33 (2).indd Anthropology & Aging Quarterly 2012: 33 (2) 31 Feature aging & anthropology in east asia I remember an advertisement in TIME in the late 1980s or early 1990s for AT&T, a “reach out and touch someone” ad with a Japanese twist. The ad portrayed a middle aged, successful businessman, who was apparently in the US on business and was calling home to his aging mother in Japan. That image of filial behavior, created or reinforced by gerontologist Erdman Palmore’s famous study of aging in Japan (1975), unfortunately remains the impression many Americans today have of a happy Japanese old age in which families remain close and younger generations behave respectfully toward their elders. Although there is increasing recognition that Japan has become an aged society with numerous social and economic problems, if my own students are any indication, the old images die hard. Of course until assigned to do so, they have not read studies of Japanese old people in nursing homes (Bethel 1992, Thang 2001, Wu 2004) or retirement communities (Kinoshita and Keifer 1992), or of strategies people adopt to find security in their coming old age (Hashimoto 1996, Jenike 2003, 2004, Lebra 1984, Traphagan 2000) or be remembered after death (Danely 2012, Kawano 2010, Suzuki 2000, Tsuji 2006). These studies demonstrate that regardless of their physical well-being, old people remain active agents, making choices and adapting to new circumstances. The reality of their lives needs to be more central in the ethnography of Japan. The topics of aging, dying, and the lives of old people are interesting and important pieces of life in Japan today, and as the population continues to age, will become even more significant to understanding Japan in the future. Given world-wide demographic trends, our collective work in these areas contributes to understanding the human experience more broadly with what David Plath (1980) foreshadowed in his discussion of Japan as a society of “mass longevity.” C O M M E N T A R Y Ruminations on Studying Late Life in Japan Susan Orpett Long John Carroll University This essay reflects on how these questions relate to anthropology and the study of Japanese society. Over the past two decades I have been engaged in two distinct studies related to aging and dying that have offered me perspectives on approaches to studying those in their last stages of life, and the people around them. One (Long 2005) focused on those directly facing death (regardless of age), and the other (Long 2008, 2011; Long, et al. 2010) on caregiving of frail elders. Here I am not reporting on the results of this research, but rather ruminating about what they have together taught me as an anthropologist of Japan. I first reflect on the different methodologies of the two studies. Then I will consider some of the things that I have learned that have led me to new perspectives on Japanese society, and my own. MethodologieS The study of end-of-life decisions in Japan was ethnographic in approach. I conducted solo fieldwork primarily in the Hanshin area in homes and in three different types of institutions where very sick people received treatment and care: a national hospital, a private university hospital, and an in-patient hospice that was located within a large, private hospital. I hung out, watched, listened, occasionally did something helpful but more often was moving out of the way; I interviewed patients, family members, and staff. It was about as classic a fieldwork methodology as it could be in late 20th century urban Japan, given the topic. The elder care project was a large quantitative and qualitative study that grew out of discussions with several Japanese and American colleagues concerning the newly instituted long term care insurance system. With such a vast new policy and tremendous increase in the availability Anthropology & Aging Quarterly 2012: 33 (2) 32 of nursing and assistive services, how could it not make a difference in the way frail old people and their care are viewed? My social gerontologist colleague, Suda Yuko put together a multidisciplinary research team and we got to work. She and TMIG geriatrician Takahashi Ryūtaro received funding from the Japanese Ministry of Education, Culture, Sports, Science and Technology, and the Ministry of Health, Labor and Welfare for a longitudinal study of the impact of the long term care insurance programs on elder care in two locales, one in Tokyo and one in northern Akita Prefecture. Suda-san asked for my participation in the project as an expert on qualitative research and felt my perspectives as an anthropologist would be helpful, despite my lack of formal methodological training or gerontological background. Some of the research team members planned and conducted a survey in 2003 of people who qualified for long term care services who were living at home, with a related survey given to their primary family caregiver. The survey was repeated in 2005 and 2007 in an attempt to capture changes in the health and functional status of the old person and in service use over the years. Where I come in is that some members of the research team interviewed a subset of 30 those old person- family member pairs who had responded to the survey in order to provide more in-depth case studies and to help interpret the results of the survey. The initial plan was to interview the families on the same schedule as the survey in alternate years. My main methodological contribution was to fairly insistently suggest that every two years was not enough to accomplish what we wanted. Fortunately the decision was made to re-interview yearly in people’s homes, for as long as they were willing and the older person was alive. Also at my suggestion, when possible we did one interview with the family member subsequent to the death if prior to the end of the study. What did I learn? One is that I missed doing ethnographic fieldwork. As well as we came to know the families we interviewed, some five times, I never felt grounded. Every year I had trouble finding their homes. How badly I wanted to stop and talk with the small tobacco shop that served as my landmark for one home, or to speak with the “bad son” who lived upstairs but never helped his parents (though he did sometimes take care of the dog). On the occasions we could see or hear a broader context, it was immeasurably helpful: the chance to speak with a non-co-residing son, the opportunities to “follow” several old people after their move to a nursing home or hospital, a granddaughter who started to come for our annual interviews. But most of the context for what we were learning had to come from a different type of data, the survey. We also learned what anthropologists would probably suspect—people don’t always say the same thing in response to a survey as they do when you are speaking with them in a more relaxed setting. Despite a time gap of only a month or so, we found differences in responses to what were sometimes simple and straightforward questions such as the medical diagnosis or how often the person went to day care. This was a matter of consternation to my quantitatively-oriented colleagues, and we were able to use the yearly interviews to try to clarify and explore some of these inconsistencies. The last point I want to mention about methodology is the question suggested by the film, Can’t Go Native? (Plath 2010) about anthropologist Keith Brown’s “long engagements” with his fieldwork site in Mizusawa and its families over decades. The richness of Keith’s ethnography cannot be duplicated by any other approach. Despite the problems with the elder care project’s methodology from my perspective, what it did accomplish was to provide at least some time depth that for me turned out to be one of the most interesting aspects of the project. Even in five years, we were able to observe changes not only in symptoms, but in relationships and attitudes. In retrospect, I have wondered how I could have obtained that time depth in the earlier end-of-life study. People died. They became unable to communicate. That study could only have been synchronic, and I had to create the relationships between my informants and myself over an artificially short period of time. I do not think that I went into the project with as much awareness of that as I might have, though ethnographically my regular presence in the institutional setting helped to telescope not only my observations, but also my emotional ties. When family members came for a visit half-way though my fieldwork, I took a week off to travel with them in Japan. The night we got back to Osaka, I received a call from a physician-mentor. A young woman with whom I had become particularly close died unexpectedly while I was gone, and I spent that evening in tears. Was I mourning for her, or for the lost opportunity for a “long engagement”? leSSonS about JapaneSe culture I do not know a lot of people in the US in their 90s. In our elder care project, most of the people we interviewed were in their 80s, and even the first year, I interviewed three who were already in their 90s. What was life like for them? How did they experience the changes in their bodies and the constantly changing world around them? Here I give thought to what my combined experience in both projects has taught me about late life in the context of contemporary Japan. Susan O. Long Ruminations on Studying Late Life in Japan Anthropology & Aging Quarterly 2012: 33 (2) 33 Pleasures and Worries When we asked what in their life gave them pleasure, some of our elderly informants responded, “Nothing.” The following interview excerpts from woman in their 80s exemplify this type of response: 87-year old widow: There is nothing good about getting old. (#0004611, 2007) Interviewer: What do you do for enjoyment? Wife: [without hesitation] Nothing. Interviewer: What did you enjoy doing in the past? Wife: In the winter, knitting. Once a month I and my friends from jogakkō used to get together for a shokujikai [they took turns making meals for each other]. I really enjoyed this and we continued to get together for years. But we don’t any more because we’re all getting old, and our husbands are getting frail and it’s harder for everyone to get out. (#3204009, 2003) A slightly more positive, alternative expression of that “nothing” response was gratitude for just being alive. One woman noted, “I’m happy, I have no pain. That alone is happiness.” (#00063114, 2003) Others referred to their children or grandchildren’s visits. Some of the women expressed appreciation for the daughter-in-law [in the room, often] who cares for them. For example, 94 year old widow: We suffered in the past, but now things are better… I’m alive because of my family’s care. I have a good daughter-in-law; I’m grateful to her. (#3200309, 2003) Woman in her 60s immobilized by severe arthritis: I can’t go out, so everyone comes over here…. So I see that whether I am here or not makes that kind of difference. If I wasn’t here, no one would come gather here, so being bedridden and staying still here, I sometimes think that even so, there are good aspects about it (#3201706, 2007) Interviewer: Is there anything you have gained because you are older, like something good with the way you think now, or do you feel lighter, is there anything like that? Mother in her 80s who had moved to her daughter’s home due to Parkinson’s: Ahh. Interviewer: When do you feel that way? Mother: When I see that my children are all living happily. Myself too. Since I came here I’ve been doing well, so I am happy about that too (#0007401, 2007) A few people answered the question about pleasure with a physical activity, “eating,” or “bathing.” Several said that continuing a hobby (calligraphy, painting, writing senryū—all men) or watching sumo (a woman) were their “fun.” A few mentioned that they enjoy talking with people at day care. Their greatest concerns often were the converse of those pleasures: would the grandson about to graduate from college find a job; could a wife ever be found for the 40 year old son of an Akita farm family; finding good spouses for children or grandchildren. One younger man in his late 60s who was dying from complications of alcoholism joked, “One of the employees [at day care] is a young woman who is not married. I’ve wondered about getting her and my second son together!” (#0009006, 2003) Some of the old people with whom we spoke expressed worries about their declining health which forced them to give up things that they had enjoyed in the past, like the woman in her 90s who loved to sing but could no longer get her voice to come out, or the woman with a broken hip in her late 80s who loved to play shamisen but could no longer sit seiza-style. Of particular anguish was when these disabilities led to increased dependency on others. Interviewer: Is there anything you wish for? Stroke victim: Ashi ga hoshii (I want legs!) (#0001600, 2003) A daughter-in-law caregiver explained that the family’s graves are nearby and she sometimes takes her mother-in- law, but that recently, the mother-in-law hasn’t wanted to go. The mother-in-law suddenly joined the conversation, “That’s because I always have to go to the toilet!” Later in the conversation she added, “In the past, I went to the mountains and to Hokkaido. But now I don’t want to ask people’s help; they’re already doing so much for me in the house.” (#0006314, 2003) A few mentioned concerns about who will care for them when they were unable to do anything for themselves, or for a spouse after their death. Occasionally, they noted anxiety about graves or who would care for the family property or the grave after their death, or they worried about dying and the impact of their death on others. One woman told us that a when a neighbor died, they couldn’t find her hanko. She went on, Susan O. Long Ruminations on Studying Late Life in Japan Anthropology & Aging Quarterly 2012: 33 (2) 34 I want to make sure the family knows where things are but they tell me not to talk like that [about dying]. I think it’s better if everyone knows, so there aren’t problems when I die like with the neighbor. Another woman spoke in more religious language of her concerns about dying, but ultimately it was still about the trouble she was afraid she was causing for others by her wish to remain alive. Really, in order for one to live, one has to die, but my wish is to live a little bit longer. So I encourage myself, saying I need to stay strong…. I really think that I don’t understand many things anymore. But you know, I’m old. I’m 94 now. I think I may have lived a bit too long…. I just don’t want to cause any more trouble before I die, for anything, all I want is to cause as little trouble as possible. Once you age, it can’t be helped that you cause trouble, but I want to try not to do that …. I don’t have long to go, so I want to die, but I don’t dare say “I want to die, I want to die” when everyone is working so hard to take care of me…. Once one passes 90, it’s natural to think about your death. Just really thinking that you don’t want to die, well, being human, I guess that feeling is just natural ….[Interviewer: I heard that you always pray for a very long time.] Yes, that I can say…. As long as you say ”nammyohorenge”, it will communicate, so I thought I should just do it for longer. I try to do that as much as possible. (3202401, 2007) Differences and Similarities Understanding what life feels like, what is important, how the world looks to old-old people is one important element of an anthropological perspective on old age and aging in Japan. Another approach is to consider the ways that life experiences have shaped that world view. This includes consideration of gender, social class, family structure and relationships, religious experience, residence (urban vs. rural), and occupation. Neither of my research projects was designed to answer these questions, but here are a couple of observations and hypothesis. 1) Gender did not seem to make much difference in attitudes toward and decisions about therapies at the end of life. People expressed a wide range of ideas about death and about how to die, but they did not appear to be tied to gender. Gender, however, does seem to matter more in people’s experience of old age based on lifelong gender roles and continuing gender stereotypes. Being male or female may call forth different caregivers, for example, the wife when a husband needs help but less often vice versa. It may make a difference in the extent to which people worry about being a burden, with women more likely to express that as a concern. Women may find it more difficult to discontinue their main pre-frailty tasks since they must now be done for them by others (men would have already retired from their main culturally sanctioned responsibilities). For example, in describing how she used to make otsukemono [pickles] and mochi [pounded rice] and was a great cook, one woman in her late 80s, commented, “Now I can’t do these things so I feel sabishii [lonely]. I see that my daughter-in-law is busy and I wish I could help.” (#0004611, 2007) Women may benefit from stronger emotional ties to children and grandchildren than men who perhaps did not cultivate these relationships in the same way when they were younger. I remember one elderly couple in which the wife, who was quite immobile due to a stroke, spoke of her daughter’s frequent visits and the grandchildren crawling into her hospital-style bed with her. The husband, in a separate interview, noted that when the grandchildren came around, it was only to receive otoshidama [New Year’s gifts] from him, there’s not much more to the relationship. There are many more possibilities regarding the way gender shapes the experience of old age, such as discussion of a husband’s desire to repay/reciprocate for his wife’s care, or the lack of that sensibility. 2) My Japanese colleagues, in designing the elder care study, set up an explicit urban-rural (center-regional) comparison. My response was that Japan must surely be beyond that distinction in the 21st century, with a cell phone in every ear, common television and radio programming, and widespread internet access. But they were right, at least for northern Akita prefecture. Daughters-in-law there were more likely than in the Tokyo sample to be caregivers, and to voice that they were doing so because “its my job” and to express resentment at the obligation. We saw a couple of examples of loving MIL-DIL relationships in Akita, but for the most part, they seemed to play out cultural expectations of tension-filled relations. The rural environment combined with poverty to introduce complications to the picture of idyllic aging among the rice fields, in particular, the long absence of many husbands from daily family life in order to leave for labor in other parts of the country. Limited educational opportunities of the past and current poverty limited access to the wider world of information and resources, although all the homes we visited had televisions. For many of the old-old in Akita, television programs were nearly in a foreign language, that is, standard Japanese, about a culture (urban, youth-oriented) they did not understand. Even for someone who grew up speaking standard Japanese rather than a strong regional dialect, television programs, as one woman put it, “are aimed at the young whose interests are different from mine.” This type Susan O. Long Ruminations on Studying Late Life in Japan Anthropology & Aging Quarterly 2012: 33 (2) 35 of experience of the world cuts across the variability in experiences of aging I have discussed. Becoming ill and becoming dependent were universally seen negatively. Another cross-cutting element among today’s old-old is the impact of history on these age cohorts. Shared memories, even in Tokyo, of a less complex childhood catching fireflies, singing songs with school classmates, and fishing in the river, serve as markers of the technological and social changes they have experienced in the course of their lifetimes. The greatest shaper of these cohorts was undoubtedly the war. In many life stories, the war represented the end of the happy days and brought the death of husbands, siblings, and fathers. Its end marks, for most, the “bad old days” of food shortages and burned out houses, and provides memories that offer the view that “things are good now.” The old-old people of the future will not have this experience from which to generate a positive counter-response to the negatives of aging. A final cross-cutting element of the last stages of life which I have noted is the concern for death, graves, and memorial. Actually, in neither study did I hear much concern for the state of being dead, but rather, with the process of dying and with the trouble it causes the survivors. For older people without a family grave, the decision about and purchase of a gravesite gave them a sense of accomplishment. Even for those with family graves, there remained for some decisions about with whom they wanted to be buried due to geographical distance or strained relationships. In other cases, people had questions about whether they would be remembered, whether rituals would be performed for them and the ancestors who had been in their care for so long. One woman described how her brother had converted to Christianity and baptized his children. Even though he was the oldest son, it was clear to their father than he would not take care of the grave at the Buddhist temple. And so Ojiichan came to me. By Ojiichan, I mean my own parent, my father. He came to seek my advice and so I promised him that I will look after [the family grave]…. That’s all I can think about recently…I made a promise, but after I die, who is going to look after it? Well, I can’t do anything about it. But that keeps coming up in my mind (#3201706, 2007) Some people, both those with dementia and those without, spoke of communicating with deceased relatives, such as the cancer patient who was certain her father was coming back from the other world at the upcoming Obon holiday, an occasion for families to reunite across the boundary of life and death, to take her back with him. In neither study did I pursue these ideas about a post-death existence, but my impression is that it suggests a peacefulness not present in their current lives, and a reunification with loved ones (cf. Smith 1999). It is the betwixt-and-between state of painful illness or lack of social personhood due to dependency that worried people as they looked forward. leSSonS about JapaneSe culture through Studying late liFe Beyond studying the elderly and dying themselves, certainly a study of significance in this era of changing demographics world-wide, what does this work teach us about Japanese culture? First, and perhaps most obviously, it reminds us that there is a large portion of the population whose exercise is tossing a large rubber ball in a rehab class rather than working out at a fitness center. They often cannot see well enough to watch television, much less play video games. For reasons of illness and cost, they are not eating sushi or drinking beer. I find that talking about old people in class provides students a deeper perspective on Japanese society that makes it easier for them to think critically about their beloved J-pop as a commodity in a larger political-economic context. Simple cell phones with giant numbers may be the fad of the future! A second lesson is the reminder of how little we know about family relations in Japan despite all that has been written about the structure and functions of the corporate household (ie). We talk about stem families and so focus on parent-heir relationships, contrasting mother-son and father-son dyads. Merely substituting a nuclear family model for the older three-generation one does not allow us to better see relationships that exist along side those that are structurally important. As Scott Clark noted a decade ago, our Japanese colleagues tell us the vertical tie of descent is more important than the horizontal tie among siblings, so we have not given significant attention to sisters (for example). Both of my projects have shown that siblings remain important to people regardless of the type of household. With parents long dead, ties to siblings may take on special meaning as their link to their past and the continuity of their lives despite migration and frailty. Many old people in the elder care study report that they speak with their distant siblings by phone since they can no longer visit, and how painful, what a narrowing of their world it is when even this becomes too difficult. One elderly caregiving wife reported being angry when her husband once taunted during an argument that she could leave; his sister would take better care of him than she did anyway. Susan O. Long Ruminations on Studying Late Life in Japan Anthropology & Aging Quarterly 2012: 33 (2) 36 Susan O. Long Ruminations on Studying Late Life in Japan The flip side of the complaint of caregiving daughters- in-law that their husband’s siblings interfere with care decisions is that someone thinks they do have a moral right to a voice in those decisions. I was surprised to learn that it was not only the oldest son and descendents who show up at the deathbed, but ideally all of the dying person’s children, with their spouses and kids as well. End-of- life decisions are made not necessarily by the person we would expect based on the structure of the Japanese family we learned in Japanese Society class, but in one case by a 14-year old son, in another by an elder daughter over the ideas of her chōnan [eldest] brother, and in yet another by a collaborative team of the wife and sister of a dying man. Perhaps no one told them sisters-in-law aren’t supposed to get along. Another relationship that has received virtually no attention in the English literature on Japan is grandparent- grandchild relations. At least among the people I have interviewed, their own children might be supportive or they might visit rarely if at all. They were grateful to those who provided care and complained about those who came occasionally and only out of obligation. But grandchildren were for many their source of joy, whether via in-person visits or photos received in the mail. Their college admission, marriage, or obtaining a job were the matters of worry on one hand and pride on the other. In one family, the elderly woman widowed just after the war had supported herself and her children as a nurse. Her granddaughter had also become a nurse. In addition to the medical knowledge she brought to the family caregiving situation, she and her grandmother felt a special bond through their shared occupation. In a couple of other cases as well, a grandchild or grandchild-in-law provided assistance, knowledge, and care directly. It is perhaps because the social lives of the dying and very old have narrowed to such a degree that our attention is drawn in these cases to these relationships. Better study of sibling and grandchild-grandparent relationships will lead to a deeper understanding of the meanings and lives Japanese families. I have no doubt that we will see some of great intimacy and respect, as well as those based on resentment and grudging tolerance. On a final note, for Americans, there are some practical applications to the study of Japanese aging. Social class may help shape the ways that Japanese old people see the world, but socioeconomic status does not prohibit their access to good, high-tech medical care or to nursing homes, The working class families who constituted the majority of our participants in the elder care study are just as likely to get treatment for medical problems as the wealthy. Lack of social capital does not keep them from obtaining medication or in-home care services. How the government will be able to continue providing medical and elder care in a society in which 1/3 of the population will be 65 and older by 2050 remains a huge policy challenge; anthropologists can and should contribute to these discussions in Japan, and in their own countries. concluding thoughtS My intent here has not been to draw conclusions about people in the last years or months of their lives as much as to consider what I have learned from the two projects in which I have been involved that might move the study of such people forward. In studying old people, we might want to be more self- conscious about the special methodological issues raised by the limited time span and the various physical and intellectual limitations of this population while retaining the benefits, and the fun, of ethnography. This can be accomplished in part by the sharing of personal reflections and field experiences among anthropologists of aging. In the second part of this essay, I raised a variety of topics and questions to which I hope my work is contributing, but I know is far from providing definitive answers. The work of eliciting the world views and understandings of people in the last part of their lives is a fascinating task, particularly well-suited to anthropological research. It is one that is critical for understanding not only Japan today but many societies in the near future. We know, too, that these understandings are shaped by experiences through their lives, and that seeing the impact of gender, social class, occupational background, and family relationships will be basic parts of our work. Nor can we discuss the experiences of people who are frail and ill without considering the broad political-economic and technological settings which frame those experiences. 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