Keyword: crisis management, Covid-19, Japan, policy, civic responsibility
Picture 1: A Temple entrance in Kita district (Tokyo), April 2020 © Adrienne Sala
Despite its high and early exposure to the SARS-Cov-2 combined to a structural vulnerability (high concentration and significant aging of the population) Japan is one of the few advanced countries having an extremely low death rate at the end of the Covid-19 epidemic first wave (the death rate of hospitalized people is also very low, 7.5%). On May 25 when the state of emergency was lifted Japan had a total number of 846 deaths and 16,706 cumulative cases. With 13 cases per 100,000 inhabitants, Japan is among the good students along with its Asian neighbors. Moreover the Japanese government did not use coercive measures or intrusive tracking of its population. However, analyses of Japanese crisis management do not all converge in the same direction, as critics pinpoint the national government slow responsiveness, the entrenched bureaucracy and lack of transparency in the decision-making process. Nevertheless there seems to be a consensus on local governors high responsiveness during the first wave of the contaminations. The complexity of the crisis analysis reflects the diversity of multi-sectorial and multi-level issues: health, economic, social and political issues intertwined at the local, national and global levels. In this paper we propose to put into perspective the three pillars of the Japanese health crisis management: health system, epidemiological investigations and civic responsibility. Articulation of these three pillars gives an overview of the Japanese preventive policy anchoring the Covid-19 crisis in the continuity of previous crises. Effectiveness of coordination between political and economic actors and citizens is nonetheless being challenged by the long duration of the epidemic and its socio-economic consequences.
Figure 1: Covid-19 daily cases and PCR test from January 24 to August 21, 2020.
Source: MHLW (https://www.mhlw.go.jp/stf/covid-19/open-data.html) (last visited on August 25 2020).
1. The medical and healthcare system – First pillar of the health crisis management
According to WHO reports, Japan's healthcare system ranks among the best in the world. In 2018, health expenditures accounted for 10.9% of GNP and life expectancy is one of the longest in the world, although it faces major issues such as aging population, rising chronic diseases, healthcare spending, and a lack of healthcare professionals and doctors (2.35 per 1,000 inhabitants). The number of beds, at 13.2 beds per 1000 inhabitants in 2015 is well above the OECD average, however only 0.2% (1,841 beds) were reserved for infectious diseases (WHO 2019). Therefore from mid-March, hospitals capacity was gradually increased to cope with the rise of confirmed cases (42,071 beds in August 21). This increase has kept the overall hospital occupancy rate relatively low since the second wave (27.4% on August 21).
In the context of a cholera epidemic, the Infectious Disease Control Act of 1897 revised in 1999, originally required provisioning of 10,000 beds. A revision of the old system was necessary as only 1,500 beds were used on average. The reform also responded to civil society's demand for compliance with human rights and dignity following various scandals such as the contaminated blood scandal (Foote 2000), for better protection of personal data and for limiting the central administrative authority power in favor of that of local governments (Nomura, Takahashi & Takeda 2003).
Ability of the health care and medical service system to manage risks associated with the current epidemic relies primarily on the resilience of understaffed services (caregivers and doctors), with only a minority of them trained in infectious diseases management. In this context of new clusters identification since early June, there has been a growing concern regarding the gap between hospitals possible overcapacity and the central government low reactivity. In addition, the "Go to travel" campaign launched from July 22 to August 31 to promote domestic tourism led to confusion and virulent criticism from the medical professionals, reflecting divergences in the coordination of actors and organizations. To contain the spread of the virus and support the Japanese healthcare and medical system, two other pillars are key.
Figure 2: Three pillars of the crisis management for Covid-19 epidemic
2. Epidemiological investigations – second pillar of the crisis management
In accordance with the system of surveillance defined by the Infectious Disease Prevention Act, identifying clusters through epidemiological surveys was the first phase of the policy to fight the virus (from January to April).
Decision not to carry out systematic PCR tests is the result of technical constraints (lack of tests and qualified personnel, lack of treatment reducing the usefulness of test) as well as health and medical system structural constraints. However, risks associated with these constraints have been efficiently remediated by the activation of the infectious disease surveillance system. According to the law, all physicians must inform the health centers (hokenjo) when a case of infectious disease is detected. The health centers then deploy contact tracing procedures. More than 500health centers are present throughout the country, representing one of the major structures involved in health crisis management. They work in close coordination with local government, Ministry of Health, Labor and Welfare, the National Institute of Infectious Diseases and the national government organized into a crisis unit.
Rather than aiming at identifying and quarantining infected people, in Japan the main objective of epidemiological investigations is to determine factors behind the spread of the virus in order to rapidly apply targeted measures (Omi 2020). Since early March the results of these investigations, conducted also on the Diamond Princess, allowed identifying key contagion vectors of the virus, summarized and communicated through the terms "san mitsu" (三密) or “three Cs”, referring to Closed places (密閉), Crowded places (密集) and places with Close proximity between individuals (密接) (Oshitani et al. 2020).
Since March, due to the magnitude of the epidemic and the increasing burden on health centers and hospitals, the Japanese government responded by adding to its policy early detection by increasing gradually testing capacity and health centers workforce. On April 7, the government declared a state of health emergency until May 25 in accordance with the Special Measures Law Against Novel Influenza, revised on March 13, 2020 to add Covid-19. This period is perceived outside of Japan as "voluntary containment" as opposed to the mandatory lockdown in most countries. Indeed, if the law does not provide for coercive measures (penalties, denunciation) and if the state of emergency is not restrictive of individual liberties (lockdown), the application of preventive policies since January helps understanding the crisis management relative effectiveness which also depends on the third pillar.
Picture 2: Set of two masks sent to each households in Japan during the state of emergency, April 26, 2020 © Adrienne Sala
3. Civic responsibility – third pillar
The restrictions requested by the national government and local governors according to the local health situation, are relayed through regular communication via media and social networks, encouraging individual and collective risk management. These "voluntary restrictions" combine individual and collective responsibility into the civic responsibility. The widespread wearing of masks is one illustration of this responsibility, whose social acceptance is the result of successive epidemic episodes.
Picture 3: JR Yamanote line Station entrance at rush hour time, August 2020 © Adrienne Sala
Since the Spanish flu (1918-1919), whereas in Europe and the United States surgical masks wearing was the subject of intense controversy, the practice gradually became widespread in Japan during the Italian flu (1949-1950), the Hong Kong flu (1966-1968), SARS in 2003 and the swine flu in 2009, transforming the practice into a social norm. Since 2009 by protecting the individual and the community, the wearing of masks has been the subject of regular media information campaigns and corporate internal communication. This is an illustration of the coordination between the State and economic actors in civic education and dissemination of behavioral norms: the wearing of masks has become a symbol of respect and responsibility among workers in the same way as hygiene rules (Burgess & Horii 2012).
Picture 4: Masks stall in a general store, August 2020 © Adrienne Sala
Individual responsibility related to collective well-being seems to reveal a "liberal" policy of crisis management in comparison with other countries where mandatory lockdown was virulently criticized for having infantilized citizens, made passive in the fight against the spread of the virus. Compared to intrusive measures in the field of individual rights and freedoms, Japan's current health crisis management policy is based on a crucial balance between freedom and security. This paradigm becomes vulnerable as soon as the balance of responsibilities deteriorates as a result of the erosion of institutional capacity to absorb risks.
Picture 5: Restaurant in a shopping street with a COVID-19 safety sticker issued as part of initiatives to encourage implementation of the Tokyo Disease Control Measures Guidelines for Businesses, August 2020 © Adrienne Sala
Adrienne Sala is social science researcher at the French Institute of Research on Japan, at the Maison franco-japonaise in Tokyo (UMIFRE 19, CNRS, MEAE), post-doctoral researcher at the Fondation France-Japon de l’EHESS and visiting researcher at the University of Tokyo since September 2019. Her main research interests include political sociology and political economy of institutional change, legal mobilizations and legal professionals role in the Japanese society. Among her publications: « Construire un problème public au Japon : l’endettement des ménages et la réglementation du prêt non sécurisé », Critique Internationale, 2019; «La mobilisation du droit et le recours aux contentieux dans les cas de mort et de suicide par surmenage au Japon: du cause lawyering à la judiciarisation du karôshi-karôjisatu?», (with E. Kasagi), Droit et Société, forthcoming. Contact : Adrienne.sala@gmail.com
References
Adrienne Sala (2020) «Le Japon face à l’épidémie. Gestion de crise et responsabilité civique»,La Vie des idées.
Oshitani Hitoshi and Experts Members of The National COVID-19 Cluster Taskforce at Ministry of Health, Labour and Welfare, Japan (2020) “Cluster-based approach to Coronavirus Disease 2019 (COVID-19) response in Japan-February-April 2020.” Japanese journal of infectious diseases.10.7883/yoken.JJID.2020.363.
Adam Burgess and Mitsutoshi Horii (2012), “Risk, ritual and health responsibilisation: Japan’s ‘safety blanket’ of surgical face mask-wearing”, Sociology of Health & Illness, Vol. 34 No. 8.
Nomura Takashi, Takahashi Hiroshi and Takeda Yoshifumi (2003), “Changes in Measures against Infectious Diseases in Japan and Proposals for the Future ”, the Journal of the Japan Medical Association, Vol. 46, No. 9.
