How Japan has Coped with Covid-19

By TANIGUCHI, Tomohiko

Japan's Ministry of Health, Labor and Welfare (MHLW), as of 28 April, reported that the country till then had 376 deaths caused by COVID-19. (Seen at 1:50 AM, JST, 29 April, at https://www.mhlw.go.jp/stf/seisakunitsuite/bunya/newpage_00032.html)

It is the Death Toll that Matters

The number of infected cases may vary, for more Polymerase Chain Reaction (PCR) tests would find more positive cases, but the death toll does not. The number of deaths is absolute, dependent on nothing else. Moreover, one can neither conceal nor cheat the number in Japan for the reason that follows. It is also an ultimate expression of the country's preparedness for such pandemics as COVID-19. The death toll, hence, counts.

It is here one finds a stark contrast between Japan and other advanced countries, notably the U.S., U.K., Italy, and Spain, in which the reported deaths range from 20,000 to 49,000.

The accompanying graph (Seen at 12:50 PM, JST, 28 April at https://web.sapmed.ac.jp/canmol/coronavirus/death_e.html) demonstrates that in comparison to two other countries that have gained acclaim for their relative successes in preventing the outbreak from happening, namely Sweden (in orange) and Germany (purple,) still, in Japan (green), deaths per one million population appear very small in number. The growth rate is also significantly lower. If (still not a small if, though,) Japan's green curve started to flatten, the country would deserve due acknowledgment as a rare case of success.

No One Dies without the Cause of Death Pinned-down

First to be noted in this conjunction is that Japan lets no one die without the cause of death being confirmed. A cremation permit would be given to you by the municipal government office, supposing you have lost your family member, only after the involved licensed doctor has given you a death certificate, also approved by the local police when the deceased person has died out of hospital. Interment is possible on the condition that you have completed the same procedure as above.

Also of note: the hospitals that accept COVID-19 patients in Japan are the ones, with no exception, that are officially designated by the Infectious Diseases Act ("Act on the Prevention of Infectious Diseases and Medical Care for Patients with Infectious Diseases") as being capable of treating infected patients, which is one reason that each and every one of those hospitals is equipped with at least one CT scanner.

A CT scan would easily distinguish COVID-19 patients from others as the paper below describes, for other diseases rarely develop acute interstitial pneumonia. (https://www.medrxiv.org/content/medrxiv/early/2020/04/01/2020.03.30.20047985.full.pdf?fbclid=IwAR0OUqSMe7_0XUmF6QnbZioNM-CcOjQ6Ohe2M0cz2udEumfzpc0UaX5b8LI)

Prime Minister Abe Knew That

At a press conference that Prime Minister ABE, Shinzō gave on 28 March, he referred to the above-mentioned phenomenon unique to COVID-19. In response to a question from the floor that asked whether Japan had somehow engineered the number of COVID-19 deaths, he pointed out that by CT-scanning the patient's lungs, whether the scanned patient has developed interstitial pneumonia can easily be detected, and that once detected such, the patient undergoes, with no exception, a PCR test. "Which is why," he concluded, "the cause of death, if it is COVID-19, cannot go unaccounted for."

On the 15th of January, Japan recorded its first COVID-19 fatality. It was on the 30th of January that the U.K. did the same. Now at this writing, on the 29th of April, the respective numbers are 376 and well over 20,000. Something fundamental sets these two nations apart. To speculate on the root difference, however, is well beyond the scope of this essay.

What Drove Japan's Response

Let us now turn to what drove Japan's response toward the pandemic, especially in its early stages. In short, the country's response was to save hospitals from getting inundated with the COVID-19 patients to enable those hospitals to concentrate their assets on those seriously ill.

The peculiar behaviour of the COVID-19 virus made the response sensible. What made it also possible is an institution the country has maintained throughout its long struggles against infectious diseases, tuberculosis (TB) inter alia, which persisted long after the end of WWII.

Epidemiologists have discovered a behavioural pattern unique to the virus. Chinese and Japanese early findings demonstrated a pattern where R0, which is what in epidemiology is called basic reproductive ratio, varied widely from as low as zero (naught) to as high as ten, which was puzzlingly unique to the virus.

The Virus Acts Differently

Even if infected, for four among five, supposing the group comprised five members, all infected, R0 can be zero, that is to say, none of the four spreads the COVID-19 virus to anyone else. Yet for the one left, the ratio can be as high as 10, in which case R0 for the five-person group as a whole, and on average, becomes 2 (R0= [0+0+0+0+10]/5), thereby triggering an exponential growth in the number of infected people. (See also: https://hopkinsidd.github.io/nCoV-Sandbox/DispersionExploration.html)

The above peculiarity of COVID-19 virus formed the basis of Japan’s science-based response, which was to focus on identifying emerging clusters as compared to conducting indiscriminate mass testing of PCR. The slowness of the growth of deaths provides factual evidence to support the rationale. It also shows us that the nation's cluster-busters did a commendable job in controlling the spread of the virus at least till the end of March. This leads us to see who those cluster-busters are.

The Expertise Unique to Japan?

In 1935, funded by the money Rockefeller Foundation gave to Japan, the nation's first "Public Health Centre (PHC)" was opened in the Kyōbashi district, Tokyo. Two years later in 1937, PHC Law came into effect, which resulted in building 187 PHCs nationwide, over the subsequent five years. The institution of PHC survived the war, even earned support, post-war, from the "allied" occupation forces, notably American civil administrators.

The priority for the health centres, pre- or post-war, was to stay watchful all the time on the emergence of TB. Their obligations included rushing to the patient's residence, finding a concentration, a.k.a. cluster, of patients, if any, and sterilizing the house and the neighbourhood. (For more, see the video that recorded the activities of a Tokyo based PHC in the year 1949 at: https://www.phcd.jp/01/enkaku/wmv/newhc_256kb.wmv)

Seventy-five years on, 469 PHCs are in operation across the country, with each manned, on average, by 64 medical professionals, including one to two licensed doctors. (sometimes dentists, see: https://www.phcd.jp/03/HCsuii/pdf/suii_temp02.pdf)

Those PHCs still play key roles in locating the clusters, tracking infection links, and conducting PCR tests. It was this accumulated wealth of expertise, rarely found elsewhere, and indeed the dedication that the licensed doctors, nurses, surveillance experts, and other medical professionals exemplify at each one of the PHCs, that the members of the advisory panels, and ultimately Prime Minister Abe, counted upon for the strategy of not relying upon mass PCR testing but on crushing clusters.

The strategy worked. The comparatively small number of deaths evinces that there has thus far emerged no inundation of patients into hospitals and that emergency room beds have not been exhausted. And yet, the number of infected patients was on the rise in early April. The rising curve having become steeper, on the 7th of the month, Prime Minister Abe declared a state of emergency covering Tokyo, its three surrounding prefectures, Osaka, Hyogo and Fukuoka. It would soon cover the entire nation, and here we all are now.

No Enforcement

Japanese Prime Minister, whoever may that be, possesses no executive power akin to the one afforded to the President of the United States. Japan's parliamentary system, unlike its Westminster variant, allows no ruling party or its coalition to act without regard to the prerogatives of the Diet. And the existing laws afford no one to exert power strong enough to enforce quarantine, city-wide or not.

True, the Infectious Diseases Act mentioned previously enables gubernatorial leaders to either stop the traffic or shut down the infected area, yet presupposes city-wide actions to be unattainable. (Article 33 reads, " If a prefectural governor deems it particularly necessary for the purpose of preventing the spread of a Class I Infectious Disease, and it is difficult to achieve the purpose by means of disinfection, the prefectural governor may restrict or block the traffic in places where patients with that Infectious Disease stay and other places contaminated or suspected to have been contaminated with pathogens of that Infectious Disease, in accordance with the standards specified by Cabinet Order, for a specified period of not more than 72 hours.")

The hastily revised law on pandemics and new infectious diseases (Shingata Influenza tō Taisaku Tokubetsu Sochi Hō, which is yet to be translated into English) gives no enforcement power to its presumed enforcer, the Governors of the prefecture. Then, absent enforcement, what could Prime Minister Abe do to bring about any tangible result after he declared the state of emergency?

The same question also applies to the Governor of each prefecture, for s/he is the one that administers the declared state of emergency to the extent that it would be effective in putting the spread of the disease under control.

The answer lies in an age-old measure: moral suasion.

"Please," Prime Minister Abe had to say, on 17 April, when he extended the state of emergency to cover the whole nation, "refrain from going out. Avoid coming into contact with others to the greatest possible extent. That will protect people at medical facilities and safeguard a large number of lives. It will also lead to protecting you and the people you love. Everything depends on the actions each one of us takes."

"Unless we achieve our target of reducing people-to-people contact by at least 70 percent, or ideally 80 percent, it will be difficult to shift the number of new cases of infection per day dramatically into a decline," the Prime Minister also articulated at the same press conference.

At this writing, amidst the country's prolonged holiday season of Golden Week, people are not moving as the table (on top of the page) shows.

As opposed to what it was like one year previously, the number of passenger-users found at each station has decreased dramatically by 84 to 92 percent. The nation has responded to the Prime Minister’s call.

It is too early to say whether Japan's measure of using no coercive means has worked. Fingers remain tightly crossed. If it has been proven effective, with the country's death toll remaining very small in number, again, Japan will gain its due accolade.

END