The novel coronavirus disease (Covid-19) was first identified in China at the end of December 2019, quickly spreading worldwide, and there are still no signs of abatement. Its impact on Western countries has been particularly strong; for example, as of February 19, 2021, the total number of people infected and the total number of deaths in the United Sates due to Covid-19 has been reported at about 28,565,929 and 506,596, respectively. The number of cases and deaths per population in Asia is relatively low compared to Western countries, although the reasons for this remain to be explored. Japan is no exception. Being the most aged country in the world (as of 2019, people over 65 years of age make up 28.4 percent of the population),1Statistics Bureau of Japan, Statistics Handbook of Japan (Statistics Bureau of Japan, Ministry of Internal Affairs and Communications, Japan, 2020). and having a high population density in large cities, such as Tokyo and Osaka, are all disadvantageous conditions for Covid-19 control. Despite this, Japan has succeeded in keeping the number of deaths per million population low; as of March 28, 2021, there have been 71.56 deaths/million, while these numbers are 908.75 in Germany, 1,395.70 in France, and 1,659.61 in the United States.“In addition to individual preventive measures by the general public, such as handwashing, hand disinfection, and wearing masks, the government and expert committee repeatedly urged the public to avoid the 3Cs.”
The characteristics of Japan’s Covid-19 strategy can be summarized in measures to prevent the formation of “clusters” and unenforceable self-restraint as distinct from lockdown. In February 2020, from the very beginning of the pandemic, an expert committee found that 80 percent of Covid-19 positive people did not infect others, while the remaining 20 percent did, and some of them further infected multiple others (becoming so-called superspreaders).2Hitoshi Oshitani, “Cluster-Based Approach to Coronavirus Disease 2019 (COVID-19) Response in Japan, from February to April 2020,” Japanese Journal of Infectious Diseases 76, no. 6 (2020): 491-493. Experts referred to the series of infections caused by a superspreader(s) a “cluster (more than five infected from one place, as defined by the Ministry of Health, Labor and Welfare (MHLW)).” Based on these characteristics, Japan has prioritized preventing the increase of clusters rather than focusing on sporadic cases. Following a detailed analysis of clusters, the experts proposed that the so-called 3Cs—closed spaces with poor ventilation, crowded places with many people nearby, and close-contact settings such as close-range conversation—produce the conditions that are more likely to trigger clusters.3Yuki Furuse et al., “Clusters of Coronavirus Disease in Communities, Japan, January–April 2020,” Emerging Infectious Diseases 26, no. 9 (2020): 2176. In addition to individual preventive measures by the general public, such as handwashing, hand disinfection, and wearing masks, the government and expert committee repeatedly urged the public to avoid the 3Cs. This cluster approach, together with avoidance of the 3Cs, remains the central tenet of Japan’s Covid-19 strategy.
PCR testing and the healthcare system
One of the significant differences in Japan’s Covid-19 strategy from other countries is its PCR testing policy.4Haruka Sakamoto, “Japan’s Pragmatic Approach to COVID-19 Testing,” The Diplomat, June 26, 2020. In keeping with its focus on preventing a cascade of clusters, testing has been limited to those who were part of clusters and any other close contacts showing symptoms at an early stage. One reason behind this policy centered on Japan’s inadequate PCR testing capacity at the beginning of the pandemic, and this strategy allowed effective use of limited testing resources. Another reason was to prevent people from rushing to healthcare facilities for testing thereby avoiding nosocomial infections, a lesson drawn from past epidemics such as the H1N1 flu in 2009. With easy access to healthcare facilities, it was not hard to imagine people rushing to seek testing, thus creating clusters. This limited testing policy has been widely criticized by the media and the general public and has sometimes been a source of political strife. However, the basics of infectious disease control are testing, contact tracing, and isolation. It is important not only to focus on testing methods but also on how effectively these three are carried out. Increasing the number of tests would have only a limited effect on the control of infection, and countries with a larger number of testing per population do not necessarily show better outcomes (i.e., number of deaths, case fatality rate) compared to countries with lower testing numbers.“This kind of health insurance system allows people to visit a medical facility whenever they are ill or hurt without worrying about medical costs, making it less likely for patients in Japan who show Covid-19 symptoms from delaying healthcare.”
Another factor that has helped keep Covid-19 deaths low in Japan is its healthcare system—a universal insurance system with public health centers.5Haruka Sakamoto et al., Japan Health System Review (World Health Organization, Regional Office for South-East Asia, 2018). Japan has had a universal health insurance system since 1961. Through this system, individuals pay monthly premiums, which are pro-rated on the basis of their income, and then pay only 30 percent of their health expenditure out-of-pocket. The remaining 70 percent is covered through a combination of tax subsidies and the funds collected from the premium payments. In addition, all the prices of healthcare procedures and medicines, both at public and private facilities, are determined by the MHLW. There is also a cap-payment system so that medical expenses above a certain amount are covered by the insurance system rather than the patient. This kind of health insurance system allows people to visit a medical facility whenever they are ill or hurt without worrying about medical costs, making it less likely for patients in Japan who show Covid-19 symptoms from delaying healthcare.6Haruka Sakamoto, Yosuke Kita, and Satoshi Ezoe, “How Japan’s Universal Health Care System Led to COVID-19 Success,” The Diplomat, August 28, 2020.
Alongside healthcare facilities, public health centers play an important role. Japan has a long history of community public health centers, and they have been essential in infectious disease control long before the Covid-19 pandemic.7Japan International Cooperation Agency (JICA), Japan’s Experiences in Public Health and Medical Systems: Towards Improving Public Health and Medical Health in Developing Countries (JICA, March 2005). If an epidemic breaks out in a community, they are responsible for conducting epidemiological investigations, tracking close contacts with the infected, and coordinating necessary treatment, such as hospitalization. Also, for some infections that significantly impact society, such as tuberculosis, the essential testing and treatment are to be paid for at public expense (tax subsidy) under the Infectious Diseases Control Law. All of this has been true of Covid-19; from the beginning, public health centers have been responsible for conducting epidemiological surveys, conducting detailed analyses of clusters, interviewing close contacts, monitoring home quarantine, etc. Thanks to this combination of tax-based public financing, a universal insurance system, and coordinated roles for public health centers and healthcare facilities, Japan has been able to limit the spread of Covid-19 and avoid overwhelming its healthcare system.
Controlling the spread of Covid-19 in care facilities“With no sign of Covid-19 abating, the key to curbing deaths is to protect older people, namely continuing to keep strong infectious control measures in long-term care facilities.”
Beyond Japan’s testing practices and the strength of its health insurance infrastructure, strong infection control measures in healthcare facilities and long-term care facilities have also contributed to successfully reining in the pandemic. Older people are at the most significant risk of contracting Covid-19, and, according to reports from European countries, the majority of deaths in those countries occur in long-term care facilities.8European Centre for Disease Prevention and Control, Surveillance of COVID-19 at Long-term Care Facilities in the EU/EEA (Stockholm, ECDC, May 19, 2020). However, in Japan, the proportion of deaths in long-term care facilities is low at 14 percent.9Kyodo News, “COVID-19 survey on long-term care facilities in Japan (Japanese only),” Kyodo News, May 13, 2020. This trend may be partly because most older people who develop symptoms in a nursing home are taken to healthcare facilities regardless of their age and severity. There is no age limitation for the transportation of older people from long-term care facilities to healthcare facilities, which some European countries have. It is assumed that older people infected with Covid-19, who usually stay at long-term care facilities, can still access quality treatment, even during the pandemic. Also, considering the low incidence of clusters in Japanese long-term care facilities, it is likely that comprehensive and intensive infection control measures were in place from the beginning of Covid-19.10→COVID-19 JMA (Japan Medical Association) medical expert meeting, “The Reason COVID-19 Did Not Spread in Long-Term Care Facilities in Japan,” August 14, 2020.
→Kazuhiro Abe and Ichiro Kawachi, “Deaths in Nursing Homes During the COVID-19 Pandemic—Lessons from Japan,” JAMA Health Forum, February 12, 2021. However, Japan’s aging population has put a strain on long-term care facilities, which have been suffering from chronic staff shortages. The exhaustion and mental burden among caregivers have reached their peak due to the pandemic. With no sign of Covid-19 abating, the key to curbing deaths is to protect older people, namely continuing to keep strong infectious control measures in long-term care facilities. To do so, sufficient support for such facilities, including financial, labor, and mental health support, is essential.
The Covid-19 pandemic has revealed many of the infectious disease control challenges facing Japan. Their Covid-19 countermeasures are characterized by the public’s self-restraint (i.e., choosing to wear a mask, not go out to restaurants, not travel, etc.) based on their own motivations rather than government mandates. Unlike in Western countries, it is not possible to carry out lockdowns or forcibly isolate patients. Due to unchecked enforcement measures during World War II, there has been a tendency in Japan to strongly discourage the government from having strong coercive power, especially from interfering in ordinary people’s lives, so as not to repeat what happened during that period. The power of the Japanese government to intervene in individuals’ lives, even during an emergency, is constitutionally and legally limited. The Infectious Diseases Control Law, for example, was enacted with the utmost consideration for individuals’ human rights and it limits the public sector’s power to intervene in a person’s life, even for the purpose of infectious disease control. Besides, tracking infected people has many privacy considerations, and it is legally difficult in Japan to use GPS tracking or credit card histories to track activities, as it is being done in other Asian countries. The government’s ability to access individual citizens’ data is minimal, making infectious disease control difficult. Given these various constraints, there is an urgent need to discuss how to promote voluntary behavioral change among the general public, and efficiently identify and track close-contacts of those infected with Covid-19; this includes a necessary discussion of the laws and regulations that limit the government’s capability to act.
Since November 2020, the number of Covid-19 cases in Japan has been increasing, and the government again declared a state of emergency for the Tokyo metropolitan area on January 8, 2021. The focus of the government’s countermeasures has remained on the cluster approach and avoiding the 3Cs. It has asked people to refrain from going to entertainment spaces and restaurants, especially in places where clusters are likely to occur. On the other hand, prolonged Covid-19 measures have depressed the economy, and people’s patience is running thin, as in many other countries. Hence, it is unclear how effective countermeasures encouraging the public to avoid the 3Cs, absent legal repercussions, have been during the resurgence of Covid-19. With a prolonged Covid-19 outbreak, the Japanese government faces even stronger pressure than before to balance controlling the spread of the coronavirus and stabilizing economic activity.
Banner photo: Jérémy Stenuit/Unsplash.
→Kazuhiro Abe and Ichiro Kawachi, “Deaths in Nursing Homes During the COVID-19 Pandemic—Lessons from Japan,” JAMA Health Forum, February 12, 2021.