April 27, 2022 What people outside Japan don’t know about the country’s coronavirus response
It’s become something of a scientific parlor game, and the subject of numerous articles in newspapers around the world – “why has Japan been so successful with the coronavirus?”
Looking at the cumulative death for coronavirus figures, according to Worldometer, as of this writing, Japan has had a cumulative death rate of 233 per million. Interestingly, Egypt has the exact same figure, but I’ve never seen an article analyzing Egypt’s coronavirus success.
This figure places Japan at number 79 when ranking countries from the fewest to the most deaths per capita. Its death per capita figure is far lower than the other G7 countries, but exceeds that of several other countries in Asia – including Singapore, New Zealand, China and Taiwan. (We should keep in mind that because each country has its own testing and reporting schemes, there are issues with taking these numbers at face value; the numbers we have are the numbers we often go by simply because they are the most convenient base for comparison.)
Rather than rehash the speculation on what has led to Japan’s relatively low death rate when compared with many other countries (scientists still don’t have a definitive explanation), or attempt to explain why it didn’t do as well as some other countries in Asia, instead I’d like to share some information on Japan’s coronavirus response from the perspective of someone who has been living in Japan throughout the pandemic – information which seems to be not well known outside of Japan.
As people around the world are looking to find lessons in how Japan has fared with the coronavirus, I believe it’s important to have an accurate understanding of what has happened. This should include both the positive and negative aspects, rather than just picking up a few isolated items such as the 3Cs and contact tracing.
I would also like people outside of Japan to be aware that the Japanese government has set aside public relations funds specifically to promote the success of its coronavirus response overseas. This may be influencing discussions in the global media and among opinion makers about Japan’s pandemic performance.
The things I share below are probably ones that the Japanese government is not going to include in its promotional efforts, but are important for people in other countries to know if they want to understand what actually happened during the pandemic here.
Before launching into my list, I’ll note that I’m very glad to have spent the pandemic in Japan rather than in my home country of the United States. I felt a lot safer here, and frankly have been horrified watching how the pandemic has played out at home. But just because Japan had a more successful response to the pandemic doesn’t mean that its response was perfect, and doesn’t mean that the problems that occurred shouldn’t be discussed and learned from.
In a poll of people in 17 countries conducted in Spring 2021, the Japanese were the most dissatisfied with their country’s handling of the pandemic. The items listed below will provide some insight into why Japanese felt that way.
Low testing levels
Japan has eschewed the mass testing for coronavirus conducted by many other countries. With 372,801 tests per million people, Japan ranks 132 in the world in terms of testing frequency according to Worldometer. (To be honest, that number, higher than South Korea’s, seems rather high in light of the daily testing numbers that have been reported; I’m assuming it includes the intensive testing conducted in connection with the Olympics.)
Official testing is limited to people who are experiencing symptoms. The initial requirement to be eligible for testing was four days with a fever over 37.5 degrees. Although that was later broadened to include earlier testing for people having difficulty breathing or feeling exhausted, in practice many doctors have stuck to the four days with fever rule. There have also been many anecdotal reports of doctors recommending tests for their patients and the request being denied by public health centers that are the gatekeepers for testing. Shortages of test kits have also been an ongoing challenge, continuing into 2022.
Another factor curbing testing is that Japan’s definition of close contact is so stringent – being within one meter of an infected person for more than 15 minutes while unmasked – that few people qualify for government testing or contact tracing based on close contact. This forces them to use private centers, paying for the tests themselves — or leaves them unaware of potential exposure.
Overwhelm of the government health offices and the medical system generally during the Delta and Omicron waves have also made it difficult for people experiencing symptoms to get tested or even see a doctor. At one point, test shortages and concerns about overburdening the health system led twenty prefectures to presume symptomatic patients had coronavirus without testing them.
Those who take tests from private testing centers where there is no doctor present are not counted in the official statistics. This likely leads to a significant undercounting of cases in official reports.
Bullying of health care workers and people with coronavirus became a significant problem, potentially influencing people to not get tested or to hide positive diagnoses.
The asymptomatic testing that was conducted for a period of time in Tokyo suggested that the official numbers based on symptomatic testing undercounted the number of infected. Japan does not have published waste-water surveillance, despite the Japanese firm Shionogi selling this as a service, and is thus missing another route for monitoring infection that has been used effectively in many countries.
The initial vaccine rollout was delayed due to the requirement that they be tested on Japanese, shortage of trained staff to give the shots, use of a complex voucher and reservation system that overwhelmed local government resources, and insufficient supplies of the shots. No learnings appeared to have been applied from the challenges of delivering the first dose, and the rollout of the second dose and first booster were also slow. This left many people vulnerable when the Delta wave hit during the summer of 2021 and unboosted when Omicron hit in 2022.
Anti-vaccine beliefs, while not as prevalent as in some other countries, have had an impact in Japan. The Japanese media’s obsessive coverage of side effects of the mRNA vaccines have also contributed to mixed feelings about getting the vaccine.
Influenced by beliefs that Japanese are less likely to get the coronavirus and that even if one gets COVID it won’t be so bad, lack of awareness of the potential for long COVID, and deterred by concerns about the side effects and the inconvenience of scheduling and getting the shot, many people have not been bothering to get the booster. This is particularly true among younger people, with only 30.1 percent and 33.2 percent of those in their 20s and 30s, respectively, having received the booster.
Vaccines for children aged 5-11 were approved in March of this year, and uptake has been slow due to fears of side effects and possible long-term effects – currently just 11.5% have had their first shot and 6.1% have had their second.
The 2021 wave
Although the Olympics bubble is thought to have held in that there was not a wave of transmission from athletes and others to the Japanese public, there has not been significant research into the likelihood, suspected at the time by Japanese public health professionals, that increased movement within the country (due to Japanese workers and volunteers supporting the Olympics, and the general party atmosphere engendered) contributed to the wave that coincided with the Olympics. For example, a group of policemen from Shimane Prefecture sent to support the Olympics became a COVID cluster, and the town in Chiba Prefecture that hosted the surfing competition saw a dramatic increase in infections.
During the August 2021 surge, hospitals were overwhelmed with patients and hundreds of coronavirus patients died at home because there was no hospital space, patients rode around in hours in ambulances looking for a hospital to take them, and coronavirus infected pregnant women could not find hospital to treat them (one woman losing her baby as a result).
Japan made much of its cluster busting contact tracing techniques, but rising infection numbers eventually overwhelmed the public health center staff that was tasked with the tracing. Tokyo significantly curtailed its contact tracing efforts in August 2021. Meanwhile the official contact-tracing app COCOA has been plagued with problems.
Strict border controls
Through the pandemic, Japan has enacted stringent border controls, the most stringent in the G7. The border controls enacted in April 2020 initially prevented non-Japanese residents who happened to be out of the country, or who needed to leave the country, from returning to their homes in Japan for months, even though Japanese could enter freely. Students and people slated to start new jobs in Japan were kept out of the country for even longer, with just brief openings immediately prior to surges which then kept them out of the country again, delaying or derailing numerous careers and courses of study, and undermining Japanese universities’ globalization efforts. When the Omicron wave emerged as a concern in the fall of 2021, the Kishida administration closed the borders so abruptly that people who had been scheduled to fly to Japan the following day were left stranded. Even now unmarried partners are unable to enter Japan, separating many couples, and tourist related industries in Japan have suffered as tourists are still not allowed to enter.
Late recognition of aerosol transmission
Japan’s National Institute of Infectious Diseases only officially recognized aerosol transmission in March 2022. Meanwhile, Japan’s health ministry, in contrast with the World Health Organization, continues to insist that there is a “clear distinction” between “aerosol transmission” and “airborne transmission,” denying that the latter can happen. These official stances have influenced the preventative practices used by the general public, so that hand sanitizer and perspex barriers are ubiquitous but HEPA filtration is less common.
Pork barrel spending
Since the beginning of the pandemic, many of Japan’s politicians have seemed more focused on pork barrel measures rather than pandemic response. One of the early ideas was for the government to hand out coupons for discounted Japanese wagyu beef. An idea that was implemented was the GoTo travel program that provided deep discounts and coupons for Japanese traveling domestically. Scholars found that the promotion of movement around the country likely spread disease, and was apparently the cause of a spike in Hokkaido.
Many of the government’s pandemic relief funds granted to local governments were used for non-coronavirus uses, most notoriously a giant pink squid statue in a town on Japan’s northern coast. A recent audit of Japan’s coronavirus-related expenditures showed that 90% could not be accounted for.
Success leads to a sense of superiority
When Japan had a much lower than expected death rate from COVID-19 in the first half of 2020, one Japanese government official known for his revealing slips of the tongue claimed that Japan had done well with the coronavirus due to a “higher cultural level.” The word he used in Japanese, mindo, conveys a sense of superiority over other cultures. Fed by media speculation on the causes behind Japan’s relatively low infection this became a common attitude in Japan. Another example of where those attitudes may have surfaced was seen in a complaint about Dr. Takeshi Kasai, a Japanese doctor who heads up WHO’s Western Pacific headquarters. The complaint alleged that Kasai had blamed the rise in COVID cases in some countries on their “lack of capacity due to their inferior culture, race and socioeconomic level.”
I hope that the information above will help put into perspective the varied issues related to the Japanese government’s response to the pandemic, and will be a reference for those outside of Japan wishing to understand the experience of those who were here.