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Japan’s Halfhearted Coronavirus Measures Are Working Anyway
Despite indifferent lockdowns and poor testing, Japan seems to be skipping the worst of the pandemic.
In its battle with the coronavirus, Japan appears to be doing everything wrong. It has tested just 0.185 percent of its population, its social distancing has been halfhearted, and a majority of Japanese are critical of the government’s response. Yet with among the lowest death rates in the world, a medical system that has avoided an overloading crisis, and a declining number of cases, everything seems to be going weirdly right.
Officials said early in the crisis that they would limit testing to those who likely needed hospitalization and that their overarching goal was to reduce the number of people who died. “The goal of this strategy is to slow the speed of expansion of transmission and to reduce mortality,” Shigeru Omi, a former World Health Organization official who is a key figure in the government’s planning, said in mid-February. The results have been impressive. As of May 14, Japan had 687 fatalities directly attributed to COVID-19 nationwide, equal to 5 per million people. That compares with a total of 85,268 deaths, or 258 per million, in the United States and 584 per million in Spain. Even Germany, seen as another success story in the pandemic, has 94 deaths per million.
These almost miraculously low figures come despite Japan being close to China, with a large number of tourists. It is also the world’s fastest-aging society—yet has escaped, it seems, being severely hit by a virus that is particularly deadly to older people. While Japanese medical experts admit that the official count may understate the real total, they say other related causes of death, such as pneumonia, have not seen any unexpected surge.
It is difficult to know if the country has just been lucky or if it’s a matter of good policy. Even senior officials have often given guarded forecasts. “Unfortunately the number of those infected keeps rising,” Prime Minister Shinzo Abe said just two weeks ago in late April. “The situation remains severe,” he warned. Even more worrying have been comments about a potential collapse of the health care system, even amid a relatively small number of cases. “We feel that the collapse of the emergency care system is already here,” the Japanese Association for Acute Medicine said in a statement in mid-April, leading to understandable concerns about a health care system that is seen as a pillar of Japanese society.
That pressure has eased in the past few weeks with the number of reported cases now showing a clear downward trend. Daily new cases peaked on April 12 at 743 and by May 14 fell to 57, breaking below the 100 mark. This has not been enough to assuage public opinion. A survey by the Kyodo news agency on Sunday found that 57.5 percent of those polled were critical of the government’s measures, with only 34.1 percent approving of the steps taken.
Confusing the situation is that the range of testing has been well below the international norm, creating uncertainty over the real scope of the problem. As of May 14, there had been just over 233,000 tests carried out across the country, or 2.2 percent of the U.S. total. Part of this was by design. When a person was diagnosed as having COVID-19, they were sent to a specially designated hospital for isolation and care. An influx of those who had only light or no symptoms would have quickly swamped the system far beyond what has been seen. Instead, people were advised to seek a test only if they had shortness of breath and fatigue or a fever of 99.5 degrees for four days. These rules were administered with a strict bureaucratic efficiency, leading to stories of those in distress still being denied even the access to a test. One harrowing account by a foreign woman trying to help a friend through a medical gauntlet garnered international attention after the saga was chronicled on Facebook.
Officials admit another motive in all this. They didn’t have the infrastructure in place for widespread testing. “The capacity was not sufficient,” said Yoshitake Yokokura, the president of the Japan Medical Association, who was among those pushing for more. With private facilities now brought into the mix, the government has now expanded the criteria for testing, with immediate tests available for older people or those seriously ill. Even with this, experts say they will still be largely in the dark on the true picture. One Tokyo medical official said the true rate of infection was likely to be around 6 percent of the Tokyo populace.
Another problem is the mundane issue of how the data is collected. Reports of new cases must be submitted by doctors, who fill in a form by hand that is then faxed to the local health departments. This is then compiled and sent to the central government. Faced with criticism that doctors were wasting valuable time filling in the detailed information, the minister in charge of Japan’s information technology policy said he would “address the problem.” The data flow is also haphazard, with reports on Sunday and Monday showing fewer cases but with an increase through the week to peak on Friday or Saturday.
Yet that seems unlikely to be the case, with countries that have seen far higher numbers of deaths finding, through antibody testing, rates of infection among the whole population at just 1 or 2 percent. Other countries that have avoided serious outbreaks have hot temperatures or young populations, often pointed to as a possible firebreak. Japan has neither—yet the deaths simply aren’t coming.
Japan’s voluntary lockdown is also much less stringent than in the majority of countries, save the United States. Even with the declaration of a national emergency, the government is not able to force people to stay at home or to order businesses to close, a legacy of the (American-drafted) post-World War II constitution that sought to constrain the power of government.
Instead, social distancing is left up to the goodwill of the individual, along with a little social shaming. When Tokyo first laid out its voluntary measures, government workers walked through the Shinjuku nightlife area with English and Japanese signs asking people to go home. The purpose of the English was not clear since foreign tourists had long headed home amid the spreading pandemic. Restaurants have been (politely) asked to close up shop by 8 p.m. and to stop serving alcohol an hour earlier, a blow to Japanese office workers used to a night of drinking until the last train to get over the stresses of the office.
The goal was ambitious, with authorities seeking a 70-80 percent reduction in social interaction. The data suggests they got close to that figure and also managed to keep people from their usual annual pilgrimage home during the early May “Golden Week” holidays. Japan Rail said its high-speed train network operated at around 5 percent of capacity over the holiday period, compared with the typical 105 percent. Getting people to work from often cramped apartments was less successful, showing just an 18 percent reduction, but in the streets of central Tokyo, crowds have fallen by around 60 percent, according to mobile phone data. Masks are in use by almost everyone, a request that has invoked few complaints since people here regularly wear masks when ill or to avoid spring pollen.
While Japan likes to picture itself as a law-abiding place and a society with close attention to health matters, not everyone has taken the isolation measures seriously. One clear area of concern were the typically crowded pachinko parlors, which offer a form of gambling that is a mixture of pinball and slots. While many closed down voluntarily, some operators refused to shut. The government responded by publicly naming the miscreants, only to see long lines forming outside the stores that were still open. In another case, national media carried the story of a female office worker in Tokyo who took a highway bus 70 miles back to her hometown even though she felt ill, was told by the health office while there that she had COVID-19, and then took another bus back to Tokyo because she was worried about her dog.
In general, however, Japan’s culture of concern for others, keeping a distance, avoiding handshakes, and good personal hygiene appears to have played a significant, if difficult to measure, part in the low numbers. A more worrying aspect of the culture has also come out, unfortunately, in sometimes negative treatment toward health care workers and patients. In contrast to the celebrations for those on the front line elsewhere, nurses and other health care workers in Japan have complained of discrimination, bans on their children attending nursery schools, and general disdain from those worried that they are carriers of COVID-19. Yokokura of the Japan Medical Association said he has been pleading on behalf of the workers and that some discrimination has declined.
In an attempt to keep the numbers on the right trend, Abe has extended the state of emergency until the end of May but, in a nod to growing public fatigue with the restrictions, has eased some of the rules. Parks and other public facilities will be allowed to open, and social interaction targets will be lowered for regional areas that have not been hit as hard as Tokyo and other big cities. Businesses have responded by starting to reopen with various limits on how they operate. As everywhere, the big question will be whether Japan can safely take its foot off the brake without creating a new crisis—but perhaps also why it didn’t have one in the first place.