Fifty-fifty: How Japan Successfully Blunted The Corona Bullet

It was early April. I was speaking to an old Japanese colleague of mine from my days of working with Japanese advertising giant, Dentsu Inc. The news did not sound too good from Tokyo: it seemed pretty apparent that the island nation was fast headed to becoming one of the world’s coronavirus “disaster zones”. There had already been a lot of bad blood, and lots of criticism, on the Japanese decision to quarantine passengers and crew aboard the Diamond Princess cruise liner, held up in Yokohama harbour. Japan was also being openly accused of underplaying the Covid-19 threat while it clung on to the slim hope of hosting the Tokyo Olympics to save trillions of yen invested in preparing for the mega event. The Tokyo Marathon had been organized in earlier weeks with only 200 elite professional runners, and the usual 30,000 amateurs who would normally have joined them in the prestigious race were banned for fear that the gathering would accelerate transmission of the coronavirus, till then still an emerging phenomenon.

The Before & After of it
My colleague was voicing what most critics were saying too: Japan was testing too few people, opting instead to focus on clusters of cases rather than overburden its healthcare system with patients displaying no or only mild symptoms who, by law, had to be admitted to hospital. One of the world’s richest countries, he regretted, was bungling its response. Japan was testing just 0.185 percent of its population – and Western experts were shaking their heads in disbelief!
However today, in just more than a month since, Japan has emerged as a strong case for being a global coronavirus success story, but a story not being lavished praise in quite the same way as other Asian nations, especially South Korea, Hong Kong and Taiwan. As of May 14, Japan had 687 fatalities directly attributed to Covid-19 nationwide, equal to 5 per million people. That compares pretty well with a total of 85,268 deaths, or 258 per million, in the United States and 584 per million in Spain. Even Germany, seen as another success story in the pandemic, has 94 deaths per million.

As of last week, Japan – a country with a population of 126 million people, and  with one of the biggest elderly populations in the world – had confirmed 16,433 infections and 784 deaths, out of a global death toll of more than 300,000 people.

Corona cases peaked in Japan on April 17. A record 206 new cases. Most thanked PM Shinzo Abe for having (hesitatingly though) imposed a state of emergency on April 7, first in Tokyo, and then in all the 47 prefectures of the country. The government response was seen to be weak kneed – neighbour South Korea was testing, tracing, and treating widely across the country – and was fast headed to a flattening curve. From then to now, the situation has undergone a massive change … Tokyo, where over 14 million Japanese live, has not crossed more than 40 cases a day for over 2 weeks now. And just five cases were reported on two consecutive days last week. In fact last Friday, the capital city had just 3 new cases in the previous 24 hours. Remarkable, to say the least. Moreso, since Abe san did not order a lockdown – some antiquated post WW-II laws promulgated by the Americans back then, do not allow him, even as Prime Minister, powers for such sweeping actions.

What did the Japanese do right ? 
Japan’s ‘lockdown’ was very dissimilar to ours – no baton-happy police, no ‘gedi’ bikers breaking the curfew, no office closures, no desperate attempts to force everyone to stay home. All the government did was to request everyone to avoid unnecessary outings, work from home and observe social distancing. PM Abe actually dispatched two reusable gauze masks to every household … though the measure invited some ridicule … nicknamed ‘Abenomasks’ … which in a way actually made fun of his much-touted ‘Abenomics’. But some political mis-steps are fine in any effort.  Abe san also appealed for the “three Cs” that needed to be avoided: 1. Confined places 2. Crowded spaces 3. Close human contact.

In January 2020, some 925,000 Chinese people traveled  to Japan, while another 89,000 made the trip in February. But Japan never really panicked. Despite having the capacity to make 6,000 diagnostic tests per day, Japan has only tested around 14,000 swabs to date — 20 times fewer than neighboring South Korea, which too has been hit hard by the pandemic. Only patients with the most severe symptoms were tested, contrary to Western strategies. So what has worked? Perhaps the Japanese culture.

Japan’s culture has played perhaps a big role in combating the virus:

* The  Feisumasuku  or the face mask is an old Japanese habit, worn very commonly during the winter flu season. Also during spring due to the fear of hay fever. So this was not a precaution that took any effort to be adopted in Japan.

* For the record, Japan as a country typically goes through 5.5 billion face masks every year — 43 per person. Sales of face masks further skyrocketed as the virus took hold.

* The Ojigi or the custom of bowing is a contactless greeting, unless the handshake or kiss or hug in the West.

* The Japanese have very high personal hygiene standards. The Genkan portico in Japanese homes is the area beyond which shoes are not taken into the house. This is a very important measure in infection control.

* Universal healthcare is attributed to be the reason Japanese live so long. So, they have over the years built healthier and better immunity as a nation.

* Japan, because of its ageing population, over the past decades, built great expertise in treating pneumonia … pulmonary problems play a big role in the corona attack. So this expertise has helped.

* Some say consumption of foods such as natto have helped boost the immune system … an unsubstantiated claim, though.

* Another somewhat weird claim centres on an unscientific experiment conducted by a TV network, claiming there are relatively low number of airborne droplets generated by spoken Japanese, reducing virus transmission!

* The possibility that the virus strain spreading in Japan may have been different, and less dangerous, to that faced by other nations, has also been raised. No one knows for sure though.
“Different people give different explanation but I believe culture and custom played significant role in preventing the spread of virus like taking off shoes and keeping  hygiene in houses, and respects and concerns to others (following stay home and keep social distance) were practiced by vast majority of people without forcing. It is all discipline, I think,” says Kenji Nogami, who worked with me for many years at Dentsu, and now lives and works in Tokyo.

What has been the strategy?
* “Japan is identifying those who really need help and its medical care is excellent, and that's why so few are dying,” says Professor Kenji Shibuya of Kings College London.

* “From the physician's point of view, it makes sense,” emphasizes Shibuya. “Forget about mild cases, focus on cases with major symptoms and save lives. Focus testing on those who have symptoms.”

This seems kind of simplistic; and dangerous. But it has worked. The “Japan model” of combating COVID-19 has been successful, at least to this point. However, this Japan model has not been well understood, with the result that reports in overseas media have been erroneous, generating quite some misunderstanding.

So what is the Japan model? First, it is a cluster-based approach, derived from a hypothesis obtained from an epidemiological study based on Chinese data and conducted on the Diamond Princess cruise ship that entered the port of Yokohama on February 3, 2020. This hypothesis accounts for the many passengers who were not infected with the coronavirus despite having had close contact with infected persons. It posits that the explosive increase in infected persons is a result of the high transmissibility of certain infected individuals, which forms a cluster. Infected individuals with even higher transmissibility appear from these clusters to form more clusters and infect many others. Based on this hypothesis, under the cluster-based approach, each cluster is tracked to the original infection source and persons with high transmissibility are isolated to prevent the spread of infection. For this reason, pinpoint testing is carried out and broad testing of the population is not required, in contrast to the approaches taken in other counties.

So what is the verdict? “I think we were just lucky.

My guess is that it is a result of many coincidences like geographical isolation which made it easier for us to control the border, shy culture that prevented people from touching each other, familiarity with wearing the mask and so on.  Strong measure like lockdown could have made some panic while the ‘guidance’ was just right for the obedient Japanese people and they kept their calm,” reiterates Jun Nakano, a well-known illustrator, who lives just outside of Tokyo.
In India, may be there is something we can learn from the Japan model, and the Japanese, in controlling the spiraling Covid infections in our country.