After his customary 12-hour day at his Tokyo office, business executive Toyoshi Suzuki, 45, dined with a client on tidbits of raw fish and warm rice wine, then rounded out the evening at a fashionable nightclub where a kimonoed hostess massaged their egos and kept their glasses brimming with mizuwaris—whisky and water—until both men were quite drunk.
It was almost midnight when the good-natured mamma-san helped them on with their coats and loaded them into a waiting taxi so they could catch the last train home, along with dozens of other swaying and tottering Japanese businessmen.
When darkness falls and blinking neon brightens normally drab Japanese cities and towns, this ritual is repeated every weekday evening throughout these crowded islands. Look-alike salarymen, white-collar workers in dark suits, with their company emblem in the lapel, crowd into lounges and karaoke bars—there are more than 12,000 in Tokyo alone—where they unwind and soothe frazzled nerves by guzzling beer and crooning Japanese folk songs. Tradesmen and laborers head for street-side stand-bars where shoulder to shoulder they gulp shochu, an inexpensive distilled spirit known as "Japanese vodka," dispensed impersonally in plastic cups from coin-operated vending machines.
But the resounding shouts of "kampai," or "cheers," as glasses are clinked together have taken on an ominous ring for physicians and others concerned with the effects of drinking in Japan.
"There is no question that alcoholism is increasing in Japan," said Katsuya Maruyama, M.D., director of the National Alcoholism Center at Kurihama National Hospital, one of 10 national hospitals specializing in the treatment of alcohol abusers and Japan’s flagship hospital for alcohol education, prevention, treatment, and research. Japan’s first specialized ward for alcohol-related illnesses was opened in 1963.
While alcohol consumption is dropping in most of the industrialized world, it is rising in Japan. "In the past 30 years total alcohol consumption, the number of alcoholics, and the drinking population have increased by almost 250 percent," Maruyama told Psychiatric News.
The latest survey by Japan’s Ministry of Health and Welfare (MHW) found that an estimated 67 percent of the 126,686,000 population drink, and almost 2.5 million, or about 2 percent, are alcoholics or heavy drinkers. The Japanese define a heavy drinker as someone who drinks the equivalent of 150 ml or more of pure alcohol a day. (In the United States, alcoholism affects about 12 million men and 4 million women.) Apart from patient surveys, no other sources are available to calculate the percentage of problem drinkers in Japan.
According to a 1999 MHW survey, 19,400 alcoholics were admitted to Japan’s psychiatric hospitals. "This is considerably smaller than expected from the estimated 2 percent to 2.3 percent of heavy drinkers, suggesting that many alcoholics are not diagnosed or fall through the cracks," Masaaki Matsushita, M.D., director of Tokyo Metropolitan Matsuzawa Hospital, told Psychiatric News. Fifteen percent of admissions to general hospitals were for exacerbation of symptoms due to drinking.
Drinking cuts across all levels of society. Sixty percent of problem drinkers are men, like Toyoshi Suzuki, who claim that getting drunk with clients and coworkers is part of their job and a mark of company loyalty.
Matsushita attributes the rising number of alcoholics among men in their 50s to unemployment and social unrest. The suicide rate is highest in this age group and more than twice that of the general population.
"The latest figures from the National Tax Agency show that the Japanese drink 6.5 liters a year, which has remained fairly constant for more than 10 years now," Kurihama National Hospital’s Susumi Higuchi, M.D., told Psychiatric News. Worldwide annual alcohol-consumption rates range from two to 15 liters. Americans consume 8.9 liters on average. Because many Japanese women are teetotalers, however, Japanese men in their 50s probably drink more than twice as much as their American contemporaries, according to some experts.
"What astonishes us is not only the size of the problem but the widening use of alcohol by housewives and female office workers, which has risen sharply since the 1980s," Maruyama said.
Japanese women are becoming alcoholic at a faster rate than men, although overall there are fewer women alcoholics here than in the West. While Japanese women are far from liberated by Western standards, more than 42 percent now take an occasional drink—up 20 percent from only eight years ago. According to government surveys, the number of female drinkers doubled over the last 30 years.
Women alcoholics tend to be kitchen drinkers in their 30s and 40s, Keiko Aoki, R.N., a health counselor for several computer firms, told Psychiatric News. "With husbands at work all day and children in school, they hit the bottle out of loneliness and become addicted in only six years compared with 10 years for men," she explained. But many female alcoholics can be found in the young and elderly populations too, according to Higuchi. A good number of young female alcoholics are bulimic or have other cross-addictions.
Teenage drinking, along with teenage suicides, is also on the rise, especially among students who face cutthroat competition for entrance into overcrowded schools. Since 1990, the government has focused attention on the drinking problems of minors. According to one survey, 20 percent of Japanese high schoolers said they needed a drink once a week just to keep going on the academic treadmill. One-third of senior high-school students said they drank at least once a month.
"Alcohol here plays the role of psychiatry in the West," says Charles Pomeroy, an American expatriate, former president of the Foreign Correspondents Club of Japan, and a Tokyo resident for more than 45 years. "I think the country would explode without it. Instead of [undergoing] analysis, they get rid of their inhibitions with a few drinks."
Traditionally there has been an indulgent attitude in Japan toward drunks—and for good reason. In this tightly knit society where concealing emotions is a highly developed and necessary part of life, getting drunk is a socially sanctioned safety valve. It is also an icebreaker. Instead of saying, "I’d like to talk and get to know you better," they say, "Let’s have a drink."
In Japan’s commerce-focused, group-oriented society, where business and government connections count far more than actual performance, cementing relationships over a bottle of whisky or sake is always appropriate. At a company outing an employee can get plastered, insult his boss, pass out on the floor, and have to be piggy-backed home. Yet his behavior is not held against him. The next day the unpleasant episode is entirely forgotten. The Japanese tend to believe it is not their fault if they behave out of character when intoxicated, according to Pomeroy.
Sober-minded Americans would react with "shock and awe" at the end-of-the-year bonenkai season when Japanese get their bonus checks and many businesses hold parties. For this is the time they get desperately drunk. Normally genteel people by day become drunken, boisterous mobs at night. Railway officials estimate that during the holidays at least two-thirds of passengers on their late-night commuter trains are drunk. One railway provides cars exclusively for women to keep drunken men from groping or sexually assaulting them.
Despite all the drunkeness, there is almost no work absenteeism due to drinking, thanks to a strong work ethic and a quirk in biology that makes some Japanese drunk on a thimbleful of liquor, hence their tiny sake cups. Forty-four percent of Japanese have a congenital deficit of the gene for the aldehyde dehydrogenase 2 (ALDH2) enzyme needed for the first step in the metabolism of alcohol to acetaldehyde. People with the defect, called "flushers," are super-sensitive to alcohol. Their face turns red, their heart pounds, and they suffer severe hangovers, which limits their intake.
"Half of the population of Japan is in a natural Antabuse state," David Goldman, M.D., chief of the Laboratory of Neurogenetics at the National Institute on Alcohol Abuse and Alcoholism, told Psychiatric News. "Japanese are much less likely to become alcoholic if they are ALDH2 Lys487/Glu heterozygotes, and very rarely become alcoholic if they have two copies of the Lys allele. The fact that they are alcohol-exposed emphasizes the protective effect of the genotype."
"The number-one enemy today is the ready availability of beer and liquor from hundreds of thousands of vending machines strategically deployed throughout our five islands, enabling anyone with a few yen to drink anytime, anywhere," Shigeru Sakuraba, Ph.D., of Hamamatsu University School of Medicine, told Psychiatric News.
But getting the 800-pound gorilla out of the room in this commerce-driven society poses a daunting task. Most Japanese are apolitical and take no interest in the need for government control over when and where they can get a drink, said Pomeroy. Beer and liquor vending machines contribute a hefty share of the $20 billion the government collects in alcohol revenues each year.
Besides the ubiquitous vending machines, there seems no end to enticements to drink. Teenagers can get their first beer from convenience stores that display alcoholic beverages on the same rack as soft drinks. Restaurant owners are free to sell alcohol to children under 18, because no law requires them to check IDs.
TV does its share of promoting alcohol to both children and adults by running commercials for beer and liquor during prime time. From 6 p.m. onward, 10 percent of ads on Tokyo’s five TV stations promote alcohol as a fun product and portray drinking as a glamorous pastime.
All experts agree that Japan’s greatest missed opportunity has been a failure to educate its population about the harmful effects of alcohol. In 1992 the Ministry of Education, Science, and Culture ordered schools to teach the harmful effects of drinking in health-education classes. Today, however, less than half of the population know the signs of alcoholism, according to a follow-up MHW study.
"Unlike Americans, Japanese people don’t regard alcohol as a drug," said Tokyo counselor of families of alcoholics Tsukasa Mizusawa. "Doctors and social workers realize alcoholism is a big problem, but I think others don’t care. Society isn’t interested. Denial is strong."
Drinking is not a moral issue in Japan; there is no religious prohibition against alcohol, so there are no strictures to limit or help the Japanese slow their pace. Drunkenness is not considered sinful or even bad, although publicly it can arouse disapproval. In this homogeneous society, thinking is a group-oriented activity, and conformity is encouraged.
"What is needed are more doctors and nurses to bring medical services to a level comparable to Japan’s economic and living standards," Matsushita said.
Approximately 1,000 physicians are members of the Japanese Medical Society of Alcohol and Drug Studies, but fewer than half that number are members of the Japanese Society of Psychiatric Research on Alcohol or the Japanese Society of Research on Alcohol-Related Problems.
There are bright spots in this somewhat bleak picture. The National Hospital at Kurihama is at the forefront of efforts to change the destructive pattern of alcohol abuse and holds courses twice a year for clinical specialists. Since 1973 more than 4,000 physicians, nurses, and counselors have trained at Kurihama, and its therapeutic methods are now practiced by hospitals throughout Japan.
Today public attitudes toward drinking are changing. Most important, the Japanese no longer have as passive a role toward alcoholism. Being intoxicated during the commission of a crime was once considered an exonerating factor. Now it is recognized that about one-third of murders are committed by intoxicated people. Also, drunken drivers are now severely penalized, often by their employer, because authorities acknowledge that drunken drivers cause 10 percent of road fatalities (see box on page 12).
At one time, physicians would make a diagnosis of alcoholism only if it was associated with violence. Surprisingly, public drinking here is rarely associated with violence. And alcoholics often went undiagnosed until they suffered from delirium tremens, at which time they were sent to hospitals for custodial care. Now all physicians are trained to recognize and treat alcoholism in its early stages. Alcohol-related problems, with the emphasis on primary and secondary prevention, are an important part of Health Japan, a 10-year project begun in 2001.
A growing number of hospital beds are now designated for alcohol-related illnesses, according to Masako Kubo, M.N.S., a lecturer at Hamamatsu University School of Medicine. At the latest tally, approximately 5,000 beds were available, up from approximately 4,000 only three years ago. Among Japan’s hospitals, 125 are sanatoria and 60 are for general care. Six of the 37 national hospitals for psychiatric diseases are specialized for treating alcoholics.
Forty private and 11 public halfway houses admit mostly alcoholics, with one-third admitting only drug addicts.
While the temperance movement never flourished in Japan or had the impact it did in the West, the Japanese have their own self-help groups. The largest is the All-Nippon Sobriety Association, or Danshukai, with 12,000 members. This largely male-oriented group is patterned after Alcoholics Anonymous, with the important differences that it lacks a religious orientation, and members are not anonymous.
The White Chrysanthemum Society, which corresponds to Al-Anon, helps relatives of people with alcoholism. Women with alcohol abuse disorders have a higher divorce rate than men, suggesting they get little support from their husbands. But single women get strong support from family ties. The social stigma attached to women alcoholics is still a powerful deterrent to their drinking.
Although expense-account businessmen once dropped more than $2 billion a year entertaining clients and co-workers, the mizu-shobai, meaning "water business," mostly dried up 12 years ago after economic twilight fell on the Land of the Rising Sun. Investigations of corruption among high-ranking government officials and business executives have drastically reduced entertainment slush funds, effectively closing the doors of many exclusive watering holes once patronized by government and business elite.
Manufacturers of alcoholic beverages who once ignored the harmful effects their products had on society are now increasingly supportive of programs to prevent heavy drinking, according to Michie Hasselbach, Ph.D., professor and director of the doctoral program at the School of Social Work at the University of Connecticut. She told Psychiatric News that Suntory, Japan’s largest manufacturer and distributor of alcoholic beverages, now funds several prevention programs, including the distribution of eye-catching posters warning of the dangers of excessive drinking.
Manufacturers of alcoholic beverages are also helping discourage time-honored practices that lead to excessive drinking, such as chug-a-lug contests on college campuses and obligatory drinking at company parties. At one time to refuse a drink from the boss was a terrible insult that could damage a career. This is no longer true in most workplaces.
Requests for the government to remove the once-omnipresent beer and liquor vending machines—made as early as 1991 at the WHO Inter-Regional Meeting on Alcohol-Related Problems held in Tokyo—have met with some success. The fact that the per-capita alcohol consumption remained stable at 6.5 liters over the past decade can be attributed partly to a sharp decrease in the number of vending machines. Electronics giant Fujitsu is reported to have devised a novel vending machine that requires customers to scan their ID card before they can purchase alcohol.
Alcohol researchers are optimistic that the Japanese can moderate their drinking behavior, because they are a highly disciplined and adaptable people with the world’s best health care system for accessibility and low cost, the world’s highest literacy rate, and a gross domestic product second only to that of the U.S. Since strict societal rules and family socialization regarding drinking have been shown to curb high rates of alcoholism, they believe much will depend on the Japanese maintaining strong family ties and adhering to traditional values, the glue that holds their society together. ▪