Social medicine as a state of exception: rethinking responsibility and public medicine through mutual aid events in Japan


If you fall into a pit, you can climb out,

but once you slip from a sheer cliff,                  

you cannot step firmly into a new life again

Tokyo Ueno Station, Yu Miri

Ghostly matters in Sugamo

Since its establishment by the US occupying forces in the aftermath of the Second World War, Sugamo Prison has operated in a state of exception, as ‘an abnormal space’, even ‘a separate country in Japan’ beyond the sovereign control of the nation (Utsumi 2004). The prison cooperated with the Tokyo Tribunal, whose legitimacy is marked today by questions over whether the trials shackled the Japanese public discussion into forever avoiding historical responsibility and symbolic negotiation (Yoshida 2005). The trial’s purview over social and legal institutions in Japan remained limited.[1] The political system that followed the invasion by the United States and the establishment of the Tokyo Tribunal maintained a ‘complex game’ where responsibility for the war was never actually faced by the Japanese state, while right-wing Japanese governments crushed dissenting groups that called for social justice to counter US military and economic aid (Shirai 2016).

Sugamo Prison, located in the bustling town of Ikebukuro, was demolished and turned into a special economic development site in 1978. Today, the only remnant of the prison is a stone monument decorated with inscriptions and offerings. Around this monument, unstably housed individuals gather to hang out and smoke during regular events organized by the mutual aid collective comprised of Tenohashi (Helping Hand), Housing First, Sekai Iryodan (Doctors of the World, known as Medicines du Monde, henceforth MDM), and Hanhinkon Nettowaku (Antipoverty Network). Every other week, these organizations offer medical, housing-related and legal consultation while distributing over-the-counter drugs and meals to more than 500 individuals.

In the summer of 2020, five months into the Covid-19 pandemic, the spike in the rate of unemployment brought wider visibility to inner-city poverty. Although there was not a massive housing shortage or a financial crisis in Japan during the pandemic, local activists, medical professionals, psychiatric social welfare workers, and Tokyo Metropolitan office workers (volunteers) collaborated to address the problems of unstably housed individuals. These events became highly televised as they brought attention to the unmet medical and shelter needs of the most impoverished population in Japan. Organizers used the platform to call for broader poverty relief and social policy reforms. According to one of the founders of Housing First and Antipoverty Network that I interviewed, their goal is to make housing a non-negotiable right of people living in Japan, rather than leaving it to administrators or individual responsibility (jikosekinin).

East Ikebukuro Park is surrounded on the old Sugamo Prison grounds by a skyscraper, a shopping mall, and a hotel with high-end offices. Humanitarian aid groups and individuals occupy this space in times of generalized anxiety and heightened focus on poverty and health crises. They amplify these concerns and, by re-purposing this public park in the middle of financial and commercial activity, establish a state of exception. During these events, the old prison ground and the ghost of the sovereign nation’s responsibility are summoned in the form of ‘neoliberal self-responsibility’ and contrasted with advocacy for social medicine and poverty relief. In the following section, in order to rethink the role of expert alliances and urban political interventions for the future of social medicine, I will introduce the activities of three individuals and their perspectives on social aid and humanitarian medicine.

East Ikebukuro Park and social responsibility

Public monument that reads ‘wish for permanent peace’. Photo Credit: Selim Gökçe Atıcı

At the park, Dr Kumakura volunteers with MDM to provide kokoro no sodan, or sodan yorozo, the local interpretation of harm reduction in Japan as it is practiced by grassroots organizations. During the 2.5 hour session at the event, medical professionals address people’s worries as they come, whether pertaining to housing needs, a broken nail, a request for a letter of medical referral, or just someone to hear them out. At every event, Dr Kumakura meets around 10 to 15 individuals and offers his expertise as a psychiatrist on a wide range of troubles (nayami), such as the need for writing medical referrals, explanation about the social welfare benefits that cover psychiatric treatment, or the need to know more about the nature of certain mental health–related issues. Sometimes he is asked to just listen to stories or give out over-the-counter drugs.

Some of the people he sees have been following him to various clinics and public medicine events for more than four years. When asked about how housing relates to mental health for the individuals at the park, he argues that ‘having a room of one’s own’ is a necessary (but not sufficient) condition for Japanese individuals in order to become citizens that can pursue their right to social and medical welfare. According to Dr Kumakura, because of the way civil rights in Japan are tethered to a residential address and official work, individuals who have lost reliable living conditions have chronic problems in accessing medical institutions. Accordingly, volunteering experts work to facilitate a safe residence and to assist those in need in obtaining life assistance social protection, a welfare scheme (seikatsu hogo).

Yet, the limits to providing psychiatric care during these events are apparent. When an individual under immense mental stress cannot go to the hospital because of an aversion to institutions or because of a lack of health insurance, Dr Kumakura says, ‘outside of the clinic, we are immensely powerless’ (muryoku sugiru). But this auspicious, semi-clinical space will be available again in two weeks. When doctors are unable to respond to the needs of the person seeking help, they can involve other medical experts who have more expertise in psychiatric social medicine and city-wide social welfare support.

One such expert is a psychiatric social worker, Kawashima. In the past, she was laid off by two general hospitals because she refused to inform the police when treating patients who had injection marks thought to be caused by methamphetamine injections. Following years of struggle, Kawashima now works at a clinic that specializes in treating people who have unstable and unsafe living conditions (seikatsu konkyusha). When she is not at social medicine events or the clinic, she is also a visiting nurse, providing medical care and logistical support for those she has met during mutual aid events.

At the park, Kawashima seeks out individuals who are reluctant to go to general hospitals for their concerns, in order to refer them to special clinics and to the city’s welfare office. She makes sure that these facilities practice ‘trauma informed care’. According to Kawashima, the ‘social’ work of a psychiatric social worker in Japan involves advocating for people seeking treatment at general hospitals and helping them navigate city offices, and putting pressure on local and metropolitan governments. Kawashima has also been working at events that question the governmental, economic, and ethical constitution of medicine in Japan. Social workers, she says, should counter the city’s reluctance to provide economic and medical welfare for impoverished and unstably housed communities.

Multiplicity of norms in social medicine

Kawashima first met with Dr Kumakura during exploratory workshops concerning ‘harm reduction’, organized by MDM in a series of seminars throughout 2019 until the outbreak of the pandemic (Kumakura 2021). In a group conversation with representatives from MDM, they argued that the inequality of access to healthcare in Japan was exacerbated by (and thrown into relief during) the pandemic. They were already volunteering at various conferences that linked social welfare and psychiatric medicine, but with the pandemic, their political involvement took a turn. They took it as an opportunity to expose the reign of individual responsibility, a term that connotes the biopolitical governance of the individual who is deemed ultimately responsible for their own health and illness. Kawashima explained that the main purpose of gathering at the park every other week was not to integrate people into the medical-welfare system, nor to merely offer meals. Through mutual aid and poverty relief practices, everyday spaces become places for connection (tsunagari). Although these events are temporary in making spaces for being (ibasho), they nonetheless jolt the media, medical professionals, and poverty relief organizations into action and pressure public debate towards housing, medicine, and social aid as civil rights.

During the preparatory phase before a mutual aid event, activists light mosquito repellents. Photo Credit: Selim Gökçe Atıcı

According to Dr Kumakura, diminishing labour productivity and real wages in Japan have coupled with weak access to medical welfare in the case of poor households. Furthermore, unstably housed populations have experienced severe loss of cultural and medical resources. These mutual aid events serve to publicize the lack of social and governmental responsibility, Dr Kumakura and Kawashima argue, and the media attention garnered should be buttressed by expert alliances and a network of administrative, medical, residential, and meal distribution support. In addressing the mental health of unstably housed individuals, they make a case for a public psychiatry, as one cannot cure what happens relationally through personalized practice. In their joint action, they espouse that by changing the way medicine works, they can reorganize what we understand about maladies and socially shaped ill-health. Furthermore, this may help us rethink the hospital-clinic-welfare system. Spaces that provide public access to medical care underline the ways that these people have been abandoned by the Japanese medical-welfare complex.

The work of mutual aid organizers is performative, because they make visible social suffering as they offer ‘fixes’ to the failure of existing forms of social insurance. The unstably housed population in Japan, as in other contexts, is shaped by an amalgam of political economic conditions and cultural responses to ‘fix’ the undergirding social precarity. Seen from below, homelessness rarely fits the tidy narratives provided by census data, as the bodily experience of journeying, narratives of time and loss, and senses of selfhood transcend our taken-for-granted notions of rootedness (Desjarlais 1997). In this sense, the work of mutual aid organizers is also critical. According to Dr Kumakura and Kubota Kenji (Kubota and Kumakura 2020) from KAZOC, a visiting nurse station, improving the medical and welfare support for Japan’s homeless requires a wider social conversation about social exclusion. Although the data presented by the Ministry of Health, Labour, and Welfare shows a declining historical trend in the number of homeless individuals, down to 3,500 individuals in the nation in 2022 from a 2003 high of 25,000 individuals (Nippon 2022), social workers and outreach professionals refer to an increase in the number of people with multiple morbidities and in need of stable housing.

Among the organizers of the anti-poverty network there are more seasoned activists who have deeper ties to Japanese city offices. I met S, one of the organizers, at the end of an event during a cold, dry Tokyo night. He was watching a Japanese hologram pop star on another activist’s smartphone. S has been at the forefront of negotiations with government welfare workers and among the various organizations and media outlets that attend the event. In a short interview, he emphasized to me that obtaining the services offered by the welfare state in Japan requires vigorous struggle. Basic life support (seikatsu hogo)is a case in point. According to S, this aid provides basic income and unrestricted medical aid but it is often denied, delayed, deferred, or gets lost in translation because of the multiplicity of means and bureaucratic standards applied during the application process. As city office employees are on mandatory rotation, losing trusted contacts might mean losing welfare support. If you are not well-versed in various communication styles at the government offices, legal rules become illegible. In addition, each of the 23 city offices in Tokyo have different barriers and preferential treatment. Although officially ‘universal’, social services have a multiple nature (Fassin 2011) that is often determined in specific encounters.

State of exception, state of social medicine

The political philosopher Giorgio Agamben (2005) defined ‘state of exception’ as an organic extension of state power to declare crises and emergencies that diminish the constitutional rights of individuals in favour of the strategic goals of the state machinery. Seen from the ground, states of exception work through the experiencing of ‘differences between membership and inclusion’; they ‘reside both inside and outside the law, do not make their appearance as ghostly spectral presences from the past but rather as practices embedded in everyday life in the present’ (Das and Poole 2004: 13). If we take the everyday suffering of unstably housed individuals as the state’s operation to govern a population or the limits of its bio-political governance, what power do communities have in declaring states of exception? What do medical professionals achieve when they bypass the standards of professional medicine and the biopolitical order of self-responsibilization? How do ‘ghostly spectral presences’ produce alternative narratives of social responsibility, as medical interventions into systemic ill-health produce exceptions to the rule?

When social assistance depends on a ‘multiplicity of norms’ (Fassin 2011:76), uneven delivery of the promise of social protection generates loss as well as opportunity. On the very grounds of Sugamo Prison, where Japan’s national conscience for wartime responsibility turned opaque, proponents of Japanese social medicine are attempting to overturn a harmful regime of self-responsibility. These gatherings repurpose this ‘abnormal space’ into a major site for humanitarian mutual aid. By exposing the ‘social’ in the making of ill-health they evoke the ghost of the past as well as the ‘real’ of contemporary biopolitics.


[1]  Twenty-eight ‘class A’ war criminals were tried, indicted, and executed on the grounds of Sugamo Prison, where the prison administration held Japanese military and government officials to respond to war-time atrocities such as the Rape of Nanking and waterboard torture. The ‘class A’ war criminals acted in unison to safeguard the wartime emperor Hirohito, ‘to protect their sovereign against any possible taint of war responsibility’ (Dower 1999: 325). The emperor Hirohito was not tried.

References

Agamben, G. (2005). State of Exception. Translated by Kevin Attell. Chicago: University of Chicago Press, 2005.

Das, V., and Deborah P., (eds). (2004). Anthropology in the Margins of the State. Santa Fe, NM: School of American Research Press.

Desjarlais, R. (1997). Shelter Blues: Sanity and Selfhood Among the Homeless. Philedelphia, PA: University of Pennsylvania Press.

Dower, J. (1999). Embracing Defeat: Japan in the Wake of World War 2. New York, NY:W. W. Norton Co.

Fassin, D. (2011). Humanitarian Reason: A Moral History of the Present. Berkeley: University of California Press.

Ginn, J. L. (1992). Sugamo Prison, Tokyo: An Account of the Trial and Sentencing of Japanese War        Criminals in 1948. Jefferson, NC: McFarland & Co.

Kubota, K and Kumakura, Y. 2020. 排除と臨床としてのハウジングファースト. In Ed. Nakatani Y.現代社会とメンタルヘルス: 排除と包括. Seiwa Shoten

Nippon News (2022). ホームレス最多は大阪市923人―厚労省調査 : 全国では過去最少3448人. Retrieved from https://www.nippon.com/ja/japan-data/h01323/

Kumakura, Y. (2021). 人権としてのハウジングファースト―共同意思決定の基盤としての権利擁護―.精神経  2021 第123 巻 第4 号

Utsumi, A. (2004). Sugamo Prison: The Peace Movement of the War Criminals (Sugamo purizun—senpantachi no heiwa undo). Tokyo: Yoshikawa Kobunkan.

Shirai, S. (2016). 戦後政治を終わらせる 永続敗戦の、その先へ (NHK出版新書) 2016

Yoshida, R. (2005). ‘60 Years On Japanese Debate the Tokyo Tribunal’s Legitimacy’. The Asia-Pacific Journal: Japan Focus 3(10), 1-4

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