How Japan survived covid-19 | The BMJ

The world’s third biggest economy seems to have emerged from the pandemic comparatively unscathed. Priy speaks to health workers who survived the frontlines about how, and at what cost

On 20 February 2020, the Diamond Princess cruise ship docked in Yokohama, 36 km south of the Japanese capital Tokyo, and turned into the world’s largest cluster of people infected with a new disease: covid-19.

Hospitals in Yokohama had trouble admitting all the passengers, especially since many of them were in severely ill, needing mechanical ventilation or extracorporeal membrane oxygenation.

The biggest challenge, says Norio Ohmagari, who leads research at the National Centre for Global Health and Medicine in Tokyo, was the low number of available beds. “It was quite obvious that we could not accommodate all covid patients,” Ohmagari says. “The Tokyo governor requested private hospitals to accommodate them [70% of hospitals in Japan are privately run], but they were scared of this novel disease, with not much information, no vaccine, paucity of PPE [personal protective equipment], and no treatment.”

“A national health crisis sadly cannot be separated from politicisation,” says Kenji Shibuya, director of a covid vaccination medical centre in Soma city in Fukushima prefecture and research director at Tokyo Foundation for Policy Research. “For the countries that did well in managing the pandemic, the primary factor was their trust in the government. Unfortunately, that trust in the government and experts from the medical community was eroded in Japan.”

Japan recorded its first case of covid-19 in January 2020. Two years later, the world’s third biggest economy and 11th most populous has recorded five million cases and 23 633 deaths—far lower than many other high income countries. But the exact reasons for the island country’s low numbers (box 1), and the effectiveness of the government’s pandemic response, are still debated.

Box 1

Why did Japan’s covid-19 numbers remain relatively low?

Among the reasons cited are a public willingness to adhere to measures, as well as Japan’s early adoption of the “3Cs” (avoiding close contact, closed spaces, and close conversations)—built on the country’s traditional approach to infectious disease control—that anticipated what scientists now understand of the airborne nature of SARS-CoV-2 transmission.

In addition, facemasks were prevalent even before the pandemic, and most experts think a culture of politeness while travelling on public transport—such as distancing and a hesitancy to talk aloud on the phone—helped limit virus transmission, even as the country’s vast train and subway systems continued to be crowded during the peak hours. Japan’s low obesity rate has also been posited as a factor.

Winter 2020

The Japanese government declared its first “state of emergency” on 7 April 2020,3 which lasted in some form throughout the rest of the year. It was one of the first countries to close schools nationally (in February 2020) and it also closed borders to foreign visitors and limited entry for Japanese residents from abroad.

Though there was criticism of the government’s confusing messaging,4 Japan got through 2020 with just 239 000 officially confirmed cases and around 3500 deaths as the public largely complied with requests to work from home and refrain from travel and going out.

But December 2020 saw rising case numbers as new variants emerged. For the first time, Tokyo logged 10 000 cases in a month.5 Ohmagari remembers that ambulances were not able to secure hospital beds for their patients. At the time, rules stated that anyone who tested positive had to be admitted to hospital. Even though a considerable number of beds were allotted for covid-19 patients at the National Centre for Global Health and Medicine, it was not enough. Subsequently, the Tokyo metropolitan government ordered public hospitals to secure non-intensive care unit beds to accommodate covid-19 patients with moderate infection.

Ohmagari says that what happened was beyond anyone’s expectation. “[The authorities] did not know that to accommodate moderate to severe patients, the whole healthcare system had to undergo a change [in the rules] and adjust to new restrictions. We had to modify the patient care flow for non-covid patients, and that was quite complicated.”

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