Early exposure to tuberculosis and the loss of part of a lung
In 1946, after joining the Tuberculosis Research Group of medical students while studying at Tokyo University’s School of Medicine, Tadao Shimao sought opportunities to learn more about tuberculosis. His search lead him to the Daiichi Dispensary of the Japan Anti-Tuberculosis Association (JATA). At this time, the tuberculosis mortality rate in Japan was around 200 per 100,000 and tuberculosis was highly prevalent.
Shimao dedicated his training to public health in rural Gunma Prefecture and the Daiichi Dispensary. While managing data to assist in group medical examinations, he discovered a formula to calculate the annual risk of tuberculosis infection from age-specific tuberculin positive rate. Intrigued by unraveling epidemiological mysteries, Shimao became completely absorbed by the epidemiology of tuberculosis. After graduating and becoming a doctor in 1949, working at JATA was a natural choice.
Shimao’s life took an unexpected turn in late 1950, when he contracted tuberculosis himself. He entered the JATA Tuberculosis Research Institute’s Sanatorium (now the Double-Barred Cross Hospital) in 1951, beginning a period of recuperation that would last almost three years and require the surgical removal of eight ribs and later the upper portion of his right lung.
The following year, Shimao was treated with isoniazid, a new antibiotic for treating tuberculosis that was introduced for general usage. Negative conversion of tubercle bacilli in sputum was achieved, and he was able to return to a normal life. However, his struggle against the very disease that he studied would shape the rest of his life. While his research focus is epidemiology, as a doctor who has experienced the same hardships and suffering that his patients endure he has a unique connection to the clinic. Now well into his 90s, he continues his outpatient medical practice to this day.
A groundbreaking souvenir from studies in Sweden
Shimao (on the right) studying abroad in Sweden
Prince Yasuhito, who died of tuberculosis in 1953, was honorary president of the Sweden–Japan Society (and was succeeded by Princess Chichibu when he contracted the disease). After observing what a serious issue tuberculosis was for Japan, Swedish members of the Society arranged for one Japanese doctor to study abroad in Sweden for a year , and altogether 5 doctors. Upon his recovery, Shimao was selected to be the first to make that trip. In 1955, he had the opportunity to spend a year studying in Sweden, an experience that significantly broadened his worldview.
Shimao studied Sweden’s tuberculosis prevention measures and learned more about health and medicine in general from this advanced nation with an established social welfare system. He brought back a groundbreaking gift for Japan from his stay in Sweden: physiotherapy.
The physiotherapists who visited tuberculosis sickbeds in Sweden guided patients through postoperative care, beginning with pre-surgical care, to minimize physical deformations. Shimao was convinced that this approach should be incorporated into Japan’s system for postoperative treatment, which at the time focused solely on rest. He obtained permission to translate a handbook from the Swedish Anti-Tuberculosis Association, completing the translation in 54 days while in transit by boat from Genoa to Yokohama. His translation, published in Japan as Hai kinou kunren ryouhou (Lung Physical Therapy), led to much faster rehabilitation of postoperative patients in Japan.
Establishing an international training course to help eradicate tuberculosis worldwide
Among Shimao’s many accomplishments, the most prominent is the international training course at Research Institute of Tuberculosis, JATA. Having joined the Colombo Plan in 1954, Japan became a donor nation, and the following year began offering technical support to developing countries. In 1960, when Shimao was sent by Japan to the United Arab Republic (present-day Egypt and Syria) as a tuberculosis specialist, he devoted himself to international cooperation from the outset. In 1962, with the establishment of Overseas Technical Cooperation Agency (OTCA), the predecessor of the Japan International Cooperation Agency (JICA), an international training course for addressing tuberculosis was created for people from developing countries at the Research Institute of Tuberculosis.
This system has been jointly operated by OTCA and WHO since 1967, and has continued for over half a century, bringing 2,237 doctors and others engaged in anti-tuberculosis efforts from 97 nations (from 1963 to 2014) to study in Japan and then return to their home countries to work on the frontlines of the battle against the disease. Three ministers of health are among graduates of the program. In his JATA advisor’s office, Shimao has a world map showing the number of graduates from the course, offering proof of the network that Japan has helped nurture. However, Shimao is adamant that this work is unfinished; to eliminate and ultimately eradicate TB, it will be necessary to continue to develop talent at the frontlines of the battle.
Drawing attention to tuberculosis on the international stage
From 1987 to 1990, Shimao served as the member of the Executive Board of the World Health Organization (WHO), coinciding with Hiroshi Nakajima’s election to Director General of WHO in 1988. WHO’s Tuberculosis Programme at the time had been reduced to just two staff. But the efforts of Japan’s Arata Kochi, who was appointed Director in 1989, strengthened the international system for dealing with tuberculosis, most notably with the strategy known as Directly Observed Treatment, Short Course (DOTS), which has been recommended by WHO since 1994. This strategy made anti-tuberculosis efforts a policy priority for governments and helped establish structures for distributing drugs, supervision by healthcare staff for administering drugs, and statistical evaluation on a global scale. Eventually, TB cases decreased drastically.
In 2015, Japan ranked among the top four Official Development Assistance (ODA) providers, having previously been at the top from 1991 until 2000, and the second just behind the United States for many years. Nakajima’s appointment as WHO’s Director General and Shimao’s appointment as a member of the WHO Executive Board, helped incentivize the Japanese government to provide support to the fight against tuberculosis. The international focus on tuberculosis owes much to these Japanese efforts and Shimao’s leadership.
Making tuberculosis a an easily curable disease, and expectations for the future
Over the years, there has been a steady decrease in the number of tuberculosis cases, but the disease is not yet completely under control. In Japan, tuberculosis programs have succeeded in reducing the death rate as well as the incidence rate, both by 10% annually, compared to when tuberculosis was highly prevalent in the country. 22 nations are still designated by WHO as high TB-burden countries. Japan’s progress overcoming its own tuberculosis epidemic offers hope for other countries still struggling to control the disease within their borders.
Complicating the fight to eradicate the disease is the unusual behavior of tubercle bacillus, which goes dormant and continues to live even when conditions are not favorable. Since it stops regenerating while dormant, drugs are no longer effective. For this reason the case rate in Japan is still higher than in other industrialized countries; most Japanese who die from the disease are elderly people with weakened immune systems whose dormant tubercle bacillus became active again. There is no countermeasure to combat tuberculosis in this dormant stage, but such a development would be groundbreaking.
Tuberculosis is an infectious disease; I think we will overcome it someday. Treatment now takes six months, which, compared to my own two years and ten months, is short, but still for anyone enduring it quite long. It has become a curable disease, but it has not yet been cured. We must continue making efforts to deal with dormant bacillus, research and develop stronger treatment, and train people with the necessary skills.
Note: Quotes are from a June 16, 2015, interview conducted with Tadao Shimao.
Re-evaluating the Japanese approach to tuberculosis
International training at a mobile medical check-up vehicle
WHO currently proposes a public–private mix (PPM) for tuberculosis control, where public and private institutions work together to treat patients. Japan introduced this type of system in 1951, soon after the end of World War II.
Japan’s tuberculosis control law, enacted in 1951 established private physician-centered tuberculosis treatment. Based on national tuberculosis prevalence surveys that began during this time (the first in 1953, and every five years thereafter, with a total of five surveys), physical health examinations expanded in 1955 from people under the age of thirty, excluding infants, to everyone in the country, excluding infants. The government covered the full costs of examinations and immunizations from 1957 onwards. These and other preventative measures were amended a number of times, with a revision in 1961 creating a system to register patients and expand government subsidies for hospitalizations. This revision represents the culminating step in establishing a comprehensive system of dealing with tuberculosis from infection all the way until the end of treatment.
As the spread of HIV/AIDS increases the risk of tuberculosis infection with less smear positive pulmonary tuberculosis, the structures Japan has created—tuberculosis prevalence surveys and collaboration of private physicians in tuberculosis treatment—are receiving renewed praise from the international community.
Research on Tuberculosis
Tadeo Shimao was born in Tokyo in 1924 and graduated from the School of Medicine at Tokyo University in 1948. He joined the Japan Anti-Tuberculosis Association (JATA) in 1949 and become director of the Research Institute of Tuberculosis in 1975, chairman in 1990, president in 1994, advisor in 2000, finally honorary advisor in 2016. He is also executive director of the Japanese Foundation for AIDS Prevention. He has a legacy of leadership in governmental and international organizations, first as a member of the Executive Board of WHO and then as head of the Overseas Medical Cooperation Committee of the Japan International Cooperation Agency (JICA) and director and chairman of the Board of Directors of JATA.