Another Tsunami Warning
Caring for Japan's Elderly

by Michael P. Birt
May 30, 2011

Japan’s elderly were hardest hit by the recent tragedy. How does their experience mirror an ongoing crisis of Japan’s demographic shift? Who will care for the caregivers in the future, and is this a global demographic shift? Read this expert brief written by Michael Birt, Director, Center for Sustainable Health, Biodesign Institute, Arizona State University

The NHK studio announcers were still shaking from the 9.0 magnitude earthquake when the tsunami alert appeared on the television screen and pinpointed the areas along the coast of Japan’s Tohoku region in gravest danger. Those alerts are a familiar sight to those who have spent any time in Japan, which has the world’s most advanced Earthquake Early Warning (EEW) system. Issued by the Japan Meteorological Agency, these alerts reach virtually every person through Japan’s extensive and highly sophisticated mass media and cellular networks.

But the earthquake that struck the Tohoku region of Japan on March 11, 2011 was unprecedented. Tragically, the subsequent tsunami washed ashore with such fury that many thousands of people simply had no time to escape a terrible fate.

Japan’s elderly were hardest hit by the crisis, as noted immediately in media coverage from both Japan and abroad. Unable to move to higher ground and vulnerable in every sense of the word to natural disasters, the elderly suffered terribly. In one particularly shocking incident, Japan’s Self Defense Force discovered 128 elderly people abandoned by medical staff at a hospital very close to the Fukushima nuclear plant. Many were perilously ill and 14 died shortly afterwards. [1] Stories of the horrible conditions in local relief centers sent a shiver of dread through a society that cares so deeply about its elderly.

With tragic irony, the dual metaphor of earthquake-tsunami has long been used to describe Japan’s rapidly aging population and its impending impact on every facet of Japan’s future. Indeed, that early warning alert has been heeded in every locale and level of society. The extent and impact of a rapidly aging society (koreika shakai) are staples of public concern in Japan. Already 23% of Japanese are age 65 or older, with the expectation that over-65s will grow to 41% by 2055. [2] Caught by the dual impact of an aging society and a plummeting birth rate, Japan’s total population is estimated to decrease by 25% from 127.8 million in 2005 to 95.2 million by 2050. [3] The impact of these trends will affect literally every aspect of Japanese society in the decades to come.

Japan has responded valiantly to these challenges. In my professional capacity, I regularly meet with Japanese government officials, business leaders, academics, and thought leaders who are dedicated to finding innovative and equitable solutions to deal with this unprecedented demographic transition. In January 2011, I accompanied a hard-working and good-natured doctor-nurse team on their home health visits to care for Japan’s most vulnerable elderly. I might be tempted to call them remarkable, but I have met many such dedicated health professionals in Japan over the course of decades. In fact, the current public and private sector response stands as a testament to Japan’s ability to heed an early warning system and respond quickly and effectively.

But tsunami is an apt metaphor. It begins with a quake and moves across the ocean almost imperceptibly at speeds of up to 600 MPH until it hits shallow water, forming a wall of water as high as 30 feet. Moving at that speed with that force, a tsunami is literally inescapable.

The speed and force of Japan’s aging tsunami may also be inescapable, regardless of the most well-intentioned policy initiatives or social responses. In one media report from the earthquake zone, a manager of a nursing home notes that even with large government subsidies, demand for care of the elderly far outstrips the supply. He said, “We have 500 people on the waiting list here. In all of Japan, there are 400,000 people on waiting lists for nursing homes. Our waiting list is three times the capacity of our facility.” [4]

An even more threatening wave now looms on the horizon—the dire shortage of caregivers for the elderly. For those of us who visit elderly facilities and nursing homes, we can see that the elderly are cared for by the near-elderly. What happens when the caregivers need care? Who will provide the physically and mentally demanding work of caring for those suffering from dementia, those who are infirm with disease, and those who are most vulnerable? Governments can build hospitals, nursing homes, and long-term care facilities, but there is no immediate solution for supplying caregivers when the population pyramid has been turned upside down.

Critically, this tsunami is rushing past Japan and aimed directly at other economies in Asia. The same demographic forces—rapid aging and plummeting birth rates—are also at work in Singapore, Korea, Taiwan, and even China.

What should we do? As a global society, do we simply run to higher ground and leave our elderly behind to suffer the worst fate of all—abandonment? I doubt any society wants to leave that legacy, least of all Asian societies rooted in a Confucian tradition of respect for elders.

Now is the time to change metaphors—from destructive tsunami to hopeful phoenix. Postwar Japan rose from the ashes of destruction to build an equitable and prosperous democratic society. It must now draw on a legacy of technology, entrepreneurship, and social innovation to meet these powerful demographic forces unleashed by the koreika shakai. In this way, Japan’s response to the tragedy of March 11 can show how all of us can care for our elders and our shared future.


[1] Robert Booth and Jason McCurry, “Japanese Earthquake Takes Heavy Toll on Ageing Population,” Guardian, March 17, 2011,

[2] Carl Haub, “Japan’s Demographic Future,” Population Reference Bureau, May 2010,

[3] Naoko Fujimura. “Japan’s Elderly Population Rises to Record, Government Says,” Bloomberg, September 17, 2007,

[4] Anthony Kuhn, “Japan’s Elderly Hit Especially Hard During Disaster,” NPR, March 23, 2011,,1004,1007,1013,1014,1017,1019,1128.