When recession hit Japan in the 1990s, many men living in Osaka lost their jobs and became homeless. Justin McCurry investigates the public-health implications of widespread drug and alcohol abuse in the world's second-richest country.
Taku Nishimori shakes his head in despair as he studies the x-ray results. The shadows on the lungs of the patient, a middle-aged man, are all too familiar. They mean yet another suspected case of tuberculosis.
According to Nishimori, a primary health-care worker, the tuberculosis rate among the men he examines stands at 870 in every 100 000—higher than in Cambodia and Zimbabwe.
The figure is shocking by any standards: that it applies to people living in a major city in the second-richest country in the world makes it doubly so.
Nishimori works in Kamagasaki, a district in southern Osaka that for decades has been home to legions of casual labourers. In the boom years of the 1960s and 70s, the area buzzed with activity as thousands of men lined the streets outside the local labour exchange every morning, waiting for fleets of buses to ferry them to work on construction sites.
The labourers stayed, but the work dried up when the economic bubble burst and recession gripped Japan in the 1990s. Now the area is synonymous with poverty, homelessness, and ill health. Between 1000 and 2000 men of the local population of 30 000 are thought to be sleeping outside, with another 5000 officially recognised as homeless.
The story is the same in other parts of Osaka. More than 9000 of the official national homeless total of 27 000 live in the city and its suburbs.
The authorities were slow to act as blue tarpaulin cities sprouted up in parks and beneath bridges. Rough sleepers were seen as an embarrassment; the solution was to conduct periodic “evictions” of homeless men from public parks.
Lobbying by non-governmental organisations (NGOs) and more enlightened policies have brought improvements, but for many in Kamagasaki and elsewhere who do not know where their next wage packet, or bed, will come from, the situation is desperate.
According to unofficial estimates, as many as 200 men die on Osaka's streets every year. In a recent survey, volunteers found that only a quarter of Kamagasaki's day labourers ate three meals a day. Two-thirds said they ate once a day, while 10% said they occasionally went an entire day without food.
Poor diet, the ravages of life on the street, and alcohol and drug abuse have brought the area to the brink of a public-health crisis. The problem is compounded by the advanced age of the residents. In the 1970s, men in their 20s and 30s came in search of work, but today they are more likely to be in their mid to late 50s.
Widespread health problems among the city's homeless—such as hepatitis C, tuberculosis, high blood pressure, and diabetes—attracted the attention of the Japanese chapter of Médecins Sans Frontières, which has started offering free medical check-ups, blood tests, and referrals.
In Kamagasaki, the sick are sent to a medical centre that offers free, but limited services. When patients—many of whom have no health insurance—require specialist care, volunteers have to negotiate to secure them treatment at regular hospitals.
Aside from sleeping rough and living on a cheap but salt-heavy diet of instant miso soup and noodles, many residents also struggle with addictions to drugs and alcohol.
“There are group meetings at the local church, but they don't seem to work for the kind of alcoholics we have here”, says Takeshi Kawanami, a Buddhist priest who helps run a homeless shelter in Osaka Castle Park. “They find the idea of going to meetings really hard. For them, taking Antabuse is much easier.”
Drinking is a way of life in Kamagasaki. As darkness falls, small groups of men gather on street corners to spend what money they have on beer and sake from banks of vending machines that dot the area. A can of beer, 230 yen in a high street off-licence, costs just 200 yen here. Every so often those who are already the worse-for-wear saunter past, muttering to themselves or yelling at imaginary adversaries.
“Even if they try to cut down or give up alcohol, they can't”, says Kawanami. “It is easily available and the peer pressure is intense. They are happy to share their supply when someone has run out of money. The temptation is too great for them.”
Kawanami estimates that five in every 100 homeless people in Kamagasaki have a drinking problem, and that about 2% are addicted to drugs. “They are easy to get here”, he says. The drug dealers, often junior members of the local yakuza (mafia), sell their wares—usually amphetamines but sometimes heroin—through their car windows. Arrests are rare.
Health problems are widespread among Osaka's homeless
Taku Nishimori studies x-ray results from another suspected case of tuberculosis
Local NGOs say the first step towards achieving some kind of normality in Kamagasaki is to get people off the streets and into proper accommodation.
In 1999, volunteers campaigned to turn more than 200 vacant rooms in the area over to the homeless. A year later a group called the Kamagasaki Community Regeneration Forum started putting local men to work cleaning the streets in return for modest wages. A day's cleaning, for example, will earn them 5700 yen—enough for meals and a room for the night.
The group also offers accommodation to those who register at the local labour welfare centre rather than slipping through the official net, as well as subsidised housing that does not require a guarantor or deposit.
The forum encourages the men to accept as much work as they can without affecting their pension and other welfare entitlements. “It shouldn't be all or nothing”, says Sen Arimura, secretary general of the forum.
“If they fall ill it costs the state 400 000 yen a month. But putting them in their own homes costs 120 000 yen. Spending money to ensure they don't suffer from high blood pressure or have strokes costs a lot less in the long run.”
The forum has introduced a local currency—the Kama—as payment for cleaning up the neighbourhood. They get 300 Kama—300 yen—for one hour's work. The currency can be spent in local shops but is not accepted by alcohol vending machines.
In addition, more accommodation is becoming available. Aside from the dozens of cheap hotels and flophouses are two sprawling complexes of prefabricated sleeping quarters for 1000 men where beds are doled out on a first-come, first-served basis.
The need for grassroots action to put Kamagasaki's homeless back to work has never been greater. Recent predictions of better days for the Japanese economy hold little promise for the district's ageing residents. The market for labourers is shrinking and although there are jobs open in the service and other “new” industries, they require special training and skills.
Amid the desperation there are individual success stories, including Katsuo Yasui, who earns extra cash working part-time conducting tours of Kamagasaki. “This is hidden from the rest of society”, he says. “People have no idea what they're going to see—all of these single men in their 50s, just milling around. It is a very strange place.”
The 60-year-old lived in a tent for 3 years after casual work in the construction industry began to dry up. “But now I'm working again and can get medicine for my high-blood pressure”, he says. “And now that I'm living in a shelter I am basically in good health.”
The project receives funding from the Osaka municipal and prefectural governments but overall the central government, under pressure from the finance ministry, is cutting back. Other cities such as Kawasaki have faced opposition to the construction of shelters from locals, and local authorities that run food stamp programmes say they cannot afford to keep them going because of the hordes of men travelling from outside the area in search of handouts.
Arimura, a cartoonist who has written a popular manga series about the men of Kamagasaki, says the authorities are more committed to helping the homeless than they were, but added: “They don't have a grand plan, either.”
Grand plans are of little concern to Nishimori. While he is encouraged that tuberculosis rates are coming down slightly, thanks in part to the local health centre's DOTS (directly observed treatment, short-course) programme, he admits that keeping track of patients over their 6 or 9 month courses of treatment can be exasperating.
“It's very difficult to get them to continue taking their medicine”, he says. They feel they have no reason to get well, no-one to love, and no-one to be loved by. This is a loveless society. They think, ‘Who cares?’”