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Fighting the Coronavirus Pandemic, East Asian Responses - Japan: Self-Restraint, Path Dependence and the Shadow of the Olympics

BLOG - 3 April 2020
Key Points
1

Requests for "self-restraint" - social distanciation, personal protection - have been rather followed

2

A focus on small clusters to prevent the formation of larger clusters with investigation teams

3

Industrial mobilisation for a rapid increase of the national production of masks, tests and medical treatment

4

Mandatory hospitalization for all patients who test positive, even with no symptoms, as a legal obligation under Japan’s Infectious Diseases Prevention Act

5

A very restrictive approach to tests to avoid overwhelming the medical system

6

A legislative amendment to authorize forms of confinement and lockdowns as part of a "state of emergency"

7

The declaration of the "state and emergency" for Tokyo and six prefectures, allowing for partial and soft lockdowns

8

The incremental preparation of the health system to a rapid increase of contagion

A massive stimulus package of 10% of GDP to be approved as a special budget by the Parliament

This article was updated on April 10.

No lockdowns, a very conservative testing policy centered on symptomatic cases, no digital contact tracing, no intrusive surveillance to enforce quarantine, open borders for a long time: Japan seems to have followed a unique path, taking none of the strong measures adopted by other East Asian countries. Yet the country has managed throughout February and March to avoid a major outbreak of COVID-19 with a package of mildly constraining policies – mostly social distancing "requests", limited travel restrictions and an emphasis on masks. However, the Japanese government is getting ready to adopt stricter measures to face the risk of a major increase of cases.  

Timeline

  • January 16: Japan confirms first case, a Chinese national (in his 30s) who previously traveled to Wuhan.
  • January 24: Shinzo Abe convenes the first high-level cabinet meeting on the novel virus, following the WHO statement, also including experts
  • January 28: Designation of coronavirus as an ‘infectious disease’ under the Infectious Diseases Control Law.
  • January 29: Japan is one of the first two countries to evacuate citizens from Wuhan.
  • January 30: Decision to create a Novel Coronavirus Response Headquarters.
  • February 1: COVID-19 is added as a designated category II infectious disease under the Infectious Diseases Control Law, which requires doctors to immediately report diagnosed COVID-19 cases to the public health center in their jurisdiction. The  Ministry of Health, Labor and Welfare (MHLW) asks prefectural authorities to establish COVID-19 related consultation centers and outpatient wards at local public health facilities.
  • February 3: First travel ban imposed on those with Hubei Province in their travel history or with a Chinese passport officially issued in Hubei.
  • February 4: The Diamond Princess is quarantined in the Port of Yokohama, with 10 positive cases.
  • February 12: The Ministry of Economy, Trade and Industry announces that it will subsidize domestic mask production, aiming to lift the current output to 150%.
  • February 13: First COVID-19 related death, a woman in her 80s in Kanagawa Prefecture.
  • February 13: Travel restriction for Zhejiang residents and foreigners with Zhejiang province travel history
  • February 14: First Novel Coronavirus Expert Meeting called by Prime Minister Abe
  • February 17: Health Minister Katsunobu Kato warns of "new phase" in the outbreak.
  • February 21: Japan suspends all major public gatherings.
  • February 24: The Ministry for Trade, Economy and Ministry institutes financial safety nets in place for SMEs and businesses affected adversely by COVID-19.
  • February 25: Six weeks after the first case, adoption of "Basic Policies for Novel Coronavirus Disease Control"
  • February 27: Shinzo Abe asks all schools in Japan to be closed temporarily, but not universities.
  • March 1: All on board the Diamond Princess, including the captain and the crew, disembark. 672 confirmed cases.
  • March 5: New quarantine restrictions.
  • March 10: The Second Novel Coronavirus Disease Emergency Response Package is instituted.
  • March 14: Diet approves amendment of the Act on Special Measures for Pandemic Influenza and New Infectious Diseases Preparedness and Response to include coronavirus
  • March 16: Expansion of entry restrictions to travelers from specific areas in Spain, Italy, Iran, Switzerland and Iceland.
  • March 24: Postponement of the Tokyo Olympics until 2021.
  • March 26: Governor of Tokyo urges people to avoid unnecessary gatherings until April 12
  • April 7: Prime Minister Abe declares a state of emergency for Tokyo, Kanagawa, Saitama Chiba, Osaka, Hyogo and Fukuoka
  • April 7: Prime Minister announces a record 108.2 trillion yen ($992 billion) stimulus package

Analysis

As of April 10, 5347 cases and 88 deaths had been reported in Japan – not including the 672 passengers of the Diamond Princess cruise ship who tested positive when in quarantine off the port of Yokohama, leading to ten additional deaths. But this relative success is fragile by all measures. The fear of a major outbreak slowly building silently in undetected clusters has overwhelmed Japan. At the beginning of April, the Ministry of Health, Labor and Welfare considers an incoming "peak of infection" inevitable and has redefined its priority to delaying and lowering that peak to avoid overwhelming the medical infrastructure and contain the socio-economic damage. By comparison, at the end of February, Japan’s stated goal was to "end the epidemic in its early stages".

With no clear end in sight to the epidemic, Japan is entering April adopting much more stringent policies: the declaration of a COVID-19 state of emergency that provides a legal basis for mandatory lockdowns, however without strong enforcement power for executive authorities, an expansion of the entry ban to cover foreigners who have been to the US, China, South Korea and most of Europe, and a 108,2 trillion yen (US$992 billion) stimulus package to help companies and households withstand the global economic shock of the coronavirus – including the postponement of Tokyo 2020 Olympics, initially scheduled for July, until the summer 2021.

Self-restraint

By the standards of East Asian democracies, Japan has reacted slowly to the Hubei crisis. The Abe administration only convened an emergency meeting on January 24, after the WHO statement that finally confirmed human-to-human transmission of the coronavirus - by that time, South Korea and Taiwan already had screening procedures in place for incoming passengers from the Wuhan area and were treating the coronavirus as a major threat. Four days later, COVID-19 is added as a designated infectious disease under the 1998 Act on the Prevention of Infectious Diseases and Medical Care for Patients with Infectious Diseases (Infectious Diseases Prevention Act) – a modern version of a legal framework adopted in 1897 in the Meiji era, when cases of cholera in Japan exceeded 100,000 per year.
 
A Class II infectious disease entails a number of standard operating procedures, and a decentralized crisis management system. In practice, strong executive power is given to the governors of Japan’s 47 prefectures.

But the keyword that captures the first phase of Japan’s containment effort is self-restraint (自粛).

They can decide to arrange questioning of patients, to authorize an investigation of the contacts and places visited by the affected persons, request individuals to undergo medical examinations, and also decide the relocation of the burial and cremation of corpses affected by any Class II disease. The Governor can rely on a number of medical institutions across the prefecture specifically designated for Class II infectious diseases. Forced hospitalization is an option under the Infectious Diseases Prevention Act.

But the keyword that captures the first phase of Japan’s containment effort is self-restraint (自粛). In the absence of a legal state of emergency, the Japanese government responds to the COVID-19 threat with polite requests to the population, which have more or less been followed. This is the essence of the February 25 Basic policies for Novel Coronavirus Disease Control: "We ask all the people in Japan to refrain from seeking medical care without appropriate consultation due to the anxiety of potential infection, and avoid the environments with high risk of infection. Moreover, we request the people to wash their hands and to cover their mouth when coughing, refrain from going out when they have symptoms, and wear masks when they need to go out".
 
This approach, reinforced by a personal call for self-restraint by Prime Minister Abe, achieves some results in containing the virus spread. On February 27, he asks the nation’s elementary, junior high and high schools to close from March 2 up through the spring break. Despite this being a request and not a legal obligation, data from the Ministry of Education shows that 98.8% of all municipally run elementary schools imposed extraordinary breaks.
 
The same approach is taken in Hokkaido after 66 cases are confirmed on the island, a major touristic winter destination. On February 28, Hokkaido governor Naomichi Suzuki declares a state of emergency, but without a legal basis – in other words, a request for self-restraint. Despite the absence of legislation, the 5,3 million inhabitants of the island who are asked for their "understanding and cooperation" mostly take it seriously. Of course, the Hokkaido state of emergency is far less strict than Chinese-style lockdown and European-style confinement. If commercial life is largely brought to standstill and a number of companies implement telework policies, the population is not asked to stay at home except during weekends. The same approach is taken by Governor Yuriko Koike in Tokyo when she asks the capital’s residents on March 25 for their "cooperation" in avoiding outdoor activities.

A political debate on the merits of self-restraint versus the importance of creating a legal framework to impose restrictions has thus been at the core of Japan’s response to the virus crisis. This debate reached a conclusion by Mid-March, when the Japanese Diet approved legislation giving the Prime Minister the authorization to declare a state of emergency by amending the 2012 Act on Special Measures for Pandemic Influenza and New Infectious Diseases Preparedness and Response (新型インフルエンザ等対策特別措置法) to include COVID-19. The 2012 act created an emergency system on the basis of the lessons learned by the Japanese government during the 2009 outbreak of A/H1N1 influenza. The state of emergency confers local governments the right to declare lockdowns, and even take over land and buildings to use as temporary medical facilities. They can also request the sale of good products and medicine as part of the emergency measures. The Act also strengthens the power of the Prime Minister’s office, which can issue mandatory orders to governors, hospitals or railway companies. As of April 1, the special measures had not been activated but were hotly debated everyday in Japan.

Crisis management and a path-dependent response to the test challenge

Another limitation to the early response capacity of the Japanese government is the lack of a centralized epidemic crisis management institution - by comparison with South Korea and Taiwan. Japan was spared the 2003 SARS and the 2015 MERS crisis and did not have to revamp its system to face an infectious respiratory disease epidemic. Japan’s institutional arrangement creates a path dependence that explains to a large extent the initial governmental approach to tests.

In Japan, the Deputy Chief Cabinet Secretary for Crisis Management is in charge of coordinating the government’s response to disease outbreaks. On January 30 a "Novel Coronavirus Response Headquarters" (新型コロナウイルス感染症対策本部)is established as a coordination meeting in the Cabinet Secretariat of the Prime Minister’s office, and chaired by Prime Minister Abe. This leads to the decision to activate Japan’s disaster medical system, organized around 700 disaster base hospitals and disaster medical assistant teams composed of doctors, nurses and other staff. But the system is geared towards addressing natural disasters – its last major revamping was in the aftermath of the 1995 Kobe earthquake – and as a result, the medical teams have no prior training for addressing outbreaks of infectious diseases. The Ministry of Health took the executive decision to involve the disaster medical teams in the disembarkation of the quarantined Diamond Princess cruise ship, with the ensuing mistakes, as there was no standard procedure to follow to address such a crisis.

Japan’s National Institute of Infectious Disease (NIID), a research institution established in 1947 under the Ministry of Health and Welfare, plays a key role in the government’s response to the COVID-19 crisis. The institution has two missions: conducting fundamental and applied research on infectious diseases; and national tests for release and development of antibiotics and vaccines.

Once activated, NIID does what it has been built for: it conducts an "active epidemiological investigation" into people with flu-like or respiratory symptoms, rather than a systematic medical procedure. The aim is to develop NIID’s own testing procedures and to get an overview of the risks for Japan. This explains why the Ministry of Health, Labor and Welfare excludes until March 6 the test kits developed by company Roche, that have been used widely in Wuhan, from the public health care insurance program. There are concerns regarding the reliability of the tests, and strict procedures in place before approvals.

Any patient infected with a class II disease is hospitalized. As a result, all patients testing positive, even with no or mild symptoms, will occupy a hospital bed.

Because NIID conducts an epidemiological investigation, each individual test needs to be approved by the Institute. The conditions for approval are set relatively high: a close contact with a person who has tested positive, an examination of an infected patient without protective measures, or a combination of fever, respiratory symptoms and a visit to Hubei or Zhejiang province. As a screen, NIID can rely on a network of 860 newly established coronavirus counseling centers across the nation for evaluation. Therefore, as of March 31, 32497 individuals only had been tested. This restrictive approach creates a major bottleneck and leads to the notion of "test refugees" (検査難民) to designate the individuals who seek testing but are not eligible. It is also the source of the debate regarding the possibility that clusters of infection may have been left undetected.

Another self-imposed constraint explaining Japan’s testing policy is the fact that under the Infectious Diseases Prevention Act, any patient infected with a class II disease is hospitalized. As a result, all patients testing positive, even with no or mild symptoms, will occupy a hospital bed. This legal obligation could create a major crisis in case of an exponential rise of the number of cases. It has led to a proposal by the Tokyo governor to revise the Act so that patients with no symptoms can recover at home and those with mild ones in designated facilities, such as the Olympics’ athletes village. A similar policy is advocated by the Medicine Nobel Laureate Shinya Yamanaka: he argues that people with no or light symptoms should not be hospitalized or asked to stay at home but cared for in special facilities to be established (無症状や軽症の感染者専用施設の設置を).

In this legal context, the question of hospital capacity is central to Japan’s crisis management challenge. According to Prime Minister Abe, Japan in Mid-March had 12000 beds for serious COVID-19 cases and a total of 3000 ventilators. Japan’s legal constraints normally prevent general hospitals with no departments specialized in infectious diseases to accept COVID-19 patients, but exceptions will be needed. And the Japanese government has asked all Japanese prefectures to increase the number of specialized beds.

A mobilized industry

At the same time, Japan displays its usual strength in mobilizing its national industrial structure to combat the pandemic, using a mix of requests and business incentives. Several Japanese companies have engaged in developing tests. Kurabo Industry is able to manufacture 1000 test kits per day, at a unit cost of 25,000 yen (US$235), with each kit able to conduct 10 tests. The test detects antibodies in blood, and thus differs from the polymerase chain reaction (PCR) that detects the presence of the virus through its genetic sequence with a nasal swab. These test kits start becoming available for designated laboratories and medical institutions on March 16.

At the same time, Nagasaki University, Canon Medical Systems and the National Institute of Infectious Diseases are developing a PCR device that can conduct 700 checks per day and deliver the results in 10 minutes. Shimadzu Corporation is developing a PCR variant and has announced plans to produce 50000 kits per month. As a result of these efforts, the daily test capacity increases from less than 4000 to more than 9000 between mid-February to the end of March. But this has no impact on the daily number of actual tests, which stay stable under 2000, according to the Ministry of Health.
 
On the treatment side, Japan Prime Minister Abe expresses support for using the anti-flu Avigan drug that was assessed to be effective by the Chinese Ministry of Science and Technology. Its producer Fujifilm subsidiary Toyama Chemical, announces an increase in production shortly after the endorsement. As a result of the Japanese government’s decision to establish a national supply system for the production of Avigan without reliance on imports, the company Denka restarts production of a key component, three years after having abandoned it as a result of foreign competition.
 
Japan does not face the mask issues - availability and energy consumed in an ill-informed debate regarding their usefulness - that have plagued several European countries. There is an ingrained habit of wearing masks as a form of social responsibility, to refrain from infecting other people. Professor Shinoda Hideaki from Hiroshima University explains by this culture of wearing masks the "Japanese mystery" that packed commuter trains never proved to become clusters of infection. Japan has an industrial base for the production of masks and has ramped up production to meet Prime Minister Abe’s promise of  600 million masks availability per month.

Japan does not face the mask issues - availability and energy consumed in an ill-informed debate regarding their usefulness - that have plagued several European countries.

For example, Sharp has converted an LCD-display panel factory in Osaka to produce 500000 masks per day. All companies have boosted production. The main limitation they face is the necessity to use existing industrial facilities, as building new ones would take up to one year, and recruiting of trained workers. For example, producer Unicharm estimates that at full capacity it can produce maximum 25 million units per week.

METI has been the key actor behind Japan’s national mask policy. The Ministry created a subsidy scheme to boost local production, first selecting a batch of three companies at the end of February (Kowa and Xins for manufacturing masks, and Hata Industries for manufacturing components). A second batch of eight companies was announced on March 13. Overall, 120 companies have been asked to increase their production. In 2018, Japan’s market absorbed 5,5 billion masks, with 20% produced domestically and 70% imported from China. Domestic production boost considerably reduces reliance on Chinese supply. However, import is not excluded. METI has encouraged imports from China since they resumed during the week of February 17, seeking a gradual increase to reach a weekly import of 20 million units per week in early April. METI has announced that these measures will suffice to reach Prime Minister Abe’s supply target. At the beginning of April, there was still some tension on the supply side, and the Japanese government decided to send two sets of washable and reusable cloth masks to 50 million addresses in Japan, to complement the market of surgical face masks.

The digital dimension

Unlike South Korea, Singapore, Taiwan and Hong Kong, Japan makes relatively little use of digital tools. For one thing, there is no quarantine for Japanese nationals as hospitalization is mandatory when testing positive. But there is still an important digital dimension to Japan’s crisis management, and a legal privacy protection issue surrounding it. Prefectural governments have created official accounts on Line, Japan’s most popular free messaging application, that users can add as friends to enter information so that the application can determine if they need to consult in a designated coronavirus facility, provide guidance and store data. But this is not a contact tracing approach, as access is not granted to the list of contacts registered in the Line app of the user. The AI software regularly asks for updates from registered users. In Kanagawa prefecture, 210000 people had registered by the end of March. The Ministry of Health is also using the application Line to run a "National Survey for New Corona Countermeasures" asking the users about different symptoms associated with COVID-19, and their postcode.

One important step was taken by the Japanese government in late March when it requested mobile phone carriers and popular internet platforms such as the GAFA and Yahoo! Japan to provide anonymized data to help with an early identification of clusters. This follows the establishment of a "Cluster Response Section" (クラスター対策班) as part of the February basic policies. In practice, once medical facilities test new cases, the cluster team is dispatched to conduct an epidemiological investigation. A data team under the leadership of NIID brings together data analysis experts from Hokkaido University, a contact tracing team from NIID’s own staff, and risk management analysts from Tohoku University. But given Japan’s privacy legislation, their investigations rely very much on human cooperation.

Facing the economic cost

Japan’s crisis management has been colored by the high stakes linked to the preparation of the 2020 Tokyo Olympics, which were finally postponed to the summer of 2021 by late March. A controversy has arisen, with Former Prime Minister and opposition politician Yukio Hatoyama accusing the government of an "Olympics first" approach with a weak response to the coronavirus crisis in order to project the impression that the city was "taking control of the virus". This accusation however neglects the fact that the Olympics postponement was a necessary measure given the international spread of the virus, and not only the situation in Tokyo. The Olympics is about international prestige, but also investment and economic gains, and their postponement sheds the light on the economic cost of the crisis for Japan. The Japan center for Economic Research estimates that Japan, mostly through public companies, has invested between US$32 and US$41 billion in infrastructure projects, including the additional hotel capacity. The Olympics Committee estimates that the additional cost of delaying the games is 300 billion yen (US$2.7 billion), a cost that does not include the delayed gains for the Japanese GDP in 2020.

Beyond the Olympics, Japan’s answer has to address the global macroeconomic environment, and the impact of weakened domestic activity, especially if the government decides to impose a state of emergency. A first package of measures is approved in mid-February, with 500 billion yen (US$4,5 billion) centered on the tourist and travel industries, with inbound tourism down 58% year-on-year in February, and a projected revenue loss of US$2.8 billion for Japanese airlines between February and April. The government announces a second emergency package of measures of US$4,2 billion in mid-March, including subsidies for freelancers and for parents obliged to stay at home as a result of the closures of schools.

A major economic policy decision is in preparation at the time of writing this article. The Japanese government is preparing a massive 60 trillion yen ($556 billion) stimulus package (close to 10% of GDP) in the form of a special budget to be approved by the Parliament. The measures envisaged include tax facilities for small and medium enterprises, subsidies to maintain employment, facilities for banks to extend loans, and possibly targeted cash handouts to eligible households.

 

Copyright: Philip FONG / AFP

 

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