The Politics of Healthy Longevity and Good Death: A Case
of Pin Pin Korori in Japan
Daisuke Watanabe
Abstract
This paper examines the hidden politics of healthy longevity and good death,
by focusing on the history of “pin pin korori” in Japan.
Japanese local governments and social organizations have attempted to
popularize the onomatopoeic phrase, “pin pin korori”, which describes the
ideal life and death in old age. The word “pin pin” means “being healthy and
energetic”, and “korori” means “fast dying without pain.” In general, this
phrase is often abbreviated as “PPK.”
Through examining literatures and interviews on PPK, this research observes
two periods of PPK movement. Firstly, in the 1970s, PPK undō (movement /
exercise) started in Nagano Prefecture as a local exercise program for the
elderly. Kitazawa, the founder of PPK undō, tried to establish a new exercise
program that the elderly were able to participate to keep their daily life
healthy. Thanks to the local radio system, PPK became widely spread in
Nagano.
Secondly, in the 1990s, the Central Committee of National Health Insurance,
who sensed a looming crisis because of the increase in healthcare cost, began
to pay attention to Nagano’s low medical expenditure. In one of its reports,
the committee found out that PPK movement was functioning as a way to
reduce the medical costs. In this period, the committee and Japanese
government tried to connect autonomy of individuals to healthy longevity
and good death.
In the historical analysis, this research would demonstrate that the discourses
on PPK have changed from the slogan for a physical exercise for the elderly
to the means for reducing medical cost. More importantly, PPK conceal
inevitable life time between active life and death, thereby obscuring
existential problems of the elderly living with illness. This research,
therefore, suggests closer attention should be paid to the hidden politics
behind the discourse on PPK as “healthy longevity and good death”.
Key Words: ageing, healthy longevity, PPK (pin pin korori), good death,
medical expenditure, Japan.
2
The Politics of Healthy Longevity and Good Death
______________________________________________________________
*****
1.
Introduction
This paper examines the politics of healthy longevity and good
death, by focusing on the history of “pin pin korori” in Japan.
As is well known, Japan has faced a rapid demographic ageing. Due
to low fertility, little migration, and mass longevity, the proportion of the
elderly continues to grow. As of September 2010, the number of people aged
65 or over was 29.4 million and accounted for 23.1 percent of the total
population. Additionally, the number of people aged 75 or over reached 14.2
million and accounted for 11.2 percent. The population projections indicate
that the percentages of older persons (65+ and 75+) will rise to 30.5 percent
and 18.2 percent by 2025. 1 These rates show a worthy testament to
achievement of public health care system and development of modern
medical system in welfare state.
However, this demographic change in Japan and also in other
developed countries faced on the change in disease structure: the old
infectious causes of death gave way to degenerative and chronic diseases
such as cardiovascular disorders, cancer, and cerebrovascular diseases.
Wilkinson mentioned about the change as following: “While the old
infectious diseases still remain the diseases of poverty in the third world
today, the degenerative diseases of old age have become the main causes of
death in the developed country”. 2 In developed countries, older people tend
to die by degenerative diseases, in other words, they have to struggle and
inevitably will die with their disease in their old age.
Peter Burger argued that death was a fundamental feature of all
societies.3 Some sociologists have been taken up his arguments. Anthony
Giddens suggested that the conditions of late modernity had instigated an
increase in anxieties about death.4 He pointed out that the discussion of death
for us had become largely a preoccupation with sickness outside strictly
theological circles, because people were left with structured ways of coping
with tensions and anxieties involved, and already death had become a
technical matter of medical profession.5 Under the late modern condition,
people finally will have to accept their own death. People are required to
construct new tradition of death.
In this paper, through analysing a case of pin pin korori’s history, I
try to rethink the politics of contemporary discussion of death and dying in
Japan.
2.
The Origins of PPK: from 1970s to 1980s
Japanese local governments, social organizations and older people
have attempted to popularise the onomatopoeic phrase, “pin pin korori”,
which describes an ideal life and death in old age. The word “pin pin” means
Daisuke Watanabe
3
______________________________________________________________
“being healthy and energetic”, and “korori” means “fast dying without pain.”
In general, this phrase is often abbreviated as “PPK”. And, the similar term of
PPK is pokkuri. A traditional word, pokkuri is one of origin words of korori,
one part of PPK, and means a sudden death. Some local small temples called
pokkuri-dera (pokkuri temple) are often found in various regions of the
country. John W. Traphagan is an anthropologist in the United States and
explained that pokkuri temple is “a Buddhist temple at which people pray for
a sudden death”, and where “people request a sudden, or merciful death,
devoid of long-term illness”.6 Recently, scholars and doctors use the word
pokkuri in a positive way, because PPK has an aspect of active life.
This phrase, PPK, is generally understood as the ideal death of older
people. In fact, since the late 1990s, some books about PPK or pokkuri have
been published.7
However, the phrase was not popular until the mid-1990s. In
addition, nowadays, almost all people and officers do not know the origin. In
this chapter, I wrote the first history of PPK in order to understand the
disconnection between two periods, before the 1980s and after the mid1990s.
PPK has been used in Nagano prefecture, central Japan since the
1970s. In the 1960s and 1970s, one of the most important issues of Nagano’s
public health office was the highest rate of death from cerebrovascular
disease in Japan. Nagano prefecture addressed this problem, and promoted
reduced salt foods and one-heater-one-room movement with the help of local
physicians and health promoting volunteers. These activities gave people
experiences to promote health and well-being in local areas.
In 1979, Toyoharu Kitazawa who was a social education coordinator
of Takamori Town in southern Nagano gave a speech titled “Physical
Exercise for middle and old age: PPK Undō at Takamori Town” at a
symposium of Nagano Society of Physical Education. While he promoted
sport activities for children and also adults, he noticed the physical problem
in farming villages that some older people became ill during agricultural offseason. Kitazawa developed few programs of physical exercise with short
melody, which incorporated elements of oriental medicine. He called these
programs as PPK undō, because he often heard older people’s voices as
following: “I wanna be pin pin, and suddenly will die like korori”. And, undō
in Japanese has two meanings: one is a physical exercise, and the other is a
social movement or a campaign. He thought that the phrase, PPK undō, had
two aspects: PPK undō (physical exercise) as a fitness training for
individuals, and PPK undō as social campaign for making group activity of
the exercise. Through a local radio broadcasting, PPK undō spread all over
Nagano in the 1970s and 1980s. However, after mid-1980s, almost all
municipalities stopped broadcasting PPK undō’s programs with the spread of
TV.
4
The Politics of Healthy Longevity and Good Death
______________________________________________________________
Kitazawa’s PPK undō is not only the exercise for prevention of
disease. The important point of the undō is that he tried to solve the problems
of everyday life in agricultural village, and did not emphasise on a particular
way of life and an ideal death.
3.
Connecting with medical expenditure reduction and PPK: since
mid- 1990s
In the mid-1990s, Nagano Prefecture came into the spotlight for one
report, the Report of Factors of Medical Expenditures between
Municipalities of the Central Committee of National Health Insurance
(CCNHI). For about one year from 1996, the research committee was
established in CCNHI. This report focused on Nagano Prefecture as an
achiever of low medical cost and healthy longevity. The average life
expectancy of the Nagano’s male, as of 1990, was 77.44 years (first place in
the country) and that of the female was 82.71 (fourth place in the country).
Furthermore, as of 1993, while the national average of medical cost for
person was 684,627 yen, the one in Nagano was the cheapest, 492,929 yen.
Nagano had ranked first in low medical cost among 47 municipalities for 19
years running from 1990.
At this time, Japan’s financial system was strongly impacted by the
collapse of the bubble economy in 1991. However, due to a rapid ageing, the
increase in social security expenses had far outstripped the rise in national
income.
Especially, the national health insurance system is operated by each
local government of municipality as insurers. And these local governments
had covered the deficits of the insurance from general account, and had faced
on an extremely tight fiscal situation. Because of the timing of the research,
the research group was targeted for Nagano Prefecture. The leader of the
research group of CCNHI Hajime Mizuno mentioned in the interview as
follows:
The medical cost for persons aged 70 or over of Nagano is
about half that of Hokkaido Prefecture, and is 200,000 yen
lower than the national average. If the national level of
medical cost for older people is suited to the Nagano’s
level, this will save 2 trillion yen per year. Through
analyzing the Nagano’s situation, we would address steps
to move forward on medical cost reduction.8
The report pointed out mainly three features of Nagano: (1) Nagano
was specially equipped to home medical care, and its average length of the
hospital stay was the shortest in Japan, (2) a larger proportion of people those
who die at home, (3) the existence of active health promoting volunteer
Daisuke Watanabe
5
______________________________________________________________
organizations and the high employment rate of older people. The report
concluded that “Nagano prefecture was evaluated not only for low medical
cost for older person but also for the longest life expectancy, and has realised
an ideal situation where older people keep their daily life healthy with low
medical expenditure.9
After the report, Nagano’s practice was focused as “Nagano model”
which was a solution for cost saving. Many researchers and policy makers
evaluated that Nagano had achieved PPK in some symposiums around the
country before and after 2000.
The important point is that the phrase PPK was not used in the
report. The only thing that report mentioned was Nagano’s and other
prefectures’ features. Researchers knew the existence of PPK undō which
had already faded away in almost all areas and which had continued only in
Takamori Town, but did not relate between Nagano's low medical
expenditure and Kitazawa’s PPK undō. Actually, regardless of Kitazawa's
activities, Nagano’s features the report explained were widely publicised that
Nagano embodied in PPK. For example, Mizuno advocated other
municipalities adopted Nagano model in order to improve healthcare and
achieve PPK in his book. 10 As such result, PPK had changed from a phrase of
exercise promotion to a slogan of healthy longevity and low medical
expenditure as a particular way of life.
On the basis of discussions among medical economics, the reasons
of Nagano’s low medical care cost are not clear. Low medical expenditure
does not directly mean good well-being conditions, because it remains
possible that the patients who should go to hospitals refuse to go, or are not
be able to go because of some economic or social barriers. Garber and others
argued that the most important reason of high medical cost for old age is an
acute medical cost among last two years. However, as they wrote, “it will be
difficult to formulate policies to limit expenditures for individuals in the last
year of life without simultaneously limiting health care delivered to sick
Medicare recipients who have the potential to survive”.11 Additionally, Lubitz
and others pointed out that health level of older people does not relate to total
lifelong medical cost.12
In other words, healthy longevity does not relate to low expenditure
but perhaps relate to high medical experience. Despite the existence of other
prefectures which have higher average life expectancy than Nagano,
Nagano’s experience was understood as the achievement of PPK and the goal
of medical and public health policies by scholars and public officers.
In next section, I argue about the understanding of PPK for
individuals, by focusing on Pin Koro Jizō.
4.
Expansion of PPK: from town development to promotion of
dying with dignity
6
The Politics of Healthy Longevity and Good Death
______________________________________________________________
On the second Saturday of every month, “Nozawa temple gate
festival (sanmon ichi)” is held in front of Yakushiji temple in Saku City,
eastern part of Nagano prefecture. This festival started in 1998. It became
famous in 2006, when Pin Koro Jizō was constructed. Pin koro is short for
pin pin korori. Jizō is one of the most popular Buddhism statues and mainly
exists in temples and at the roadsides. Pin koro jizō is a nickname and its
official name is Chōju Jizō Son (longevity bodhisattva). Mr. Ichikawa, who is
one of founders of the festival and pin koro jizō, explained about the jizō in
my interview. When he was the president of Nozawa shopping streets union
in 2006, his shopping streets suffered from ageing and depopulation.
Mr. Ichikawa: The festival continued for some years, and
we needed to conduct the festival in order to pull more
customers. I heard that the shopping streets in Sugamo
profit by famous Togenuki Jizō. As the result of our
meeting, we tried to construct jizō. Then, when we thought
the naming of new jizō, we noticed that mayor and local
hospital director emphasised on PPK life. [The mayor at
that time said that] “Let’s be active, and then die quickly
like korori at end of life.” ...... So, we named it “pin koro
jizō”.
...... The original aim was only a town development. The
basic purpose was to attract more customers and to make
our city to better. I was not interested in PPK.
He explained that he thought very little about a concept of PPK and
well-being of older people. He also expressed pin koro as “advertising copy”.
After the construction of pin koro jizō, Nozawa shopping streets union has
registered “pin koro jizō” as a trademark, and developed a lot of goods, such
as key holder, washcloth, alcohol, sweets, and clothes.
Recently, Saku city has implemented “pin koro station” which
officers put a brief health check into action in the festival and “pin koro
taisō” (pin koro physical exercise) is a brief physical excise program for older
people. Through using pin koro for names of these programs, the city
attempts to assemble a mass of staffs for wellness projects. The idea of Saku
city is similar to Nozawa shopping streets union. In other words, they
appropriate the phrase PPK or “pin koro” for their customer or user
marketing, because PPK was changed from Kitazawa’s phrase to the phrase
so that everybody could accept.
Then, why do people visit pin koro jizō and accept the phrase? A
physician Takuma Sato who promote PPK and pokkuri death, reported in his
book about their mentalities as follows:
Daisuke Watanabe
7
______________________________________________________________
When I talked with older patients, one of major points is
about pokkuri jizō visiting. ...... They said that the reason
why they visit pokkuri jizō is to pray for their sudden death
(pokkuri), because they did not want to become a burden to
their family when they would be bedridden.
......In contrast to these very popular pokkuri jizōs, there is
enmei jizō (life-prolonging jizō) too. Yet, curiously, enmei
jizō is not popular. ...... I think the reason is because the
image of the word enmei (life-prolonging) has gradually
been changing. When enmei jizō was erected in the past,
probably the word enmei was used in a sense of longevity.
However, nowadays, when older people mention enmei,
they would imagine the situation in which persons without
a chance for cure are kept alive by medical technology. 13
Through comparing differences between pin koro jizō and enmei
jizō, he explained people’s mentalities based on a critique of medicalised
society such as an unhumanistic characteristic of life prolonging technology.
And, this people’s mentalities consequently have sympathised with a
discussion of positive dying. A following statement which the president of
Japan society for dying with dignity mentioned by typical example of their
mentalities.
If health expectancy coincides with life expectancy, PPK is
accomplished. But it is still very rare. In a lot of cases,
people experience the gap of some years between health
expectancy and life expectancy. During the gap, people
become ill, suffer, despair, and finally die.14
Kaori Muto pointed out that the argument of PPK has an affinity for
dying with dignity.15 In other words, people want to ignore an effort with
illness and to abandon a way to live with illness in their old age. As Chizuko
Ueno wrote the thought of PPK is a quality control of human 16, it is possible
for person whose body are weakened to drop out his/her life and to die
quickly.
In this section, I wrote the process of PPK which widespread to
various areas. In the process, PPK was appropriated by officers, activists,
physicians, and people. And also, in the process, it became for us to deny the
concept of active life and good death.
5.
In lieu of conclusion: toward politics of good death
In this paper, I wrote a rough history of PPK in Japan. Through
analysing the history, I pointed out the process of shifting PPK
8
The Politics of Healthy Longevity and Good Death
______________________________________________________________
understanding. At first, when Kitazawa proposed the concept of PPK, he
focused on the people’s physical condition and their everyday lives. In mid1990s, the research group of CCNHI focused on “Nagano model”. Their
reports and books fulfilled the important role which they meant PPK as a
goal of healthcare policy, and put forward PPK all over the county. Then,
PPK was shifted to a useful phrase for marketing, healthcare promotion, and
promoting legislation of dying with dignity. People who use the phrase can
control an important point of the phrase for their own convenience, because
of the origin of the words. PPK consists of two heterogeneous words; pin pin
(how to live) and korori (how to die). And, the intricately link between the
two words has been naturalised. As such result, the penetration of PPK has
been concealing an inevitable life-time between active life and death, thereby
obscuring existential problems of the elderly living with illness. John Vincent
argued the problem of modern death as follows:
The nearest the cultural domination of medical science, ......
come to understanding a good death is a painless death.
The good death is thought of in bodily terms, not human
terms. It is constructed in the right dosage of medication; it
is not constructed out of human relationships and symbols
that transcend individuals and their bodies. 17
Under the late modern condition, people have already lost the
framework which could mean death with illness, and have to discover the
meaning by them. Regardless of their hopes, people will have to live with
pain. The politics of PPK provided us good death on the surface. Still, the
politics substantially enforce to abandon a way to live with illness in old age.
In other words, the politics of PPK obstructs to make new care relation with
ageing and illness. It is a conclusion of this thesis.
Notes
1
Refer to the following, NIPSSR (National Institute of Population and Social Security Research) ed., Population
Projections for Japan: 2001-2050. National Institute of Population and Social Security Research, Tokyo, 2002.
2
Wilkinson, R. G., The Impact of Inequality: How to Make Sick Societies Healthier. The New Press, New York, 2005, p10.
3
Berger, P., The Sacred Canopy: Elements of a Sociological Theory of Religion. Anchor Books, New York, 1967, p.23.
4
Giddens, A., The Consequence of Modernity. Polity Press, Cambridge, 1990.
5
Giddens, A., Modernity and Self-Identity: Self and Society in the Late Modern Age. Stanford University Press, California,
1991, pp.161-162, and pp.202-205.
6
Traphagan, J. W., Taming Oblivion: Aging Bodies and the Fear of Senility in Japan. Stage University of New York Press,
New York, 2000, p.213.
7
For example, Mizuno, H., and Aoyama, H., An Encouragement of PPK: Being Active, Dying without Decease, Kinokuniya
Shoten, Tokyo, 1998., Mizuno, H., Smart Ageing: Toward the Peaceful Death of PPK. Shufunotomosha, Tokyo, 2003., and
Sato, T., The Tips of How to Pokkuri Death. Aspect, Tokyo, 2009.
8
Shakai Hoken Junpo, No.2027, 1999 July 11th, p.6.
9
Central Committee of National Health Insurance ed., The Report of Factors of Medical Expenditures Between
Municipalities. Central Committee of National Health Insurance, Tokyo, 1997, p.13.
10
Mizuno, H., and Aoyama, H., An Encouragement of PPK: Being Active, Dying without Decease, Kinokuniya Shoten,
Tokyo, 1998.
11
Garber, A., MaCurdy, T., and McClellan, M., ‘Diagnosis and Medicare Spending at he End of Life’, Wise, D. A. ed.,
Frontiers in the Economics of Aging. University of Chicago Press, Chicago, 1998, p.272.
12
Lubitz, J., Cai, L., Kramarow, E., and Lentzner, H., ‘Health, Life Expectancy, and Health Care Spending among the
Elderly’. New England Journal of Medicine, vol. 349, 2003, pp.1048-1055.
13
Sato, T., The Tips of How to Pokkuri Die. Aspect, Tokyo, 2009, pp.36-38.
14
Japanese Association of Religious Organizations ed., The Report of Discussions about Legislation of Dying with Dignity.
Japanese Association of Religious Organizations, Tokyo, 2010.
15
Muto, K., ‘A Story of ‘Pin Pin Korori’: Is this what we want?’. Gendai Siso, Vol.36, No.3, p.124.
16
Ueno, C., Old Age for Single, Houken, Tokyo, 2007.
17
Vincent, J., Old Age. Routledge, New York, 2003, p.159.
Bibliography
Central Committee of National Health Insurance ed., The Report of Factors of Medical Expenditures Between
Municipalities. Central Committee of National Health Insurance, Tokyo, 1997.
Berger, P., The Sacred Canopy: Elements of a Sociological Theory of Religion. Anchor Books, New York, 1967.
Emi, A., Smile Rescues Japan: Active Ageing and PPK. Nihon Kyobunsha, Tokyo, 2006.
Garber, A., MaCurdy, T., and McClellan, M., ‘Diagnosis and Medicare Spending at he End of Life’, Wise, D. A. ed.,
Frontiers in the Economics of Aging. University of Chicago Press, Chicago, 1998, pp.247-273.
Giddens, A., The Consequence of Modernity, Polity Press, Cambridge, 1990.
–––, Modernity and Self-Identity: Self and Society in the Late Modern Age. Stanford University Press, California, 1991.
Japanese Association of Religious Organizations ed., The Report of Discussions about Legislation of Dying with Dignity.
Japanese Association of Religious Organizations, Tokyo, 2010.
Lubitz, J., Cai, L., Kramarow, E., and Lentzner, H., ‘Health, Life Expectancy, and Health Care Spending among the
Elderly’. New England Journal of Medicine, vol. 349, 2003, pp.1048-1055.
Mizuno, H., and Aoyama, H., An Encouragement of PPK: Being Active, Dying without Decease, Kinokuniya Shoten,
Tokyo, 1998.
Mizuno, H., Smart Ageing: Toward the Peaceful Death of PPK. Shufunotomosha, Tokyo, 2003.
Muto, K., ‘A Story of ‘Pin Pin Korori’: Is this what we want?’. Gendai Siso, Vol.36, No.3, pp.116-125.
NIPSSR (National Institute of Population and Social Security Research) ed., Population Projections for Japan: 2001-2050.
National Institute of Population and Social Security Research, Tokyo, 2002. [online; cited January 2002] available from
URL: http://www.ipss.go.jp/pp-newest/e/ppfj02/ppfj02.pdf
Sato, T., The Tips of How to Pokkuri Death. Aspect, Tokyo, 2009.
Traphagan, J. W., Taming Oblivion: Aging Bodies and the Fear of Senility in Japan. Stage University of New York Press,
New York, 2000.
Ueno, C., Old Age for Single, Houken, Tokyo, 2007.
Vincent, J., Old Age. Routledge, New York, 2003.
Wilkinson, R. G., The Impact of Inequality: How to Make Sick Societies Healthier. The New Press, New York, 2005.
Daisuke Watanabe is an Assistant Research Fellow, Centre for Asian and Pacific Studies at Seikei University, Tokyo,
Japan.
Email: watanabe.d@gmail.com