Although Japan seems to have largely dodged the COVID-19 bullet, the pandemic has highlighted one of the country’s most persistent problems, namely its labor shortage in the health care sector. One aspect of the issue that has received more potent coverage is the need for more nonmedical care workers. Japan is known for its large senior population, and a shortage of help in the elderly care sector has been a burgeoning problem for years. Amid the pandemic, it has been tipping over into catastrophe.

The reasons for the shortage are more complicated than many people believe them to be. Care work, which involves close contact with people who are usually in frail health, is not pleasant by most people’s standards, and is also believed to require few technical skills. Consequently, care workers are at the bottom of the health care pyramid in terms of pay and respect.

According to an article posted on Feb. 6, 2019, on Diamond Online, care workers make up 25 percent of the labor force in some hospitals, with nurses accounting for 21 percent and the rest divided among physicians, rehabilitation technicians and administration. As explained by Hideki Nakamura of the caregiving service company Life Care Support, doctors are obviously at the top of the pyramid and care workers form the base.

Nakamura says this dynamic creates friction, especially between nurses, who have medical training, and care workers, who often do not. Changing diapers, for instance, can be handled by nursing staff, but some nurses delegate this task to care workers because they don’t want to do it, and not just because changing diapers is considered unpleasant. Nurses tend to be evaluated solely on their medical-related tasks, such as dispensing drugs and giving injections. Changing diapers doesn’t count toward their evaluations, so they put pressure on the certified care workers who tend to supervise all other care workers. Certified care workers do have some measure of medical knowledge, but Nakamura says that they are discouraged from using that knowledge in the workplace due to hierarchical structures.

Care personnel have their own internal structures, and most of those positioned at the bottom are older women with little formal training. Nurses tend to be younger, and may not want to give orders to people who are older than they are, so they place that burden on certified care workers, who also tend to be younger than the people they supervise. This situation causes tension in the workplace that goes beyond pay discrepancies.

However, resolving pay discrepancies would definitely go a long way toward making the job more attractive, as would more general recognition of the fact that people with experience as care workers are vital resources in today’s society.

They’re especially vital outside of hospitals, meaning in dedicated care facilities and in an on-call capacity at users’ homes, where care workers may receive even less respect. Keiko Kawaguchi, a professor at the Osaka College of Social Health and Welfare, told the Asahi Shimbun an anecdote that reveals the public’s attitude toward care workers. After a worker changes an elderly person’s diaper, Kawaguchi says, the person expresses gratitude but adds that they would not want their own child or grandchild doing such a “dirty job.” Kawaguchi also says that in situations where the care worker is visiting a user who still lives with their family, the family may ask the worker to enter through the back door. Most doctors and nurses, however, are welcomed at the front door.

Kawaguchi partly blames the media for mainstreaming such an attitude, especially in the way it reports the government’s push to bring in more foreign workers to make up for the labor shortage. Some media outlets tend to characterize this trend as “opening the gates for manual labor,” a phrase that characterizes foreign workers as an invading horde, and many related media stories are on foreign workers who are coming to Japan as caregivers.

When Kawaguchi carries out an internet search for the phrase “teihen-shoku” (“lowest jobs”), care work is one of the most common results. School guidance counselors typically don’t suggest caregiving to students as a possible future occupation. Prestigious high schools rarely allow care work representatives on their campuses for explanation sessions. The number of caregiving programs at institutions of higher learning are decreasing. As a consequence, caregiving companies are going out of business even as the demand for their services increases.

In another interview carried out by Asahi Shimbun, Joe Sakai, vice president of caregiving provider Lyxis Co. also places the onus on the media for this disaster, saying that greater knowledge about the nature and importance of professional caregiving is vital to the public.

Every year, between 80,000 and 100,000 salaried employees quit their jobs in order to take care of older family members full time, thus placing a burden on their employers and the economy in general.

Traditionally, family takes care of family, a notion institutionalized in the caregiving (kaigo) insurance program launched in 2000. Although every worker in Japan starts paying into this program when they’re 40, there is no guarantee the person will receive caregiving benefits when they get older, since they need to be evaluated in order to determine what level of care assistance they can receive from the state. If they still live with their family, the family may be expected to take on the burden of caring for them.

The common thread in these articles is that because care work is for the most part not taken seriously as an occupation, people who enter the field may not take it seriously, either. But care workers need to be qualified, either through a dedicated course program or monitored on-the-job training and, as Kawaguchi points out, experience is vital to the effectiveness of care work. There may be no greater proof that the system is broken than the fact that almost no one wants to work in one of the most essential jobs in Japan.

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