From time to time, until the crisis has passed, the HEPL blog series authors will be given the opportunity to provide short updates on their country/region’s continuing response to this worldwide catastrophe and their further reflections on those responses. Each update will be labelled accordingly with the original response at the bottom of each post.

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HEPL blog series: Country Responses to the Covid19 Pandemic

 

Japan’s response to the coronavirus pandemic: Update (May 2020)

Ryozo Matsuda

 

On April 16, the Government declared a nationwide state of emergency (SOE) through May 6 and recommended thirteen prefectures to conduct strict measures to tackle the spread of COVID-19. All prefectures have implemented their policies for controlling the pandemic in accordance with the national guideline.

Faced with the soaring numbers of confirmed cases, the Government brought physical distancing into focus instead of field epidemiological surveys. Japan, however, has implemented lax policies for physical distancing, although they have seemingly worked well so far. First, the government requests and persuades people to contact as few people as possible. Physical distancing and organized isolation have become the social norm: people refrain from shopping and eating out, and companies voluntarily closed their offices. Second, prefectures have closed public buildings and parks. They are particularly worried about people gathering for cherry blossom viewing and have made business closure requests to restaurants, bars, and leisure facilities. Although defying the requests carry no penalties except naming and shaming, compliance appeared almost complete. Third, nearly all elementary, junior and high schools were closed in mid-April. Some universities simply shut down; others made the switch to online education. It should be noted that a significant part of business activity has remained open. Surveys showed the number of commuters between central Tokyo and suburban areas were far less than that of the previous year but remained significant, although almost all passengers wear face masks.

The Government gave new options for isolation: home and designated facilities (e.g. hotels). Until early April, all infected persons were hospitalized regardless of their symptoms. Because the policy undermined the capacity of hospitalizing severe cases, those with mild or no symptoms were moved from hospitals to hotels or their homes. The latter option was suspended soon after a man died in his home.

Initially treatment of infected persons and PCR tests were provided only by undisclosed designated hospitals, where only patients meeting the national criteria for testing were transferred, due to limited capacity of local public health laboratories. This policy occasionally resulted in failure to respond to test requests from patients and physicians. The Government has made slow progress in increasing the capacity of testing: local medical associations and health facilities have currently led the establishment of test centres. Second, as more and more hospitals faced infected people, the government has increasingly been requesting collaboration between providers with different organisational principles: prefectures have been mandated to promote their coordination to meet overall healthcare needs in their jurisdictions. Different prefectures, with a different mix of providers, have been developing different ways of coordination. This policy seems to be developing quite slowly: even numbers of ICU-like beds in prefectures was not released until May 6. Third, because providers except designated hospitals maintain their discretion to refuse to treat suspected cases, the government first introduced financial incentives, within the Statutory Health Insurance System, and then tax-funded subsidies for hospitals caring for them. Fourth, the government has enhanced its capacity of providing essential equipment for health professionals, including masks and gowns. The Prime Minister also announced an unpopular policy, yet to be fully implemented, of allocating two masks each to all households. Finally, because patients experienced difficulties in deciding whether they shall visit providers or not, a free SNS-based health counselling was established. A similar free counselling system was established for companies supporting workers. Despite that, patients’ fear stories have been repeatedly reported. From early April, the Government and prefectures have gradually developed and implemented controversial measures to economically support people and private business companies.

The number of daily confirmed COVID-19 cases peaked in mid-April. The SOE, however, has been extended until May 31. The current concern has been on when and how Japan relaxes the physical distancing measures without a resurgence of coronavirus. The Government appears to contemplate possible strategies, though some governors have already pioneered such strategies, including indicators for changing social and economic activities. Meanwhile, the national government has been developing new measures to intervene in the transmission, including a contact-tracing application, the rapid approval of pharmaceuticals to treat COVID-19, and supporting the R&D of test kits, vaccines and effective pharmaceuticals.

The first reflection is that Japan took an unusual strategy that relied on social collaboration to promote physical distancing and that it has appeared to reduce infections so far. Second, the initial policy of hospitalizing the infected presumably resulted in slow action in increasing the capacity of testing and adapting the health system to the pandemic. The slowness may be partly explained by a lack of preparedness for a new virus and complexities of the existing health and administrative systems. Finally, to what extent the flatter curve of Japan than other countries can be explained by the response is still uncertain.

 

Japan’s response to the coronavirus pandemic – Original post (April 2020)

Ryozo Matsuda
Institute of Human Sciences, Ritsumeikan University

The Japanese Government has gradually developed its policy responses to COVID-19 since its emergence in early January in Wuhan. The first response of the Government, led by the Ministry of Health, Labour and Welfare and the National Institute of Infectious Diseases (NIID), was to organize the monitoring of the new disease: enhancement of quarantine, an alarm to local governments and medical institutions, and monitoring of the new disease’s incidences using the epidemiological surveillance system.

When the first infected case in Japan – a person who had stayed in Wuhan – was confirmed on January 15, the Government called on people to keep calm and to maintain and enhance general procedures for preventing virus infections, like handwashing and cough etiquette. The NIID issued its guidelines for active epidemiological investigation. New cases in travelers were sporadically reported and, on January 29, the first domestically infected case was confirmed. Newly acquired knowledge on person-to-person transmission sharply increased the demand for masks and hand sanitizer, resulting in their shortage; they were traded for extraordinary prices since late January. To control market prices of masks, the government introduced a new rule to punish the reselling of masks for profit in mid-March. On January 28, the Cabinet promulgated an order to make COVID-19 quarantinable and designated it as an Infectious Disease to increase its power to control the epidemic. Also, the government announced that it would advance vaccine development with international agencies.

Meanwhile, the government chartered five planes, three of which were between January 29 and 31, to repatriate Japanese nationals from Wuhan and, later, other areas of China. Problems occurred in the process of their re-entry to Japan in terms of epidemiological control: the Cabinet had not authorized detention of suspected cases. Instead, the government requested them to participate in voluntary screening tests and 14- day isolation at designated accommodations. All but two passengers of the first plane joined: two passengers bypassed the tests and went back to their home by public transport and then were put into monitoring. Potential dissemination of viruses in the process somewhat damaged the public’s trust in the Government’s capability to deal with the new infectious disease, though the Government immediately closed that route by making screening tests and 14-day isolation a condition of repatriation.

On February 3, when 16 domestic cases were reported, the arrival of a British-registered cruise ship, the Diamond Princess (DP), brought a new challenge of quarantining a ship with 3,711 multi-national people. Put simply, the Government dispatched an expert team to monitor, isolate, and screen people and to support their life on board. According to the NIID guidelines, the team used a selective strategy in their utilization of PCR tests. Their isolation procedures were revealed later to be effective but also criticized as incomplete: some of the team members were infected and some countries repatriated their citizens in fear of infections on board. Another criticism that the emerging scientific evidence provoked arose when the government allowed asymptomatic passengers with negative test results to go back home using public transport in mid-February. The government introduce 14-day self-quarantine and found seven infected persons among them.

Looking at the increased number of domestic cases (e.g. 144 cases were confirmed by February 23), the Government introduced further responses. First, with advice from an ad-hoc advisory group, the Government officially declared its basic policies, which are to end the epidemic in its early stages, to minimize the incidence of severe cases, and to minimize the socio-economic impacts. A strategy that prioritizes the detection of clusters of infected cases and prevent further transmission with active epidemiology surveys was established. The strategy has been accompanied with controversial restrictive utilization of PCR tests, partly due to the limited capacity of public health laboratories. Second, the Government did not force, as before, but requested citizens to conduct physical distancing more strictly. Prime Minister Shinzo Abe abruptly requested all schools nationwide to shut down for a month on February 27, which had compelling effects. Also, with the explosions of infections in other countries, immigration restrictions were progressively extended. Third, the Government began to prepare for treating COVID-19, and started to calculate the number of available hospital beds with enough quality and medical devices. Fourth, the Government began to develop financial support for individuals and companies. Finally, the Government legislated to provide temporary additional authority to the national and local governments. For example, in a state of emergency (SOE), declared by the Prime Minister, governors of designated prefectures have the authority to request local people to stay at home, to direct public institutions (schools etc.) to close, to deliver healthcare at temporary medical institutions, and to compulsorily take necessary goods from private companies.

Cluster control worked well in some occasions as in Hokkaido. Also, the expert group produced more easily understandable guidelines for citizens: “Avoid the Three Cs, i.e., Closed spaces with poor ventilation, Crowded places with many people nearby, and Closed-contact settings.” The Government, however, admitted that Japan faced a significant risk of rampant infection in late March because new confirmed cases with undetected sources of infection increased. Also, concerns over the economy had been rising. To implement further policies, the Prime Minister declared a SOE on April 7 for seven prefectures, including Tokyo, and revealed economic measures to support individuals and companies severely impacted by the epidemic. Meanwhile, the Government emphasized differentiated responses in different prefectures with different situations for the purpose of reducing social and economic impacts of COVID-19.

A Brief reflection on the Japanese policy response to COVID-19

First, the existing legal system critically matters. The Government developed its response incrementally, although it is sometimes criticized as being too slow, since the Japanese legal system does not grant the Government emergency power in a crisis. Instead of new legislation to implement strong interventions that would violate private rights, the Government took a strategy that relied heavily on voluntary cooperation of individuals and institutions: even in a SOE, the Government has no power to make people stay at home and to stop the operation of companies. This mobilization of voluntary actions appears to partly work but to be insufficient to control infections. How the SOE, with economic support, facilitates such actions, and with what outcomes, has yet to be observed.

Second, it seems crucial to develop and implement innovative measures quickly to respond to an unprecedented epidemic, but how the Government achieves this depends on the existing institutions. The Japanese response so far has been organized within the existing institutions, excluding such new measures as PCR test centers or alarm systems using mobile phones. Meanwhile, an innovative mixed strategy of cluster-focused and behavioral change approaches has been implemented.

Finally, the process has been highly politicized: issues arose around the leadership of the PM, Japan’s hosting of the Olympics, and its international relations.

 

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