Reduced Medical Expenditures with Social Participation of Elders:
The Case of Kamikatsu, Tokushima Prefecture
Outline of Kamikatsu
The town of Kamikatsu is located somewhat to the southwest in central Tokushima
Prefecture, about 40 km south of Tokushima City (Figure 1). The distance is justunder one hour by car from Tokushima City, but when driving along the Katsuura
River from the town of Awa Katsuura the mountains rapidly become steep. Further on
the scenery is breathtaking, with small villages dotted along both sides of the
Katsuura River. Within the town of Kamikatsu itself the elevation differs by more than
700 m. Kamikatsu was formed in 1955 with the merger of the villages of Takahoko
and Fukuhara. These two villages were located on the upper Katsuura River (referred
to as “Kamikatsu” in Japanese), and the town was given the new name Kamikatsufrom the fact that lumber from the area was stamped “Kamikatsu” to be transported
and sold on the market.
In the past many people in this area earned their livelihoods from forestry andgrowing tangerines. However, the town suffered devastating blows in both forestry,
with low lumber prices, and tangerine farming with the death of about 80% of thetown’s 120 ha of orchards in an unusual cold spell in 1981. The town is formed along
the Katsuura River in an areathat records the greatest amountof rainfall in the prefecture, andalso struggles every year with

Figure 1. Location of the town of Kamikatsu
Kagawa Prefecture
Tokushima City

disasters including heavy
flooding and landslides from

Kamikatsu Town

concentrated downpours. At thetime of the merger in 1955 theTokushima Prefecture

population was more than 6,000,
but by the 1980s it had

Kochi Prefecture

decreased by half.
Leaf business changed the town
In 1986 Tomoji Yokoishi was an agricultural consultant in Kamikatsu during thisdecline. In those difficult circumstances, and with the cooperation of four farming
households, he started the “Irodori” project to ship leaves and sprigs as tsumamono
1

for Japanese food in restaurants. Tsumamono are the leaves and other natural things
used as adornment in Japanese dishes. To an outsider it may seem that all one would
have to do for this business is to pick up fallen leaves and ship them, but it is not that
simple.
In this undeveloped tsumamono market, it required great effort to gather more than
100 varieties of leaves and flowers in the different seasons—at their most beautiful
and of consistent quality—and ship them quickly to meet demand. With thecooperation of farming families, Yokoishi fought an uphill struggle for 10 years to get
the Irodori project on track. The business developed to sales of more than 200 million
yen per year after 2003. The Irodori Association membership, which started with four
people, also grew to reach 195 people in 2009.
Kamikatsu is also famous for town development by the third sector enterprises
utilizing town-financed corporations. The Irodori Corporation was established as athird sector enterprise in 1999 for Irodori project planning and sales, with the mayor
as president and Yokoishi serving as vice-president. Yokoishi has received a numberof awards, including the Special Prize at the Entrepreneur of the Year Japan
Competition in 2002 and the Japan Soft Award in 2003, and has attracted attention forsuccess in regional vitalization. A movie about the Irodori project was also made in2012 under the title It’s a Beautiful Life—Irodori, starring Kazuko Yoshiyuki, Sumiko
Fuji, and Mie Nakao. These successes, however, have not been able to hold back thewaves of a shrinking and aging population; according to the Kamikatsu town website
the population was 1,869 as of March 1, 2013, while people aged 65 years or older
accounted for 49.7% of the population as of March 1, 2011.
Medical expenses below the prefectural average even with such an aging
population
Despite the very aged population of Kamikatsu, it is also known for its low per
capita medical care expenditures for the elderly in Tokushima Prefecture. As shown in
Figure 2, despite the aging of its population, from 1992 to 2007 the per capita level of
medical care expenditures for the elderly in Kamikatsu was below the prefectural
average in all years except 2002.
Yokoishi, who launched the Irodori project, offers the explanation that the people
are healthy because they are employed. He stresses that the low level of per capital
medical care expenditures for the elderly in Kamikatsu is because of the high rate of
employment in the town’s elderly, centered on the Irodori project. This is illustrated in2the following with quotations from Yokoishi’s books. 1)2)
Among Irodori farm households, continuing the leaf work is a form of mental andphysical rehabilitation even among individuals suffering a major disease or facing a greatsadness, and it has helped more than a few people regain their vitality.
For one person with a progressive spinal disease, Irodori was a reason to live. Saying “Itis good exercise and I want to keep at it as long as I am able,” this person continued to ship
dozens of types of tsumamono.
Another person, who had collapsed with a stroke and still had slight paralysis in one leg,
still made the effort to plant new seedlings as she did every year. “I’m so glad that theleaves are light. I like this work of making beautiful things. It makes me feel good,” shesaid.
A person with a bad pelvis, who could no longer lift heavy things, concentrated herefforts on pulling weeds and caring for the leaves, saying “This feels better than going to
the hospital for rehabilitation.”(Omission)
Another person had lost a child to sudden illness, and spent her days closed in the house,crying. Her neighbors worried about her and encouraged her to participate in the Irodori

Figure 2. Trends in per capita medical care expenses for people aged
65 years and older (Tokushiima Prefecture average and Kamikatsu)

Thousand yen

Tokushima Prefecture average

Kamikatsu Town

Fiscal year
Prepared based on Tokushima Prefectural data3

project even if it was only a little, thinking it would take her mind off her loss. They said
she was gradually able to recover her spirits while doing the leaf work (That’s It! We’ll Sell
Leaves, 2) p. 204).

Giving an older people an opportunity and keeping them mentally energetic is not the
only good thing about “work wellbeing.”
In “Irodori” work, for example, older women carefully separate the leaves gathered fromthe mountains by quality and size, counting them during packing. This work using thefingers activates the brain and helps to prevent dementia.
Going to the fields and walking up and down mountain slopes strengthens the lower
body, helping to maintain health and prevent individuals from becoming bedridden.
(Omission)
This means that these elder women do not use much money for medical care, since they
are healthy from working, earning money, and staying busy (How to Build a Society ofLifelong Gainful Activity, 2) p. 32-33).

Having a job and working gives elderly people a reason for living, and actively using the
body contributes to disease prevention. One could say that the result is manifested in
reduced medical care expenditures (ibid., p. 44).

Survey on social capital and life satisfaction
Interested in the claims of Yokoishi, the author gained the approval of the
Kamikatsu town office in 2009 and conducted a questionnaire survey in collaboration
with the town’s medical clinic. Figure 3 shows a comparison with the results of anational survey conducted by the author in 2010. As seen in the figure, “Trust inneighbors” is much higher in Kamikatsu than in the nation as a whole. Trust in
relatives and trust in workplace colleagues is also higher in Kamikatsu than in thenational survey. Frequency of socializing with neighbors, and the number of people
who do so, is again much higher in Kamikatsu than in the nation as a whole. These
trends are similar to what is seen with participation in community-based activities andparticipation in volunteer work, NPOs, and civic activities.
Aggregate values for the participants in the Irodori project are shown in Figure 3.
For the Irodori project participants, the trends are more pronounced than theabovementioned figures for Kamikatsu as a whole in comparison with national
averages.
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Looking at these aggregate figures only, relationships with neighbors, relatives, andworkplace colleagues seem to be much stronger in Kamikatsu than in the nation as awhole. Socializing with neighbors, friends and acquaintances, and workplacecolleagues also far exceeds that in the entire nation. The group participation rate,
excluding sports, hobbies, and leisure activities, is higher than the national averagefor community-based activities, volunteer activities, and NPO activities, respectively.
The town is somewhat closed to the outside, as one may expect from a community offewer than 2,000 people, but residents have a high level of trust in each other and atight network.
Although not shown here, individual data also indicate higher levels of life
satisfaction and subjective health, and lower levels of depression, plus higher levels of
the general trust and networking known as social capital. Although a causal

Figure 3. Comparison of social capital• Level, participation, and frequency have high rates• Sample number: National 1599, Kamikatsu 632 (including 51 Irodori members)%

All Japan in 2010
Kamikatsu Town in 2009
Irodori member
Volunteer or NPO activity

Sports, hobby, or recreation

Neighborhood activity

Private contacts with colleagues in workplace

Contacts with relatives

Contacts with friends

Number of acquaintances in neighborhood

Contacts in neighborhood

Trust for colleagues in workplace

Trust for friends

Trust for relatives

Trust for family

Trust for neighborhood

5

Various indices aboutsocial capitalassociation is not clear, these findings suggest some kind of relationship betweensocial capital and the levels of life satisfaction, subjective health, and depression inresidents of Kamikatsu.
Does social participation improve health?
If we had annual data on social participation we could examine how they relate tohealth-related data, such as medical care expenditures. Unfortunately, the only data on
trends in the elderly employment rate in Kamikatsu available are the data from thenational census every five years. According to the Kamikatsu town office, noyear-by-year data exist. Moreover, just under 200 town residents, or about 10% of thetown’s population, participate in the Irodori project, so not all elderly people in the
town are involved in the project.
However, looking at the sales from the Irodori project and the data for per capita
medical expenditures forpeople aged 65 years andolder for the past 23 years,
provided by the town
government, we find thatan inverse U-shaped curve

Figure 4. Irodori project sales and per capita medicalcare expenditure for the elderly in Kamikatsu
Per capita elderly medical care expenditure decreased
when Irodori project sales exceeded 150 million yen

fits the scatter diagrams
Figure 4. In other words,
per capita medical careexpenditures for theelderly rose until the sales
from the Irodori project
reach 150 million yen.
Then, after sales went
beyond 150 million yen,

Per capita elderly medical carefor both, as shown in

Observed
Quadratic
equationthese per capita medicalcare expenditures
declined.

Irodori project sales (thousand yen)

Although this does notdemonstrate a causal

Adjusted coefficient of determination = 0.732

association, more thanPrepared based on Tokushima Prefectural data6

70% of the per capita medical care expenditures for the elderly in Kamikatsu can be
explained by the changes in Irodori sales. However, both Irodori sales and medicalcare expenditures are nominal rather than real values, and as a result we are limited toan approximation. Moreover, this could also be seen as a result of pure economic
factors rather than the social factor of social participation. However, interpretation ofthese results as consistent with Yokoishi’s hypothesis that social participation makes
elderly people healthier is certainly plausible.
In the above we looked at the data for Kamikatsu, but, as seen in Figure 5, therelationship between employment rates for the elderly and per capita medical careexpenses for the elderly in other cities, towns, and villages also show a clear decreasein elderly medical care expenses in cities, towns, and villages with high elderly
employment rates. Of course, this could also be understood as showing that the people
in those places work because they are healthy. However, a visit to Kamikatsu in
Tokushima Prefecture holds much persuasive power for the opposite way of thinking:that people become energized by social participation (employment). Of course,
readers will view this in the light of their own experiences.
Figure 5. Per capita medical care expenditure for the elderly and elderly
employment rate: Scatter diagrams for individual municipalities
The dots indicate municipalities. Per capita medical care expenditures forthe elderly are lower in municipalities with higher elderly employment rates
Per capita medical care expenditures for the elderly%
Elderly employment rate
7

Source: Reference 3

● References
1) Tomoji Yokoishi. That’s It! We’ll Sell Leaves—Revitalization of a Shrinking Town
that Had Hit Bottom. SoftBank Creative, 2007 (in Japanese).
2) Tomoji Yokoishi. How to Build a Society of Lifelong Gainful Activity. SoftBank
Creative, 2009 (in Japanese).
3) Yoji Inaba, Yoshinori Fujiwara. Policy Implications of Social Capital in the Era of
the Aging Population: An Analysis on the Medical Expenditures for the Elderly.
Japanese Journal of Behaviormetrics, 37(1), 39-52, 2010 (in Japanese).
4) Kazuichi Kasamatsu, Yumi Sato. Sustainable Towns—Small and Beautiful. The
Great Undertaking of Kamikatsu. Gakugei Shuppansha, 2008 (in Japanese).
5) Kamikatsu Town. History of Kamikatsu Town (the sequel). Kamikatsu Town, 2008
(in Japanese).
6) Tamami Kobayashi, Hisae Tanaka, Toshiko Tada. Employment of Elderly People inMountainous Regions Is a Factor Affecting QOL. Quality of Life Journal, 9(1),109-121, 2008 (in Japanese).
7) Kamikatsu Town Histrory Editorial Committee. History of Kamikatsu Town.
Kamikatsu Town, 1979 (in Japanese).
Translated from the Japanese manuscript written by
Yoji Inaba (Collage of Law, Nihon University)8