Published January 12, 2023
30 min read
On an overcast Saturday morning in Iwase, a sleepy port district on the lip of Toyama Bay on Japan’s largest island, the streets are deserted until the appointed hour approaches.
An elderly woman pokes her head out of her doorway and peers down the main thoroughfare lined with traditional low-slung wooden buildings. Another advances gingerly along a narrow side lane. A few minutes later, two tiny trucks trundle up and roll to a stop.
The area suddenly springs to life. Five orange-vested workers emerge and bustle about, setting up traffic cones, handing out shopping baskets, and apologizing profusely for shifting the Tokushimaru mobile grocery a few feet from its usual spot. They ferry groceries from the first truck to the second, which efficiently morphs into a miniaturized shop with fold-out shelves and red awnings. The left side is refrigerated and stocked with individual portions of fish and meat, yogurt, eggs, and other perishables. Produce is on the right; snacks and crackers, at the back. Half a dozen shoppers, all older women, move haltingly around the truck.
Miwako Kawakami, a stooped 87-year-old with bobbed hair, hands her cane to a worker and takes a small basket. She buys leeks, carrots, three onions, and a carton of milk. Kawakami lives alone behind a nearby temple. “There used to be a lot of stores here, but they’re all gone,” she says. “The vegetable stand, the fish stand—they all closed about five years ago.” She totters across the street to meet her 86-year-old neighbor, who has come to help carry her groceries.
Iwase has emptied out. Its young have left, and those still here grow older. This dynamic is happening all over Japan as the birth rate continues its decades-long decline. The country’s population peaked in 2010, at 128 million. Now it’s less than 125 million and projected to keep shrinking over the next four decades. At the same time, Japanese people are living longer—87.6 years for women and 81.5 years for men, on average. Except for the tiny principality of Monaco, Japan’s population is now the oldest in the world.
The numbers, though stark, don’t convey how profoundly this demographic shift is playing out day to day. The increasingly disproportionate mix of more and more seniors and fewer and fewer young people is already altering every aspect of life in Japan, from its physical appearance to its social policies, from business strategy to the labor market, from public spaces to private homes. Japan is becoming a country designed for and dominated by the old.
Watch the nightly news, and you’ll hear reports on Japan’s “aging society” as regularly as the weather. Young people caring for family members need greater support. 100-year-old driver steers car onto sidewalk, hits pedestrian. Majority of yakuza in Japan now over age 50. Aging is everywhere. On some train station platforms, there’s a notch in the base of each seat: It’s a place to park your cane. Abandoned “ghost houses” strangled in vines are a common sight in hollowed-out communities like Iwase but also in big-city neighborhoods.
Japan’s path foreshadows what’s coming in many areas of the world. China, South Korea, Italy, and Germany are on a similar trajectory; so too is the United States, although at a slower pace. Five years ago, the world reached an ominous milestone: For the first time in history, adults 65 and older outnumbered children under five years old.
If Japan is any guide, aging will change the fabric of society in ways both obvious and subtle. It will run up a huge tab that governments will struggle to pay. Meeting the challenge won’t be easy, but the future isn’t necessarily all downhill. Japan’s experience, with its characteristic attention to detail and design, suggests extreme aging—a world in which an increasing share of the population is old—may inspire an era of innovation.
(Can aging be cured? Scientists are giving it a try.)
In 2020, Japan’s health ministry launched eight “living labs” dedicated to developing nursing-care robots. Yet in a way, the entire country is one big living lab grappling with the repercussions of a rapidly aging society. In business, academia, and communities around Japan, countless experiments are under way, all aiming to keep the old healthy for as long as possible while easing the burden of caring for society’s frailest.
Osamu Yamanaka is on a mission to prevent lonely deaths. Several times a week, the 67-year-old doctor leaves his Yokohama clinic to make the rounds of pensioners who live alone in ramshackle single-room-occupancy units in Kotobukicho. The hardscrabble neighborhood sprang up during the postwar building boom to house day laborers and is now home to aging welfare recipients and “people fleeing social obligations for one reason or another,” Yamanaka says—alcoholics, the mentally ill, ex-convicts.
On one of Yamanaka’s stops, he visits Seiji Yamazaki, 83, a former construction worker. As is his habit, Yamanaka forgoes the elevator and walks determinedly up seven flights of stairs without stopping, carrying the scuffed black bag that belonged to his physician father. His patient lies on a hospital cot, one fist permanently clenched. Aside from the bed, the narrow room holds a mini-fridge, a microwave, a collection of stuffed Winnie the Poohs, and little else.
“I’m dizzy,” he tells the doctor. “How’s my blood pressure?” Yamanaka takes the bedridden man’s vitals, assures him he will check his medication, and reviews the visitors log; health aides also come by daily to bring food, administer medicine, and change diapers.
Japan’s long-term care insurance system is among the most generous in the world, and Yamazaki’s needs are well covered. Compared with people in other industrialized countries, the Japanese receive far more benefits than they pay for in taxes and premiums. The program subsidizes between 70 and 100 percent of elder care, depending on income. Before the system began in 2000, the ailing old would go to hospitals and stay until death. Now they tend to die at home. “In some ways,” Yamanaka says, “we’re the most advanced socialist country in terms of medical welfare.”
But the system is strained. There’s already a shortage of care workers; the government estimates the country will need 700,000 more by 2040. Proposed fixes include raising their pay, recruiting retirees and volunteers, promoting nursing as a career, relying on robotics, and—last and likely to stay last—allowing more foreign workers. Immigrants from countries such as Vietnam and the Philippines are working in nursing homes, but there’s a tight cap on the number of visas for skilled workers. Japanese insularity combined with the difficulty of learning the language makes it hard to fill the gap in care workers from abroad.
Meanwhile, the cost of benefits is escalating. Social security expenses, which include public health care, long-term care, and pensions, tripled between 1990 and 2022, financed by government debt. “The universal system we introduced has lots of advantages, and people are used to it,” says Hirotaka Unami, a senior aide to Prime Minister Fumio Kishida. “To maintain that, we have to restore the balance between benefits and burdens. Otherwise it’s not sustainable.”
The solution, he says, is fourfold: accelerate economic growth, incentivize more women and older adults to work, raise the consumption tax, and curb social security expenditures. “The goal is to have more elderly people be contributors to society rather than receivers,” Unami says.
It’s a daunting list. Economic growth can’t be engineered at will. Tax increases are unpopular: It took Japan five years to raise the consumption tax from 8 percent to 10 percent. More than 70 percent of Japanese women 64 and younger already work, but mostly part-time because of poor childcare options and financial disincentives, including being paid less than men.
The government is trying to raise the retirement age from 65, and people are working longer. In 2021, more than a third of Japanese companies let people work past 70; in 2016, only 21 percent did. Demographics leave no other option: By 2050, almost 38 percent of Japan’s population is projected to be 65 and over, putting enormous pressure on the labor force to support them.
“I don’t think we’ve got good answers,” says Sagiri Kitao, an economist at the University of Tokyo. “To be honest, it’s too late. Politicians don’t want to talk about reducing benefits.”
More than half of all municipalities in Japan are now designated as depopulated areas, where the population has dropped by 30 percent or more since 1980. In many, older residents are organizing to adapt their communities to this new reality. A housing development in Yokohama, on the other side of Honshu Island from Iwase, is emblematic of how aging is reshaping Japan from the ground up.
At Kamigo Neopolis, 868 detached homes perch atop a steep hill. Daiwa House, one of Japan’s largest homebuilders, opened it in 1974 to house the explosion of young families that followed the postwar baby boom. Designed as a bedroom community for salarymen making the hour-and-a-half train commute to Tokyo, it’s one of 61 “neopolises.” In Kamigo, residents could walk to shops and an elementary school.
(A detailed look at how we age—at the cellular level)
These days, more than half of Kamigo’s 2,000 residents are 65 and older. The school closed years ago. The shops are gone. Weeds have taken over the four parks. Residents joke that “Neopolis,” which means “New Town,” is now “Old Town.”
The Aeon shopping center at Kamigo’s train station, an 18-minute bus ride down the hill, has a whole aisle of nursing-care products, such as aprons for use while bathing an elderly parent, disposal bags for adult diapers, odor-absorbing cloths to hang on a bed rail, and bags of thickening powder, called toromi, that’s used in drinks and soups to help prevent choking.
As Kamigo’s population shrank and its inhabitants aged, residents felt physically and socially isolated. A loose network evolved to check up on one another, and that became a committee called Kamigo Machizukuri, a term for a distinctly Japanese form of bottom-up, collaborative community engagement. In 2016 the group started lobbying Daiwa House to create a central area for shopping and socializing. The result was a single-story building with a mini-mart, a produce stand, five tables with chairs, and a video screen. There’s an outdoor terrace with benches. The center’s restroom includes a deep sink reserved for the disposal of ostomy-bag waste, a now ubiquitous fixture in Japan marked by a distinctive icon outside bathroom doors.
“We’re thinking about setting up a transportation system to the hospital for people who can’t get around,” says Nobuyuki Yoshii, a 74-year-old retiree and father of three. He moved to Kamigo more than 40 years ago for its easy access to surfing and the then thriving jazz scene in downtown Yokohama, a quick car ride to the north. For decades, Yoshii got up at 5 a.m. to commute to his architectural planning job in Tokyo, often returning at midnight. These days, he heads the machizukuri committee. An on-site nursing-care clinic is also high on the wish list.
Kamigo is one small example of how Japanese communities are working to enable aging in place. Toyama, a city of more than 410,000 that includes Iwase, is a more ambitious case study in reimagining a city space, one now widely praised as a model. The catalyst was Masashi Mori, who until 2021 was Toyama’s charismatic mayor for nearly 20 years.
He traveled the world looking for ideas to accommodate the old. Inspired by light-rail systems in Portland, Oregon, and Strasbourg, France, Toyama installed trams that the elderly ride at a discount and can board without climbing any steps. They get into local attractions for free with grandchildren. The city turned a shuttered school into a preventive-care center that functions as a health club for older adults, with gym equipment, classes, and waist-deep pools, one with a built-in walking path and handrails.
“The more people walk, the less they spend on health,” says Mori, 69, now a pear farmer with a thick shock of dyed black hair and “Mr. Mori” embroidered on his shirt cuffs. “You’ve got to get them active and interacting with other people.” Mori is proud of Toyama’s work to create a more compact, navigable city. “We took the initiative early,” he notes.
In Toyama’s rural areas, close to 40 percent of the population is over 65. They’re served by a gleaming care center that delivers home nursing. “We’re seeing an increase in single sons living with their aging mothers, as well as lots of couples where both have dementia,” says Naoko Kobayashi, one of the center’s three doctors who work to ease the suffering of aging patients and also their exhausted families. “Dying is not an easy thing.”
The city has had less success dealing with the empty ghost houses that no one wants, especially those in which someone died alone. There are more than eight million of them around Japan. Laws are slowly changing to enable local governments to fine and publicly report delinquent property owners to shame them. It took Toyama five years in a drawn-out process to raze just three houses, barely making a dent in the more than 7,000 that are abandoned in the city.
At Yume Paratiis, a pristine nursing home in Amagasaki, near Osaka, a robot called the Hug carefully transfers 98-year-old Kotoyo Shiraishi from her wheelchair to her bed. Padded armrests gently squeeze and support the tiny woman, who wears fleece pants and cushioned slippers. Staff at the 116-resident home say the Hug enables aides to do lifting and lowering tasks solo instead of in pairs.
The nursing home industry, naturally, is ground zero of the living lab that is Japan. The Hug is one of 20 technologies that Yume Paratiis is testing, from room monitors to communication robots. The latter include Telenoid, which has nubs for limbs and a realistic but expressionless face. It talks via a care worker who operates it from a distance. Telenoid wears an orange-and-white onesie and matching hat. “This is a boy, right?” asks 89-year-old Kazuko Kori, who tells it to sing her a song. Some residents open up to it, staff members say; others are turned off. Hidenobu Sumioka of Kyoto-based ATR, who helped create Telenoid, concedes that it’s not for everyone, but he envisions a future where robots play a social role for people in nursing homes: “I’d like to use them to form more of a community, the way people used to live.”
Among the most prominent companies focused on aging is Sompo Holdings, one of Japan’s top insurance companies, which started acquiring nursing homes in 2015. Sompo now owns around 400, making it one of the largest operators. The company is also the only business running one of the eight living labs; the others are overseen by research centers.
Sompo’s Future Care Lab, in Tokyo, houses two spotless testing rooms tricked out like nursing homes on steroids. Motion sensors on the floors and walls detect falls and send alerts to caregivers’ phones. A high-tech bed made by Panasonic has a mattress that splits down the middle so a patient can be rolled onto the outer half, which can fold into a wheelchair. At more than $10,000, though, it isn’t cheap.
Other devices include a lavender-and-white bathtub that looks like a cross between a giant Easter egg and an isolation tank. A person in a wheelchair gets steered into the tub and sprayed with soapy foam from all sides at the push of a button, followed by warm water. But a full-body soak is a cherished Japanese ritual that nursing homes try to provide. Yume Paratiis prefers a rotating chair lift that gently lowers residents into a tub. When Takeo Okuzono, 85, is immersed, he reclines into the bath and closes his eyes. “I’m sleepy,” he mumbles.
Sompo is working to make nursing care more efficient. In one ongoing study, workers in 10 Sompo homes collect data from “smart bed” sensors that detect whether residents are asleep, in bed but awake, or out of bed. The technology enables 150 workers to check on 500 residents remotely instead of visiting every room at two-hour intervals, according to Albert Chu, Sompo’s chief digital officer. Sompo now uses the wired pads in nearly all its homes. “There are empty wings in care homes because they can’t hire enough people,” Chu says.
Robotics can help—and the Japanese government subsidizes their use—but they’re not a panacea. Only a fifth of the nursing homes in Japan use any type of robotics, according to a 2020 survey, and primarily for monitoring and communication rather than helping lift, bathe, and interact with residents.
Even industries not explicitly focused on nursing care are tackling “aging society” problems. In stark contrast to the incremental pace of national fiscal reform, companies throughout Japan, from conglomerates to start-ups, are experimenting with gusto.
Some big companies are devising incentives to keep seniors active in ways that are equal parts marketing and corporate social responsibility. Rakuten, Japan’s e-commerce giant, launched the app Rakuten Senior in 2019. It rewards steps walked with points that can be used toward purchases, such as trial music lessons. Hitachi partnered with the nationally funded Japan Gerontological Evaluation Study (JAGES) to create a “social participation encouragement” app that aims to lower the cost of nursing care by keeping people active. The app measures outdoor activity and ranks it in four categories, from beginner to expert. It also recommends events to attend and pushes evidence of the benefits of social participation to users.
Hitachi says it’s in discussions with 70 businesses and municipalities about partnerships that would link the app to elder-focused services. Yuji Kamata, who leads the Hitachi team that developed the app, notes that the data will also benefit JAGES, which does national surveys every three years; now the information will be digitized at a lower cost and provide real-time results. The app is free. Hitachi hopes one day to sell the anonymized data.
Even Daiwa House, spurred by Kamigo’s residents, formed a new division, called Livness Town Project, to adapt 10 more of its planned communities for aging. “We’re not doing this to make money. It could be unprofitable,” says Koji Harano, who runs Livness. “But it has social value. It helps our brand.” He hopes the company will market its aging-related housing expertise overseas.
Other services have emerged to address the ripple effect of solitary deaths. In 2020 more than 4,200 people over 65 in Tokyo died alone. Many companies now insure owners of rental units against the risk of someone dying and going undiscovered on their properties, addressing the growing reluctance of landlords to rent to older tenants. Such policies cover the loss of rent as well as the cost of cleaning. Thousands of companies now specialize in residential deep cleaning after a solitary death, a fate likely to become more common in Japan given that more than one in four adults 65 and older lives alone.
Japan’s economic prowess and industrial innovation were envied around the world until the Lost Decade, a long stretch of stagnation that began in the 1990s. Although the country remains a digital laggard, Japan’s creative responses to its aging citizens may become a source of inspiration as the world grows older.
“You see next-generation talent thinking about aging as a big opportunity,” says Jin Montesano, a senior executive at Lixil, which sells bathroom and other housing products. One of Lixil’s newer items is a shower that dispenses cleansing foam from two adjustable bars that lower to wheelchair height. Increasingly focused on aging in the home, the company is encouraging employees to come up with more ideas.
“Age tech” is also beginning to be seen as an opportunity for Japanese start-ups. The amount of venture capital in Japan is comparatively low but growing. One VC funding recipient is Tokyo-based LifeHub, which is developing a wheelchair that can raise its user to a standing position and can ascend stairs and escalators. “Wheelchair users want legs—healthy legs,” says Hiroshi Nakano, LifeHub’s co-founder and CEO.
Start-ups are also taking on the most intimate nursing tasks. Yoshimi Ui, an outgoing 33-year-old engineer, invented the Helppad, a mattress-odor sensor that detects and tracks excretions to make toileting care more efficient. She runs her company, called Aba, out of a small two-story house near Tokyo. Ui grew up with an ailing, severely depressed grandmother at home and was troubled by her suffering. That motivated her to marry engineering know-how with social impact. Ui says that her Helppad, which is being tested in Sompo’s Future Care Lab, is used at about a hundred Japanese nursing homes.
Both LifeHub and Aba envision international sales. Aba, whose website proclaims, “Live well, die well, build the future,” is getting inquiries from South Korea, Taiwan, and Singapore.
Japan’s present challenges are our collective future. Just as no one wants to dwell on getting old, Ui says, most people don’t give nursing care a second thought until a parent becomes ill and the burden suddenly falls on them. She wants to change that mindset. Her vision, she says passionately, is to “make the world a place where there’s nursing-care support everywhere.”
Sarah Lubman studied Japanese literature, lived in Japan, and has traveled there regularly over the past 15 years. Noriko Hayashi focuses on documenting social issues. She is based in Tokyo.
This story appears in the February 2023 issue of National Geographic magazine.