2005 we were able to establish a laboratory called the Exploratory Medicine and Human Network Research Division at the Institute of Medical Science, the University of Tokyo, and become independent.

Preventing the Collapse of Perinatal Medicine

A spirited question-and-answer session at the symposium. (November 2024)

I was starving for meaningful work. I desperately wanted to do something. The first issue I became involved in was the arrest of an obstetrician at Ono Hospital in Fukushima Prefecture in February 2006. A former classmate of the arrested doctor called my mobile phone and asked me to support him. The case involved a patient who died of hemorrhage after the rare complications of placenta previa and placenta accreta occurred together, and it seemed unreasonable to pursue criminal liability against the operating physician.

The first person I consulted at that time was Suzuki. When I told him about the case, his expression turned grim, and he said that if criminal cases like this began to occur, the medical profession would collapse. The first person he asked for help was Yoshihito Sengoku, a member of the House of Representatives. Sengoku immediately telephoned a senior official at the Ministry of Justice whom he knew well, but was told, “This is a weak case. If it had been a few days earlier, we might have been able to stop the indictment, but now it is already difficult.” Sengoku said, “At this point, it will be a battle for public opinion,” but we did not know how to move forward.

Around that time, we managed to get in touch with Professor Akira Sato of Fukushima Medical University, the superior of the arrested physician and professor of obstetrics and gynecology there. He told us, “I do not care what happens to me. I will do anything to protect him.” Once the people directly involved resolved themselves, the situation began to move. Together with Professor Sato and Suzuki, we established the Association to Prevent the Collapse of Perinatal Medicine and began a petition campaign. In the end, 5,520 signatures were collected, and Professor Sato submitted them to Jiro Kawasaki, then Minister of Health, Labour and Welfare.

The media also moved. The person I turned to was Takashi Munakata, a producer of Fuji Television’s Tokudane! and a native of Fukushima. He had been two years ahead of me in the University of Tokyo kendo club, and because it concerned his home prefecture, he took a strong interest and introduced us to excellent staff members. They told us, “This is a major issue for the public. We will act.” Once Tokudane! aired a feature on the case, other television networks followed. Before long, the direction of public opinion shifted from “medical malpractice” to “the collapse of obstetric care.”

In August 2008, the Fukushima District Court issued a not-guilty verdict, the prosecution did not appeal, and the ruling became final. The case later became so well known that it was included in law school textbooks. I realized that public support can move society, depending on how one approaches the issue. This case helped make “the collapse of healthcare” a matter of national consensus. At the same time, the number of like-minded allies increased. Thus, in November 2006, the Medical Reforms Promoting Practical Solutions from the Field was launched. Its founders included physicians, nurses, patients, media figures, and politicians such as Yoichi Masuzoe and Yoshihito Sengoku, while Suzuki and I served as the secretariat.

In this conference, people with a sense of purpose gather voluntarily, build trust through repeated dialogue, and act in a decentralized manner. With the spread of the internet and mobile phones, it became possible to continue discussions without creating an overly formal organization. The opposite of this is Kasumigaseki. Healthcare administration in Japan is led by medical bureaucrats who rotate posts every few years and by advisory councils made up of experts who follow their direction. People say that the essence lies in the details, but a group of “amateurs” composed of bureaucrats and establishment experts cannot engage in truly substantive debate.

Achieving Financial Independence through In-Station Convenience Clinics

Politicians also began to make use of our framework. One of them was Yoichi Masuzoe, who became Minister of Health, Labour and Welfare in 2007. At his inaugural press conference, he mentioned theMedical Reforms Promoting Practical Solutions from the Field and said he was discussing policy with an independent group of experts. It was probably a statement made with bureaucrats and the media in mind, but on that very day my mobile phone was flooded with interview requests.

In June 2008, Masuzoe reversed the 1997 policy of reducing medical school quotas, and by 2016 about 1,500 additional places had been created. At the time, medical bureaucrats strongly resisted and urged university executives to oppose Masuzoe’s policy, but he pushed through the opposition with the backing of public opinion and appeals from the medical front lines. He established a committee to formulate the Vision for Securing Safe and Hopeful Healthcare and entrusted discussion to it. Four of the eleven committee members were connected to our reform conference, and I was also consulted about the selection of members. Medical bureaucrats criticized this as “the minister running wild,” but given today’s physician shortage, there is really no room for debate over which side was right. Japan’s healthcare system remains stagnant precisely because this kind of resistance continues.

Since the Great East Japan Earthquake, I have continued to support the reconstruction of Fukushima, and the starting point for that effort was also the reform conference. Immediately after the disaster, Sengoku, then Deputy Chief Cabinet Secretary, told me, “Mayor Tachiya of Soma City is asking for support. He is one of the most capable local leaders I know. Please use your network of doctors to help where the government cannot.”

When I spoke with Mayor Hideki Tachiya by telephone, I was struck by the precision of his judgment. From the very night of the earthquake, he was already issuing forward-looking instructions one after another, including securing coffins, arranging land for temporary housing, and accepting evacuees from Futaba District. At that time, the person we dispatched from the reform conference to Soma City was Dr. Masaharu Tsubokura, then a graduate student at the Institute of Medical Science, the University of Tokyo. Mayor Tachiya was himself also a clinician, deeply concerned with residents’ health and radiation exposure measures, and he independently promoted health checkups and exposure testing. Working together with city hall on practical tasks in the field was Dr. Tsubokura. Building on this experience, he went on to conduct further research and has since grown into a world-leading figure in radiation disaster medicine as a professor at Fukushima Medical University. It is a concrete example of how people are cultivated through trial and error on the front lines.

Not only in medicine but throughout Japanese society, the pressure to conform is extremely strong. In order to survive, people feel compelled to go along with the powerful, and before they know it, they lose the ability to make sound judgments. I am sometimes asked, “Why are you able to say what you want and keep doing what you do?” The answer is that we are economically independent. Our activities do not depend on tax money. In addition to being fortunate in our supporters, we also run medical institutions ourselves. One such example is Navitas Clinic, which operates convenience-style clinics inside JR East stations in Kawasaki, Shinjuku, and Tachikawa.

Its predecessor was the Collabo Clinic, which began in a mixed-use building near the west exit of Shinjuku Station, and Suzuki helped us launch it. In fact, the idea of a “convenience clinic” was originally his. He foresaw that medicine, like the distribution industry, would change so that general hospitals would become specialized hospitals and private practitioners would become chains of convenience-style clinics. He not only helped us secure funding and space but also gathered student staff and mentors. Kawabe and others joined the effort and regularly came to our laboratory at the Institute of Medical Science, the University of Tokyo, where they helped train younger people. From them we learned basic principles such as, “To succeed in business, you need relentless thoroughness,” and “Do not send emails at night; observe proper etiquette.” I was surprised by this unexpected side of the so-called “Roppongi Hills tribe.” Among the students of that time, people such as Yohei Shiroguchi, who went on to found the energy-tech company Enechange, were cultivated.

When Navitas Clinic was established, we also received support from JR East. In particular, Ryoaki Arai, then Executive Vice President of JR East and President of Lumine, and Yumiko Kamata, then President of Ecute, were extremely helpful. They pursued the effective use of stations as public spaces, and Takanawa Gateway City was first conceived by Mr. Arai. I learned a great deal from the way they worked.

Publishing the Pharmaceutical Money Database

As another activity embodying “publicness that is not government,” I would like to mention the publication of the Pharmaceutical Money Database. Collusion between pharmaceutical companies and physicians is a phenomenon seen throughout the world, reflecting structural problems unique to the medical industry, and countries everywhere have been grappling with it through trial and error. For example, the United States enacted the Sunshine Act in 2010, and information on payments from pharmaceutical companies to physicians is now disclosed on government websites and used in research as well.

In Japan, after the Novartis Pharma research misconduct scandal that became an issue in the early 2010s, the Japan Pharmaceutical Manufacturers Association began releasing such data. However, the information was difficult to search and secondary use of the data was prohibited. Since, unlike in the United States, the government did not take the lead, we decided we had no choice but to do it ourselves. In January 2019, we launched Japan’s first searchable database of payments to physicians. The central figure in the project was Dr. Akihiko Ozaki. He graduated from the University of Tokyo Faculty of Medicine in 2010 and continues both clinical practice and research in Iwaki City, Fukushima Prefecture. He is also a director of the Medical Governance Research Institute.

The backlash from the medical world against this project was intense. Dr. Ozaki and I were given “advice” such as, “If you do this, it will not be good for your future.” Pressure was even applied to our supporters, telling them that they would be better off not associating with us. It was a very typical medical-world way of doing things. In September 2018, when the Medical Governance Research Institute hosted a symposium, a physician employed by Takeda Pharmaceutical even distributed flyers at the venue slandering me. Later, his superior came to apologize, but I was astonished that a major pharmaceutical company would go so far.

Today, this database is attracting attention both in Japan and abroad. It has reportedly been used by police investigators and has in some cases provided the starting point for bribery investigations. I believe it has contributed to realizing “publicness that is not government.”

This has been a brief account of the twenty-year path of “medical reform from the front lines.” On November 1 and 2, we will hold the 20th Symposium of the Medical Reforms Promoting Practical Solutions from the Field at Kenchikukaikan in Tamachi, Tokyo. All of the individuals mentioned in this article will take the stage. Participation is being accepted both in person and online.

This article was originally published in FACTA in November 2025.