Why a doctor created a small library in a vacant shop in a shopping district. What is "Daikai Bunko," an ecosystem that circulates care?

In December 2020, as a family medicine resident, I created a small library in a vacant shop in Toyooka City. Thanks to everyone's support, the library, which I named Daikai Bunko, has become a bustling place where about 400 books have been borrowed in the four months since it opened.

This library is a "shared-type library." It is not a public institution like a municipal or university library, but a private shared-type library. It is a system where people living in the town contribute from 2,400 yen per month to become owners of a single-box bookshelf, place books they recommend in the library, and take turns managing the shop. Currently, there are over 50 single-box bookshelf owners. We have a diverse range of borrowers, including individuals and companies. About 15 of these single-box bookshelf owners take turns managing the shop.

I also manage the shop once a week. Meanwhile, I work full-time as a doctor in the general medicine department of a hospital. (Though I am still very much in the apprentice stage...)

How did a doctor come to create a shared-type library? How is the library being utilized? Why does the library continue in a sustainable way? I would like to write about the current situation in its fifth month of operation from a realistic perspective.

● In the era of care and community development

I would like to look back starting from the current state of care. Japanese society has long been described as having a declining birthrate and an aging population. Due to aging and advances in medical technology, diseases that used to be fully cured by surgery or hospitalization have become incurable. Heart failure, dysphagia, and lifestyle-related diseases have shifted from things to be cured to things to be lived with. From cure to care. From curing to supporting, the role of medicine is also changing. In such an era, how can we support people living in the community while dealing with illnesses?

The Ministry of Health, Labour and Welfare has presented a path forward. One is the Community-based Integrated Care System. This is to ensure that people who leave the hospital and live in the community can receive services from the perspectives of medical care, nursing care, and daily life support so that they can live in their familiar communities until the very end.

And, as a higher-level positioning for that, it indicates a "Community-based Inclusive Society." The Ministry of Health, Labour and Welfare's page contains the following description.

A community-based inclusive society refers to a society where local residents and diverse entities in the region participate, transcending the "silos" of systems and fields and the relationships of "supporters" and "receivers," and where people and people, and people and resources, connect across generations and fields to create the lives, sense of purpose, and the community for each resident together 1).

In other words, it is a society where anyone, even if they have a disability or illness, can live with a sense of purpose in the local community while supporting and being supported by others. To realize a community-based inclusive society, it is necessary for everyone to have a "place" that suits them, where they can have a "role" and feel a "sense of purpose." For example, research results have shown that loneliness carries a mortality risk equivalent to smoking 15 cigarettes a day 2). Creating places where people can have a sense of belonging, a role, and a sense of purpose is also becoming a role of care.

On the other hand, in rural areas where depopulation is progressing, the number of vacant houses is increasing, and the "spongification" of cities is advancing 3). Specific examples include town centers in front of stations filled with vacant shops, and mountain villages where the number of residents is decreasing, leading to "marginal villages." Like a sponge, administrative services and relationships between people are becoming hollowed out. In spongifying regions, there may be situations where public assistance from medical and administrative services, and mutual aid from local residents, do not reach those in need. Also, there is a risk that relationships between people will become sparse, and isolation may progress further. In such spongifying regions, efforts to create small-scale, multi-functional spaces are spreading. These include initiatives such as turning vacant rooms in housing complexes into libraries where residents can gather. By making medical and welfare the core of such initiatives and combining them with design and art to create small-scale, multi-functional public spaces, it should be possible to reweave a life that is true to the individual, including not only medical and welfare aspects but also the creation of places to belong and roles to play. By medical professionals going out into the town and collaborating with people engaged in community development, it becomes possible to create community-based inclusive places to belong.

This is the significance of medical professionals going out into the town, and the significance of continuously carrying out "care and community development" activities 4).

● Our first step that started from a health class that only one person attended

Toyooka City, which is the town next to my hometown and is still the base for my care and community development activities. It was in 2015 that I started getting involved with Toyooka City. First, to find local issues and resources, I started a community diagnosis with about 10 medical students. This is a method used by public health nurses to identify local health issues through fieldwork, interviews, and statistical data. One of the issues discovered was that some residents tended to endure their symptoms, leading to delays in calling an ambulance. So, we medical students decided to hold a medical class. We had the local newspaper write a promotional article, and I was sure that many people would come, but there was only one participant. Even if we wanted to convey correct medical information on a Sunday afternoon, the people who came were limited. We were doing something like forcing health on others.

With that experience of frustration, we decided to go out into the town. To reach the indifferent, we jumped out of medical institutions. We started the Mobile Yatai de Health Cafe activities, conducted by family physician Dr. Daisuke Mago and Dr. Yoyo Mitsuyama (then at the University of Tokyo), in Toyooka City as well. It is an activity where doctors pull a mobile stall out into the town and have casual, healthy conversations over a cup of coffee. While the original version participated in an annual festival for research purposes, in Toyooka, we have been doing it continuously at least once a month. Also, based on nudge theory (an approach that encourages people to take desirable actions based on insights from behavioral science), we changed the name to the more casual "YATAI CAFE", which sounded more interesting, fun, and delicious, leading to attracting many people. Even though there were interruptions due to the COVID-19 pandemic, there were many roles that became visible by pulling the stall in the same area for over four years.

It had become a small-scale, multi-functional public space with diverse roles: being able to casually consult on health, becoming a place for local residents to chat, serving as a hub to connect people, acting as a learning space for medical professionals to engage with the community, and creating a role for brewing coffee. Sometimes we recommend a medical examination, introduce someone, or prescribe a community. Through four years of activities, YATAI CAFE has become a place that connects with various local people and places, provides consultation support, supports social participation, and builds the community. Such efforts have been recognized, and medical and welfare researchers as well as officials from the Ministry of Health, Labour and Welfare have come to visit. (Details are described in the note below)

Also, in collaboration with the local movie theater "Toyooka Theater", we held an event to think about Advanced Care Planning when screening a documentary film about home medical care. It is a meeting where everyone thinks together about where they want to spend their final moments and what kind of medical care they want to receive in preparation for an emergency. By planning and operating it together with a local hub, unlike medical classes, it became an event with over 40 participants.

● How to permeate care into the region

The YATAI CAFE initiative we had been conducting also reached its limits. I thought that because we were only doing it once a month, there might be people we were missing. Although we had built a multi-layered network with diverse local communities, there was the constraint of opening hours. Because YATAI CAFE is a loose activity that does not involve money, we cannot open it many times a week.

In "Care and Town Development, Sometimes Art4)", which I wrote as a co-author, Dr. Tomohiro Nishi, a palliative care physician who runs a "Living Health Room" in Kawasaki City, Kanagawa Prefecture, says that there are three plans to comprehensively cover local residents: "Go, Call, Exist." With YATAI CAFE, we "went" out into the town, and by holding events with the local movie theater, we "called" people in. Next, I thought about creating a point of contact with care that continues to exist in the town.

We looked for a vacant shop in the town's shopping district and thought about creating a place that would continue to "exist" there. This was the beginning of the shared library, "Daikai Bunko: A Place with Books and Living."

● Why books this time?

"I believe that a place where everyone can gather does not exist." Even places that claim to be "places where everyone gathers" are cut off by some axis. Medical classes are for people who come with the axis of "people interested in medical care," and local community cafes are for people who come with the axis of "people who want to have fun in the community" or "people who like the person at the center of the community." What about our activities? YATAI CAFE had the axis of coffee and a mobile stall. People were gathering with the novelty of a mobile stall and the casual approach of coffee. We would have salutogenic conversations with those who came, introduce someone if necessary, connect them to services, or prescribe a community.

This time, Daikai Bunko has "books" as its approach. Why did I choose books? Mr. Hiramatsu of Kosugiyu in Koenji, Tokyo, said, "Public baths are places for medium-distance communication." Public baths are not places for intense conversation. On the other hand, public baths are points of contact with people on daily routes, such as meeting regular customer so-and-so if you come at this time and exchanging greetings, or having a little conversation with the person at the front desk when paying. He used the term medium-distance communication as a place where you can feel a connection with someone, even if it is not a close distance 5). I thought this might also be common to places with books, such as bookstores and libraries. I thought that casual conversations with librarians and the presence of people reading books at the same time every day are exactly medium-distance communication. I thought that if it were medium-distance communication, even people who are not good at talking to others or who are not good at events could come. What if that librarian was a medical professional and you could consult about your troubles? What if you could find your own community from the relationships of people who happened to be there? With that thought in mind, I decided to create a place with books. I thought that between the culture of books and the culture of care, there might be care and town development activities as a local symbiotic society, such as roles and places to belong.

For those who came, we created a consultation place for finding a place to belong several times a month. It is a place where medical and welfare professionals provide health consultations and consultations on finding a place to belong. While utilizing the connections with the region cultivated at YATAI CAFE, we connect people to people and people to places.

While living in the town, I think there are times when you feel lonely after losing a family member, feel lonely because you don't have acquaintances with the same hobbies, or think you want this kind of support. At the consultation place for finding a place to belong, medical and welfare experts involved in Daikai Bunko provide health consultations and consultations regarding places to belong. (From the Daikai Bunko website)

● About the mechanism of Daikai Bunko

Daikai Bunko, a place with books and daily life, is a shared library. This initiative is an adaptation of shared bookstore projects like Mitsubachi Kosho-bu in Osaka City and Book Mansion in Musashino City, and is similar to initiatives like Minna no Toshokan Sankaku in Numazu City, Shizuoka Prefecture.

It is a shared library system where residents become "one-box bookshelf owners," renting a shelf for a fixed monthly fee to display books, while users can borrow those books for free. Shop-sitting duties are shared among them. In the case of Daikai Bunko, we also sell new books because there were no bookstores in the area dealing with humanities or welfare-related books. Additionally, since there were no cafes open late at night, we also operate a cafe using YATAI CAFE, for which we have obtained a business license. Details about one-box bookshelf owners are described in detail on the note page of Minna no Toshokan Sankaku. We also received advice from Junya Doi of Sankaku when establishing Daikai Bunko.

Although it is primarily a shared library, Daikai Bunko, a place with books and daily life, is also partly a new bookstore, a cafe, and a place that hosts a consultation space for finding one's place twice a week.

● Creating a mechanism to circulate money in a place of care

There is resistance to generating profit from welfare and medical initiatives due to their public nature. Comments like "not enough honorarium is paid for lectures" or "since it's a good cause, know-how should be provided for free" are common. While I think running toward mammonism is questionable, on the other hand, it is better to build an ecosystem where money circulates properly in order to create a sustainable mechanism.

Private consultation spaces like "Kurashi no Hokenshitsu" (Living Health Rooms) are often run on goodwill. A "Kurashi no Hokenshitsu" is a place where health consultation windows are set up in locations other than medical facilities or government agencies, making them easy places to consult. It began in 2011 when Masako Akiyama, a nurse who operated a visiting nursing station, set one up on the first floor of an apartment complex in Shinjuku. Since then, the number of cases of setting up such rooms has increased due to the rise in regional care, but in many cases, the operating funds are supplemented by profits from the main business of visiting nursing stations. There are also cases where local medical professionals gather and operate them as volunteers.

Based on the belief that money should be generated when expertise is demonstrated, Daikai Bunko pays a salary to staff who work as consultation counselors for finding one's place, while also fulfilling their roles as librarians and bookstore staff for the shared library.

Most of Daikai Bunko's profits come from the one-box bookshelf owners. By designing multiple entry points such as crowdfunding, renovation workshops, and media coverage, we gathered about 40 groups of owners before opening. Therefore, even before opening, we were able to create a mechanism that could sustain hiring counselors for finding one's place twice a week.

The renovation workshops we held by calling out to local people were conducted with many people, although the number of participants was limited due to the COVID-19 pandemic. Over the course of three weeks, people from diverse professions including high school students, doctors, nurses, care workers, Buddhist priests, community development stakeholders, and medical students gathered to create a base for care and books.

● 5 months since opening. Why is it a sustainable ecosystem?

Daikai Bunko, which opened in December 2020, has 57 one-box bookshelf owners, over 122 library card registrants, over 370 books lent out, and over 160 new books sold in the five months since opening. Consultations are also gradually being brought to the consultation space. The number of owners who take turns sitting at the shop on opening days is gradually increasing, and combined with the days staff are open, it was open for a total of 25 days in April. There are people who drop in, people who come after seeing Instagram, etc., people who come to borrow books, and people who come for consultations.

"A place for book culture, and also a place for care"

People who fit the concept of Daikai Bunko are coming. It is a smooth start.

● The One-Box Bookshelf Owner as a place for expression

Why do the one-box bookshelf owners, who make Daikai Bunko sustainable, continue to do so? They pay 2,400 yen every month for the act of having someone read their books. I think one reason is that it serves as a place for expression. Junya Doi, a community facilitator who runs "Minna no Toshokan Sankaku," also mentions this in his note. A shared library is a place for expression. Some people line up books related to kokeshi dolls because they want others to know about their hobbies. Others line up books related to their own companies because they want to create a point of contact between their company and local people. There are also people who line up their own essays because they don't have a store but want people to read the books they have written. Everyone is looking for a place to express something. Talking to the owners, I feel that the reason there are many people who belong to public institutions, such as government employees, school teachers, and medical professionals, not just those who own stores, is because they want to share their feelings and thoughts—which cannot be expressed with large tags—with someone within a tangible range.

● A well-being space where you can have chance encounters with people

We conducted a survey of the owners two months after opening. The most common benefits of becoming an owner were meeting people and encountering books.

I mentioned "medium-distance communication" above, but there is a gradation in how people interact at Daikai Bunko. Those who want to consult carefully come to the consultation desk, and you can also talk a little when an owner you are interested in is working at the store. Sometimes people who are there start talking about the town or books. On the other hand, it is fine to just come in and borrow a book. I think this gradation leads to the ease of getting involved with Daikai Bunko. By increasing the opportunities for involvement, people who are interested in books and care can get involved with Daikai Bunko in a way that is comfortable for them.

Because of the COVID-19 pandemic, active events cannot be held. Even so, people meet others while in the process of coming to Daikai Bunko to borrow books. Such encounters with people in daily life are taking place at Daikai Bunko.

Also, the one-box bookshelf owners are already becoming a community. They are people who pay 2,400 yen a month, have their own bookshelves, and work at the store. Of course, they are not the majority. There are many things that the one-box bookshelf owners have in common, such as self-expression through bookshelves, communication through books, and a slight awareness of the public and community development. People who would not have met even in a small town are becoming a community through the one-box bookshelf owners. It is becoming a third place for them.

The benefits of becoming an owner found in the survey results, such as being useful to someone, being known by others, and meeting people, are linked to well-being. PERMA is cited as a component of well-being proposed by Seligman.

Positive emotion, Engagement, Relationship, Meaning, Accomplishment

I think the series of actions of a one-box bookshelf owner—getting absorbed in making a bookshelf at Daikai Bunko, meeting people, building relationships, and leading to a sense of accomplishment—and the meaning that it is useful to someone else, is connected to well-being.

● And, to a place where social prescribing begins

People who have illnesses, disabilities, or who are suffering from loneliness or difficulty in living are also visiting Daikai Bunko. There are people who are recovering while meeting someone there, encountering books that push them forward, or talking to someone. There is also a sense of security because it is run by medical and welfare professionals. I think there are more people who are struggling with life there than in other local places.

Among them, those who are truly in trouble visit the consultation desk. Some people are not connected to public support even though it exists, and some come to consult about the community casually. I think some people visit because it starts from a slightly ambiguous relationship of talking to someone who is both a consultant and a librarian in a space that is both a consultation desk and a library.

Of course, for those who are not connected to public support or services, the first step is to connect them. There are many public support services and self-help communities supported by the government. However, I introduce music circles to those who like music, art classes to those who like art, and reading groups to those who like books. Daikai Bunko has the goodness of an intermediate area between care and the town, introducing such informal communities. This can be said to be the role of a link worker in social prescribing in the UK, who prescribes communities. The one-box bookshelf owners of Daikai Bunko and the people I have met through YATAI CAFE and events can become destinations for prescriptions for people who are worried about where to belong. It is only in the UK that medical institutions are the starting point. Wouldn't it be okay for people other than doctors to prescribe communities? Even if there is resistance to visiting a medical institution, there are probably people who think, "I can go to a bookstore" or "I can go to a movie theater." I hope to create a model of social prescribing that involves stakeholders from the entire region, starting with Daikai Bunko.

● To medical and welfare professionals venturing out into the town

You don't have to go as far as running a shared library; just pulling a food stall into town or placing a bench in front of your house and talking to people who sit there is fine. I believe there are forms of community care that begin from relationships that are not doctor-patient relationships. As a contribution to a community-based inclusive society, I believe that if more people venture out into the town to create or help with small-scale, multi-functional public spaces, society will gradually improve. For medical professionals venturing into the town, I recommend this book, which I wrote with Dr. Tomohiro Nishi and Satoko Fujioka, as a first step. It is a bit expensive, but I would like you to read it. Shuji Terayama said, "Throw away your books, go out into the streets." This time, I would like you to take this book and go out into the streets.

● How to get involved with Daikai Bunko

For those who have read this far and would like to get involved with Daikai Bunko.

Become an owner
Daikai Bunko is currently looking for one-box bookshelf owners. While the bookshelves are currently almost full, there are still a few empty corner book boxes. If you are still interested, we would appreciate it if you could apply via the following site.

Donate
With donations from everyone, we believe we can further develop the activities of Daikai Bunko and work toward the realization of social prescribing. If you are far away and cannot set up a bookshelf, but have the desire to watch over the development of Daikai Bunko from a place close to us, we would be happy to become partners and create a caring town together. Thank you for your support.

Visit for observation
Daikai Bunko, a place with books and living, accepts visits for observation. We accept groups of 3 or more at 3,000 yen per person. We talk about operation methods, how to create points of contact with care, and how to get involved, so if you are interested, please specify the date and time and contact us at info@carekura.com.

● References

1) Ministry of Health, Labour and Welfare. Portal site for a community-based inclusive society. 2021-04. URL<https://www.mhlw.go.jp/kyouseisyakaiportal/>
2) Julianna Holt-Luntad et al. Social Relationships and Mortality Risk: A Meta-analytic Review. Plos medicine. 2010
3) Shin Aiba. Folding the City. Kadensha. 2015
4) Tomohiro Nishi, Yoichi Morimoto, Satoko Fujioka. Care, Community Development, and Sometimes Art. Chugai Igakusha. 2020
5) Yuichi Kato, Yusuke Hiramatsu. Thinking about the future "neighborhood" from the town's public bathhouse. Osoi Internet
6) Seligman, M. E. P. Flourish. New York, NY: Simon & Schuster. 2011

Yoichi Morimoto
Representative Director, Care and Living Editorial Office (General Incorporated Association)
Staff Physician, Department of General Medicine, Izushi Medical Center, Public Toyooka Hospital Association
Born in Kanagawa Prefecture in 1993, from Hyogo Prefecture. Family physician. Since his student days, he has been involved in activities related to care and community development, such as YATAI CAFE (Mobile Stall de Health Cafe), where medical professionals pull food stalls and walk around the city, and community diagnosis in the Tajima region of Hyogo Prefecture. In November 2020, he established the Care and Living Editorial Office. As a base for social prescribing, he renovated a vacant shop in a shopping district and opened and operates a shared library, Daikai Bunko, a place with books and living. Co-author of "Care, Community Development, and Sometimes Art (Chugai Igakusha)", "Social Prescribing (Gakugei Shuppan-sha)", and others.

★ In addition to writing articles on note, I also tweet on Twitter.